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 |
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The MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP. Read full sectionThe MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP. The VSS is a government agency responsible for the administration of the various social insurance programs, including the collection of insurance premiums. In addition to collecting revenues, VSS’s main responsibility is to issue health insurance cards and reimburse service providers. The MoF manages the tax-transfer process that provides the resources that local governments use to provide budget support to public facilities and to pay the VSS for subsidized enrollees. VSS collects mandatory (and voluntary) contributions to the health insurance program, then pools these with the subsidies from the MoF, and pays the providers for care received by people covered by VSS. Compulsory and Voluntary Health Insurance SchemesInstitutional structures Key Actors in Insurance Administration: Central Government, State Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The MoH is responsible for overseeing all health insurance programs, while the VSS is the main agency implementing the schemes. The Ministry of Labor - Invalids and Social Affairs (MOLISA) is tasked with identifying the beneficiaries of the HCFP. The VSS is a government agency responsible for the administration of the various social insurance programs, including the collection of insurance premiums. In addition to collecting revenues, VSS’s main responsibility is to issue health insurance cards and reimburse service providers. The MoF manages the tax-transfer process that provides the resources that local governments use to provide budget support to public facilities and to pay the VSS for subsidized enrollees. VSS collects mandatory (and voluntary) contributions to the health insurance program, then pools these with the subsidies from the MoF, and pays the providers for care received by people covered by VSS. |
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| Estonia: Estonian Health Insurance Fund |
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The Estonian Health System is centralized at the national level. Funds collection is managed by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the Estonian Health Insurance Fund (EHIF). The EHIF is also responsible for the operations of the financing system, as it is the only purchaser for health care services within the country. Health system oversight is carried out by both the EHIF supervisory board as well as the health division of the Ministry of Social Affairs. Read full sectionThe Estonian Health System is centralized at the national level. Funds collection is managed by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the Estonian Health Insurance Fund (EHIF). The EHIF is also responsible for the operations of the financing system, as it is the only purchaser for health care services within the country. Health system oversight is carried out by both the EHIF supervisory board as well as the health division of the Ministry of Social Affairs. The Estonian Health Insurance Fund (EHIF) is responsible for the financing of the health system. Its responsibilities include:
A 15 member supervisory board is responsible for EHIF results. This board is composed of representatives from employer organizations, insured individuals’ organizations, and the state. This board approves the four year development plan and the annual budget. The supervisory board also composes necessary reports and selects providers for contracting. It also has the authority to examine and audit all documents. The management board is responsible for daily EHIF operations. Under the management board, the central and four regional departments conduct needs assessments, contract with providers, and process claims. The government plays a role in planning and regulating the health system by:
The health division of the Ministry of Social Affairs is responsible for:
Table 2: Influence on decisions made by the EHIF
(++ Strong Influence; + Moderate Influence; -- No Influence) County governments are responsible for:
All health care providers within Estonia function as private parties operating under the purview of private law. Family practices are organized as private businesses or joint-stock companies, while hospitals are organized as for-profit joint stock companies or non-profit foundations. Estonian Health Insurance FundInstitutional structures Key Actors in Insurance Administration:
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The Estonian Health System is centralized at the national level. Funds collection is managed by the Estonian Tax and Customs Board. The tax board then transfers the health contribution to the Estonian Health Insurance Fund (EHIF). The EHIF is also responsible for the operations of the financing system, as it is the only purchaser for health care services within the country. Health system oversight is carried out by both the EHIF supervisory board as well as the health division of the Ministry of Social Affairs. The Estonian Health Insurance Fund (EHIF) is responsible for the financing of the health system. Its responsibilities include:
A 15 member supervisory board is responsible for EHIF results. This board is composed of representatives from employer organizations, insured individuals’ organizations, and the state. This board approves the four year development plan and the annual budget. The supervisory board also composes necessary reports and selects providers for contracting. It also has the authority to examine and audit all documents. The management board is responsible for daily EHIF operations. Under the management board, the central and four regional departments conduct needs assessments, contract with providers, and process claims. The government plays a role in planning and regulating the health system by:
The health division of the Ministry of Social Affairs is responsible for:
Table 2: Influence on decisions made by the EHIF
(++ Strong Influence; + Moderate Influence; -- No Influence) County governments are responsible for:
All health care providers within Estonia function as private parties operating under the purview of private law. Family practices are organized as private businesses or joint-stock companies, while hospitals are organized as for-profit joint stock companies or non-profit foundations. |
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| India: RSBY |
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Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Read full sectionSeveral stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
RSBYInstitutional structures Key Actors in Insurance Administration: Central Government, State Government, Commercial insurers, NGOs
Organization: Decentralized to state level
Collections Responsibility: State Government, Commercial insurers
Operations Responsibility: Commercial insurers
Oversight Responsibility: Central Government, State Government Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
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