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 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Estonia: Estonian Health Insurance Fund |
|
|
|
|
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. |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Colombia: General System of Social Security in Health |
|
|
|
|
|
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. |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Chile: National Health Fund (FONASA) |
|
|
|
|
|
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.
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Nigeria: National Health Insurance System |
|
|
|
|
|
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. |
