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. |
| 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. |
| 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. |
| Thailand: Universal Coverage Scheme |
|
50 million |
The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. Read full sectionThe Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. A centralized registration database, which is updated regularly, is also a useful tool in identifying and enrolling beneficiaries in the USC scheme. The central registration database consolidates information on the entire Thai population, and includes registration information of the CSMBS, the SSS and the UCS. When patients seek care, their entitlements are checked with the centralized online database to ensure that they are enrolled in an insurance scheme. If the database shows that that are not members of the CSMBS or the SSS, they are asked to register for the UCS at that time. Universal Coverage SchemePopulation covered Target Populations: All populations
Coverage Level: 50 million The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. A centralized registration database, which is updated regularly, is also a useful tool in identifying and enrolling beneficiaries in the USC scheme. The central registration database consolidates information on the entire Thai population, and includes registration information of the CSMBS, the SSS and the UCS. When patients seek care, their entitlements are checked with the centralized online database to ensure that they are enrolled in an insurance scheme. If the database shows that that are not members of the CSMBS or the SSS, they are asked to register for the UCS at that time. |