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 |
|---|---|---|---|
| Colombia: General System of Social Security in Health |
|
40,835,265 |
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. Read full sectionIn 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. General System of Social Security in HealthPopulation covered Target Populations: All populations
Coverage Level: 40,835,265 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. |
| 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. |
| 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. |
| India: RSBY |
|
40 million |
RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. Read full sectionRSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district. To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance. Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital. The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes. Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp. At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled. The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint. Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population. RSBYPopulation covered Target Populations: Below Poverty Line
Coverage Level: 40 million RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An electronic list of eligible BPL households is provided to the insurers by each state’s Ministry of Labor and Employment (MoLE). Enrolled members receive Smart Cards, which acts as the enrollment, identification, and record-keeping mechanism for the scheme. RSBY aims to cover all below-the-poverty-line residents of participating Indian states. An enrollment schedule for each village, along with dates, is prepared by the insurance company with the help of district officials. The insurance companies are provided a maximum of four months to enroll BPL families in each district. To communicate and market the RSBY scheme and enrollment camps, insurance companies are required to hire intermediaries to provide grassroots outreach prior to enrollment. (These organizations could also be used to provide assistance to members in utilizing services after enrollment.) In addition, the BPL list is posted in each village at the enrollment station and prominent places prior to the enrollment camp. The date/location of the enrollment camp are also publicized in advance. Mobile enrollment stations are established at local centers (e.g., public schools) at each village at least once a year. These stations are equipped by the insurer with a printer to print SmartCards, as well as hardware to collect biometric information (fingerprints) and photographs of household members to be covered. A SmartCard is given to each BPL family at the time of enrollment in the scheme. Fingerprints of all beneficiaries are collected during enrollment at the village level. One thumb impression of each of the household beneficiaries is stored in the SmartCard. This fingerprint is used to verify the identity of the beneficiaries at the hospital. The SmartCard is prepared and printed on-the-spot in the village by the insurer and handed over to the beneficiary. This SmartCard can be used by the beneficiary in any empanelled hospital across India to obtain treatment. The SmartCard given to each enrolled household also contains a new national unique ID for each family—a program the Government of India is implementing nationwide. The SmartCard, along with an information packet describing benefits, hospitals in network, and other relevant information is provided to all enrollees once they have paid the Rs. 30/- registration fee. The process normally takes less than 10 minutes. Another unique feature of the scheme is its key management system which helps in reducing enrollment fraud and improves accountability. A government official from the district (field key officer—FKO) needs to be present at the camp and must insert his/her own government-issued SmartCard and provide his/her fingerprint to verify the legitimacy of the enrollment. This way each enrollee can be tracked to a particular government official. The details of each BPL family who is authenticated by the FKO gets transferred to the FKO’s SmartCard; the data is also transferred from the FKO’s card to the government server at the district level. In addition to the FKO, an insurance company/SmartCard agency rep is present at the enrollment camp. At the end of the enrollment camp, a list of enrolled households is sent to the state nodal agency by the Insurer. The list of enrolled households is maintained centrally and the insurer is paid once data provided from the insurer and FKO card has been reconciled. The aim of the scheme is to use technology not only for controlling fraud and monitoring utilization, but also to find innovative solutions to insurance-related problems. For example, enrollment software has been designed to ensure that male heads of households must insure their spouses. In addition, since the scheme aims to provide quality treatment to all beneficiaries, technology has been implemented to ensure that every beneficiary receives needed treatment. For example, if a patient is not in a condition to validate his/her identity at the hospital then any family member who is on the SmartCard can validate the identity of the patient by providing his/her fingerprint. Currently, the Government of India is considering how the SmartCard can be used for other social sector schemes and how the RSBY technology platform can be used to provide other services to the below-the-poverty-line population. |
| 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. |