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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| 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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| 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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| 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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| 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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| 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. |
