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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| 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. |
| Rwanda: Mutuelles de Sante |
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The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. Read full sectionThe health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels. The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers. In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.
Mutuelles de SanteInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: Mutuelles
Operations Responsibility: District/Local Government, Mutuelles
Oversight Responsibility: Central Government, District/Local Government The health system is organized on a 3-tier pyramid system composed of central, district, and sector levels. The central government is managed by the Ministry of Health (MOH) and is responsible for the stewardship of the Mutuelles program, focusing on policy development, capacity building, monitoring and evaluation of operational programs, and resource mobilization. The central level monitors and coordinates technical and logistic support and training at the district and sector levels. The central level is also in charge of the payment to national tertiary care hospitals. The district level is composed of about 5 sectors, with roughly 250,000-500,000 people each (Rwanda has 30 districts in total), and at least one hospital and secondary care facility. A board of directors governs the district Mutuelle and a permanent salaried agent conduct audits and overviews. At the district level, the Mutuelle Fund manages member premium subsidies and disburses funds to the appropriate district and sector level facilities based on need and service utilization. Districts guide and facilitate the administrative, logistical, technical, and political supervision, training, and management of the sector level Mutuelles. The district level is also responsible for contractual relations with the district hospital, hospital reimbursement, and quality-of-care supervision at the district hospital levels. The sector-level includes roughly 50,000 people, with at least one health center for primary care. Each sector has a Mutuelle that is managed by community elected officials. At the sector level, Mutuelles are owned and privately managed by their members. Sector level Mutuelle organizations adopt a Constitution and By-laws, through which they define the organizational structure, roles and functions of management, and election of organizational leaders. These leaders then determine benefit packages, annual premiums and periodicity of the subscriptions, establish conventions on care and health services, service providers and reimbursement. In addition, these sector-level Mutuelles are responsible for recruitment of members and membership collections, as well as monitoring and evaluation of local health and reimbursing health centers. In 2009 the government created the Rwanda Social Security Board which merges Rwanda Health Insurance Scheme (RAMA) and Military Medical Insurance (MMI) with the Society Security Fund with the objective of improving performance and decision-making.
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| Chile: National Health Fund (FONASA) |
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The National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. Read full sectionThe National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. The Ministry of Health (MOH) exercises many responsibilities within the health system: (1) it formulates, controls, and evaluates general plans and programs within the health sector; (2) it defines national health objectives; (3) it directs all national activities related to the provision of health activities; (4) it establishes general norms relating to technical, administrative, and financial matters within the health sector; (5) it monitors the fulfillment of health norms through the Regional Ministerial Health Secretariats; (6) it evaluates the states of public health issues; and (7) it formulates, evaluates, and implements the Universal Access with Explicit Guarantees (AUGE) plan. The National Health Superintendence was established in 2005 and charged with the responsibility of watching and controlling FONASA and the ISAPREs. Its primary tasks are to license both public and private health providers and to oversee AUGE compliance by both FONASA and the ISAPREs. The Health Insurance Institutions (ISAPREs) are for-profit or non-profit private insurers that must offer a minimum benefits package that is equal to the benefits covered under GES. However, they are free to provide additional coverage to those willing to purchase it.
National Health Fund (FONASA)Institutional structures Key Actors in Insurance Administration: Central Government, State Government
Organization: Centralized
Collections Responsibility: Central Government
Operations Responsibility: Central Government, State Government
Oversight Responsibility: Central Government The National Health Fund (FONASA) is a public insurer responsible for providing health coverage to persons who contribute 7% of their monthly wages as well as to the indigent. FONASA provides health coverage to all its beneficiaries without exclusions based on age, sex, income, number of family members, or preexisting conditions. It is also responsible for financing both the Institutional and Free Election modalities by collecting, administering, and distributing health resources. FONASA also finances the purchase of equipment, instruments, implements and other infrastructure elements that are needed for the public health system. The Ministry of Health (MOH) exercises many responsibilities within the health system: (1) it formulates, controls, and evaluates general plans and programs within the health sector; (2) it defines national health objectives; (3) it directs all national activities related to the provision of health activities; (4) it establishes general norms relating to technical, administrative, and financial matters within the health sector; (5) it monitors the fulfillment of health norms through the Regional Ministerial Health Secretariats; (6) it evaluates the states of public health issues; and (7) it formulates, evaluates, and implements the Universal Access with Explicit Guarantees (AUGE) plan. The National Health Superintendence was established in 2005 and charged with the responsibility of watching and controlling FONASA and the ISAPREs. Its primary tasks are to license both public and private health providers and to oversee AUGE compliance by both FONASA and the ISAPREs. The Health Insurance Institutions (ISAPREs) are for-profit or non-profit private insurers that must offer a minimum benefits package that is equal to the benefits covered under GES. However, they are free to provide additional coverage to those willing to purchase it.
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| Mexico: Seguro Popular |
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Mexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH. Read full sectionMexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH. The function of the Social Protection in Health Regimes (REPSS) at the state level is to integrate and coordinate the network of health care providers in order to guarantee that SP enrollees have access to the services offered under the benefits package. The mechanisms used to control the network of providers are subscription agreements and contracts with public, private, and civil society institutions. The General Health Committee, which is chaired by the Health Minister, includes the leaders of all the public health institutions in Mexico as well as experts in the field, non-governmental organizations, professional associations and the private sector. This Committee is responsible for defining the diseases, treatments, and medications that are covered under the FPGC.
Seguro PopularInstitutional structures Key Actors in Insurance Administration: Central Government, State Government
Organization: Decentralized to state level
Collections Responsibility: State Government
Operations Responsibility: State Government
Oversight Responsibility: Central Government Mexico’s health system is guided by the federal government but operations are decentralized to the state level. Family premiums as well as federal transfers are collected at the state level. The states are also responsible for the provision of health services. Health system oversight is carried out at the national level by the MOH. The function of the Social Protection in Health Regimes (REPSS) at the state level is to integrate and coordinate the network of health care providers in order to guarantee that SP enrollees have access to the services offered under the benefits package. The mechanisms used to control the network of providers are subscription agreements and contracts with public, private, and civil society institutions. The General Health Committee, which is chaired by the Health Minister, includes the leaders of all the public health institutions in Mexico as well as experts in the field, non-governmental organizations, professional associations and the private sector. This Committee is responsible for defining the diseases, treatments, and medications that are covered under the FPGC.
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