OIT - Universal Health Insurance Schemes - A comparative analysis of implementation features in 10 low- and middle-income countries

X Universal Health Insurance Schemes A comparative analysis of implementation features in 10 lowand middle-income countries Authors / Martina Bergthaller, Lou Tessier

December / 2025 ILO Working Paper 156© International Labour Organization 2025 Attribution 4.0 International (CC BY 4.0) This work is licensed under the Creative Commons Attribution 4.0 International. See: https:// creativecommons.org/licenses/by/4.0/. The user is allowed to reuse, share (copy and redistribute), adapt (remix, transform and build upon the original work) as detailed in the licence. The user must clearly credit the ILO as the source of the material and indicate if changes were made to the original content. Use of the emblem, name and logo of the ILO is not permitted in connection with translations, adaptations or other derivative works. Attribution – The user must indicate if changes were made and must cite the work as follows: Bergthaller, M., Tessier, L. Universal Health Insurance Schemes: A comparative analysis of implementation features in 10 lowand middle-income countries. ILO Working Paper 156. Geneva: International Labour Office, 2025.© ILO. Translations – In case of a translation of this work, the following disclaimer must be added along with the attribution: This is a translation of a copyrighted work of the International Labour Organization (ILO). This translation has not been prepared, reviewed or endorsed by the ILO and should not be considered an official ILO translation. The ILO disclaims all responsibility for its content and accuracy. Responsibility rests solely with the author(s) of the translation. Adaptations – In case of an adaptation of this work, the following disclaimer must be added along with the attribution: This is an adaptation of a copyrighted work of the International Labour Organization (ILO). This adaptation has not been prepared, reviewed or endorsed by the ILO and should

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Authorization for publication: Shahrashoub Razavi, Director of SOCPRO ILO Working Papers can be found at: www.ilo.org/research-and-publications/working-papers Suggested citation: Bergthaller, M., Tessier, L. 2025. Universal Health Insurance Schemes: A comparative analysis of implementation features in 10 lowand middle-income countries, ILO Working Paper 156

(Geneva, ILO). https://doi.org/10.54394/PLHO130601 ILO Working Paper 156 Abstract Reaching universal health coverage is a central objective of social protection systems. Countries can choose a variety of mechanisms to secure the right to social health protection for all. This report focuses on those countries that have chosen a universal health insurance model. More specifically, while a range of publications have explored the design of such schemes, published literature on implementation modalities used in low and middle-income countries is scarce. Notably, the documentation and comparative analysis of practical processes through which vulnerable groups – such as the poor or those working in the informal economy and their families - can successfully be integrated into such schemes. This work draws on case studies spanning ten lowand middle-income countries. The analysis highlights that the unique historical trajectories and socio-economic context of each country have shaped distinct approaches to the design and delivery of universal health insurance schemes.

Key words: health insurance, social health protection, social protection, universal health coverage, public health, informal economy, informal employment About the authors

socio-economic context of each country have shaped distinct approaches to the design and delivery of universal health insurance schemes.

Key words: health insurance, social health protection, social protection, universal health coverage, public health, informal economy, informal employment About the authors Martina Bergthaller is an independent social policy expert with over 15 years of experience in social protection and employment promotion. She began her career at the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH, where she worked as an advisor on strengthening social protection systems. Since 2017, she has been an independent consultant contributing to: policy advisory and capacity-building initiatives, social protection extension strategies to vulnerable populations and workers in the informal economy, comparative policy research and the facilitation of peer-to-peer learning in international knowledge exchange. She holds Master’s degrees in Development Studies and Political Science from the University of Vienna and in Comparative Social Policies and Welfare (COSOPO) from the Johannes Kepler University Linz and the University of Tampere.

Lou Tessier is a Health Protection Specialist at the Universal Social Protection Department of the International Labour Organization (ILO). Lou started her career supporting the development of community-based health insurance (CBHI) in West Africa before joining Deloitte advisory services to the national health insurance system in France. Lou joined the ILO in 2011 in support of the adoption of Recommendation No. 202 on Social Protection Floors and has subsequently occupied various positions on social protection and occupational safety and health in headquarters and in the field, particularly in Asia. Lou holds an MSc in international law and economics from Sciences Po Lyon, an MBA from ESSEC Business School and an MPH (Global Health) from the University of Manchester.02 ILO Working Paper 156 Abstract 01 About the authors 01 Acronyms 07 X Introduction 10 Social health protection 10 Scope of the study and conceptual framework 14 X 1 A diversity of contexts and scheme designs across the ten countries 21 Poverty, vulnerability and the labour market 21 Trajectories towards social health protection coverage extension 24

Acronyms 07 X Introduction 10 Social health protection 10 Scope of the study and conceptual framework 14 X 1 A diversity of contexts and scheme designs across the ten countries 21 Poverty, vulnerability and the labour market 21 Trajectories towards social health protection coverage extension 24 Main design features of UHI schemes 28 X 2 Administrative modalities to implement universal health insurance schemes 48 Outreach 49 Identification and determination of eligibility 50 Registration, enrolment and beneficiary management 54 Contribution collection (when applicable) 57 Registration and contribution collection compliance 61 Access to healthcare benefits 62 Complaint and grievance management 63 Monitoring coverage, utilization, financial protection and beneficiary satisfaction to improve coverage and retain beneficiaries 64 X Conclusion 67 Annex 1 69 Colombia 69 Costa Rica 81 Indonesia 94 Kazakhstan 106 Lao PDR 117 Morocco 126 Philippines 137 Rwanda 148 Türkiye 160 Table of contents03 ILO Working Paper 156 Viet Nam 173 Annex 2 185 References 186 Acknowledgements 18904 ILO Working Paper 156 List of Figures Figure 1. Proportion of the population protected by social health protection (protected persons), regional estimates, 2023 or latest year available 12 Figure 2. National health insurance administrative interface with beneficiaries 4905 ILO Working Paper 156 List of Tables Table 1. Guiding principles from international social security standards related to social health protection 10 Table 2. Key indicators related to poverty 23 Table 3. Key indicators related to the labour force 23 Table 4. National health insurance coverage and effective access without hardship 24 Table 5. Personal scope of coverage 30 Table 6. Overview of benefit designs 32 Table 7. A financing mix to guarantee access to all 41 Table 8. Overview of contribution levels 44

Table 4. National health insurance coverage and effective access without hardship 24 Table 5. Personal scope of coverage 30 Table 6. Overview of benefit designs 32 Table 7. A financing mix to guarantee access to all 41 Table 8. Overview of contribution levels 44 Table 9. Monitoring coverage, utilization, financial protection and beneficiary satisfaction 6506 ILO Working Paper 156 List of Boxes Box 1. International social security standards and the extension of social health protection coverage 15 Box 2. Means-tested schemes 17 Box 3. Defining the informal sector and informal employment 19 Box 4. Reducing fragmentation in Indonesia 25 Box 5. The creation of the National Health Insurance in Lao PDR 26 Box 6. Universalization of health insurance in Viet Nam 26 Box 7. Progressive integration of schemes in Costa Rica 26 Box 8. Understanding Viet Nam’s high out-of-pocket spending 28 Box 9. Philippines: Legal coverage of Overseas Foreign Workers (OFW) 29 Box 10. Morocco: Legal coverage of family members 29 Box 11. Differences in entitlements across population groups in Indonesia 38 Box 12. Benefits under the national health insurance of Türkiye 38 Box 13. Viet Nam: Co-payment levels of different membership categories 39 Box 14. The inclusion of private providers within the network under national health insurance in Colombia 40 Box 15. Balance billing in Vietnam and the Philippines 40 Box 16. Kazakhstan: Full contribution subsidy for vulnerable population categories 42 Box 17. Fully subsidized health insurance for the whole population outside formal employment outside of Vientiane capital in Lao PDR 42 Box 18. Adapting to different groups of workers in precarious working conditions in Costa Rica 46 Box 19. Rwanda: Contributions rates and funding sources for the Community-Based Health Insurance (CBHI) scheme 46 Box 20. Contribution levels in Indonesia 47 Box 21. Social registries 51 Box 22. Community-based classification in Rwanda 53

Box 19. Rwanda: Contributions rates and funding sources for the Community-Based Health Insurance (CBHI) scheme 46 Box 20. Contribution levels in Indonesia 47 Box 21. Social registries 51 Box 22. Community-based classification in Rwanda 53 Box 23. The SISBEN in Colombia 53 Box 24. Categorical targeting in Kazakhstan 54 Box 25. Support to registration for workers outside of formal employment and non-subsidized populations in Indonesia 56 Box 26. Automatic registration into national health insurance for groups enrolled via other administrations in Vietnam 57 Box 27. Flexible contribution payment schedule in the Philippines 59 Box 28. Collective payment in Rwanda 59 Box 29. Mobile registration in Rwanda 60 Box 30. Complaint management in Türkiye 6407 ILO Working Paper 156 Acronyms ASEAN Association of Southeast Asian Nations CBHI Community-based health insurance CHE Current health expenditure CIS Commonwealth of Independent States COP Colombian peso COVID-19 Coronavirus disease CRC Costa Rican Colón CSR Corporate Social Responsibility (Indonesia) EAEU Eurasian Economic Union ESCWA United Nations Economic and Social Commission for Western Asia FCU5 Free treatment for children under 5 years of age (Lao PDR) FMAT Free maternal treatment (Lao PDR) GDP Gross domestic product HDI Human Development Index (United Nations Development Programme) HEF Health Equity Fund (Lao PDR) HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome IDR Indonesian rupiah ILO International Labour Organization KZT Kazakhstani tenge LAK Lao kip Lao PDR Lao People's Democratic Republic LIC Low-income country LMIC Low and lower-middle income country LSSO, or SSO (Lao) Social Security Office (Lao PDR)08 ILO Working Paper 156 MAD Moroccan dinar MDG Millennium Development Goal MFI Microfinance institution MoH Ministry of health MSE Microand small enterprise MSME Micro-, smalland medium-sized enterprise

LSSO, or SSO (Lao) Social Security Office (Lao PDR)08 ILO Working Paper 156 MAD Moroccan dinar MDG Millennium Development Goal MFI Microfinance institution MoH Ministry of health MSE Microand small enterprise MSME Micro-, smalland medium-sized enterprise NCD Non-communicable disease NGO Non-governmental organization NHI National health insurance NSSF National Social Security Fund (Lao PDR) OECD Organisation for Economic Co-operation and Development OOP Out-of-pocket PHP Philippine peso PPP Purchasing power parity RWF Rwandan franc SDG Sustainable Development Goal SHI Social health insurance SHP Social health protection UHC Universal health coverage UHI Universal health insurance UN United Nations UNGA United Nations General Assembly UNHCR Office of the United Nations High Commissioner for Refugees UNICEF United Nations Children's Fund US$ United States dollar USP Universal social protection09 ILO Working Paper 156 WHO World Health Organization10 ILO Working Paper 156 X Introduction Reaching universal health coverage (UHC) is a central objective of social protection systems. Social health protection is a stepping stone towards realizing human rights to both health and social security. Effective access to quality healthcare without hardship, including maternity care, and income security in case of sickness are at the heart of International Social Security Standards, and are highlighted as the first guarantee of universal social protection floors as part of comprehensive social protection systems. This systemic approach aims at preserving health and addressing the multiple dimensions of financial protection in case of illness, encompassing direct healthcare and non-healthcare costs as well as income loss due to sickness and care seeking. It also calls for institutional coordination, which is indispensable for effectively addressing key determinants of health equity. Social health protection Definition Social health protection includes a series of public or publicly organized and mandated private measures to achieve effective access to affordable healthcare services and adequate sickness benefits for all. Both are supportive of the objective of universal health coverage (UHC). The second political declaration of the United Nations General Assembly (UNGA) on UHC, adopted in

Social health protection includes a series of public or publicly organized and mandated private measures to achieve effective access to affordable healthcare services and adequate sickness benefits for all. Both are supportive of the objective of universal health coverage (UHC). The second political declaration of the United Nations General Assembly (UNGA) on UHC, adopted in September 2023, recognizes the fundamental importance of “social protection mechanisms […] to ensure universal and equitable access to quality health services without financial hardship for all people”(UN 2023). The Sustainable Development Goal (SDG) targets on UHC (3.8) and USP (1.3) are synergetic priority measures aimed at achieving a healthy and dignified life for all. X Table 1. Guiding principles from international social security standards related to social health protection Principle Explanation Universality of protection Health and social security are human rights and as such, should be guaranteed to all persons, leaving no one behind. Diversity of approaches and progressive realization Diverse arrangements can exist for the financing, purchasing and provision of healthcare as long as they respect the guiding principles. Progressive realization recognizes that not all governments can mobilize the needed resources to comply immediately with international standards. It requires governments to take effective measures to gradually establish, as a matter of priority, a USP floor by mobilizing the maximum of available resources and continue to increase available resources to guarantee the higher levels of health and social security to as many people as possible as quickly as possible, while refraining from retrogressive measures. Risk-sharing and solidarity in financing Collectively financed mechanisms to cover the costs of healthcare, maternity and sickness are promoted because they generate positive redistributive effects and transfer the financial and labour market risks onto society rather than individuals11 ILO Working Paper 156

Principle Explanation Overall and primary responsibility of the State The State is responsible to respect, protect and fulfil the right to health and social security in line with international human rights. ILO standards impose on the State the overall and primarily responsibility for the proper administration of health care, maternity and sickness schemes and the due provision of these benefits. This includes ensuring the financial sustainability, revenue collection, pooling and purchasing of health services as well as health service provision. Adequacy of benefits Both medical care (including maternity care) and cash sickness and maternity benefits need to be adequate and meet the needs of all persons in terms of the range, scope and quality of the benefits provided, as well as financial protection in line with the minimum benchmarks set out in international standards. Specific criteria related to health care include accessibility, availability, acceptability and good quality. Predictability of benefits The national legal framework establishes the benefits and ensures necessary financial resources are secured so that benefits and services are delivered in the prescribed situations and conditions. Non-discrimination, gender equality and social inclusion Design of SHP systems should ensure non-discrimination, gender equality and responsiveness to special needs. Fiscal and economic sustainability with regards to social justice and equity The SHP system has the capacity to bear the costs of its operation in the country context, while ensuring equity and is regulated through a comprehensive accountability framework. Participation, social dialogue and accountability Governance structures include tripartite representation and dialogue with protected persons and employers, consultation mechanisms with other relevant and representative organizations of persons concerned as well as efficient and accessible complaint and appeal procedures within accountability framework. Integration within comprehensive social protection systems SHP should be an integral part of coordinated, coherent and comprehensive social protection systems. Social health protection coverage globally Coverage of the population An analysis of the legal framework of 164 countries shows that 83.6 per cent of their population have a right to access a range of healthcare services for free or with limited co-payments. The

tection systems. Social health protection coverage globally Coverage of the population An analysis of the legal framework of 164 countries shows that 83.6 per cent of their population have a right to access a range of healthcare services for free or with limited co-payments. The proportion was less than two thirds in low-income countries, providing a clear illustration of uneven legal coverage across country income groups. Furthermore, some regions rely on voluntary mechanisms and/or employer’s liability rather than mandatory or automatic mechanisms, which are more robust in providing effective protection. Almost two thirds of the global population is effectively protected by a scheme, already showing a gap in implementation of the legal guarantees put in place by many countries. Lowand lower-middle income countries (LMICs) as well as the regions of Sub-Saharan Africa and Southern Asia experience the largest gaps between legal coverage and effective protection, pointing to difficulties in enforcing legal frameworks and giving effect to people’s rights in practice. The global coverage rate has stalled, with almost no progress since 2020. Coverage varies strongly across country income groups, showing stark inequalities and an uneven trend between 2020 and 2023, and indeed, coverage in low-income countries (LICs) has even decreased (figure 1). More than four in five persons in LICs are left unprotected and Southern Asia and Sub-Saharan Africa remain far below global averages.12 ILO Working Paper 156 X Figure 1. Proportion of the population protected by social health protection (protected persons), regional estimates, 2023 or latest year available1

Source: Based on data from ILO Social Security Inquiry and OECD Health Statistics 2023 national administrative data published in official reports, information from regular national surveys of target populations on awareness on rights. 1 Based on data collected for 127 countries and territories representing over 90 per cent of the world’s population. Regional estimates are weighted by the total population. It represents the best estimate of people protected by a healthcare scheme for their primary coverage. Mechanisms include national health insurance; social health insurance mandated by the State (including subsidized cov1 Based on data collected for 127 countries and territories representing over 90 per cent of the world’s population. Regional estimates are weighted by the total population. It represents the best estimate of people protected by a healthcare scheme for their primary coverage. Mechanisms include national health insurance; social health insurance mandated by the State (including subsidized coverage for the poor); national healthcare service guaranteed for free or with small co-payments; and other programmes (user fee waivers, vouchers, etc.). 202 schemes for primary coverage were identified and included. This is substantially more than in 2020, therefore in order to generate trends the 2020 estimates were recalculated including the new countries and schemes for which data points are available in both periods. Only public or publicly mandated privately administered primary healthcare schemes were included. Supplementary public and private programmes were not included.13 ILO Working Paper 156

Adequacy Over the past decades, major developments in the area of social health protection have given rise to an increasing number of people being protected. Extending social health protection requires the establishment of national legislations that ensure a legal entitlement to access healthcare without financial hardship, in line with human rights instruments and international social security standards. However, translating these legal entitlements into effective access often faces practical challenges. Many barriers can remain, compromising adequacy: ● The availability, accessibility, acceptability and quality of healthcare services may be poor, not allowing effective access in practice or access to a level that would allow improvements in health status. ● Benefit packages may be limited, covering few services and leaving patients to cover high out-of-pocket (OOP) expenses. ● High official co-payments or informal payments may be requested, leaving an important share of the total costs of care to be borne by patients. Despite the adoption of a dedicated SDG on health and well-being, more than four decades after the Declaration of Alma-Ata on Primary Healthcare (PHC), over half of the world’s population do not receive essential health services when they need them, with large disparities evident across countries (WHO and World Bank 2023). One billion people worldwide faced catastrophic health

the Declaration of Alma-Ata on Primary Healthcare (PHC), over half of the world’s population do not receive essential health services when they need them, with large disparities evident across countries (WHO and World Bank 2023). One billion people worldwide faced catastrophic health spending in 2019, defined as OOP expenditures exceeding 10 per cent of total yearly household consumption or income, posing a major poverty risk. Significant disparities across regions and country income groups remain (WHO and World Bank 2023). Globally, the share of the global population who faced catastrophic health expenditures – exceeding 10 per cent of household income or consumption – has risen by almost four percentage points between 2000–2022, with a particularly pronounced increase in middle-income countries (WHO and World Bank 2023). At the same time, low catastrophic health spending and more broadly low OOP could stem from forgone care which is rooted in insufficient service coverage and/or additional barriers, rather than being the result of improved financial protection. This reinforces the need to analyse all dimensions of coverage in tandem and to pay particular attention to the adequacy of social health protection coverage (ILO 2021c). Institutional and financing arrangements for social health protection According to ILO standards, social health protection can encompass a wide variety of institutional and financial arrangements. It can be financed through social security contributions from workers, employers and government, by general government revenues coming from taxes and other revenues, and by a combination of these sources. Social health protection can be the mandate of: ● a national health service, where services are financed and provided for free or with minimal user fees directly by the Ministry of Health; ● a national/social health insurance, where an autonomous institution pools revenues from social security contributions and government transfers and is in charge of purchasing healthcare services on behalf of the population; or ● a mix of those arrangements, with a large array of options for centralization/decentralization, concentration/fragmentation of programmes, etc. In practice the two first options are very rarely encountered in their ‘pure form‘ and mixed arrangements are prevalent. Various regional reviews of financing and institutional arrangements for

● a mix of those arrangements, with a large array of options for centralization/decentralization, concentration/fragmentation of programmes, etc. In practice the two first options are very rarely encountered in their ‘pure form‘ and mixed arrangements are prevalent. Various regional reviews of financing and institutional arrangements for social health protection have shown that those are poor predictors of outcome and that, rather,14 ILO Working Paper 156 the respect of core principles in line with ILO standards, political will and financial commitments are decisive factors (ILO 2021c, 2024a; ILO, forthcoming). To extend social health protection, countries have adopted different types of measures, such as: ● Universal approaches: ● National health services free at the point of care in public facilities. This is the case, for instance, in Malaysia or Brunei. ● National Health Insurance combining different contributory and non-contributory entry points for different categories of populations. For example, Costa Rica, Indonesia, the Philippines, Türkiye and Viet Nam have adopted such a strategy. In some countries, this is achieved through different schemes managed by different institutions for different populations groups, such as in Thailand. ● In a smaller number of countries, mandatory private health insurance for the entire resident population with non-contributory entry points for vulnerable populations. ● Categorical and targeted approaches: ● User fee waivers/exemptions or non-contributory health insurance for specific categories of the population. For instance, in India a scheme has been created to cover specifically people below the poverty line, in Niger user fee waivers are applied to pregnant women and children under 5. ● User fee waivers or vouchers for specific health interventions. For instance, in Kenya, Madagascar and many other countries, such mechanisms have been put in place for maternal and child health interventions, tuberculosis, malaria or HIV. ● Dedicated contributory social health insurance schemes are in place for specific groups, for instance in Togo (with the initial creation of a mandatory social health insu