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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Indonesia: Jamkesmas |
|
76.4 million |
Though the scheme has never been formally marketed, Jamkesmas has enrolled more beneficiaries than any other Indonesian health insurance plan. Its target population is defined using an annually administered national survey known as the SUSENAS according to daily household consumption estimates. Read full sectionThough the scheme has never been formally marketed, Jamkesmas has enrolled more beneficiaries than any other Indonesian health insurance plan. Its target population is defined using an annually administered national survey known as the SUSENAS according to daily household consumption estimates. SUSENAS is a social and economic household survey used to define total household consumption for GDP estimation purposes. Based on standard definitions of the poor in terms of daily household consumption, the total number of poor has been defined. The sub-national distribution of this total has also been defined in a similar manner. P.T. Askes remains the administrator of membership in the Jamkesmas program since it has operated the program since 2005. P.T. Askes has a contract with the MoH to administer the membership part of the program separate from other programs. P.T. Askes obtains a list of the number of persons eligible each year from the Central Bureau of Statistics which is a part of Bappenas (the national planning agency). P.T. Askes then distributes the cards and registers enrollees into the program. The Ministry of Home Affairs (MoHA) is responsible for the development of a national identity card to be distributed throughout the entire population. When this card has been distributed, it will become the basis for enrollment into the national health insurance program. Jamkesmas is not being formally marketed, as it has been oversubscribed since its inception in 2008. JamkesmasPopulation covered Target Populations: Below Poverty Line
Coverage Level: 76.4 million Though the scheme has never been formally marketed, Jamkesmas has enrolled more beneficiaries than any other Indonesian health insurance plan. Its target population is defined using an annually administered national survey known as the SUSENAS according to daily household consumption estimates. SUSENAS is a social and economic household survey used to define total household consumption for GDP estimation purposes. Based on standard definitions of the poor in terms of daily household consumption, the total number of poor has been defined. The sub-national distribution of this total has also been defined in a similar manner. P.T. Askes remains the administrator of membership in the Jamkesmas program since it has operated the program since 2005. P.T. Askes has a contract with the MoH to administer the membership part of the program separate from other programs. P.T. Askes obtains a list of the number of persons eligible each year from the Central Bureau of Statistics which is a part of Bappenas (the national planning agency). P.T. Askes then distributes the cards and registers enrollees into the program. The Ministry of Home Affairs (MoHA) is responsible for the development of a national identity card to be distributed throughout the entire population. When this card has been distributed, it will become the basis for enrollment into the national health insurance program. Jamkesmas is not being formally marketed, as it has been oversubscribed since its inception in 2008. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
|
5.2 million |
Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Read full sectionKyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period. Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF. Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
Source: Jakab, M., and Manjieva, E. Mandatory Health Insurance Fund (MHIF)Population covered Target Populations: All populations
Coverage Level: 5.2 million Kyrgyzstan offers free primary health care services to all citizens through the State Guaranteed Benefits Package (SGPB) regardless of insurance status. By 2003, 98% of the population was enrolled with a Family Group Practice (FGP) for their primary health care needs. Enrollees choose a FGP of their choice and are free to move between FGPs once per year during the annual registration period. Population groups covered by the MHIF include formal sector employees, civil servants, pensioners, the registered unemployed, children and students under age 21, welfare benefit recipients, farmers, and the self-employed. In 2001, over 80% of the population was covered by the MHIF. Table 3: Coverage additions (1997-2001): Population groups, sources of financing and benefits
Source: Jakab, M., and Manjieva, E. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Korea, Rep.: National Health Insurance Program |
|
50 million |
All South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Read full sectionAll South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Those in the self-employed insured category include about 41% of the total insured population.
National Health Insurance ProgramPopulation covered Target Populations: All populations
Coverage Level: 50 million All South Koreans are eligible and required to have health coverage under the National Health Insurance Program (NHIP). NHIP is managed by the National Health Insurance Corporation, which is responsible for enrollment and communication. NHIC uses local branches to enroll individuals and to collect premiums. The insured are divided into two groups: employee insured and self-employed insured. The employee insured category composes about 59% of the total number of insured. Those in the self-employed insured category include about 41% of the total insured population.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ghana: National Health Insurance Scheme (NHIS) |
|
12 million |
Each Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. Read full sectionEach Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. The DWMHI schemes have their own management structures and have a certain level of autonomy in the setting of premiums and the charging of other costs, although these have to be kept within the limits established by the NHIA. As one of the reasons for the NHIS’s existence is to stop out-of-pocket healthcare payments, there are no deductibles, and no copayments have to be made by NHIS members when accessing healthcare. As one of the reasons for the NHIS's existence is to stop out-of-pocket healthcare payments, there are no deductibles and no copayments. Enrollment: Contributions to SSNIT are automatic for members of DWMHI schemes because of the health insurance deductions made from their SSNIT contributions, and are only required to pay an initial registration fee. The premium structure therefore applies only to those who work in the informal economy or who are not SSNIT contributors. These members pay their premiums to the DWMHI schemes directly. The schemes employ collectors who move between houses and market stalls to receive premium payments. Alternatively, premiums can be paid to banks, or to designated pharmacies or ‘chemical shops.’ Premiums can be paid at any time during the year – there is no set registration period. Exemptions: Exemptions from premium payments exist for SSNIT contributors, SSNIT pensioners, those over the age of 70, and for those classed as indigent. Indigents are classified as those people who:
Currently all children under the age under 18 are exempted from NHIS premium payments irrespective of the NHIS membership status of their parents. If parents are NHIS members, then children are covered for free. However, if parents are not NHIS members, children cannot access benefits. National Health Insurance Scheme (NHIS)Population covered Target Populations: All populations
Coverage Level: 12 million Each Ghanaian district has a District Wide Mutual Health Insurance (DWMHI) scheme, and each metropolis has two such schemes. Contributions to SSNIT are automatic for members of the DWMHIs. The DWMHI schemes have their own management structures and a certain level of autonomy in the setting of premiums and other costs, although these have to be kept within the limits established by the NHIA. As with the other CBHI schemes, membership is voluntary, although there are plans to eventually introduce compulsory membership. The DWMHI schemes have their own management structures and have a certain level of autonomy in the setting of premiums and the charging of other costs, although these have to be kept within the limits established by the NHIA. As one of the reasons for the NHIS’s existence is to stop out-of-pocket healthcare payments, there are no deductibles, and no copayments have to be made by NHIS members when accessing healthcare. As one of the reasons for the NHIS's existence is to stop out-of-pocket healthcare payments, there are no deductibles and no copayments. Enrollment: Contributions to SSNIT are automatic for members of DWMHI schemes because of the health insurance deductions made from their SSNIT contributions, and are only required to pay an initial registration fee. The premium structure therefore applies only to those who work in the informal economy or who are not SSNIT contributors. These members pay their premiums to the DWMHI schemes directly. The schemes employ collectors who move between houses and market stalls to receive premium payments. Alternatively, premiums can be paid to banks, or to designated pharmacies or ‘chemical shops.’ Premiums can be paid at any time during the year – there is no set registration period. Exemptions: Exemptions from premium payments exist for SSNIT contributors, SSNIT pensioners, those over the age of 70, and for those classed as indigent. Indigents are classified as those people who:
Currently all children under the age under 18 are exempted from NHIS premium payments irrespective of the NHIS membership status of their parents. If parents are NHIS members, then children are covered for free. However, if parents are not NHIS members, children cannot access benefits. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Philippines: PhilHealth |
|
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 sectionPhilHealth 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:
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. PhilHealthPopulation 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:
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Brazil: Unified Health System (SUS) |
|
143 million |
Brazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. Read full sectionBrazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. The Brazilian Supplementary Health System (SHS) served 33 million Brazilians in 2002, or 19% of the population. By 2007, it accounted for more than 50% of health care expenditure, yet it served less than 30% of the population. Health care operators within the SHS are grouped into categories by the Agency for Supplementary Health within the MOH, depending on their economic and financial status. Ordered by market share in 2002, these categories are group medicine, medical cooperatives, health insurance, charity, self-management, group dentistry, and dentistry cooperatives. Most of these plans are connected to employment. The majority of these plans tend to be small or medium in size and operate mostly through contractual arrangements with doctors’ offices and hospitals. In 2002, group medicine, medical cooperatives and health insurance served around 80% of supplementary users and accounted for 90% of billing. Initially, private prepayment plans had an incentive not to provide comprehensive coverage to enrollees, as high-cost procedures were usually funneled to the SUS for treatment. However, in 1999, the government instituted a norm that allows it to recover the costs associated with services rendered by the SUS to beneficiaries of private health plans. This norm is implemented through the National Supplementary Health Council (CNSS). Unified Health System (SUS)Population covered Target Populations: All populations
Coverage Level: 143 million Brazil’s health system is based on the notion of free, universal care. In 1998, 71.2% of the population reported that they had a regular-use service. In 2003, this number had increased to 80%. This is significant, since it means that individuals have a service which they use as an entry point into the health system. While 100 % of the population is able to receive services under the SUS, approximately 25% opt for private insurance coverage. The Brazilian Supplementary Health System (SHS) served 33 million Brazilians in 2002, or 19% of the population. By 2007, it accounted for more than 50% of health care expenditure, yet it served less than 30% of the population. Health care operators within the SHS are grouped into categories by the Agency for Supplementary Health within the MOH, depending on their economic and financial status. Ordered by market share in 2002, these categories are group medicine, medical cooperatives, health insurance, charity, self-management, group dentistry, and dentistry cooperatives. Most of these plans are connected to employment. The majority of these plans tend to be small or medium in size and operate mostly through contractual arrangements with doctors’ offices and hospitals. In 2002, group medicine, medical cooperatives and health insurance served around 80% of supplementary users and accounted for 90% of billing. Initially, private prepayment plans had an incentive not to provide comprehensive coverage to enrollees, as high-cost procedures were usually funneled to the SUS for treatment. However, in 1999, the government instituted a norm that allows it to recover the costs associated with services rendered by the SUS to beneficiaries of private health plans. This norm is implemented through the National Supplementary Health Council (CNSS). |
