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 | Target population | Coverage | Population covered | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Estonia: Estonian Health Insurance Fund |
|
1.28 million |
Health insurance through EHIF is mandatory. There are three main categories of enrollees:
Health insurance through EHIF is mandatory. There are three main categories of enrollees:
In order to receive services, patients must show their national identification card to providers. An online information system is used to verify that the card is valid and to provide details of insurance status and family doctor. Estonian Health Insurance FundPopulation covered Target Populations: All populations
Coverage Level: 1.28 million Health insurance through EHIF is mandatory. There are three main categories of enrollees:
In order to receive services, patients must show their national identification card to providers. An online information system is used to verify that the card is valid and to provide details of insurance status and family doctor. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
|
5.2 million |
Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Read full sectionKyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period. Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF. Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
Source: Jakab, M., and Manjieva, E. Mandatory Health Insurance Fund (MHIF)Population covered Target Populations: All populations
Coverage Level: 5.2 million Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period. Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF. Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
Source: Jakab, M., and Manjieva, E. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Mali: Mutuelles |
|
400,000 |
The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. Read full sectionThe Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. The main challenge in promoting the Mutuelle movement for large-scale enrollment thus continues to be implementing a major information and awareness campaign for Mutuelles at the national scale. This is part of the national strategy and advocacy activities that also include local and national leaders . Since the AMO is mandatory, beneficiaries are enrolled automatically by withdrawing dues from their wages. Benefit eligibility begins on May 1, 2011 for those who have paid dues for six months. With regard to identifying the indigent for RAMED, the social services in each commune routinely conduct a social survey to assess the situation after interested parties submit an application. The social services or other persons may also prepare an application on behalf of someone else who has not taken the initiative to do so for several reasons. Based on the social survey, the communal authorities issue an indigent card that serves as physical evidence to enroll the member and to obtain the card from the National Medical Assistance Agency (ANAM – the management agency for RAMED) and to obtain care (including the beneficiaries whose applications are submitted to ANAM staff). The status of indigence is always considered temporary, so that the insured member’s card is annual. MutuellesPopulation covered Target Populations: Informal Sector
Coverage Level: 400,000 The Mutuelle system is still voluntary, and thus steps must be taken to bring about large-scale enrollment of the people. Thus, the “national strategy to extend health coverage through Mutuelles” contains solutions for the slow pace at which Mutuelles grew in the past, for the poor capacities of the players involved in promoting the Mutuelle movement, the management of Mutuelle movement organizations, and the lack of information and awareness about the Mutuelle movement on the national level. It was found that the principal actors were not enlisted sufficiently at the local level in the past. Health care workers, the ASACOs, and the territorial governments were only marginally involved in promoting the Mutuelle movement. By organizing Mutuelles at the commune level, the strategy seeks to have the mayors and local elected officials play an active role in mobilizing the population. The main challenge in promoting the Mutuelle movement for large-scale enrollment thus continues to be implementing a major information and awareness campaign for Mutuelles at the national scale. This is part of the national strategy and advocacy activities that also include local and national leaders . Since the AMO is mandatory, beneficiaries are enrolled automatically by withdrawing dues from their wages. Benefit eligibility begins on May 1, 2011 for those who have paid dues for six months. With regard to identifying the indigent for RAMED, the social services in each commune routinely conduct a social survey to assess the situation after interested parties submit an application. The social services or other persons may also prepare an application on behalf of someone else who has not taken the initiative to do so for several reasons. Based on the social survey, the communal authorities issue an indigent card that serves as physical evidence to enroll the member and to obtain the card from the National Medical Assistance Agency (ANAM – the management agency for RAMED) and to obtain care (including the beneficiaries whose applications are submitted to ANAM staff). The status of indigence is always considered temporary, so that the insured member’s card is annual. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Korea, Rep.: National Health Insurance Program |
|
50 million |
All South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Read full sectionAll South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Those in the self-employed insured category include about 41% of the total insured population.
National Health Insurance ProgramPopulation covered Target Populations: All populations
Coverage Level: 50 million All South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Those in the self-employed insured category include about 41% of the total insured population.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ghana: National Health Insurance Scheme (NHIS) |
|
12 million |
Each Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. Read full sectionEach Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. The DWMHI schemes have their own management structures and have a certain level of autonomy in the setting of premiums and the charging of other costs, although these have to be kept within the limits established by the NHIA. As one of the reasons for the NHIS’s existence is to stop out-of-pocket healthcare payments, there are no deductibles, and no copayments have to be made by NHIS members when accessing healthcare. As one of the reasons for the NHIS's existence is to stop out-of-pocket healthcare payments, there are no deductibles and no copayments. Enrollment: Contributions to SSNIT are automatic for members of DWMHI schemes because of the health insurance deductions made from their SSNIT contributions, and are only required to pay an initial registration fee. The premium structure therefore applies only to those who work in the informal economy or who are not SSNIT contributors. These members pay their premiums to the DWMHI schemes directly. The schemes employ collectors who move between houses and market stalls to receive premium payments. Alternatively, premiums can be paid to banks, or to designated pharmacies or ‘chemical shops.’ Premiums can be paid at any time during the year – there is no set registration period. Exemptions: Exemptions from premium payments exist for SSNIT contributors, SSNIT pensioners, those over the age of 70, and for those classed as indigent. Indigents are classified as those people who:
Currently all children under the age under 18 are exempted from NHIS premium payments irrespective of the NHIS membership status of their parents. If parents are NHIS members, then children are covered for free. However, if parents are not NHIS members, children cannot access benefits. National Health Insurance Scheme (NHIS)Population covered Target Populations: All populations
Coverage Level: 12 million Each Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. The DWMHI schemes have their own management structures and have a certain level of autonomy in the setting of premiums and the charging of other costs, although these have to be kept within the limits established by the NHIA. As one of the reasons for the NHIS’s existence is to stop out-of-pocket healthcare payments, there are no deductibles, and no copayments have to be made by NHIS members when accessing healthcare. As one of the reasons for the NHIS's existence is to stop out-of-pocket healthcare payments, there are no deductibles and no copayments. Enrollment: Contributions to SSNIT are automatic for members of DWMHI schemes because of the health insurance deductions made from their SSNIT contributions, and are only required to pay an initial registration fee. The premium structure therefore applies only to those who work in the informal economy or who are not SSNIT contributors. These members pay their premiums to the DWMHI schemes directly. The schemes employ collectors who move between houses and market stalls to receive premium payments. Alternatively, premiums can be paid to banks, or to designated pharmacies or ‘chemical shops.’ Premiums can be paid at any time during the year – there is no set registration period. Exemptions: Exemptions from premium payments exist for SSNIT contributors, SSNIT pensioners, those over the age of 70, and for those classed as indigent. Indigents are classified as those people who:
Currently all children under the age under 18 are exempted from NHIS premium payments irrespective of the NHIS membership status of their parents. If parents are NHIS members, then children are covered for free. However, if parents are not NHIS members, children cannot access benefits. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Nigeria: National Health Insurance System |
|
5 million |
Health insurance is obtained either through private insurers or the National Health Insurance Scheme (NHIS). About 5 million people are enrolled in the 3 NHIS Programs, which represents just about 3% of the population. In the Formal Sector Program, employees in the formal sector who pay premiums are covered, in addition to their spouse and up to 4 dependants. Companies that employ more than 10 workers are responsible for enrollment of their employees. Read full sectionHealth insurance is obtained either through private insurers or the National Health Insurance Scheme (NHIS). About 5 million people are enrolled in the 3 NHIS Programs, which represents just about 3% of the population. In the Formal Sector Program, employees in the formal sector who pay premiums are covered, in addition to their spouse and up to 4 dependants. Companies that employ more than 10 workers are responsible for enrollment of their employees. In the Informal Sector Program, the self-employed and individuals living in rural communities enroll themselves. The self-employed must join with at least 500 other members who are occupation based (ie: taxi drivers) to qualify. Rural dwellers have a similar modus operandi, but participants need to belong to the same community rather than the same occupational group. These Social Health Insurance Schemes are self-governed, with elections held to determine who will represent the community. In order to stay enrolled, members are expected to make a monthly contribution actuarially determined based on the benefits package of their choice. Participants requiring specialist or longer treatment would need to pay for the balance from what they are entitled from the common pool. These schemes are expected to cover more than 60% of the rural and self-employed population, though due to poor data collection, the exact population enrolled is difficult to determine. The enrollment levels in private insurance is uncertain, but based on submissions from private insurers to NHIS, less than 1 million people are privately insured. The NHIS utilizes 61 Health Maintenance Organizations (HMOs) as health managers for paying healthcare providers, quality assurance, and registration of enrollees and sensitization of participants as part of improving transparency of the system. HMOs contract with the NHIS to manage the enrollment of individuals in health insurance schemes; to collect their payments; pay the healthcare providers; and to provide basic quality management of the health insurance scheme that covers formal employees. National Health Insurance SystemPopulation covered Target Populations: All populations
Coverage Level: 5 million Health insurance is obtained either through private insurers or the National Health Insurance Scheme (NHIS). About 5 million people are enrolled in the 3 NHIS Programs, which represents just about 3% of the population. In the Formal Sector Program, employees in the formal sector who pay premiums are covered, in addition to their spouse and up to 4 dependants. Companies that employ more than 10 workers are responsible for enrollment of their employees. In the Informal Sector Program, the self-employed and individuals living in rural communities enroll themselves. The self-employed must join with at least 500 other members who are occupation based (ie: taxi drivers) to qualify. Rural dwellers have a similar modus operandi, but participants need to belong to the same community rather than the same occupational group. These Social Health Insurance Schemes are self-governed, with elections held to determine who will represent the community. In order to stay enrolled, members are expected to make a monthly contribution actuarially determined based on the benefits package of their choice. Participants requiring specialist or longer treatment would need to pay for the balance from what they are entitled from the common pool. These schemes are expected to cover more than 60% of the rural and self-employed population, though due to poor data collection, the exact population enrolled is difficult to determine. The enrollment levels in private insurance is uncertain, but based on submissions from private insurers to NHIS, less than 1 million people are privately insured. The NHIS utilizes 61 Health Maintenance Organizations (HMOs) as health managers for paying healthcare providers, quality assurance, and registration of enrollees and sensitization of participants as part of improving transparency of the system. HMOs contract with the NHIS to manage the enrollment of individuals in health insurance schemes; to collect their payments; pay the healthcare providers; and to provide basic quality management of the health insurance scheme that covers formal employees. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kenya: National Hospital Insurance Fund |
|
2.7 million |
To be a member of the National Hospital Insurance Fund (NHIF), one must simply be a Kenyan resident age 18 or older. NHIF covers certain dependents of the primary policy holder automatically, including spouses, children under the age of 18, students (even if over the age of 18), and disabled dependents. Other adult family members require separate premium contributions to be covered. NHIF is responsible for enrolling and registering all eligible members from the formal and informal sectors. Read full sectionTo be a member of the National Hospital Insurance Fund (NHIF), one must simply be a Kenyan resident age 18 or older. NHIF covers certain dependents of the primary policy holder automatically, including spouses, children under the age of 18, students (even if over the age of 18), and disabled dependents. Other adult family members require separate premium contributions to be covered. NHIF is responsible for enrolling and registering all eligible members from the formal and informal sectors. Total membership in NHIF rose from about 206,000 in 1998 to 1,372,000 in 2006. By 2011 about 2.7 million people were insured by NHIF, 2.1 million of which are employed in the formal sector. Approximately 88% of the people with insurance in Kenya are insured by the NHIF. However, currently only about 25% of the poor have medical coverage. Recently, NHIF has embarked on a program to work with community-based organizations to expand informal sector membership. National Hospital Insurance FundPopulation covered Target Populations: All populations
Coverage Level: 2.7 million To be a member of the National Hospital Insurance Fund (NHIF), one must simply be a Kenyan resident age 18 or older. NHIF covers certain dependents of the primary policy holder automatically, including spouses, children under the age of 18, students (even if over the age of 18), and disabled dependents. Other adult family members require separate premium contributions to be covered. NHIF is responsible for enrolling and registering all eligible members from the formal and informal sectors. Total membership in NHIF rose from about 206,000 in 1998 to 1,372,000 in 2006. By 2011 about 2.7 million people were insured by NHIF, 2.1 million of which are employed in the formal sector. Approximately 88% of the people with insurance in Kenya are insured by the NHIF. However, currently only about 25% of the poor have medical coverage. Recently, NHIF has embarked on a program to work with community-based organizations to expand informal sector membership. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Brazil: Unified Health System (SUS) |
|
143 million |
Brazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. Read full sectionBrazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. The Brazilian Supplementary Health System (SHS) served 33 million Brazilians in 2002, or 19% of the population. By 2007, it accounted for more than 50% of health care expenditure, yet it served less than 30% of the population. Health care operators within the SHS are grouped into categories by the Agency for Supplementary Health within the MOH, depending on their economic and financial status. Ordered by market share in 2002, these categories are group medicine, medical cooperatives, health insurance, charity, self-management, group dentistry, and dentistry cooperatives. Most of these plans are connected to employment. The majority of these plans tend to be small or medium in size and operate mostly through contractual arrangements with doctors’ offices and hospitals. In 2002, group medicine, medical cooperatives and health insurance served around 80% of supplementary users and accounted for 90% of billing. Initially, private prepayment plans had an incentive not to provide comprehensive coverage to enrollees, as high-cost procedures were usually funneled to the SUS for treatment. However, in 1999, the government instituted a norm that allows it to recover the costs associated with services rendered by the SUS to beneficiaries of private health plans. This norm is implemented through the National Supplementary Health Council (CNSS). Unified Health System (SUS)Population covered Target Populations: All populations
Coverage Level: 143 million Brazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. The Brazilian Supplementary Health System (SHS) served 33 million Brazilians in 2002, or 19% of the population. By 2007, it accounted for more than 50% of health care expenditure, yet it served less than 30% of the population. Health care operators within the SHS are grouped into categories by the Agency for Supplementary Health within the MOH, depending on their economic and financial status. Ordered by market share in 2002, these categories are group medicine, medical cooperatives, health insurance, charity, self-management, group dentistry, and dentistry cooperatives. Most of these plans are connected to employment. The majority of these plans tend to be small or medium in size and operate mostly through contractual arrangements with doctors’ offices and hospitals. In 2002, group medicine, medical cooperatives and health insurance served around 80% of supplementary users and accounted for 90% of billing. Initially, private prepayment plans had an incentive not to provide comprehensive coverage to enrollees, as high-cost procedures were usually funneled to the SUS for treatment. However, in 1999, the government instituted a norm that allows it to recover the costs associated with services rendered by the SUS to beneficiaries of private health plans. This norm is implemented through the National Supplementary Health Council (CNSS). |
