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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| 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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| Korea, Rep.: National Health Insurance Program |
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The Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW. Read full sectionThe Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW. The National Health Insurance Program (NHIP) is managed directly by the National Health Insurance Corporation (NHIC), the single purchaser in Korea. NHIC is in charge of managing the enrollment of insured people and their dependents, collecting contributions, and setting the medical fee schedule. The Health Insurance Review Agency (HIRA) reviews medical fees and health care evaluation. The HIRA also receives and reimburses claims from health care providers. The HIRA committee consists of 10 full-time and 630 part-time medical specialists divided into a central committee and local committees. The committee reviews the appropriateness of medical care claims based on health benefits standards and fees that are determined by the MoHW.
National Health Insurance ProgramInstitutional structures Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The Ministry of Health and Welfare (MoHW) supervises the overall matters relating to health insurance and health sector. MoHW is in charge of the centralized policy formation and implementation, regulating the health insurance system, and approving the annual plans and budgets set by the National Health Insurance Corporation (NHIC) and the Health Insurance Review Agency (HIRA), both of which are discrete non-profit organizations that are supervised and regulated by the MoHW. The National Health Insurance Program (NHIP) is managed directly by the National Health Insurance Corporation (NHIC), the single purchaser in Korea. NHIC is in charge of managing the enrollment of insured people and their dependents, collecting contributions, and setting the medical fee schedule. The Health Insurance Review Agency (HIRA) reviews medical fees and health care evaluation. The HIRA also receives and reimburses claims from health care providers. The HIRA committee consists of 10 full-time and 630 part-time medical specialists divided into a central committee and local committees. The committee reviews the appropriateness of medical care claims based on health benefits standards and fees that are determined by the MoHW.
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| Nigeria: National Health Insurance System |
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The National Health Insurance Scheme (NHIS) is the body responsible for regulation of the system and the different health insurance schemes. The Governing Board of the National Health Insurance Scheme is the National Health Insurance Council (NHIC). NHIC works to regulate the scheme (including setting standards, determining contribution rates, providing technical support, etc), license HMOs and providers, train health care providers, and manage the National Health Insurance Fund (NHIF). Read full sectionThe National Health Insurance Scheme (NHIS) is the body responsible for regulation of the system and the different health insurance schemes. The Governing Board of the National Health Insurance Scheme is the National Health Insurance Council (NHIC). NHIC works to regulate the scheme (including setting standards, determining contribution rates, providing technical support, etc), license HMOs and providers, train health care providers, and manage the National Health Insurance Fund (NHIF). HMOS are licensed by the NHIS to facilitate the provision of healthcare benefits to contributors under the Formal Sector Social health Insurance Program; to interface between eligible contributors, including voluntary contributors and the healthcare providers, ensure member registration, public education about the schemes, collect premiums from members and employers, contract with providers, process claims, and pay claims directly to providers.
The informal sector scheme under the NHIS is managed by a Board of Trustees composed of the Chairman, Secretary, Treasurer and four others. A clerk is appointed to carry out clerical and accounting duties. The Board of Trustees has executive power and is responsible for collecting contributions from participants, paying providers for services rendered, and operating a bank account with an NHIS accredited Bank. The Nigerian system is organized as a federation and divided into three tiers: federal, state, and local. The federal government sets overall policy direction and standards, implements national immunization programs, and oversees federally funded tertiary health facilities. The states undertake policy making and regulation as well as financial responsibility for the personnel, operating costs, and capital investment of the tertiary, secondary, and primary care facilities. The 774 local government associations (LGAs) are responsible for primary health care delivery, under the guidance and supervision of federal and state departments of primary health care. LGAs tend to exert the least influence in this system, and frequently suffer from insufficient funding. National Health Insurance SystemInstitutional structures Key Actors in Insurance Administration: Central Government, Other
Organization: Centralized
Collections Responsibility: Other
Operations Responsibility: Central Government, Other
Oversight Responsibility: Central Government The National Health Insurance Scheme (NHIS) is the body responsible for regulation of the system and the different health insurance schemes. The Governing Board of the National Health Insurance Scheme is the National Health Insurance Council (NHIC). NHIC works to regulate the scheme (including setting standards, determining contribution rates, providing technical support, etc), license HMOs and providers, train health care providers, and manage the National Health Insurance Fund (NHIF). HMOS are licensed by the NHIS to facilitate the provision of healthcare benefits to contributors under the Formal Sector Social health Insurance Program; to interface between eligible contributors, including voluntary contributors and the healthcare providers, ensure member registration, public education about the schemes, collect premiums from members and employers, contract with providers, process claims, and pay claims directly to providers.
The informal sector scheme under the NHIS is managed by a Board of Trustees composed of the Chairman, Secretary, Treasurer and four others. A clerk is appointed to carry out clerical and accounting duties. The Board of Trustees has executive power and is responsible for collecting contributions from participants, paying providers for services rendered, and operating a bank account with an NHIS accredited Bank. The Nigerian system is organized as a federation and divided into three tiers: federal, state, and local. The federal government sets overall policy direction and standards, implements national immunization programs, and oversees federally funded tertiary health facilities. The states undertake policy making and regulation as well as financial responsibility for the personnel, operating costs, and capital investment of the tertiary, secondary, and primary care facilities. The 774 local government associations (LGAs) are responsible for primary health care delivery, under the guidance and supervision of federal and state departments of primary health care. LGAs tend to exert the least influence in this system, and frequently suffer from insufficient funding. |
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| India: Rajiv Aarogyasri |
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Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. Read full sectionAarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. The administrative structure of Aarogyasri is comprised of four main organizations:
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
Rajiv AarogyasriInstitutional structures Key Actors in Insurance Administration:
Organization: Centralized
Collections Responsibility: State Government
Operations Responsibility: State Government, Commercial insurers
Oversight Responsibility: State Government Aarogyasri is managed by the Aarogyasri Healthcare Trust, a body that is responsible for overseeing the entire insurance program, including certain administrative functions such as setting benefits packages and pricing, managing contracts with insurer(s) and in-network providers, approving claims and monitoring of the scheme. The administrative structure of Aarogyasri is comprised of four main organizations:
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
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