UHC Forward: Towards Universal Health Coverage

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

Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The scheme has been implemented in all districts in the state. Upon enrollment, beneficiary households receive a Rajiv Aarogyasri Bhima Health Card, a mechanism through which patients are identified and medical records are kept. Aarogyasri covers all below-the-poverty-line residents of Andrah Pradesh. The state already had a mechanism for defining, identifying, and enrolling below-the-poverty-line families. Each eligible family is issued a “White Card” (a ration card) to identify them as below-the-poverty line. Aarogyasri uses the “White Card” as a targeting mechanism for its scheme.

Families in the state who already have “White Cards” are provided with Rajiv Aarogyasri Bhima Health Cards. Everyone in a household can be included in the Rajiv Aarogyasri Health Card. This means the head of the family, spouse, dependent children, and dependent parents. The Health Card captures the family’s data and pictures of each family member. It is presented by beneficiaries when they arrive at a health facility to identify them. The card is also used to store patient visit records and transmit utilization information.

Once enrolled, beneficiaries are guided through the process of seeking care. In order to ensure that beneficiaries know what benefits they are entitled to, and are able to navigate the system of care, Aarogyasri has developed a team of 4,000 Aarogya Mithras. Aarogya Mithras are health workers representing the community of the insured. One Aarogya Mithra sits in each primary health center across the state. These health centers are most often the first points of contact for most families seeking care. In addition, district hospitals and network hospitals also have help desks manned by Aarogya Mithras to facilitate smooth service delivery for Aarogyasri beneficiaries. Aarogya Mithras help to guide beneficiaries through the network of care and inform them about their insurance benefits.

In addition to contacts with Aarogya Mithras, beneficiaries can visit health screening camps that are set up by network providers in rural areas. Under the scheme, all network hospitals are required to undertake a specified number of village health camps in order to maintain their network status. Beneficiaries and potential beneficiaries attend the health camps to be screened for diseases and are provided with preventive care. Those that can be treated at the camp are treated; those that require further treatment are referred to network hospitals where their ailment will be treated free of cost under their Aarogyasri benefits. As of November 2009, there have been more than 15,000 camps and nearly 2.5 million people have been screened.

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