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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| 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. |
| 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. |
| Kenya: National Hospital Insurance Fund |
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When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. Read full sectionWhen the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF. Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).
Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations. National Hospital Insurance FundInstitutional structures Key Actors in Insurance Administration: Central Government, District/Local Government
Organization: Decentralized to district/local level
Collections Responsibility: District/Local Government
Operations Responsibility: District/Local Government
Oversight Responsibility: Central Government When the National Hospital Insurance Fund (NHIF) was transformed from a department of the Ministry of Health to a State Corporation, the management of the organization switched to become an all-inclusive board composed of the Permanent Secretary in the Ministry of Health (MOH), Central Organisation of Trade Unions, Directorate of Personnel Management, Kenya National Union of Teachers, Director of Medical Services, Federation of Kenya Employers, Association Kenya Insurers, Christian Health Association of Kenya, Kenya Medical Association and an additional, rotating member of civil society. In all, 2/3 of the board comes from outside of the ranks of the government itself. The NHIF board makes the primary decisions regarding management of NHIF. The Board suggests an annual budget which is then voted on by the National Assembly. The NHIF has decentralized its operations to 31 local branches and 82 service points across the country. These branches are responsible for claims processing and quality assurance, enrollment and collection of premiums (especially from informal sector employees and other ‘voluntary’ enrollees), and marketing of the program. The branches also implement quality programs alongside contracted providers, and execute most of the monitoring and evaluation programs within the NHIF. Since its separation from the MOH, the NHIF is no longer held directly accountable by the MOH. Several new mechanisms for ensuring accountability have been instituted, however. These include the Board’s Audit and Integrity Subcommittee, the Auditor General of the Kenyan Government (which files annual reports to the Parliament on the performance of each government agency, including the NHIF), the NHIF’s Efficiency Monitoring Unit (which handles complaints and performs periodic audits of the operations of the agency) and finally the NHIF Ombudsman (which receives and mediates complaints).
Implementing partners and development partners aid the MOH in implementing health plans by providing services such as funding, specialized care, research, training or health insurance. The majority of them are parastatals who receive a portion of their annual funds from the Government of Kenya and have to raise the other part themselves through cost sharing or other sources, such as the National Hospital Insurance Fund, the Kenyatta National Hospital, and Kenya Medical Research Institute, though they can also be private organizations. |
| 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. |
Source: National Hospital Insurance Fund
The Kenyan health system is administered from the top down by the Ministry of Health (MOH), which was broken into two Ministries after the post-election turmoil of 2007: the Ministry of Medical Services, and the Ministry of Public Health and Sanitation. Kenya has a Sector Wide Approach (SWAp) to coordinate and support the health care system, which incorporates health partners on all levels. The role of the central government is to formulate policy, set priorities, budget and allocate resources, and regulate service provision through a decentralized framework. Provinces, districts and local community areas are increasingly responsible for implementation and day to day management of the health system.