UHC Forward: Towards Universal Health Coverage

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.

Enrollment in the Mutuelle system is voluntary and is primarily coordinated at the district and sector level. Each community-based Mutuelle is responsible for increasing enrollment, maintaining re-enrollment, educating the population about the program, verifying the number of participants in each household, and collecting membership contributions. Outreach is done most frequently at the community level via church services, radio broadcasts, etc, and tends to focus largely on the rural and informal sector in order to most effectively target those individuals unable to access formal health insurance through other means.

Enrollment for Rwanda Health Insurance Scheme (La Rwandaise d’Assurance Maladie or RAMA) and Military Medical Insurance (MMI) are coordinated through the government and employers. Initially only civil servants and their families were covered with RAMA, however, in 2003 coverage expanded to all those employed in both the public and the private sector. In 2006 RAMA only covered approximately 2.2% of the population. Coverage through MMI is provided for all members of the Rwandan Defense Force. Family members of MMI affiliates are covered under the same conditions as in RAMA. The exact number of beneficiaries is difficult to calculate due to national security issues but an estimated figure of 100,000 individuals or approximately 1.1% of the total Rwandan population is estimated to be covered. Combined, these programs insure less than 5% of the population.

The result of these health insurance programs has been an incredible upsurge in health insurance enrollment. USAID estimates that in 2010 approximately 92% of the population had health coverage, up from about 10% in 1999 since the implementation of the Community-Based Health Initiatives (CBHI). Geographically, enrollment has expanded from about 4 provinces to all 11 provinces. After national expansion of CBHI, participation increased coverage to 5.8 million persons, about 70% of the population. The Ministry of Health has stated that the rapid uptake seen in the early years of the program undoubtedly speaks to the communal and grassroots dynamics of the country.

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.

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