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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| 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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| Kyrgyz Republic: Mandatory Health Insurance Fund (MHIF) |
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The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system. Read full sectionThe Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system. The MHIF is an agency of the MOH responsible for collecting premiums and for funding individual health services in the SGBP and the Additional Outpatient Drug Benefit. The MHIF is responsible for contracting with primary health care providers and hospitals and for paying them for services they provide to enrollees. The Ministry of Health is responsible for creating a unified state policy for the health sector, functioning as the steward of health care in Kyrgyzstan. Under this banner, the MOH has the following responsibilities:
Mandatory Health Insurance Fund (MHIF)Institutional structures Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government The Kyrgyz health system is centralized at the national level. The Ministry of Health is responsible for health policy, regulation and the oversight of the health care system. Funds collection, pooling, and health purchasing is managed by the Mandatory Health Insurance Fund (MHIF) in the capital city of Bishkek. The MHIF is also responsible for the operations of the financing system, as it is the sole purchasing agency for health services within the Kyrgyz health system. The MHIF is an agency of the MOH responsible for collecting premiums and for funding individual health services in the SGBP and the Additional Outpatient Drug Benefit. The MHIF is responsible for contracting with primary health care providers and hospitals and for paying them for services they provide to enrollees. The Ministry of Health is responsible for creating a unified state policy for the health sector, functioning as the steward of health care in Kyrgyzstan. Under this banner, the MOH has the following responsibilities:
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| Philippines: PhilHealth |
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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. |
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| Thailand: Universal Coverage Scheme |
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UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Read full sectionUCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Furthermore, the NHSO has regional and provincial branch offices to handle beneficiary questions and requests. Governance in the Thai public health insurance system is fragmented. The National Health Security Office manages and oversees the UCS, while the Ministry of Finance and Ministry of Labor oversee the other public insurance schemes as well as the private insurance market. The figure below presents a snapshot of the governance structure of Thai public insurance.
While there are no standardized coding and reporting systems among Thai health care facilities and among insurers, the various public health insurance schemes have joined an initiative to integrate utilization databases among the schemes to develop statistical analysis of utilization activity, planning and monitoring processes. The National Health Security Board has autonomy by law to steer overall management of the scheme. Co-payments, benefits package, standard guidelines, quality standards, contract processes, and payment mechanisms are decided by Board. There is a Standard Board which is responsible to prepare quality standards and oversee beneficiary complaints and grievances. The UCS has its own IT infrastructure. While the clinical information system of the UCS is similar to other schemes, it is not identical. The UCS has also developed specific applications for health facilities to collect data for reimbursement in specific disease management programs (e.g. leukemia, diabetic mellitus, HIV/AIDS, etc.). The UCS also has dedicated customer service facilities including a dedicated call centre. Branch offices and the call centre are available to beneficiaries to answer questions and request. Complaints and grievances are reviewed at branch offices and at the central office. Finally, outstanding grievances are decided in a subcommittee of the Standard Board. The NHSO has regional branches offices and province branch offices to handle beneficiary questions and requests. Universal Coverage SchemeInstitutional structures Key Actors in Insurance Administration: Central Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government
Oversight Responsibility: Central Government UCS is managed and overseen by the National Health Security Office (NHSO), an autonomous agency that was established by the National Health Security Act of 2002. The scheme also has a National Health Security Board within the NHSO, chaired by the Minister of Public Health. Copayments, benefits package, standards guidelines, quality standards, contract processes, and payment mechanisms are all decided by Board. Furthermore, the NHSO has regional and provincial branch offices to handle beneficiary questions and requests. Governance in the Thai public health insurance system is fragmented. The National Health Security Office manages and oversees the UCS, while the Ministry of Finance and Ministry of Labor oversee the other public insurance schemes as well as the private insurance market. The figure below presents a snapshot of the governance structure of Thai public insurance.
While there are no standardized coding and reporting systems among Thai health care facilities and among insurers, the various public health insurance schemes have joined an initiative to integrate utilization databases among the schemes to develop statistical analysis of utilization activity, planning and monitoring processes. The National Health Security Board has autonomy by law to steer overall management of the scheme. Co-payments, benefits package, standard guidelines, quality standards, contract processes, and payment mechanisms are decided by Board. There is a Standard Board which is responsible to prepare quality standards and oversee beneficiary complaints and grievances. The UCS has its own IT infrastructure. While the clinical information system of the UCS is similar to other schemes, it is not identical. The UCS has also developed specific applications for health facilities to collect data for reimbursement in specific disease management programs (e.g. leukemia, diabetic mellitus, HIV/AIDS, etc.). The UCS also has dedicated customer service facilities including a dedicated call centre. Branch offices and the call centre are available to beneficiaries to answer questions and request. Complaints and grievances are reviewed at branch offices and at the central office. Finally, outstanding grievances are decided in a subcommittee of the Standard Board. The NHSO has regional branches offices and province branch offices to handle beneficiary questions and requests. |
