Medical Health Insurance Systems in Asia

Medical Health Insurance Systems in Asia
Yoriko Matsuoka,Kakuhiro Fukai
Fukai Institute of Health Science

Abstract: Aging is a natural biological process which increases the risk of disease, thereby requiring medical care. This is now a global phenomenon with an urgent public health challenge and continues
to accelerate rapidly. To confront this challenge, the United Nations has recommended Universal
Health Coverage (UHC), adopted in all countries by 2030, as one of its Sustainable Development
Goals (SDGs). In fact, however, there is a great variation of the pace at which different countries
are moving toward the goal of UHC for all people. Most Asian countries are struggling to achieve
this goal with rapid progressing of aging and low birthrate and often insufficient resources.
This report focuses on the medical health insurance systems in Asian countries with a large number of elderly people. We summarize the characteristics and challenges of the health insurance
systems and classification of financial resources of medical health insurance, based on research
reports and government records in 2008 to 2018. It is necessary to develop country-specific variations of UHC, and this can best be completed by sharing information and incorporating the mostuseful aspects of mutual nation’s system. This process would contribute to the goal of establishing
UHC on a global scale, not limited in Asia.
Key words : Universal Health Coverage, low birthrate, aging, medical health insurance
Introduction

Monitoring Report written by World Health Orga-

Everyone should be equal wherever one is bornnization and the World Bank,“at least half thein the world, but there are health disparities evenworld’
s population still lacks access to essential

in the same country or different environment

health services. Furthermore, some 800 million

where they are born. According to the 2017 Global

people spend more than 10 per cent of their household budget on health care, and almost 100 million
people are pushed into extreme poverty each year

【著者連絡先】〒341-0003 埼⽟県三郷市彦成 3-86
深井⻭科医院・深井保健科学研究所
松岡順⼦
TEL&FAX:048-957-3315
E-mail:yorikom@wg8.so-net.ne.jp
受付⽇:2018 年 7 ⽉ 1 ⽇ 受理⽇:2018 年 8 ⽉ 10 ⽇

because of out-of-pocket health expenses1).
”Underthe condition, Universal Health Coverage (UHC)with core of right for health is aiming to achieve
that“every individual and community, irrespective of their circumstances, should receive thehealth services they need without risking financial
̶ 20 ̶

ヘルスサイエンス・ヘルスケア Volume 18,No.1(2018)of 10 to 30 years, aging will be faster in Asian

hardship1).
”
In the Sustainable Development Goals (SDGs)

countries17,18).

adopted at the United Nations Summit in 2015, theTotal fertility rate (TFR) fell below the popula-

UHC promotion was raised in the Goal 3 (healthtion replacement level 2.1 to 1.3 in Singapore, 1.5 inand welfare). As of now, the degree of its achieve-

Thailand, 1.6 in China, 2.0 in Malaysia and Viet

ment varies in each country: already achieved, or

Nam with low birthrate17).While the aging popu-

nominal succeeded but not actually working, andlation is increasing, it implies the declining in total

being on the target but not completed.

and productive population, and labor force. Thus,
for instance in Thailand, declining birthrate and

Rapidly declining birthrate and accelerated

accelerated aging goes up in the early stages ofaging in Asia

economic development. Government has to pre-In Asia, population aged over 65 years rated

pare for two kinds of policy, social security system

6.7% and 13.0% in Viet Nam and Korea respective-

for the elderly and childcare support at the same

ly in 2108 as shown in Talbe1 . Viet Nam andtime. Actually, insufficient financial resources block

Korea are forecasted to become an aging society

to prepare for the aging and low birthrate.

16)

and an aged society in each soon. The doublingtime to become population aging rate of 7% toFinancial resources patterns of

14% is estimated to 14 years in Viet Nam, 16

medical health insurance

years in Singapore, 17 years in Korea, 19 years in

Global medical health insurance systems are

Indonesia, 20 years in Thailand, Malaysia, Philip-

mainly divided into three models: the nationalpine, and 23 years in China. Within a short period

health service (single-payer) model, the social

Table 1 Basic Statistics of the Asian Countries

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Medical Health Insurance Systems in Asia

insurance (multiple-payer) model, and the private

Medical health insurance systems in(market-based) model. The national health service

Asian countries
It is summarized the characteristics and tasks

model is that the government is the primary
providerof

medicalserviceswithfinancialresource from tax like England and Canada. Theof health insurance systems in Asia, based on the
documents in 2008 to 2018 in Table 3.

social insurance model is that the providers of
medical services are mixed with public (primarily)

Chinaand private (optionally) insurance organizations

China has three sorts of medical insurance sys-

like Japan and Germany. The market model istems: Urban Employee Basic Medical Insurance

that medical services are mainly provided by pri-

System; Basic Medical Insurance System forvate organizations with private medical insurance

Urban Residents; New Rural Co-operative Medical

premiums like America19).

Care System (NRCMCS). It was announced that

Medical health insurance systems in Asia con-Urban Employee Basic Medical Insurance System

sist of a mixture of the social insurance premiums

and Basic Medical Insurance System for Urban

and public expenditure, but some countries are not

Residents were integrated into Urban and Ruralin Table 2. For instance, Malaysia has no public

Residents’ Basic Medical Insurance Systems in

medical insurance system and manages medical

2016 2−4,20,21).

health services with financial resource from tax.
The medical health insurance system in Singapore

Urban Employee Basic Medical Insurance System

is based on a fund system, managing the fund inThis is a compulsory coverage for company

the Central Provident Fund. In countries where

workers in the city including urban and rural fami-

the majority of workers occupy the informal labor

ly registers, self-employed, public officers and theirsector and therefore have unstable incomes such

retirees. It is composed of two-story structure: per-as Indonesia and India, it is not a proper way tosonal account (personal savings) and fund (social

pay for fixed insurance premiums.

insurance system). Hospitals and pharmacies

Medical health service is apt to be given priority

which are eligible for medical insurance benefits

for public officers, not for socially vulnerable peo-

have a system designated by the government.

ple such as rural residents, farmers, fishermen,

Medical insurance system involves two-story

low-income people, and ethnic minorities. While,

structure. The first floor includes benefits of basic

India has medical health insurance system called

medical expenses. The second one comprises ben-Rashtriya Swasthya Bima Yojana (RSBY) for theefits of high-cost hospitalization and visits for treat-poor belonging to the Below Poverty Line (BPL)

ments of specific diseases. Personal accounts are

adopted in 2008. This system is not enough toused to pay for medical treatments and medica-

cover the outpatient care and medical products

tion. The first and second floors are benefits fromwhich will be occupied the most of medical

the public medical insurance fund.

expenses with out-of-pocket payments, due tosecure for only certain inpatients. Some countries[Old] Basic Medical Insurance System for Urban

have limited and small amount of public financial

Residents

resources which can be reliable for the poor like
Viet Nam of socialist country.

It is an optional coverage for non-workers, elderly, defectives, elementary students to college stu-

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ヘルスサイエンス・ヘルスケア Volume 18,No.1(2018)

Table 2 Financial resource patterns of medical health insurance system̶ 23 ̶

Medical Health Insurance Systems in Asia

Table 3 Medical health insurance Systems in Asia̶ 24 ̶

ヘルスサイエンス・ヘルスケア Volume 18,No.1(2018)̶ 25 ̶

Medical Health Insurance Systems in Asia̶ 26 ̶

ヘルスサイエンス・ヘルスケア Volume 18,No.1(2018)

dents, and children aged under 16 years in the city

Employee’s State Insurance Scheme (ESIS)
Employee’s State Insurance Corporation (ESIC)

family register.

mainly manages operating body. Financial resources[Old] New Rural Co-operative Medical Careare premiums that employer burdens 4.75% of the

System (NRCMCS)

wages and employees burden 1.75% of theirThis is a healthcare system of optional coverage,

wages. On the public expenditures, provincial gov-

intended to make more affordable for the ruralernment subsidizes 12.5% of medical benefit costs,

farmers. The Urban and Rural Residents’Basic

within the maximum of 15,000 Rupees per person

Medical Insurance Systems, integrated in 2016, has

annually. Benefits cover the in-kind payments such

two-story structure system. On the first floor, ben-as outpatient and hospitalization, and the cash pay-efits of basic medical expenses are paid from pub-ments as an invalidity allowance.

lic medical insurance fund. On the second floor,
benefits of high-cost hospitalization and visits for

Rashtriya Swasthya Bima Yojana (RSBY)

treatments of specific diseases are paid from med-

Under the main management of provincial gov-

ical insurance for serious illness, managed by pub-ernment, central government and provincial gov-

lic-private collaboration.

ernment subsidizes 75% and 25% of all medical
insurance, respectively. There is no self-burden of

India

insurance premiums. In the registered medical

Three types of medical insurance systems exist

institutions, the insured can be hospitalized forin India: Central Government Health Scheme

free surgery, provided with transportation expens-(CGHS) for public servants; Employees’Statees for hospitalization.

Insurance Scheme (ESIS) for employees of private

The health care costs of public hospitals are freeformal sector; Rashtriya Swasthya Bima Yojana

thanks to RSBY. Due to a shortage of medical sup-

(RSBY) for the poor. The poor are households

ply, waiting for medical services becomes common

belonging to the Below Poverty Line (BPL), deter-

problems5−7,20).

mined by the government. The institutional subscribers of ESIS and RSBY can use free medical

Indonesia

care in the registered medical institutions. These

Sistem Jaminan Sosial Nasional Health (SJSN

medical security systems do not reach the Univer-

Health) was introduced, mainly managed by BPJS

sal Health Coverage because of the limited targets.

Health in 2014. Eligibility contains all Indonesian
people and foreigners working in Indonesia overCentral Government Health Scheme (CGHS)

six months. Insured person can get medical treat-

Financial resources are social insurance systems

ments for free contact burden in general. Financial

and public expenditures. The premiums are paid

resources consist of premiums and governmentby the insured person’s salary, 250〜 1000 Rupees

subsidization. Insurance premiums vary depending

per month. The public expenditures are subsidizedon the occupations and the type of services eachfrom Central Government budget. Benefits coverindividual offers. The government is responsible

the comprehensive medical care such as outpa-

for the poverty. Over 30 % of all nations was unin-

tient, hospitalization, and medicine.

sured in 2014, despite of aiming to achieve Universal Health Coverage8,9,20,25).
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Medical Health Insurance Systems in Asia

Korea

ment. PhilHealth, headquartered in Manila, has 15

Social health insurance was introduced with thenationwide branches and 72 service bases. The

National Health Insurance Act in 1977, which wasPhilippine government is aiming to achieve theassured of industrial workers in large corporations.

Universal Health Coverage System for all citizens

It was expanded to contain other workers such as

to be insured by the PhilHealth.

public servants and private teachers in 1978, farm-Financial resources consist of social insurance

ers and fisheries in 1988, and urban area in 1989.

premiums which capital and labors share 2.5%

This program had finally achieved Universal

wages in half, asset management through invest-

Health Coverage in 1989, as a compulsory regis-

ment activities, and public expenditure fromtered insurance for all residents in Korea.

Development of Health and local governments.

It is operated by National Health Insurance Cor-

Payment is in-kind benefits centered on inpatients.

poration (NHIC) and Health Insurance Review and

Public and private medical institutions designated

Assessment Service (HIRA). Financial resources

by PhilHealth are public medical facilities provided

consist of premiums sharing in half with a capital

by PhilHealth. A certain amount of medical

and labors, and public revenues such as general

expenses will be redeemed to physicians or hospi-

and tobacco taxes

tals, based on the severity of illness and the levels.

10,11,20)of medical facilities. Medical service fees of PhilMalaysia

Health are not covered all costs of medical institu-

Malaysia is aiming to succeed fair medical
access, in spite of no public medical insurance sys-

tions charging a patient. Expenses beyond a certain
amount will be a patient’s self-burden13,20,22).

tem. Residents can receive medical services atpublic medical institutions with less self-burden,

Singaporedue to the help of federal budget. Medical treat-

The government in Singapore has no idea toment fees of public medical institutions have beentake care of people at the national level because of

set up, based on the Fee Act in 1951. Additionala small city state on the lack of economic basis.

expenses such as examinations, surgery, hospital-

People need self-help in health care as much asization, and medicine are set up low burden. Pri-possible. The government involvement stays atvate medical institutions provide medical treat-

the minimum indirect assistance.

ments, not covered by health insurance, concentrating on urban areas

Medical health insurance systems in Singapore
are based on the Fund system, managing the fund.

12,20)

in the Central Provident Fund (CPF), which capital
Philippinesand labors compulsory build up money of a certain

In 1995, national healthcare insurance system inpercentage from wages to a labor’s personal

Philippines was introduced by the integration of

account. There are three kinds of medical insur-

parts of medical insurance (Medicaid), common toance systems: Medisave; MediShield; Medifund. In

both systems: Social Security System (SSS) andcase of outpatient prescriptions and treatments ofGovernment Service Insurance System (GSIS).

general outpatients such as colds, medical expens-

Philippines Health Insurance Corporation (PHIC:es will be self-burden20,23).

PhilHealth) manages nationwide healthcare insurance as an institution controlled by the govern̶ 28 ̶

ヘルスサイエンス・ヘルスケア Volume 18,No.1(2018)

Medisavesystems are provided: Civil Servant Medical Bene-

It is a national medical savings scheme operated

fit Scheme (CSMBS); Invalidity Benefits of Social

by CPF which can be used to pay for healthcare

Security Scheme (SSS); Universal Coverage (UC).

expenses such as personal or family’s hospitaliza-

In 2002, Universal Coverage was established andtions, day surgeries throughout the individual’sthe public health insurance system institutionally

lifetime, even after retirement. Account grows

covered all Thailand residents. Thailand haswith interests.

achieved Universal Health Coverage14,20,24).

MediShield

Civil Servant Medical Benefit Scheme (CSMBS)

It is a health insurance scheme operated by

Civil servants who have worked in government

CPF, which helps to pay for large and long-termbodies are assured of their health care needs

hospital bills, without covering with Medisave. All

through the CSMBS. It is operated with tax

insured members in Medisave have to join inresources as a public welfare. In general, insured

MediShield as a rule. Health insurance system pro-person will be free to choose medical institutions

vided by the government is an insurance for med-

to consult and for its payment. Benefits cover theical services in public hospitals. The benefit is only

comprehensive medical care with in-kind payment.

for the insured person, and the upper limitation isPatients will receive no cash benefit.

for the insurance claims according to the hospitalInvalidity Benefits of Social Security Scheme (SSS)

ization days and sorts of surgeries.

Within Social Security Scheme, invalidity beneMedifund

fits are the public health insurance system for pri-

It is an endowment fund set up by the govern-

vate employees. It is operated by the premiums ofment bearing by the National Treasury to help

sharing in half with capital and labors, and addi-

low-income people who cannot pay with Medisave

tional subsidization of the government. In general,

and MediShield for all cost of medical expenses.

insured person can visit to the pre-registered med-

The benefit is only for the registered members,

ical institutions. Insured person has no personal

supporting the cost of hospitalization, outpatient

payment at the time of consultations within thetreatments, and nursing care.

fixed limit. Benefits cover cash and in-kind pay-

As for public hospitals, Western Singapore isments such as consultations, nursing, medicine,

operated by National Health Hospitals (NHG), andand transportation. Payments from the system

Singapore Health (Singhealth) operates Eastern

operators (insurers) to medical institutions are aside. In case of the emergency, a patient will trans-

capitation payment system.

port to the public hospitals determined by theregion. The cost of medical treatments including

Universal Coverage (UC)general outpatient and prescriptions is set up that

Universal Coverage operated by tax resources

general people can consult. Treatment fee will be

is voluntary registered insurance for all residents

reduced for over 65-year-old people and children.

such as farmers and self-employed, except for
insured people of CSMBS and SSS. In general,

Thailandinsured person can use only pre-registered med-

In Thailand, three types of medical insurance

ical institutions (mostly public hospitals). Personal̶ 29 ̶

Medical Health Insurance Systems in Asia

payment for a consultation is 30 baht, and free forment globally, not only in Asian countries.

low-income people. Benefits mainly assure fortreatments of acute symptoms with in-kind pay-

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The progress of medical health insurance systems vary in Asian countries. There are countries
where benefit systems have relatively achieved
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