One hundred and eighteen years of German health insurance


A number of low and middle income countries (LMICs) are considering social health insurance (SHI) for adoption into their social and economic environment or striving to sustain and improve already existing SHI schemes. For each of the following lessons, this paper considers if and under which conditions they may be of relevance to LMICs. First, small, informal, voluntary health insurance schemes may serve as learning models for fund administration and solidarity, but in order to achieve universal coverage government action is needed to formalize these schemes and to introduce a principle of compulsion. Second, in order to ensure sustainability of SHI, the mandated benefit package should be adapted incrementally in accordance with changing needs, values and economic circumstances. Third, in a pluralistic SHI, system equity, efficiency, risk pooling and spreading can be enhanced if funds merge. Fourth, as an alternative to both state and market regulation, self-governance may serve as a source of stability and sustainability as well as a means of decentralizing and democratizing a health care system. Finally, costs can be successfully contained in a fee-for-service system, if cost-escalating provider behavior is constrained by either political pressure or technical means.

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  • MLI Voices

    Jun 22 2009 - 4:25pm

    Sierra Leone

    Even though I have worked in Sierra Leone in the past, the role of MLI Country Lead has given me the opportunity to build upon these previous experiences and to work closely with members of the Ministry of Health and Sanitation (MOHS), to support the implementation of health policies and reforms that they have prioritized.


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