The Joint Learning Network 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.
Use the compare reforms feature below to view comparable technical information across multiple programs at once. Select a reform element to the right, and filter the selection of countries and programs using the selection list.
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.
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.
General System of Social Security in Health
Institutional structures
Commercial insurers
Centralized
Commercial insurers
Commercial insurers
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.
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.
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:
National Soc Sec Council (DJSN)
National government agencies (MoH, MoF, MoHA, Menkokesra, Bappenas)
Provincial and district governments
Providers of care
Insurer/TPA (Askes/
Jamsostek)
Oversight of scheme
X (LR)
X (SR)
Financing scheme
X
X
Setting parameters (benefits package, definitions of poor, etc.)
X (LR)
X (SR)
Accreditation/Empanelment of providers
X
X
Enrollment
X
X
X
Financial management/planning
X (LR)
X (SR)
Actuarial analysis
X (LR)
Setting rate schedules for services/reimbursement rates
X (LR)
X (SR)
Claims processing and payment
X (Under Review)
X
X (District level)
Outreach, Marketing to beneficiaries
X
Service delivery
X
Developing clinical information system for monitoring/eval
X (LR)
X (SR)
Monitoring local-level utilization and other patient information
X (LR)
X (SR)
Monitoring national aggregate information
X (LR)
Customer service
X
X
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.
Jamkesmas
Institutional structures
Central Government, District/Local Government, Commercial insurers
Decentralized to district/local level
District/Local Government
Central Government, District/Local Government
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:
National Soc Sec Council (DJSN)
National government agencies (MoH, MoF, MoHA, Menkokesra, Bappenas)
Provincial and district governments
Providers of care
Insurer/TPA (Askes/
Jamsostek)
Oversight of scheme
X (LR)
X (SR)
Financing scheme
X
X
Setting parameters (benefits package, definitions of poor, etc.)
X (LR)
X (SR)
Accreditation/Empanelment of providers
X
X
Enrollment
X
X
X
Financial management/planning
X (LR)
X (SR)
Actuarial analysis
X (LR)
Setting rate schedules for services/reimbursement rates
X (LR)
X (SR)
Claims processing and payment
X (Under Review)
X
X (District level)
Outreach, Marketing to beneficiaries
X
Service delivery
X
Developing clinical information system for monitoring/eval
X (LR)
X (SR)
Monitoring local-level utilization and other patient information
X (LR)
X (SR)
Monitoring national aggregate information
X (LR)
Customer service
X
X
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.
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.
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
Committee
Role
Composition
Operating procedures
Pilot Phase Steering and Monitoring Committee (CPSPP) at the national level
Strategic management and decision-making that contribute to achieving the following goals:
Validate the annual development operating plans for the Mutuelle system, including the financial framework
Recruit the implementation agencies
Raise the funds needed to implement the strategy
Assess the results of the activities carried out under this strategy
Give orientation and instructions to achieve the strategy’s results
Chairs - Secretaries General MDSSPA, MS, MPFEF
Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles
The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health
National level Technical Committee (TC)
Technical coordination of activities carried out under the Strategy Pilot:
Validate the training materials
Validate the Mutuelle management tools
Validate the communication plan
Assess the investment requirements
Assess the results of activities carried out as part of this strategy
Send the assessment of the results achieved to the CPSPP
Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
Chair - DNPSES Director
Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles
The TC meets at least three times a year and reports on its work to the CPSPP
Regional Monitoring Committee (CSR)
Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:
Facilitate the implementation of scheduled activities
Mobilize local resources
Assess the results of the activities carried out under this strategy
Send the evaluation of the results to the TC
Propose to the TC all the corrections it deems necessary to help achieve the objectives
Chair - Governor
Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks)
The CSR meets at least four times a year and reports on its work to the TC
District Monitoring Committee (CSL)
Monitoring of the activities planned under the strategy at the district level:
Facilitate the implementation of the scheduled activities
Mobilize local resources
Assess the results of the activities carried out under this strategy
Submit the evaluation of the results to the CSR
Propose to the CSR all the corrections it deems necessary to help achieve the objectives
Chair - District prefect
Members -
Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks)
The CSL meets at least four times a year and reports to the CSR on its work
Communal Monitoring Committee (CSC)
Monitoring of the status of strategy implementation at the commune level:
Report on the status of implementation of the planned activities
Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
Report to the CSL
Chair - Mayor(s)
Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils
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
Body and system
Role
Representation
Board of directors (RAMED and AMO)
Adopt the budget and annual activities program
Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
Authorize the implementing regulations for the system
Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
Determine the organization of the Fund or the Agency
Approve the financial statements for the fiscal year and the report on the MD’s activities
Approve other investment and real estate transactions and real estate guarantees
AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM
RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM
Managing Director (RAMED and AMO)
Manage, coordinate, lead and oversee all CANAM or ANAM activities
MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection
Delegated management bodies (AMO)
Collect dues
Pay for care services
The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS)
Source: Ministry of Social Protection
Mutuelles
Institutional structures
Central Government, District/Local Government, Mutuelles
Decentralized to district/local level
Mutuelles
Mutuelles
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
Committee
Role
Composition
Operating procedures
Pilot Phase Steering and Monitoring Committee (CPSPP) at the national level
Strategic management and decision-making that contribute to achieving the following goals:
Validate the annual development operating plans for the Mutuelle system, including the financial framework
Recruit the implementation agencies
Raise the funds needed to implement the strategy
Assess the results of the activities carried out under this strategy
Give orientation and instructions to achieve the strategy’s results
Chairs - Secretaries General MDSSPA, MS, MPFEF
Members - CPS/SSDSPF, DNS, DNPSES, DNDS, APCAM, APCMM, CCIM, CNC, AMM, UTM, DNI, HCCT, DNB, ANAM, CANAM, FENASCOM, Health professional associations, technical and financial partners, National Federation of Mutuelles
The Committee meets twice a year and reports on its work to the Ministers of Social Protection and Health
National level Technical Committee (TC)
Technical coordination of activities carried out under the Strategy Pilot:
Validate the training materials
Validate the Mutuelle management tools
Validate the communication plan
Assess the investment requirements
Assess the results of activities carried out as part of this strategy
Send the assessment of the results achieved to the CPSPP
Submit all the corrections it deems necessary to promote achieving the objectives to the CPSPP
Chair - DNPSES Director
Members - DNDS, DNPSES, CPS, DNS, UTM, CAMASC, DNB, AMM, National Federation of Mutuelles
The TC meets at least three times a year and reports on its work to the CPSPP
Regional Monitoring Committee (CSR)
Monitoring of the activities that are planned under the strategy at the regional level. All the technical parameters, the draft laws and the organizing of unions of district Mutuelles are determined and the Local (District) Monitoring Committee is fully involved:
Facilitate the implementation of scheduled activities
Mobilize local resources
Assess the results of the activities carried out under this strategy
Send the evaluation of the results to the TC
Propose to the TC all the corrections it deems necessary to help achieve the objectives
Chair - Governor
Members - Decentralized government units (Finances, Social Development and Health), Regional Assembly, Regional Federation of Mutuelles, FERASCOM, cooperatives, women’s associations and decentralized financing systems (microfinance networks)
The CSR meets at least four times a year and reports on its work to the TC
District Monitoring Committee (CSL)
Monitoring of the activities planned under the strategy at the district level:
Facilitate the implementation of the scheduled activities
Mobilize local resources
Assess the results of the activities carried out under this strategy
Submit the evaluation of the results to the CSR
Propose to the CSR all the corrections it deems necessary to help achieve the objectives
Chair - District prefect
Members -
Decentralized government units (Finance, Social Development and Health), District Council, District Federation of Mutuelles, FELASCOM, agricultural cooperatives, women’s associations and decentralized financing systems (microfinance networks)
The CSL meets at least four times a year and reports to the CSR on its work
Communal Monitoring Committee (CSC)
Monitoring of the status of strategy implementation at the commune level:
Report on the status of implementation of the planned activities
Make decisions to remove the obstacles that prevent the communal Mutuelle from working properly
Report to the CSL
Chair - Mayor(s)
Members - Decentralized technical entities, ASACO, Communal health Mutuelle, local NGOs, village councils
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
Body and system
Role
Representation
Board of directors (RAMED and AMO)
Adopt the budget and annual activities program
Determine the annual qualitative and quantitative Objectives that the CANAM or the ANAM is to achieve
Authorize the implementing regulations for the system
Authorize the Managing Director (MD) to sign all the contracts and conventions that are binding on CANAM or ANAM for a period longer than 24 months (for CANAM) or that exceed CFAF 10 million (for ANAM)
Determine the organization of the Fund or the Agency
Approve the financial statements for the fiscal year and the report on the MD’s activities
Approve other investment and real estate transactions and real estate guarantees
AMO - Ministry of Social Protection, Ministry of Finance, Ministry of the Civil Service, Ministry of Health, Ministry of Defense, Associations of employers, workers, retires, MPs, and CANAM
RAMED - Ministry of Social Protection, Ministry of Finance, Ministry of National Administration, Ministry of Health, High Council of Territorial Governments, Association of District and Regional Governments of Mali, Association of Municipalities of Mali, National Federation of Community Health Associations (FENASCOM), ANAM
Managing Director (RAMED and AMO)
Manage, coordinate, lead and oversee all CANAM or ANAM activities
MD appointed by a decree of the Council of Ministers based on a proposal from the Minister of Social Protection
Delegated management bodies (AMO)
Collect dues
Pay for care services
The Mali Social Security Fund (CMSS) and the National Social Welfare Institute (INPS)
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.
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:
Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
Setting rate schedules for services/reimbursement rates
X
Claims processing and payment
X
X
Outreach, Marketing to beneficiaries
X
X
X
Service delivery
X
Developing clinical information system for monitoring/eval
X
X
Monitoring utilization and other patient information
X
X
Customer service
X
X
X
Rajiv Aarogyasri
Institutional structures
Centralized
State Government
State Government, Commercial insurers
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:
Aarogyasri Healthcare Trust: The Trust is responsible for oversight of the entire insurance program as well as some important administrative functions such as setting benefits and pricing, managing contracts with insurer(s) and in-network providers, approving claims, and monitoring.
Insurer: The insurer is selected based on a competitive bidding process to bear risk and manage all back-end insurance administration, including claims processing, reimbursements to providers, oversight of hospitals. The Insurer is also responsible for holding health camps in villages to screen, diagnose, treat, and make beneficiaries aware of any health problems they might have; health camps are also used to enroll eligible beneficiaries.
Network hospitals: Network hospitals provide care to Aarogyasri beneficiaries.
Aarogya Mithras: Aarogya Mithras are patient advocates and assist Aarogyasri beneficiaries to navigate through the system and ensure beneficiaries receive quality care. Aarogya Mithras are also responsible for community outreach.
The table below summarizes the roles and responsibilities of all of the organizations involved in operationalizing Aarogyasri:
