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. |
| Colombia: General System of Social Security in Health |
|
40,835,265 |
In both the CR and the SR individuals choose their insurer as well as the provider within the insurer’s network. Enrollment mechanisms between the two systems, however, are quite distinct. While anyone is free to enroll in the CR, it is mandatory for formal sector workers and self-employed workers who earn one minimum salary per month. The CR enrolled 13,335,932 persons in 2001 and 17,234,265 persons in 2008. Read full sectionIn both the CR and the SR individuals choose their insurer as well as the provider within the insurer’s network. Enrollment mechanisms between the two systems, however, are quite distinct. While anyone is free to enroll in the CR, it is mandatory for formal sector workers and self-employed workers who earn one minimum salary per month. The CR enrolled 13,335,932 persons in 2001 and 17,234,265 persons in 2008. Between 1993, when the reform was passed, and 2002, there arose the need to implement monitoring and supervision mechanisms to enforce the enrollment of self-employed workers in the CR. This has largely been achieved through two distinct methods. First, law 797 of 2003 linked pension and health insurance contributions. This affected enrollee evasion, as individuals wishing to have a pension must also have health insurance. It also affected contribution evasion, since the income level used to calculate pension contributions is also used to calculate CR contributions. Second, decree 1703 of 2002 instituted sanctions on employers if they did not ensure that self-employed workers (e.g. consultants) participated in the CR. Finally, between 2006and 2007 the Integrated Payroll Contributions Settlement system was instituted, obliging all companies and the self-employed to settle their social security payments through electronic fund transfers. While the expansion of the SR was taking place, a unique and innovative enrollment qualification criteria was used designed to give priority to targeted groups based on income level and degree of vulnerability/likely need for care, while taking into consideration the available funds. Priority was given to special populations such as orphans and the elderly, regardless of SISBEN score, which is the proxy-means test used to identify the most vulnerable members of a community. Preference was then assigned to the poor who were either pregnant, under the age of 5, displaced by violence, or disabled. The rest of the population was ordered by SISBEN score, with a score of 1 representing the most destitute and a score of 5 representing the least destitute. Once the ranked list was published, individuals signed up with an EPSS of their choice. If an individual did not sign up, he or she had to wait until the next round of affiliations to do so. Enrollment of those who were eligible was ongoing as additional funds become available. Also, after all level 1 and 2 individuals were covered, municipalities that had resources left over could begin to cover level 3 individuals. This process was slightly altered by Accord number 415 of 2009, which states that the non-affiliated, eligible population can sign up with the SR at any point during the year. In 2002 the SR enrolled 11,444,003 persons. By 2009, this number had risen to 23,804,788. An important issue is the monitoring of fraud within the SR. Starting in 2000, the government began monitoring and updating the subsidized scheme databases. This led to the expulsion of many fraudulent enrollees. By 2005, a complete database of SR enrollees had been set up and included their names, identification numbers, and the name of their EPSS. This database was completed in 2009. Beginning in 2004, there was an expansion of partial subsidies to SISBEN level 3 individuals. The UPC for this plan equals approximately 42% of the CR UPC. While this plan expands coverage to those who remain uninsured, it offers a smaller benefits package. As of March 2009 there are 1,115,789 individuals covered by partial subsidies. Lack of automatic mobility between the SR and CR upon a change in labor standing among the poor is thought to be a disincentive for Colombians to move into formal employment. The fear existed primarily among subsidized regime enrollees who would not be able to easily rejoin the SR if they lost their formal sector employment. To deal with this concern, in 2005 the government stated that a person can be reinstated into the SR within the year in case of subsequent eligibility changes. Furthermore, at the end of the year the process of re-enrolling in the SR will be quicker and easier. This change should lead to expansions in the formal workforce and higher levels of CR enrollment as more people are willing to leave the SR. Population coverage has increased significantly since the 1993 reform, with a substantial part of the growth taking place after 2002. In 1990, 15.7% of the population had health insurance coverage. By 2008 the percentage of those covered had risen to 89.36%. This is a 570% increase in coverage over an 18 year span. The populations that were most affected by the reform were the bottom 2 income quintiles. Figure II shows that coverage for quintile 1 increased by 540% while quintile 2 increased by 250% between 1992 and 2003. Figure 2 also shows that there was a drop in coverage between 1997 and 2000, with an eventual recovery in 2003. This effect was primarily caused by a severe macroeconomic recession between 1998 and 2000. The recession not only reduced formal employment, affecting enrollment in the CR as well as the solidarity contribution to the SR, but it also reduced general tax transfers to the SR. With the recession ended and renewed political support for health coverage, the growth trend continued its upward movement. General System of Social Security in HealthPopulation covered Target Populations: All populations
Coverage Level: 40,835,265 In both the CR and the SR individuals choose their insurer as well as the provider within the insurer’s network. Enrollment mechanisms between the two systems, however, are quite distinct. While anyone is free to enroll in the CR, it is mandatory for formal sector workers and self-employed workers who earn one minimum salary per month. The CR enrolled 13,335,932 persons in 2001 and 17,234,265 persons in 2008. Between 1993, when the reform was passed, and 2002, there arose the need to implement monitoring and supervision mechanisms to enforce the enrollment of self-employed workers in the CR. This has largely been achieved through two distinct methods. First, law 797 of 2003 linked pension and health insurance contributions. This affected enrollee evasion, as individuals wishing to have a pension must also have health insurance. It also affected contribution evasion, since the income level used to calculate pension contributions is also used to calculate CR contributions. Second, decree 1703 of 2002 instituted sanctions on employers if they did not ensure that self-employed workers (e.g. consultants) participated in the CR. Finally, between 2006and 2007 the Integrated Payroll Contributions Settlement system was instituted, obliging all companies and the self-employed to settle their social security payments through electronic fund transfers. While the expansion of the SR was taking place, a unique and innovative enrollment qualification criteria was used designed to give priority to targeted groups based on income level and degree of vulnerability/likely need for care, while taking into consideration the available funds. Priority was given to special populations such as orphans and the elderly, regardless of SISBEN score, which is the proxy-means test used to identify the most vulnerable members of a community. Preference was then assigned to the poor who were either pregnant, under the age of 5, displaced by violence, or disabled. The rest of the population was ordered by SISBEN score, with a score of 1 representing the most destitute and a score of 5 representing the least destitute. Once the ranked list was published, individuals signed up with an EPSS of their choice. If an individual did not sign up, he or she had to wait until the next round of affiliations to do so. Enrollment of those who were eligible was ongoing as additional funds become available. Also, after all level 1 and 2 individuals were covered, municipalities that had resources left over could begin to cover level 3 individuals. This process was slightly altered by Accord number 415 of 2009, which states that the non-affiliated, eligible population can sign up with the SR at any point during the year. In 2002 the SR enrolled 11,444,003 persons. By 2009, this number had risen to 23,804,788. An important issue is the monitoring of fraud within the SR. Starting in 2000, the government began monitoring and updating the subsidized scheme databases. This led to the expulsion of many fraudulent enrollees. By 2005, a complete database of SR enrollees had been set up and included their names, identification numbers, and the name of their EPSS. This database was completed in 2009. Beginning in 2004, there was an expansion of partial subsidies to SISBEN level 3 individuals. The UPC for this plan equals approximately 42% of the CR UPC. While this plan expands coverage to those who remain uninsured, it offers a smaller benefits package. As of March 2009 there are 1,115,789 individuals covered by partial subsidies. Lack of automatic mobility between the SR and CR upon a change in labor standing among the poor is thought to be a disincentive for Colombians to move into formal employment. The fear existed primarily among subsidized regime enrollees who would not be able to easily rejoin the SR if they lost their formal sector employment. To deal with this concern, in 2005 the government stated that a person can be reinstated into the SR within the year in case of subsequent eligibility changes. Furthermore, at the end of the year the process of re-enrolling in the SR will be quicker and easier. This change should lead to expansions in the formal workforce and higher levels of CR enrollment as more people are willing to leave the SR. Population coverage has increased significantly since the 1993 reform, with a substantial part of the growth taking place after 2002. In 1990, 15.7% of the population had health insurance coverage. By 2008 the percentage of those covered had risen to 89.36%. This is a 570% increase in coverage over an 18 year span. The populations that were most affected by the reform were the bottom 2 income quintiles. Figure II shows that coverage for quintile 1 increased by 540% while quintile 2 increased by 250% between 1992 and 2003. Figure 2 also shows that there was a drop in coverage between 1997 and 2000, with an eventual recovery in 2003. This effect was primarily caused by a severe macroeconomic recession between 1998 and 2000. The recession not only reduced formal employment, affecting enrollment in the CR as well as the solidarity contribution to the SR, but it also reduced general tax transfers to the SR. With the recession ended and renewed political support for health coverage, the growth trend continued its upward movement. |
| 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. |
| : Taiwan: National Health Insurance |
|
23 million |
Participation in the National Health Insurance (NHI) system is mandatory to ensure adequate risk pooling and the efficient broad-based collection of funds. Since NHI was implemented in March 1995, enrollment increased to 92% by the end of 1995, and 97% by 2001. The Bureau of National Health Insurance (BNHI) collects premiums and enrolls new members. BNHI provides each participant in the program with a smart card that contains their basic medical data. Read full sectionParticipation in the National Health Insurance (NHI) system is mandatory to ensure adequate risk pooling and the efficient broad-based collection of funds. Since NHI was implemented in March 1995, enrollment increased to 92% by the end of 1995, and 97% by 2001. The Bureau of National Health Insurance (BNHI) collects premiums and enrolls new members. BNHI provides each participant in the program with a smart card that contains their basic medical data. They can use this card at any clinic or hospital in the country, with a small co-pay. The smart card is a valuable tool for maintaining data on patients, and reducing insurance fraud, overcharges, and duplication of medical services. National Health InsurancePopulation covered Target Populations: All populations
Coverage Level: 23 million Participation in the National Health Insurance (NHI) system is mandatory to ensure adequate risk pooling and the efficient broad-based collection of funds. Since NHI was implemented in March 1995, enrollment increased to 92% by the end of 1995, and 97% by 2001. The Bureau of National Health Insurance (BNHI) collects premiums and enrolls new members. BNHI provides each participant in the program with a smart card that contains their basic medical data. They can use this card at any clinic or hospital in the country, with a small co-pay. The smart card is a valuable tool for maintaining data on patients, and reducing insurance fraud, overcharges, and duplication of medical services. |
| India: RSBY |
|
40 million |
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. Read full sectionRSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district. To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance. Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital. The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes. Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp. At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled. The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint. Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population. RSBYPopulation covered Target Populations: Below Poverty Line
Coverage Level: 40 million RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district. To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance. Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital. The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes. Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp. At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled. The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint. Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population. |