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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| Vietnam: Compulsory and Voluntary Health Insurance Schemes |
|
36.5 million |
It is the responsibility of the provinces to identify beneficiaries for the HCFP. While ethnic minorities and communes are fairly easy to identify because they are well documented, developing a list of the poor is more challenging. Local governments use already existing lists produced for other government programs in addition to household surveys. About 15 million additional persons, classified as poor, are now covered by the compulsory health insurance. Read full sectionIt is the responsibility of the provinces to identify beneficiaries for the HCFP. While ethnic minorities and communes are fairly easy to identify because they are well documented, developing a list of the poor is more challenging. Local governments use already existing lists produced for other government programs in addition to household surveys. About 15 million additional persons, classified as poor, are now covered by the compulsory health insurance. When the SHI program initially began, only large employers were required to enroll their workers in the scheme. However, in 2005 the government expanded the mandate to companies of all sizes. Of Vietnam’s 7.7 million formal sector workers, 4.8 million (63%) are in the contributory scheme, but 2 million formal sector workers (26%) remain without coverage. Furthermore, SHI enrollment appears to be higher among the “better-off,” while middle-income groups currently have the lowest enrollment rates. Under the VHI, until the end of 2009, full-time students were typically enrolled en masse by insurance agents operating at schools and colleges. As of January 2010, full-time students are automatically enrolled as a part of the CHI. Family members/dependents of the compulsorily insured can enroll in the VSS scheme of their own accord. Others can enroll through group organizations, including communes. Prior to 2007, dependents were required to enroll all household members together and group organizations required a 20% minimum rate of participation. However, these stipulations have since been eliminated. Nonetheless, voluntary enrollment among the non-student population has stayed low with no signs of improvement. Enrollment in HCFP is a bit more complex. Provinces are tasked with identifying beneficiaries under the target groups. Identification has not been a challenge for at least two of the target groups, as communes and ethnic minority households are well documented. In the case of poor households, who have proved to be the most difficult group to identify, local governments begin by building upon lists of officially poor households produced for other government programs. Then commune officials conduct further household surveys to produce a proposed list of HCFP beneficiaries, which is then discussed and voted upon at a public meeting presided over by the village or commune leader. Officials from the district government’s labor and social affairs offices (MOLISA) then review the list, which can be revised before it is sent to the provincial department of labor and social affairs for final approval. Until recently, provinces were free to decide whether to enroll HCFP beneficiaries in the government’s SHI program, or to manage the risk themselves and provide direct reimbursement to providers. However, this latter option, which was initially the most popular with provinces, has since been phased out through a 2005 government directive updating Decision 139. According new Health Insurance Law, effective since July, 2009, the poor are included in the compulsory health insurance program. About 15 million additional persons, classified as poor, are now covered by compulsory health insurance. Compulsory and Voluntary Health Insurance SchemesPopulation covered Target Populations: All populations
Coverage Level: 36.5 million It is the responsibility of the provinces to identify beneficiaries for the HCFP. While ethnic minorities and communes are fairly easy to identify because they are well documented, developing a list of the poor is more challenging. Local governments use already existing lists produced for other government programs in addition to household surveys. About 15 million additional persons, classified as poor, are now covered by the compulsory health insurance. When the SHI program initially began, only large employers were required to enroll their workers in the scheme. However, in 2005 the government expanded the mandate to companies of all sizes. Of Vietnam’s 7.7 million formal sector workers, 4.8 million (63%) are in the contributory scheme, but 2 million formal sector workers (26%) remain without coverage. Furthermore, SHI enrollment appears to be higher among the “better-off,” while middle-income groups currently have the lowest enrollment rates. Under the VHI, until the end of 2009, full-time students were typically enrolled en masse by insurance agents operating at schools and colleges. As of January 2010, full-time students are automatically enrolled as a part of the CHI. Family members/dependents of the compulsorily insured can enroll in the VSS scheme of their own accord. Others can enroll through group organizations, including communes. Prior to 2007, dependents were required to enroll all household members together and group organizations required a 20% minimum rate of participation. However, these stipulations have since been eliminated. Nonetheless, voluntary enrollment among the non-student population has stayed low with no signs of improvement. Enrollment in HCFP is a bit more complex. Provinces are tasked with identifying beneficiaries under the target groups. Identification has not been a challenge for at least two of the target groups, as communes and ethnic minority households are well documented. In the case of poor households, who have proved to be the most difficult group to identify, local governments begin by building upon lists of officially poor households produced for other government programs. Then commune officials conduct further household surveys to produce a proposed list of HCFP beneficiaries, which is then discussed and voted upon at a public meeting presided over by the village or commune leader. Officials from the district government’s labor and social affairs offices (MOLISA) then review the list, which can be revised before it is sent to the provincial department of labor and social affairs for final approval. Until recently, provinces were free to decide whether to enroll HCFP beneficiaries in the government’s SHI program, or to manage the risk themselves and provide direct reimbursement to providers. However, this latter option, which was initially the most popular with provinces, has since been phased out through a 2005 government directive updating Decision 139. According new Health Insurance Law, effective since July, 2009, the poor are included in the compulsory health insurance program. About 15 million additional persons, classified as poor, are now covered by compulsory health insurance. |
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| Chile: National Health Fund (FONASA) |
|
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 sectionEnrollment 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
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
Source: Bitran, R., Urcullo, G., 106 |
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| 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. |
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| Thailand: Universal Coverage Scheme |
|
50 million |
The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. Read full sectionThe Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. A centralized registration database, which is updated regularly, is also a useful tool in identifying and enrolling beneficiaries in the USC scheme. The central registration database consolidates information on the entire Thai population, and includes registration information of the CSMBS, the SSS and the UCS. When patients seek care, their entitlements are checked with the centralized online database to ensure that they are enrolled in an insurance scheme. If the database shows that that are not members of the CSMBS or the SSS, they are asked to register for the UCS at that time. Universal Coverage SchemePopulation covered Target Populations: All populations
Coverage Level: 50 million The Universal Coverage Scheme enrolls those not covered by either the Civil Servant Medical Benefit Scheme (CSMBS) or the Compulsory Social Security Scheme (SSS) – about 74% of the entire population. To be enrolled in UCS, all members must register with a contracting unit (CUP) and receive a card for care in their home area. When first implemented, potential beneficiaries were identified by health volunteers and medical personal, as well as through mass communications and media campaigns. A centralized registration database, which is updated regularly, is also a useful tool in identifying and enrolling beneficiaries in the USC scheme. The central registration database consolidates information on the entire Thai population, and includes registration information of the CSMBS, the SSS and the UCS. When patients seek care, their entitlements are checked with the centralized online database to ensure that they are enrolled in an insurance scheme. If the database shows that that are not members of the CSMBS or the SSS, they are asked to register for the UCS at that time. |