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.
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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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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. |
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| Ghana: National Health Insurance Scheme (NHIS) |
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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. |
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| Kenya: National Hospital Insurance Fund |
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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. |
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| India: Rajiv Aarogyasri |
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65 million people |
Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept. Read full sectionAarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept. Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The state already had a mechanism for defining, identifying, and enrolling below-the-poverty-line families. Each eligible family is issued a “White Card” (a ration card) to identify them as below-the-poverty line. Aarogyasri uses the “White Card” as a targeting mechanism for its scheme. Families in the state who already have “White Cards” are provided with Rajiv Aarogyasri Bhima Health Cards. Everyone in a household can be included in the Rajiv Aarogyasri Health Card. This means the head of the family, spouse, dependent children, and dependent parents. The Health Card captures the family’s data and pictures of each family member. It is presented by beneficiaries when they arrive at a health facility to identify them. The card is also used to store patient visit records and transmit utilization information. Once enrolled, beneficiaries are guided through the process of seeking care. In order to ensure that beneficiaries know what benefits they are entitled to, and are able to navigate the system of care, Aarogyasri has developed a team of 4,000 Aarogya Mithras. Aarogya Mithras are health workers representing the community of the insured. One Aarogya Mithra sits in each primary health center across the state. These health centers are most often the first points of contact for most families seeking care. In addition, district hospitals and network hospitals also have help desks manned by Aarogya Mithras to facilitate smooth service delivery for Aarogyasri beneficiaries. Aarogya Mithras help to guide beneficiaries through the network of care and inform them about their insurance benefits. In addition to contacts with Aarogya Mithras, beneficiaries can visit health screening camps that are set up by network providers in rural areas. Under the scheme, all network hospitals are required to undertake a specified number of village health camps in order to maintain their network status. Beneficiaries and potential beneficiaries attend the health camps to be screened for diseases and are provided with preventive care. Those that can be treated at the camp are treated; those that require further treatment are referred to network hospitals where their ailment will be treated free of cost under their Aarogyasri benefits. As of November 2009, there have been more than 15,000 camps and nearly 2.5 million people have been screened. Rajiv AarogyasriPopulation covered Target Populations: Below Poverty Line
Coverage Level: 65 million people Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept. Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The state already had a mechanism for defining, identifying, and enrolling below-the-poverty-line families. Each eligible family is issued a “White Card” (a ration card) to identify them as below-the-poverty line. Aarogyasri uses the “White Card” as a targeting mechanism for its scheme. Families in the state who already have “White Cards” are provided with Rajiv Aarogyasri Bhima Health Cards. Everyone in a household can be included in the Rajiv Aarogyasri Health Card. This means the head of the family, spouse, dependent children, and dependent parents. The Health Card captures the family’s data and pictures of each family member. It is presented by beneficiaries when they arrive at a health facility to identify them. The card is also used to store patient visit records and transmit utilization information. Once enrolled, beneficiaries are guided through the process of seeking care. In order to ensure that beneficiaries know what benefits they are entitled to, and are able to navigate the system of care, Aarogyasri has developed a team of 4,000 Aarogya Mithras. Aarogya Mithras are health workers representing the community of the insured. One Aarogya Mithra sits in each primary health center across the state. These health centers are most often the first points of contact for most families seeking care. In addition, district hospitals and network hospitals also have help desks manned by Aarogya Mithras to facilitate smooth service delivery for Aarogyasri beneficiaries. Aarogya Mithras help to guide beneficiaries through the network of care and inform them about their insurance benefits. In addition to contacts with Aarogya Mithras, beneficiaries can visit health screening camps that are set up by network providers in rural areas. Under the scheme, all network hospitals are required to undertake a specified number of village health camps in order to maintain their network status. Beneficiaries and potential beneficiaries attend the health camps to be screened for diseases and are provided with preventive care. Those that can be treated at the camp are treated; those that require further treatment are referred to network hospitals where their ailment will be treated free of cost under their Aarogyasri benefits. As of November 2009, there have been more than 15,000 camps and nearly 2.5 million people have been screened. |
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| India: RSBY |
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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. |