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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| 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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| Indonesia: Jamkesmas |
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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. |
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| Ghana: National Health Insurance Scheme (NHIS) |
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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.
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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: RSBY |
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Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Read full sectionSeveral stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
RSBYInstitutional structures Key Actors in Insurance Administration: Central Government, State Government, Commercial insurers, NGOs
Organization: Decentralized to state level
Collections Responsibility: State Government, Commercial insurers
Operations Responsibility: Commercial insurers
Oversight Responsibility: Central Government, State Government Several stakeholders are involved in the oversight and execution of RSBY at both the national and state levels. A key actor in the administration of the scheme is the insurer. The insurer must cover the benefit package designed by the central MoLE through a cashless facility. Additionally, it acts as an intermediary between RSBY and local organizations in order to provide grassroots outreach and assist members in utilizing the services after enrollment. Once a state has agreed to implement RSBY, a nodal department is selected by the State. The nodal department designate sets up a nodal agency which is responsible for implementing RSBY. The nodal agency seeks bids from registered public or private insurance companies. The financial bid is essentially an annual premium per enrolled household. Technically qualified insurer(s) with the lowest bid is/are selected as the state’s RSBY insurer. A state can seek bids from multiple insurers for various districts. Selected insurers are compensated on the basis of the number of SmartCards issued (i.e. households covered). Each contract is specified on the basis of an individual district in a state, with the insurer agreeing to set up an office in each district where it operates. While more than one insurer can operate in a particular state, only one insurer can operate in a single district at any given point in time. The use of a cashless facility in turn requires the use of SmartCards which must be issued to all members. This requires that a sub-contract be arranged with a qualified Third Party Administrator/SmartCard provider. The insurer must also agree to engage intermediaries with local presence (e.g., NGOs) in order to provide grassroots outreach and assist members in utilizing the services after enrollment. The insurer must also build a list of empanelled hospitals that will participate in the cashless arrangement. These hospitals must meet certain basic minimum requirements (e.g., size and registration) and must agree to set up a special RSBY desk with SmartCard and fingerprint readers and train the hospital staff. The list should include public and private hospitals. The insurer must also establish a separate Project Office for implementing the scheme and coordinating activities with the state nodal agency in the state capital. The insurer will have appropriate people in their own/TPA, state, and district offices to perform the following functions:
As of January 2010, eleven public and private insurance companies were engaged in insuring RSBY beneficiaries across 23 states. Since in the initial phases of RSBY, the focus was on stabilizing processes and operations, insurer contracts were set for one year. Now that processes and basic operations have been ironed out and stabilized, the contract period has been extended to a maximum period of three years. However, even three year contracts are subject to annual renewal based on insurer performance, with annual performance goals defined by the government at the time of initial contract signing. The table below summarizes the roles and responsibilities of all organizations involved in operationalizing RSBY at the state and national level:
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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. |
