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 | Key Actors in Insurance Administration | Organizational Structure | Collections Responsibility | Operations Responsibility | Oversight Responsibility | Institutional structures | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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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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| Colombia: General System of Social Security in Health |
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In 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs. Read full sectionIn 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs. The National Council on Social Security in Health (CNSSS)—which is composed of representatives from the government, insurers, unions, employers, and pensioners among others—had been responsible for setting the UPC and content of the benefits packages. However, law 1122 of 2007 called for the CNSSS to take on a solely advisory role. As such, some of its duties include defining medications to be part of the CR and SR plans, designing the criteria by which beneficiaries of the SR are selected, and developing the necessary measures to avoid adverse selection on the part of EPSs and EPSSs. Law 1122 passed the responsibility for setting the UPC and the content of the benefits packages to a new entity, the Health Regulatory Commission (CRES). This commission is presided by the MPS and also includes the Treasury as well as five expert commissioners as established under decree 1429. The shift in responsibility took place in order to have a more technically competent body overseeing what are by nature more technical issues. The Health Superintendence is an entity separate from the MPS that is responsible for authorizing the entrance of new insurers into the regulated marketplace. It also supervises the performance of insurers, paying particular attention to their risk management practices. Finally, it functions as the entity through which complaints can be brought by the different actors within the health system. General System of Social Security in HealthInstitutional structures Key Actors in Insurance Administration: Commercial insurers
Organization: Centralized
Collections Responsibility: Commercial insurers
Operations Responsibility: Commercial insurers
Oversight Responsibility: Central Government In 2002, what had been the Ministry of Labor and the Ministry of Health were merged together to form the Ministry of Social Protection (MPS). The MPS is responsible for pensions, health insurance, public health programs, and other social assistance programs. The National Council on Social Security in Health (CNSSS)—which is composed of representatives from the government, insurers, unions, employers, and pensioners among others—had been responsible for setting the UPC and content of the benefits packages. However, law 1122 of 2007 called for the CNSSS to take on a solely advisory role. As such, some of its duties include defining medications to be part of the CR and SR plans, designing the criteria by which beneficiaries of the SR are selected, and developing the necessary measures to avoid adverse selection on the part of EPSs and EPSSs. Law 1122 passed the responsibility for setting the UPC and the content of the benefits packages to a new entity, the Health Regulatory Commission (CRES). This commission is presided by the MPS and also includes the Treasury as well as five expert commissioners as established under decree 1429. The shift in responsibility took place in order to have a more technically competent body overseeing what are by nature more technical issues. The Health Superintendence is an entity separate from the MPS that is responsible for authorizing the entrance of new insurers into the regulated marketplace. It also supervises the performance of insurers, paying particular attention to their risk management practices. Finally, it functions as the entity through which complaints can be brought by the different actors within the health system. |
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| Mali: Mutuelles |
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Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one. For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles. Read full sectionAlthough the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one. For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.
Table 4 illustrates the institutional framework planned for the Mutuelle system. Table 4: Institutional system for the Mutuelle system
Source: Ministry of Social Protection For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5. Table 5: Organization and operating procedures– AMO and RAMED
Source: Ministry of Social Protection MutuellesInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government, Mutuelles
Organization: Decentralized to district/local level
Collections Responsibility: Mutuelles
Operations Responsibility: Mutuelles
Oversight Responsibility: Central Government, District/Local Government Although the Social Protection Ministry is the sole entity in charge of the three medical coverage systems, the institutional framework is different for each one. For the Mutuelles, the National Strategy identifies a new organizational chart, illustrated below. This scheme seeks to create Mutuelles at the community or commune level, networked at the higher levels by the district Mutuelle unions, the regional federations of Mutuelles, and a national federation of Mutuelles.
Table 4 illustrates the institutional framework planned for the Mutuelle system. Table 4: Institutional system for the Mutuelle system
Source: Ministry of Social Protection For the AMO, a National Health Insurance Fund (CANAM) was set up as a management agency, with two delegated management entities: the Malian Health Insurance Fund (CMSS) and the National Social Welfare Institute (INPS) for collecting dues and paying for health care services. The National Medical Assistance Agency (ANAM) was set up for RAMED. The management bodies and their respective roles are shown in Table 5. Table 5: Organization and operating procedures– AMO and RAMED
Source: Ministry of Social Protection |
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| : Taiwan: National Health Insurance |
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The organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. Read full sectionThe organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. The Department of Health (DOH) has jurisdiction over the Bureau of National Health Insurance (BNHI), the NHI supervisory Committee, the NHI Dispute Mediation Committee, and the NHI Medical Expenditure Negotiation Committee, all of which plan and monitor tasks that relate to the NHI. BNHI acts as the primary executive of the NHI. BNHI contracts with health care facilities and is the primary organization responsible for administering the National Health Insurance system, collecting premiums from the insured and regulating health care services for the insured. Under the executive branch, Taiwan has 6 regional divisions divided into 25 local health bureaus under city or county local governments. These local bureaus are responsible for daily operations of health management and directly handle underwriting operations, insurance premium collection, review and payment of medical claims, and management of NHI-contracted medical care institutions. The bureaus all have close relationships to local level health and aid in managing the contracted medical institutions through quality counseling, and management of emergency rescue services, mental health services, and human resources. In addition, each of the 25 county governments in Taiwan has a health liaison bureau, which is responsible for the operation of public health centers within their geographical region under the guidance of the health department. While the NHI is governed by the central government, most management of NHI is decentralized. The BNHI is the primary overseer of NHI, acts to set the annual national budget, and implements most policy in a centralized, top-down fashion. The BNHI also acts as the primary intermediary between the insured and the providers. Oversight of the NHI is also provided by the NHI Supervisory Committee (NHISC), which provides a forum for social associations, employers and providers to communicate with one another; the NHI Disputes Mediation Committee (NHIDM), which mediates disputes between the insured and providers; the NHI Expenditure Negotiation Committee (NHIENC), which negotiates the payments for providers under the Global Budget Payment; and the NHI Task Force. The daily management of the NHI, however, is highly decentralized. The BNHI distributes responsibilities to the 6 regional divisions and local governments. National Health InsuranceInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: Central Government, District/Local Government
Operations Responsibility: Central Government, District/Local Government
Oversight Responsibility: Central Government The organization of health administration in Taiwan is divided into two structures: The National level and the local level. The National Health Insurance (NHI) system is administered by the central government, which has the overall responsibility for the formulation of health care policies and the regulation of health care services throughout Taiwan. The Department of Health (DOH) has jurisdiction over the Bureau of National Health Insurance (BNHI), the NHI supervisory Committee, the NHI Dispute Mediation Committee, and the NHI Medical Expenditure Negotiation Committee, all of which plan and monitor tasks that relate to the NHI. BNHI acts as the primary executive of the NHI. BNHI contracts with health care facilities and is the primary organization responsible for administering the National Health Insurance system, collecting premiums from the insured and regulating health care services for the insured. Under the executive branch, Taiwan has 6 regional divisions divided into 25 local health bureaus under city or county local governments. These local bureaus are responsible for daily operations of health management and directly handle underwriting operations, insurance premium collection, review and payment of medical claims, and management of NHI-contracted medical care institutions. The bureaus all have close relationships to local level health and aid in managing the contracted medical institutions through quality counseling, and management of emergency rescue services, mental health services, and human resources. In addition, each of the 25 county governments in Taiwan has a health liaison bureau, which is responsible for the operation of public health centers within their geographical region under the guidance of the health department. While the NHI is governed by the central government, most management of NHI is decentralized. The BNHI is the primary overseer of NHI, acts to set the annual national budget, and implements most policy in a centralized, top-down fashion. The BNHI also acts as the primary intermediary between the insured and the providers. Oversight of the NHI is also provided by the NHI Supervisory Committee (NHISC), which provides a forum for social associations, employers and providers to communicate with one another; the NHI Disputes Mediation Committee (NHIDM), which mediates disputes between the insured and providers; the NHI Expenditure Negotiation Committee (NHIENC), which negotiates the payments for providers under the Global Budget Payment; and the NHI Task Force. The daily management of the NHI, however, is highly decentralized. The BNHI distributes responsibilities to the 6 regional divisions and local governments. |
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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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