Act No. 24/An/14/7Th Establishing A Universal Health Insurance System.

Original Language Title: Loi N° 24/AN/14/7ème L portant mise en place d'un système d'Assurance Maladie Universelle.

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Act No. 24/AN/14/7th L establishing a universal health insurance system.


VU The Constitution of 15 September 1992;
VU Law No. 212/AN/05/5th L of 19 January 2008, establishing the National Social Security Fund (C.N.S.S.);
VU Law n°199/AN/13/6th L of 20 February 2013, supplementing the law n°212/AN/07/5th The establishment of the National Social Security Fund (N.C.S.S.) and extending care services to Independent Workers;
VU Decree No.2013-0044/PRE of 31 March 2013 appointing the Prime Minister;
VU Decree No.2013-0045/PRE of 31 March 2013 appointing members of the Government;
VU Decree No.2011-0058/PRE of 14 April 2013 establishing the powers of the Ministries;
VU Circular No. 27/PAN of 27/01/14 calling for the fourth public session of the 2nd Ordinary Session of the year 2013/2014;

The Council of Ministers heard in its meeting of September 10, 2013.


General principles of insurance
Universal disease

Article 1: A health insurance system is established based on the principles of national solidarity, law and access to health for all enshrined in law n°48/AN/99/4th Guidance to Health Policy.

Article 2: The health insurance system is a prevention and social protection against the risks of the disease. It provides basic medical coverage to the entire population living in the territory of the Republic of Djibouti and provides compulsory health insurance for the active population.

Article 3: The universal health insurance system (AMU) includes, on the one hand, the compulsory health insurance plan (AMO) and on the other hand, the social health assistance program (SSA).

Article 4: The universal health insurance system ensures that the costs of the benefits provided by the service providers to the beneficiaries of the AMU are met.

Part II-

Compulsory health insurance (AMO)

Chapter I - Recipients

Article 5: Based on the contributory principle, compulsory health insurance includes three plans:
1- The regime of:
- Officers;
- Employee workers under the Labour Code.
2- Independent workers:
3- The regime of ;
- Students;
- Retired.

Article 6: The compulsory health insurance system covers the rights of persons identified as subject to this coverage, provided that no other coverage of this nature is claimed.
The AMO beneficiaries are:
- The insured;
- The spouse of the insured;
- Minor dependent children up to the age of 18;
- Children with disabilities;
- The survivor pension beneficiary when their pension is inferior to 50,000fdj/month under the legislation in force.

Article 7: Dependant children are reported only by one of the parents in order to avoid double registrations to the AMO regime.
The dependent child remains a beneficiary of the AMO until the age limit provided for in section 6.

Chapter II - Guaranteed benefits

Article 8: Compulsory health insurance is entitled to access to care for the categories of beneficiaries referred to in section 6.
Care includes:
- The universal package: it is served for free and without distinction to the whole population. It consists of health care services provided by community health centres in the context of vertical programs such as the Expanded Immunization Program, consultations of children under 5 years of age, reproductive health (pre-postnatal counselling) and reviews, including ultrasound and family planning, care for diseases such as tuberculosis, malaria, epidemics and public health problems etc;
- A basic package 1 supported 100% composed of basic care services such as consultations (children and adults) by a generalist, a standard assessment, radiology examinations and delivery of essential medicines as well as simple delivery including caesarean;
- A second base package 2 consisting of curative consultations (children and adults), medicines (generic of the National List of Essential Drugs) and all medical tests prescribed by medical specialists.
Hospital care benefits guaranteed by the AMO include:
- hospitalizations without surgical intervention including the patient's stay, standard care and examinations, all medications prescribed and included in the national list of essential medicines;
- hospitalizations with surgical intervention.

Article 9: The details of the health care benefits guaranteed by the AMO regime, the costs of health transport and the rates of care are defined by decree jointly taken by the Minister for Health and the Minister for Social Security.

Article 10: The benefits not available in the treated care centres will only be taken care of when they meet a healing need.

Article 11: The body responsible for monitoring and monitoring the implementation of the conventions, according to criteria defined by the Ministry of Health, will be responsible for defining acts that meet a healing need.

Chapter III-

Care arrangements

Article 12: The costs related to the care of ODA recipients are covered by the managerial organization (CNSS) in two ways:
- either directly to care providers on the basis of a declarative system provided for by an agreement signed between the managerial organization (CNSS) and the care provider organization,
- either by reimbursing costs to beneficiaries in the event of prepayment by OMA beneficiaries.

Article 13: Reimbursement or care for expenses incurred by recipients of compulsory health insurance is made:
- the act, on the basis of the nomenclature of professional acts determined by the Ministry of Health;
- in the form of a package by pathology or homogeneous group of diseases;
- in the form of global endowment or prepayment;
- in the form of capitation.

The conditions for the care and reimbursement of care expenses required by the recipient's state of health will be defined by decree.

Article 14: Guaranteed benefits under compulsory health insurance can only be refunded or taken care of if the care has been prescribed and performed by registered health-care providers.

Chapter IV-

Methods of financing

Article 15: The AMO's resources consist of:
- contributions;
- investment financial products;
- gifts and bequests.

Article 16: As the contribution rate is set at 7%, it will be distributed as follows:
- 2% of the deduction applied on the gross remuneration of insured persons (workers and employees under the Labour Code);
- 5% deduction on the gross remuneration of insured persons but at the expense of employers.

Article 17: Depending on the categories of recipients, the financing of the compulsory health insurance plan is based on:
- the rate of social contributions seated on gross wages for workers under the Labour Code and civil servants;
- the rate of contributions seated on income for self-employed persons as provided for in Act No. 199/AN/13/6th L, promulgated on 20 February 2013;
- pension retirees and survivors with a pension of more than 50,000fdj per month will pay to the management organization, a contribution to the UA of 7% of the amount of their pension by pension deduction;
- pensioners with a pension less than 50,000 FDJ are covered for free;
- students will be subject to a lump sum method indexed on their registration fee.

Article 18: In addition to these financing methods based mainly on social contributions and other contributions from social insurance, moderator tickets and admission fees or complementary participations of insured persons will be instituted by regulation.

Article 19: The managerial body has the obligation to establish:
- a security reserve fund with a minimum ceiling equivalent to the sum of the plan expenditures of the last two years;
- a working capital equivalent to at least one quarter of the operating expenses of the plan.

Part III-

Assistance Program

Chapter I - Recipients

Article 20: The plan of the social health assistance program based on a subsidized plan covers all persons not covered by the compulsory health insurance system and previously identified as having “no income” by the competent authorities.

Article 21: Can claim the Social Health Assistance Program:
- persons identified by the competent authorities as not having sufficient income to benefit from the compulsory health insurance scheme;
- their spouses;
- their dependent children according to the definitions of national legislation.

Section II- Benefits

Article 22: In addition to the universal package that is served free of charge and without distinction to the entire population, the beneficiaries of the Social Health Assistance Program receive the following care:
- a 100% basic package that includes consultations (children and adults) at the generalist, simple births, births with caesarean, five (5) standard medical tests, medications (general LNMEs) as well as radiology examinations except scanners, ultrasound, fibroscopy and special examinations;
- a basic package 2 consisting of curative consultations (children and adults), medicines (generic of the National List of Essential Drugs) and all medical analyses prescribed by specialists;
This covered care basket, on the basis of the detailed indications above, will be extended to medically required hospital care services and available from public health institutions, according to their levels of benefits.
The department responsible for national solidarity on the basis of a convention established with the managerial body is responsible for identifying the needy population.

Chapter III-Making arrangements

Article 23: Diseases covered by national programmes are provided free of charge in the universal package. The other costs of basic care benefits (base package 1 and base package 2) are covered by the Solidarity Fund of the Social Health Assistance Program, created by regulatory act.

Any extension of the rights to hospital care benefits will be covered under the same conditions with the participation of the beneficiaries to be determined by regulatory action.

Chapter IV-Financing modalities

Article 24: Funding for the Social Health Assistance Program (SAP) is provided through the Universal Health Insurance Solidarity Fund.
The funding resources of this fund will be defined by regulatory action.

Part IV- Conventioning system

Chapter I- Conventional framework

care providers

Article 25: The relationship between the managerial body and care providers is governed by medical agreements concluded, separately:
- for doctors (generalists, specialists, surgeon-dentists) exercising in a liberal capacity;
- for public health institutions, parapublic, private;
- for pharmaceutical institutions, medical biology laboratories and medical imaging centres.

Article 26: Health providers exercising a liberal role and having made the choice to exercise under the conventional regime conclude medical conventions directly with the managerial body.

Article 27: For public, para-public, private health care institutions and for pharmaceutical establishments, medical biology laboratories, medical imaging centres, conventions are concluded between the management body and these different institutions.

Article 28: The medical convention determines, inter alia:
- the reciprocal obligations of the management body and health professionals;
- the conditions for granting and exercising care and hospitality benefits;
- mechanisms for controlling health expenditure;
- respect for the free choice of the doctor “refer” by the insured,
- the conditions for payment of fees according to the existing conventional rates;
- dispute resolution procedures.

Article 29: Conventions, annexes or amendments come into force only after their approval by order on the proposal of the Minister for Social Security.
Upon their approval, the medical conventions apply to all relevant health providers who have chosen to be governed by medical conventions.


Article 30: Medical control on behalf of the managerial body is provided by general practitioners and consulting specialists, pharmacists-advisors and dentists responsible for the missions and powers provided for in this letter.

Article 31: These medical consultants are responsible for conducting medical checks to verify compliance with the care requirements, verifying the quality of the services, detecting abuses and frauds in terms of requirements, care and billing.
They are responsible for:
- to express their opinion on the benefits of prescribed care;
- to monitor the quality of services rendered by care providers for the benefit of beneficiaries;
- within the limits of the confidentiality rules and subject to ethical principles, consulting physicians may summon beneficiaries to submit them to medical expertise.

Article 32: The terms, conditions and deadlines in which medical control is exercised are determined by decree.

The procedures for the exercise of consulting physicians are defined by regulatory action.


Monitoring and evaluation of the implementation of conventions

Article 33: This Act establishes a National Health Insurance Commission, a consultative body composed of representatives of the managerial body, care providers, the public authority and representatives of insured persons, responsible for monitoring the effective implementation of medical conventions.

Article 34: The modalities for the organization and operation of this body of consultation will be defined by decree.

Part VI-Organization

Chapter I- of the AMU management organization

Article 35: The management of universal health insurance is entrusted to the CNSS.

Article 36: The administrative organization provided for by law n°212/AN/07/5th The establishment of the National Social Security Fund (N.C.S.S.) will be amended with respect to the prerogatives of the NSSC in the area of care.

To this end, the introduction of the universal health insurance system requires the NSS to not accumulate the functions of care provider and insurance manager.

The CNSS's organizational structure that takes into account the UA reform will be proposed by the CNSS management to the Board of Directors upon promulgation of this Act.

Article 37: It is established by order a commission to assess the movable and real estate heritage as well as the financial assets of the two CNSS care centres.

Chapter II- of the care provider organization

Article 38: It is established a public health institution, which is the result of the separation of the employee and family care centres of the National Social Security Fund. This institution is a health care provider and has a moral personality and financial autonomy.
The public health facility is attached to the Ministry of Labour.
The management of the institution will be entrusted to social security professionals, with recognized risk management skills, as part of a tripartite parity representation (the representatives of employers' employees and the state).

Article 39: The procedure for the operation, organization and constitution of the heritage of the institution shall be defined by decree taken in Council of Ministers in accordance with the provisions of Law No.2/AN/98/4 L on the definition and management of public institutions.

Part VII- Insurance Plans

Article 40: Care benefits not covered by AMO's basic plans will be covered by optional supplementary insurance plans.

Part VIII - Final provisions

Article 41: Pending the establishment of the AMU, care benefits will be guaranteed by the NSSC health centres without discontinuity to the insured.

Article 42: All provisions contrary to this Act are repealed, in particular, the provisions of section 28 of Act No. 212/AN/07/5th The establishment of the National Social Security Fund (CNSS).

Article 43: This Act comes into force three months after its promulgation.

Done in Djibouti on 05/02/2014

President of the Republic,
Head of Government