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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Indonesia: Jamkesmas |
|
|
|
|
|
Presently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator. Read full sectionPresently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator. A revised institutional structure of Indonesia’s Jamkesmas scheme is currently being developed. The table below summarizes the roles and responsibilities of all of the organizations involved in implementing national health insurance, including Jamkesmas:
LR = long run; SR = short run Note that the Ministry of Finance has an office overseeing insurance programs and carriers of all types. They also have actuarial capacity available when required. JamkesmasInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government, Commercial insurers
Organization: Decentralized to district/local level
Collections Responsibility: District/Local Government
Operations Responsibility: Central Government, District/Local Government
Oversight Responsibility: Central Government Presently, five main actors are involved in the administration of the Jamkesmas scheme (1) the National Social Security Council (DJSN), (2) national government agencies, including Depkes (MoH), the Ministry of Finance (MoF), the Ministry of Home Affairs (MoHA), Ministry of Social Affairs (Menkokesra), and the Ministry of National Development Planning (Bappenas), (3) provincial and district governments, (4) public and private providers of care, and (5) the insurer/third-party administrator. A revised institutional structure of Indonesia’s Jamkesmas scheme is currently being developed. The table below summarizes the roles and responsibilities of all of the organizations involved in implementing national health insurance, including Jamkesmas:
LR = long run; SR = short run Note that the Ministry of Finance has an office overseeing insurance programs and carriers of all types. They also have actuarial capacity available when required. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Ghana: National Health Insurance Scheme (NHIS) |
|
|
|
|
|
The National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers. Read full sectionThe National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers. See Figure 1 below for an illustrative depiction of the institutional structure of the NHIS.
Its mandate is “to secure the implementation of a national health insurance policy that ensures basic healthcare services to all residents.” Section 3 of the Act establishes the governing body of the Authority, known as the National Health Insurance Council (NHIC), which administers the National Health Insurance Fund. The President of Ghana is given sole power to appoint the chairperson and members of the Council. CHIC representatives represent geographically determined ‘Health Insurance Communities’ within each district. The CHIC exists officially to oversee the collection of contributions within its designated Health Insurance Community, to supervise the deposit of these into the District Health Insurance Fund, and to represent community interests in the management structures of the DWMHIS. The figure below presents an illustrative depiction of the financial structure of the NHIS, including sources of cash flow and the organizational structure of the management of NHIS financial resources.
National Health Insurance Scheme (NHIS)Institutional 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: District/Local Government
Oversight Responsibility: Central Government The National Health Insurance Authority is the national governing body of the NHIS. Each DWMHI scheme is managed by a Board, which is elected by a General Assembly comprised of Community Health Insurance Committee (CHIC) representatives. Monitoring is carried out at all levels, including by the NHIS, district schemes, and health care providers. See Figure 1 below for an illustrative depiction of the institutional structure of the NHIS.
Its mandate is “to secure the implementation of a national health insurance policy that ensures basic healthcare services to all residents.” Section 3 of the Act establishes the governing body of the Authority, known as the National Health Insurance Council (NHIC), which administers the National Health Insurance Fund. The President of Ghana is given sole power to appoint the chairperson and members of the Council. CHIC representatives represent geographically determined ‘Health Insurance Communities’ within each district. The CHIC exists officially to oversee the collection of contributions within its designated Health Insurance Community, to supervise the deposit of these into the District Health Insurance Fund, and to represent community interests in the management structures of the DWMHIS. The figure below presents an illustrative depiction of the financial structure of the NHIS, including sources of cash flow and the organizational structure of the management of NHIS financial resources.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Kenya: National Hospital Insurance Fund |
|
|
|
|
|
When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. Read full sectionWhen the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF. Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).
Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations. National Hospital Insurance FundInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: District/Local Government
Operations Responsibility: District/Local Government
Oversight Responsibility: Central Government When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF. Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).
Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Philippines: PhilHealth |
|
|
|
|
|
The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. Read full sectionThe scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector. PhilHealth also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of Philhealth as vice-chariman. The president and CEO have a fixed term of 6 years. Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses. For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth. PhilHealthInstitutional structures Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The scheme is entirely administered by PhilHealth, a government corporation attached to the Department of Health. PhilHealth collects premiums, accredits providers, sets the benefits packages and provider payment mechanisms, processes claims, and reimburses providers for their services. PhilHealth is responsible for oversight and administration of public sector insurance schemes. It has a governing board chaired by the Secretary of Health with representation from other government departments (ministries) and agencies, and the private sector including the OFW sector. PhilHealth also features a governing board composed of 13 individuals, chaired by the Secretary of Health, with the president and CEO of Philhealth as vice-chariman. The president and CEO have a fixed term of 6 years. Salaries and other operating expenses are derived from premium payments and the income of the funds under management. PhilHealth can use up to 12% of the previous year’s premium and 3% of the income of the fund it manages towards operating expenses. For monitoring and evaluation, Congress has mandated the National Institutes of Health (based in the University of the Philippines) to conduct studies that will verify and validate the performance of PhilHealth. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| India: Rajiv Aarogyasri |
|
|
|
|
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:
|
Source: National Hospital Insurance Fund
The Kenyan health system is administered from the top down by the Ministry of Health (MOH), which was broken into two Ministries after the post-election turmoil of 2007: the Ministry of Medical Services, and the Ministry of Public Health and Sanitation. Kenya has a Sector Wide Approach (SWAp) to coordinate and support the health care system, which incorporates health partners on all levels. The role of the central government is to formulate policy, set priorities, budget and allocate resources, and regulate service provision through a decentralized framework. Provinces, districts and local community areas are increasingly responsible for implementation and day to day management of the health system.