Compare: Population covered

Joint Learning Network for Universal Health Coverage

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
Colombia: General System of Social Security in Health
  • All populations
 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 section

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.

General System of Social Security in Health

Population 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.
Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF)
  • All populations
 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 section

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

Population groupYearSource of financingServices provided (depth of coverage)
Formal sector employees, except civil servants19972% from the wage bill administered by the Social Fund (SF)Drugs at hospital level, salary bonuses
1998Emergency care at the primary level
2000Additional/outpatient drug package
Civil servants19982% from the wage bill administered by the SFDrugs at hospital level, salary bonuses
2000Additional/outpatient drug package
Pensioners1997Value of 1.5x minimum salary administered by the SF (Pension Fund)Drugs at hospital level, salary bonuses
1998Emergency care at primary level
2000Additional/outpatient drug package
2003Republican budgetCoverage unchanged
Registered unemployed1997Value of 1.5x minimum salary administered by SF (Unemployment Fund)Drugs at hospital level, salary bonuses
1998Republican budgetEmergency care at primary level
2000Additional/outpatient drug package
2002Effectively not covered: no funding provided this group by Republican budget
Children and students under 212000Value of 1.5x minimum salaryDrugs at hospital level, salary bonuses
Republican budgetEmergency care at the primary level
Additional/outpatient drug package
Welfare benefits recipients2000Value of 1.5 minimum salaryDrugs at hospital level, salary bonuses
Republican budgetEmergency care at the primary level
Additional/outpatient drug package
Farmers19972% of the land tax administered by SF (5% in 2000, 6% in 2003)Drugs at hospital level, salary bonuses
Emergency care at primary level
2002Health insurance policies (400 KGS = US $10/year) administered by MHIFCoverage unchanged
Self-employed19982% of the value of 3x minimum salaryDrugs at hospital level, salary bonuses
Emergency care at primary level
2000Additional/outpatient drug package
2002Health insurance policies (400 KGS = US$10/year) administered by the MHIFCoverage unchanged

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

Population groupYearSource of financingServices provided (depth of coverage)
Formal sector employees, except civil servants19972% from the wage bill administered by the Social Fund (SF)Drugs at hospital level, salary bonuses
1998Emergency care at the primary level
2000Additional/outpatient drug package
Civil servants19982% from the wage bill administered by the SFDrugs at hospital level, salary bonuses
2000Additional/outpatient drug package
Pensioners1997Value of 1.5x minimum salary administered by the SF (Pension Fund)Drugs at hospital level, salary bonuses
1998Emergency care at primary level
2000Additional/outpatient drug package
2003Republican budgetCoverage unchanged
Registered unemployed1997Value of 1.5x minimum salary administered by SF (Unemployment Fund)Drugs at hospital level, salary bonuses
1998Republican budgetEmergency care at primary level
2000Additional/outpatient drug package
2002Effectively not covered: no funding provided this group by Republican budget
Children and students under 212000Value of 1.5x minimum salaryDrugs at hospital level, salary bonuses
Republican budgetEmergency care at the primary level
Additional/outpatient drug package
Welfare benefits recipients2000Value of 1.5 minimum salaryDrugs at hospital level, salary bonuses
Republican budgetEmergency care at the primary level
Additional/outpatient drug package
Farmers19972% of the land tax administered by SF (5% in 2000, 6% in 2003)Drugs at hospital level, salary bonuses
Emergency care at primary level
2002Health insurance policies (400 KGS = US $10/year) administered by MHIFCoverage unchanged
Self-employed19982% of the value of 3x minimum salaryDrugs at hospital level, salary bonuses
Emergency care at primary level
2000Additional/outpatient drug package
2002Health insurance policies (400 KGS = US$10/year) administered by the MHIFCoverage unchanged

Source: Jakab, M., and Manjieva, E.
Chile: National Health Fund (FONASA)
  • All populations
 11 million

Enrollment into FONASA or ISAPREs tends to be tied to income, with lower income individuals joining FONASA and higher income individuals enrolling in an ISAPRE. In 2003, the mean income of ISAPRE members was four times higher than that of FONASA members. Formal sector workers must enroll by allocating 7% of their monthly income or pension (2,000USD monthly maximum) to healthcare. Those who do not work in the formal sector have the option to enroll by allocating 7% of their monthly income, but are not required to do so. These groups can enroll with either FONASA or an ISAPRE of their choice. The indigent and the unemployed are entitled to free coverage by FONASA.

Read full section

Enrollment into FONASA or ISAPREs tends to be tied to income, with lower income individuals joining FONASA and higher income individuals enrolling in an ISAPRE. In 2003, the mean income of ISAPRE members was four times higher than that of FONASA members. Formal sector workers must enroll by allocating 7% of their monthly income or pension (2,000USD monthly maximum) to healthcare. Those who do not work in the formal sector have the option to enroll by allocating 7% of their monthly income, but are not required to do so. These groups can enroll with either FONASA or an ISAPRE of their choice. The indigent and the unemployed are entitled to free coverage by FONASA.

FONASA divides its beneficiary population into four categories based on income. Category A is composed of the indigent, category B is composed of the very low income population, category C is composed of the lower-middle income population, and category D is composed of the higher-middle income population. Copayment rates are based on these categories.

In 2005, FONASA enrollees numbered 11,329,481, about 70% of the population. ISAPRE enrollees accounted for 2,660,338 during the same year, equaling 17% of the population. In 2006 there were 15 ISAPREs, but over two thirds of members belonged to the three largest: Banmedica, Consalud, and ING Salud. Open ISAPREs are available to the population at large, while closed ISAPREs are only available to particular groups of individuals such as professional associations.

Table 1: Individuals covered per category

InsurerIndividuals coveredPopulation covered (%)
FONASA11,329,48169.65
Open ISAPREs2,521,44415.50
Closed ISAPREs138,8940.85
Uninsured1,701,64810.46
Others575,7713.54
Total population16,267,278100.00

Source: Bitran, R., Urcullo, G., 106

National Health Fund (FONASA)

Population covered

Target Populations: All populations
Coverage Level: 11 million

Enrollment into FONASA or ISAPREs tends to be tied to income, with lower income individuals joining FONASA and higher income individuals enrolling in an ISAPRE. In 2003, the mean income of ISAPRE members was four times higher than that of FONASA members. Formal sector workers must enroll by allocating 7% of their monthly income or pension (2,000USD monthly maximum) to healthcare. Those who do not work in the formal sector have the option to enroll by allocating 7% of their monthly income, but are not required to do so. These groups can enroll with either FONASA or an ISAPRE of their choice. The indigent and the unemployed are entitled to free coverage by FONASA.

FONASA divides its beneficiary population into four categories based on income. Category A is composed of the indigent, category B is composed of the very low income population, category C is composed of the lower-middle income population, and category D is composed of the higher-middle income population. Copayment rates are based on these categories.

In 2005, FONASA enrollees numbered 11,329,481, about 70% of the population. ISAPRE enrollees accounted for 2,660,338 during the same year, equaling 17% of the population. In 2006 there were 15 ISAPREs, but over two thirds of members belonged to the three largest: Banmedica, Consalud, and ING Salud. Open ISAPREs are available to the population at large, while closed ISAPREs are only available to particular groups of individuals such as professional associations.

Table 1: Individuals covered per category

InsurerIndividuals coveredPopulation covered (%)
FONASA11,329,48169.65
Open ISAPREs2,521,44415.50
Closed ISAPREs138,8940.85
Uninsured1,701,64810.46
Others575,7713.54
Total population16,267,278100.00

Source: Bitran, R., Urcullo, G., 106
Nigeria: National Health Insurance System
  • All populations
 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 section

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.

National Health Insurance System

Population 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.
Philippines: PhilHealth
  • All populations
 75 million

PhilHealth coverage is theoretically available to the entire population. The enrollment process differs based on the population group. For example, all formal sector workers must enroll at the start of employment.

Read full section

PhilHealth coverage is theoretically available to the entire population. The enrollment process differs based on the population group. For example, all formal sector workers must enroll at the start of employment. The poor are identified and enrolled by the local government.

The population is tagged to one of the four major population categorizations:

  • Formal sector
  • Indigents that are financed by central and local governments
  • Retirees (non-paying members) who have already paid 120 months of membership
  • The individual paying program (IPP) for those not eligible for the other three categories

The benefits package is essentially the same for each population group. The exception is for indigents and the Overseas Filipino Workers (OFW) who have additional outpatient primary care benefits (with the providers paid by capitation) however these benefits are available only through public providers.

However, the enrollment process for each population category differs. For the formal sector, employees are enrolled upon the start of employment. It is mandatory that all employees enroll in health insurance. No exceptions are allowed for the size of the company. For the poor, the local government determines “poorness” and enrolls those who are determined poor. For the rest of the population there is open enrollment—one can walk into a local enrollment office anytime to enroll.

While enrollment is mandatory only for the formal sector, for the remainder of the population, it is “construed” as voluntary although the law can be interpreted as being mandatory. There is an ongoing debate on the issue of mandated versus voluntary enrollment.

Enrollment in PhilHealth is by family so the premium paid covers the member, the spouse, eligible children (those less than 21 years of age), and eligible parents (those 60 years and above and who depend financially on the member). Given that enrollment is by family, documentation of proof of marriage and birth(s) are required before spouses and children are enrolled. This is a problem for indigenous population as they usually do not have marriage and birth certificates.

While the country has achieved significant strides in moving towards universal enrollment, covering the poor and informal sectors remains a challenge, with methods to enroll these populations through organized groups gaining very little traction. There is much ongoing discussion regarding the need for the central government to finance and/or subsidize the enrollment of the nation’s entire poor population. Leaving financial responsibility for insuring the poorest to local governments, coupled with a refusal to outright declare insurance as mandatory for all populations, makes it nearly impossible for the government to reach universal health coverage. It also forces PhilHealth to invest heavily in marketing campaigns for the program to local governments.

PhilHealth

Population covered

Target Populations: All populations
Coverage Level: 75 million

PhilHealth coverage is theoretically available to the entire population. The enrollment process differs based on the population group. For example, all formal sector workers must enroll at the start of employment. The poor are identified and enrolled by the local government.

The population is tagged to one of the four major population categorizations:

  • Formal sector
  • Indigents that are financed by central and local governments
  • Retirees (non-paying members) who have already paid 120 months of membership
  • The individual paying program (IPP) for those not eligible for the other three categories

The benefits package is essentially the same for each population group. The exception is for indigents and the Overseas Filipino Workers (OFW) who have additional outpatient primary care benefits (with the providers paid by capitation) however these benefits are available only through public providers.

However, the enrollment process for each population category differs. For the formal sector, employees are enrolled upon the start of employment. It is mandatory that all employees enroll in health insurance. No exceptions are allowed for the size of the company. For the poor, the local government determines “poorness” and enrolls those who are determined poor. For the rest of the population there is open enrollment—one can walk into a local enrollment office anytime to enroll.

While enrollment is mandatory only for the formal sector, for the remainder of the population, it is “construed” as voluntary although the law can be interpreted as being mandatory. There is an ongoing debate on the issue of mandated versus voluntary enrollment.

Enrollment in PhilHealth is by family so the premium paid covers the member, the spouse, eligible children (those less than 21 years of age), and eligible parents (those 60 years and above and who depend financially on the member). Given that enrollment is by family, documentation of proof of marriage and birth(s) are required before spouses and children are enrolled. This is a problem for indigenous population as they usually do not have marriage and birth certificates.

While the country has achieved significant strides in moving towards universal enrollment, covering the poor and informal sectors remains a challenge, with methods to enroll these populations through organized groups gaining very little traction. There is much ongoing discussion regarding the need for the central government to finance and/or subsidize the enrollment of the nation’s entire poor population. Leaving financial responsibility for insuring the poorest to local governments, coupled with a refusal to outright declare insurance as mandatory for all populations, makes it nearly impossible for the government to reach universal health coverage. It also forces PhilHealth to invest heavily in marketing campaigns for the program to local governments.
India: RSBY
  • Below Poverty Line
 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 section

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.

RSBY

Population 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.