The Joint Learning Network for Universal Health Coverage systematically documents the reforms of its member countries and other countries that have expanded health coverage through demand-side financing. The case studies contained in these pages are brief, comparative and modular in nature, describing the key highlights and technical features of each program.
Compare various dimensions of country reform efforts using our interactive tool.
| Program | Primary source of funding | Secondary source of funding | Contributing Populations | Types of Contributions | Funding |
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| Colombia: General System of Social Security in Health |
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Two different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Read full sectionTwo different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Under the CR, employees and the self-employed (informal workers above a set income threshold) pay 12.5% of their salaries to EPSs, which are then responsible for transferring the funds to FOSYGA. In turn, FOSYGA remits a UPC back to the EPS to cover the premium of the insured. The UPC initially adjusted risk based on three variables: age, gender, and geographic location. The premium and risk adjusters are modified yearly by the National Board of Health Social Security (CNSSS). By 2006 the board had introduced risk adjusters for End-Stage Renal Disease and other adjusters have been introduced since. When patients receive services, the EPS handles all payment transactions with the exception of copayments. From 2007 to 2008, CR revenues increased by 12.75%, which indicates an expansion of the CR and a move toward greater coverage. There are three primary funding mechanisms for the SR: 1) national transfers from general taxation providing for 48% of SR resources, 2) solidarity contributions from the CR that are transferred by FOSYGA providing for 40%, and 3) district and municipal efforts providing for 11% of SR funds. National transfers are pooled under the Subsidized Regime’s System of General Participation (SGP) which is responsible for allocating resources to the different districts and municipalities across the country. The solidarity contribution from the CR is transferred by FOSYGA directly to the municipalities. The municipality then transfers the UPC to an EPSS of the patient’s choosing. In 1997 there were over 200 EPSS, but by 2005 there were only 43 EPSS, of which 28% were private for profit, 16% were private not-for-profit, 14% were public, 36% were community based, and 6% were for indigenous populations. The subsidized regime UPC is approximately 60% of the contributing regime UPC, which is in line with the reduced number of services offered within the SR. As with EPSs, the EPSS is responsible for payment transactions with service providers for their members. Finally, supply-side subsidies to public hospitals/providers and public health programs are paid for by national transfers from general taxes. These funds flow into the SGP, which is then responsible for their disbursement. General System of Social Security in HealthFunding Primary Source of Funding: Payroll Tax
Secondary Source of Funding: General government revenues, Employer contributions
Contributing Populations: Formal Sector, Government Employees, Informal Sector
Types of Contributions: Premiums, Co-payments Two different funding streams for insurance currently exist within the Colombian health system. The Contributive Regime (CR) relies on wage contributions for its sustainability. The Subsidized Regime (SR), however, relies on three distinct funding mechanisms. Under the CR, employees and the self-employed (informal workers above a set income threshold) pay 12.5% of their salaries to EPSs, which are then responsible for transferring the funds to FOSYGA. In turn, FOSYGA remits a UPC back to the EPS to cover the premium of the insured. The UPC initially adjusted risk based on three variables: age, gender, and geographic location. The premium and risk adjusters are modified yearly by the National Board of Health Social Security (CNSSS). By 2006 the board had introduced risk adjusters for End-Stage Renal Disease and other adjusters have been introduced since. When patients receive services, the EPS handles all payment transactions with the exception of copayments. From 2007 to 2008, CR revenues increased by 12.75%, which indicates an expansion of the CR and a move toward greater coverage. There are three primary funding mechanisms for the SR: 1) national transfers from general taxation providing for 48% of SR resources, 2) solidarity contributions from the CR that are transferred by FOSYGA providing for 40%, and 3) district and municipal efforts providing for 11% of SR funds. National transfers are pooled under the Subsidized Regime’s System of General Participation (SGP) which is responsible for allocating resources to the different districts and municipalities across the country. The solidarity contribution from the CR is transferred by FOSYGA directly to the municipalities. The municipality then transfers the UPC to an EPSS of the patient’s choosing. In 1997 there were over 200 EPSS, but by 2005 there were only 43 EPSS, of which 28% were private for profit, 16% were private not-for-profit, 14% were public, 36% were community based, and 6% were for indigenous populations. The subsidized regime UPC is approximately 60% of the contributing regime UPC, which is in line with the reduced number of services offered within the SR. As with EPSs, the EPSS is responsible for payment transactions with service providers for their members. Finally, supply-side subsidies to public hospitals/providers and public health programs are paid for by national transfers from general taxes. These funds flow into the SGP, which is then responsible for their disbursement. |
| Nigeria: National Health Insurance System |
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The National Health Insurance Scheme (NHIS) is funded primarily by contributions from members based on income. For the Formal Sector Social Health Insurance Program contributions are premiums that make up 15% of an individual’s basic salary, with the employer contributing 10% while the employee pays 5% for coverage of themselves, their spouse, and up to 4 children. An employer may negotiate with an HMO for coverage of additional supplementary benefits and pay the extra contributions required. Participants in the Informal Sector Program are expected to make a monthly contribution based on the benefits package of their choice as well as other factors. The poor, elderly, veterans, and disabled are exempted from paying membership premiums. Read full sectionThe National Health Insurance Scheme (NHIS) is funded primarily by contributions from members based on income. For the Formal Sector Social Health Insurance Program contributions are premiums that make up 15% of an individual’s basic salary, with the employer contributing 10% while the employee pays 5% for coverage of themselves, their spouse, and up to 4 children. An employer may negotiate with an HMO for coverage of additional supplementary benefits and pay the extra contributions required. Participants in the Informal Sector Program are expected to make a monthly contribution based on the benefits package of their choice as well as other factors. The poor, elderly, veterans, and disabled are exempted from paying membership premiums. The funding structure of the Nigerian health system draws on colonial origins, when services were financed primarily by the central government. Currently, allocations from general government revenue comprise about 26.1% of overall funding, 6.1% comes from private organizations and 1.8% from development partners. Household out of pocket expenditures remain the largest source of financing, providing about 55.9% of total revenue. National Health Insurance SystemFunding Primary Source of Funding: Employer contributions
Secondary Source of Funding: General government revenues, Member contributions
Contributing Populations: Formal Sector, Informal Sector
Types of Contributions: Premiums The National Health Insurance Scheme (NHIS) is funded primarily by contributions from members based on income. For the Formal Sector Social Health Insurance Program contributions are premiums that make up 15% of an individual’s basic salary, with the employer contributing 10% while the employee pays 5% for coverage of themselves, their spouse, and up to 4 children. An employer may negotiate with an HMO for coverage of additional supplementary benefits and pay the extra contributions required. Participants in the Informal Sector Program are expected to make a monthly contribution based on the benefits package of their choice as well as other factors. The poor, elderly, veterans, and disabled are exempted from paying membership premiums. The funding structure of the Nigerian health system draws on colonial origins, when services were financed primarily by the central government. Currently, allocations from general government revenue comprise about 26.1% of overall funding, 6.1% comes from private organizations and 1.8% from development partners. Household out of pocket expenditures remain the largest source of financing, providing about 55.9% of total revenue. |
| Philippines: PhilHealth |
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Funding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). Read full sectionFunding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). However, the cost of insurance for the poor is fully subsidized by the central and local governments. Funding by population is as follows:
Both national and local governments are responsible for the full subsidy for indigents. A recent policy proposal is for the national government to fully pay the subsidy in order to accelerate the efforts towards universal coverage by enrolling the poorest. However, this proposal has not been approved and the current cost-sharing scheme remains. Currently, the local government identifies and determines who is poor, then enrolls them in the national health insurance program. Once enrolled, the national government is expected to pay its counterpart. The central government cost-sharing percentage depends on the income level of the local government, but on average local governments contribute 25% and the national government contributes 75%. All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The frequency of premium contributions varies by each population category. For example, formal sector payroll collections naturally occur monthly, while for the non-poor, premium contributions occur based on when individuals seek to enroll. For OFWs, the premium is collected upon departure from the country and then on an annual basis. For the poor subsidized by the government, enrollment occurs annually and the local government pays quarterly while the national government is billed as soon as enough local governments have enrolled their poor. National government payment is dependent on the availability of funds. Premiums for formal sector are set by law to be up to 3% of the monthly income. However, the current level is 2.5%, applied up to the first 30,000 pesos of income (i.e., all people earning up to or more than 30,000 pesos pay the same premium, while people with salaries under 30,000 pesos pay less). The premium of 1,200 pesos annually for the poor and informal sector has been the same for more than 9 years. The rate for the OFWs was 900 pesos annually until two years ago when it was increased to 1,200 pesos. PhilHealthFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: Member contributions
Contributing Populations: Formal Sector
Types of Contributions: Premiums Funding for the scheme varies based on the population covered, although the majority of funds flow from general taxation. Premiums for the formal sector are set by law to be up to 3% of monthly income. Premiums for both the poor and the informal sector are 1,200 pesos annually (about 25 USD). However, the cost of insurance for the poor is fully subsidized by the central and local governments. Funding by population is as follows:
Both national and local governments are responsible for the full subsidy for indigents. A recent policy proposal is for the national government to fully pay the subsidy in order to accelerate the efforts towards universal coverage by enrolling the poorest. However, this proposal has not been approved and the current cost-sharing scheme remains. Currently, the local government identifies and determines who is poor, then enrolls them in the national health insurance program. Once enrolled, the national government is expected to pay its counterpart. The central government cost-sharing percentage depends on the income level of the local government, but on average local governments contribute 25% and the national government contributes 75%. All premiums are pooled nationally and in effect, there is cross-subsidization across districts. The frequency of premium contributions varies by each population category. For example, formal sector payroll collections naturally occur monthly, while for the non-poor, premium contributions occur based on when individuals seek to enroll. For OFWs, the premium is collected upon departure from the country and then on an annual basis. For the poor subsidized by the government, enrollment occurs annually and the local government pays quarterly while the national government is billed as soon as enough local governments have enrolled their poor. National government payment is dependent on the availability of funds. Premiums for formal sector are set by law to be up to 3% of the monthly income. However, the current level is 2.5%, applied up to the first 30,000 pesos of income (i.e., all people earning up to or more than 30,000 pesos pay the same premium, while people with salaries under 30,000 pesos pay less). The premium of 1,200 pesos annually for the poor and informal sector has been the same for more than 9 years. The rate for the OFWs was 900 pesos annually until two years ago when it was increased to 1,200 pesos. |
| India: RSBY |
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RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Read full sectionRSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Funding from central and state governments is divided as follows:
The insurance premium is determined at the state-level based on an open tender process. Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground. RSBYFunding Primary Source of Funding: General government revenues
Secondary Source of Funding: None
Contributing Populations: Below Poverty Line
Types of Contributions: Registration Fees RSBY is funded by the central and state governments through general tax revenue. The insurance premium is determined at the state-level and varies from state to state and district to district in the range of Rs. 400 (USD8) to Rs. 600 (USD12). Beneficiaries also pay a small amount (Rs. 30, less than one US dollar) as a registration fee, which is used to cover certain administrative costs associated with scheme. Funding from central and state governments is divided as follows:
The insurance premium is determined at the state-level based on an open tender process. Indian Insurance Regulatory Development Authority (IRDA) registered insurers compete in competitive bidding; the organization that fulfils technical criteria and has the lowest premium is chosen. The state and central governments pay the agreed upon premium to the insurance company commensurate with the number of BPL families enrolled. The insurer bears all the risk of the scheme and though the state governments provide support to the insurer(s), it is the responsibility of the insurer to operationalize the scheme on the ground. |