UHC Forward: Towards Universal Health Coverage

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.

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:

• Have no visible source of income
• Have no fixed abode
• Are not living with an employed person with a fixed abode
• Have no consistent source of support from another person

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.

Enrollment in the SP takes place on a per-family basis. A family is composed of the father and/or mother, children and adopted children younger than eighteen or minors younger than eighteen who are dependents and live in the same household, those older than sixty-four years of age who live in the same household, single student children up to age twenty-five, and disabled children. Upon enrollment, families receive a pamphlet with their rights and duties that outlines the health interventions and services to which they are entitled. The SP was intended to be rolled out at the health center level. Regions were permitted to enroll individuals only if they had sufficient facilities and human resources to provide adequate care under the program. Enrollment took place at the municipal level, which meant that many municipalities without adequate facilities were not initially able to accommodate large-scale enrollment. State ministries of health are responsible for promotion of the SP program. Voluntary affiliation takes place on a quarterly basis, but enrollees must wait until the following trimester to begin receiving services. Due to the voluntary nature of the program, enrollees must choose to re-enroll annually.

At the start of the program, the primary strategies for enrollment focused on large-scale affiliation campaigns for vulnerable families. Strategies that have been used to aid in the enrollment and re-enrollment process have included the following: coordinating enrollment activities with other programs targeted to poor populations; promoting enrollment in public gathering places like markets and health clinics; communicating with state and local governments to help identify priority populations; collaborating with local governments to speed the processing of official documentation; re-enrollment invitations through mass-mailings to current enrollees; using mass-marketing campaigns to motivate re-enrollment; and launching special brigades for special enrollment campaigns in localities with low levels of enrollment or re-enrollment. However, due to the fact that there were annual quotas on the number of new enrollees, certain states limited the size of their communication campaigns.

During the first years of the SP targeted populations were given priority affiliation. These included those living in rural regions, those who belonged to poverty alleviating programs such as Oportunidades, and indigenous populations. As of 2009, special targeted populations included newborns and pregnant women. Moreover, the last few years have seen the growth of unemployment leading many families to lose their rights to public services such as IMSS or ISSSTE, which has led to an expansion of the enrollment goals for SP beyond what had previously been established.

During the two years of the pilot program between 2001 and 2003, 614,000 families were affiliated. By the end of 2006, this number had increased to 4 million families. In terms of percentages, in 2005 the SPSS covered approximately 14% of the previously uninsured population. By 2009, this number had reached in excess of 90% of the uninsured.

Table 1: Affiliation Coverage per State, 2009

Source: Secretaria de Salud