f'h":',r-A',. &oJ'.t-I\'E '-'tlfOn'&Jn..

ree;:tTllttn

LAIPA ",;J&~ ;J,N,4l,

F,ED,ERAL,NEGARIT "GAZETTE ... , "~r",,, '"... . ". I' ,

?F THE FKDERA'L DEMOCRA1?i~,~EPU1H~IC OF:i:TBIOPIA

,...._....;.. ....;.._--.io........... ....,.~~--- .•.....-- •..••
~P'1r I1m~r,: '}oo~· 4l'I'Cr On.1.f"~·Y U.lrt\<e .It'f"nlrl'LY<e tT11l\.n •., i' '''?: '19YearN~, '3th

Mfl MfJ lJ"IC Iii 'f") fl'i.(; '}.~.:\';n1Hl -r(J)qf"1' 9"nC (l,:" mCl4:W' f(J)fT) ,~99is A~~,,4~~,N?vember 7012

OTJm-6Jil,
f.111 -r.'l'C~i~~/~i'i.(; '}.rD. Regulation No. 271/2012
f "'iLJf11r <e mS' OU~ LJ'} fuTJ;'l. ();).C':f Social Health Insurance Scheme Courlcil of Ministers '"
~~g4Iation~ .. , ..•_.. _.. ':,' ,,,;pl.lge 6641,
.9"nC(l,1·l,~Hl.. ; '1'/\ ?;i'i.7;xf'ili

~·I.{)')·C'1·.9°tiC 0',1:.r.~}il </rrCl{i'C'6/fO,?j ,COUNCIL OF MINISTERS REGULATION No, 27112005

'< -, 1 - -" 1""0" I""

M"'iLJfllr <e (Jb ~ !70 ~ LJ'}\' (J)fT), f"'i. 'l.{)')'C'':j'. COUNCIL OF MINISTERS REGULATION TO

9"nC (l,.). f:HI PROVIDE Fd~ SOCIAL HEAt TH INSURANCE'SCHEME

t ".,,' -r :.

fUTf.'l.{)')'C;:r- 9"nC (l,.). f h:')'f"A'Y' 't.,f.lrl'j<e .It <7"n This Regulatiol'\ is ~js~u,ed by th((;,Cou~cil of Ministers
Rursuanl to Article 5 of the Definition of Powers and
Ir('l.Y<e tTilt\.n h{1t.~"'L 'hqI\1"} P't\fT)'}~ -r"lClC
i Duties'offhe E~ec~tive Or~~~s of the Feder~l'Democratic
t\ou(J)t'l1
< ".
O(J)fT)(J)' h<P~ -r.'l'C
'!'
?;x2MmE h'}ef'7\
,
?i ReRublic of EthioRia Proclamation No. 691/20 10 and
h~ O"'iLJOIr<e mS OU~LJ1 h<P~ -r.'l'C U2IJ:i'i.ll ArtiCle; 10 of the S(;cial+le~lth Insurance 'Proclamation
. h'}ef'~ I ouiPl1' ~LJ1'} 'f.111 ~\(1»'l';tt\:: No.~,690/2010. .L

~. ~,~C C60
f.LJ f:}11 "f"'iLJfllr<e mS OU~LJ'} fUTf,'l.{)-}·C'1· This Regtllation may be cited as the "Social Health

9°nC (l,.). f:HI ":'l'c-J:,~{tlilfO.'(;" 'rllt\G I\.mef'{l InsurartceScheme Council of Ministers Regulation
~1·t\t\:: \ No. 271/2011";

ll. ·)·C:,}"'l.

flti: LJ f:}il (J):{l'l'" f :J>t\. h1Clll tbt\ ·)·C?-9" In 'this Reguiation,tinTess the <context otherwise

fUTf.Yt'lm(J)· qt\lJ"l flM·ef'C:· requires:"'·,

(il "h<P~" drJM' f"'iLJfllr<e fnS OU~LJ'} h<P~ ,11 "Proclamation" means 'the" Social

-r.'l'C ?;x2Illi'i.J: 'i(J)'! Insurance Proclamation No:'690/20 10;

21 the definitions Rrovided for in Article 2 of the

J:I flh<P~ h1ef'7\ ~ f-rom· ')·C~"'l.!J1:r· t\H.LJ
Proclamation shall also aRRly tothis Regulation;
f:}ll9" -rt.~UTf, f,1f~t\'1
31 "generic drugs" means any drug'mitrketed under

EI "o'}(\ {)9"~ou~iJ'd''''''iM'f'}''l~{)9'' 'l'fI:J> its scientific an!:!..chemical maro~. without· trade

q,e'J l(1»'. Oqf,'}{l~ fllbffl;qt\ (lou· 11~ name R~otectiQn;

fUTf.7i'l' ou~ iJ 'I.,.)' '1(1» I 41 "to-payment'" h1eans a Rertentage af total health

j ,-,~;." fi- \,:"','. ".
!il "ef''l'-r~ / n~Y'i."'it\:'· 'l'm:J>"'l,OJ. fmS service expense that a beneficiary is required to
h7t\"l~'1' flUTf,Y'l:-Sfl:" (J):":" hm:"t\t\ Ray in cash at th~~~6intrif getting'theservice;
f (htr9"~ (J)6b\..(J)' I\~ -r(\t\f. flef''l';t' fI'l' ~
'"'ntH} r"'i.h~t\(J1. ~(l)o I ~Pt+ PILlfJ T.ut.'/!
-y-·)--'\.-'f'-;1------ Negarit Gazeta
l Unit Price 3.10
 l;1 "f'-r1Hlfto7i P'C'}:"u ai[t1:" hh'}~ f'm.ct. 5, "referral system" means the system of
1'*S'" roY. 4'fTJ~ h~1'~ f'mS 1':t:~' . transferring patients from a health facility to the
'1 f' :I'I1Olf.91r hftfth
f'drJ.Y.1. P'C'}:" ~ro-i next higher level health facility;

II "h.~'M.u UTJtI:" OOlf.'l.ll1'Cr S"'hC 0.:" Y.111 . 6/ "Agency" means the Ethiopian Health
,~'l'C /iX'llili7l.E f'1'**ooro- f'h.:',r-A'f f'mS Insurance Agency established under the Council
tib~U1 h.~1t'L ~ro-:: of Ministers Regulation No. 191/2010.
r. OOmS h7t\ "lfto:" ;rh,~ 3. Health Service Package
lil 0'f1~ro-9° f'D1JUOt-'l? mCJ oo~U'} P'C'}:" 1/ Any beneficiary of the Social Health Insurance
1'm:J>Olf. f'Olf.h-f't'I-:"1 "mCJ h7t\"lftof.r Scheme shall have the right to receive the
hh.~1t'Lro- ,?C ro-t\ h7fl- f'mS 1'*UTJ:" following health services from health facilities
which have concluded contract with the
f'UTI '17:' , uoll:" ~CJI.<f't\:-
Agency:
IJ) f'-f'ooftft7i c"hhS"'CJI
a) outpatient care;
(1) f'1':-Sf. c"hhS"'CJI
b) inpatient care;
m) f'rot\.~ h7t\ "lfto:" I c) delivery services;
(0) f'4'Po UhS"'CJI d) surgical services;
LP) Oc"hhS"'CJ CltlOO-f 91r f' :I't1l1- fS"'Coot- e) diagnostic tests and generic drugs included
h7t\'1ftof.rCJ Oh.~1t'Lro· f'oo~'1'l.f·r in the drug list of the Agency, and
1fC1fC f"rl11'1; ~1t'1 1lS'" oo~'1'l.f.r:: prescribed by medical practitioners.

if f'1t U h '}4' 7\ 'W·ll h '}4' 7\ (li) J':'},?7. 0, CJC9'" 2/ Notwithstanding the provision of sub-article (1)
f'Olf.h1't'l-:', rm.CJ h7t\'1ftof,"f OmCJ of this Article, the following health services are
h7t\"lfto1' ;rh,~ ro·ll'l' h~I1'r'p?,,:- excluded from the health service package:
IJ) h h.:" r- A'f ro- 6L" f' Olf.Y,I. '1 r
UTJCJ ro·?" a) any treatment outside Ethiopia;
c"hhS"'CJi
(1) 01't.'l'C hy',?$Dr i OUTJUot-'l?
ll'l'll'l'i oroI.C7i:-S ~CJ h~1'~ hY.,?
Clftrro- llTC:I''l? ro·~ ~Cr t1tTCJ.y,Ct'I-
7-~f."f f'Olf.Y,I.7- c"hhS"'CJ91r I
th) hY.7~ ~Pr'} Oooro-t'l~ t11'hl'I1' 7-~:"
(J)~S'" t1t'1-11 1'710:" f'0lf.Y. I. "l
c"hhS"'CJI

(0) Of'7.tLro- f'Olf.Y.I.7- huoo?" ,?C ft\1' d) periodic medical check-up unrelated to
fftt- f'Q),1~1' lr'l.:I' S"'Coot-$Dri
illness;
LP) f' P't- ft~ 7-~f.1" i f',),t-&.h hY.;J$Dr
e) occupational injuries, traffic accidents and
~CJ Ot\ft U'1 7i4-1 f'-f't'lfTJrro, t\fto r
hY.,?$Dr I other injuries covered by other laws;

I.) t1ro-O:" t'LClt\ rOlf.Y,1.7- 4'Po

uhS"'CJ911'-1
LP) f'hl1t\ 4');1. UTJl1roCI

~171'~ rh-ftt\.1, llt-

t'loo:I'Y,"l hOlf.t'I'l' uh?"CJ
f'Olf.Y,I."l r "tft'l.t'Lll c"hhS"'CJi
f''} ~'} oo~7\CCJ p'} :I'h')'
h-rC(l:"1
 0,
77.: ~~li.Zt:1i.'6..UrA ~;Jt·}· ;JlbfTI ·/,'j'e [ U"\C ill 'V> i1i'i.?;' 'Uru. Federal Negarit Gazette _ NO.3 November 28th 2012 Page 6643

MilD' (}t-fi t19" hft}l(,\ OJ·Ii};" (\OTJM~II

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f OTJ.

'r) f~t\ oo't''l'}'!

~) (}OJ· (It-fi· '1'CII OTJII'rh(,\ : '1'CII

OTJII'/''lh(,\ he; M\. '} &uhn'} 9"h'} .f"}'
fOTJ.Y.L"7 f ~,,}. 'lc; (,\ uh9"'}'} ",,e.(XlSuC
M\ OTJ'}~OJ'9° f<;"}' }l'}(,\ uh9nc; 1

f ooIlOTJ'}' ~ }.',(,\'} fOTJ.Y"7tl· 00''1 tY )D'f

n'l'cn'}' !

(\OTJ'}~OJ'9° ,rm:J'OTJ. .f'(\h~.f' fOTJ.(}m·

f mS ft7(,\ "7(\0-1"1';;

31 The Agency, by taking into consideration the

u n,;Ot'LOJ' Ol1.u Y:}-f1 ft14>7\' Q ooLPd'
amount of accumulated fund from contributions
fOTJ.MMOJ·'} 00<p(;lib'} fOTJ.7"'iOJ"} f ft:Hi
. collected and investment income derived
1I1'oo'}-}' 70. h9":1-1' oom'} "79°'}' OJ·11'1'
pursuant to Article 4 of this Regulation, may
OOTJI1711'}'f mS ft7t\ "7(\o,p'} ,Th.;e:. (\OTJII,H·
recommend to government to expand the health
f OJ·",b lJ'" -f1 (\oo'}"7111' It.f'",C-f1 .e,r"'(,\;: service package.

4. Contribution

!il LPt-'I'~ flf~ ftllt\'} OOTJ.oo(\h'}· On<P~: II The amount of contribution to the Social Health
n'}"'7\' P'(li) ooLPd' (\OTJUflt-'e (nS oo~u'} Insurance Scheme in accordance with Article
;»CC}'}' OMtl·'} OftLPtOJ' ml.f"}~'}~~OJ· 9(1) of the Proclamation >.bya member, who is
an employee, and his emploY~I: shall be 3% of
fOTJ.Y.L7OJ. oo<p(;lib oom'} fftlltl· .f'('\'t'ffJt-
the member's gross salary with respect to each
Y.aoOJ11 E 000-1" ,e.lfc; (,\:: of them.
~I m'L't'~ flf~ Mt\1 OOTJ.ootlh')· flft<P;lf. 21 The amount of contributi'onto the Social Health
ft'}4>7\' j](ii) ooLPd' tlOTJUOt-'e mS ao~u'} Insurance S.cheme in accordance with Article
PCC}'}' OMtl·'} 0001"7 p,}. Oh.f"}~'}~~OJ· 9(1) of the Proclamation by a member, who is a
pensioner, and the government shall be I % of
fOTJ.Y.L7OJ. oo<p(;lib oom'} fftlltl· fm'L;t'
the member's pension allowance with respect to
Mt\ ti Oaof· ,e.lf'}t\:: each of them.
1:1 ftU'tOJ' OJ,f',9° fOTJ.ootlh,rOJ· fOTJuOt·'e 31 The employer or the relevant social security
<PII'}''} n,;e:'}t'L f1Itu ft'}"'?, 'W'II ft'}"'7\' (§) agency shall transfer to the Agency within one
OJ,e.9° UO f'raotlh't'OJ"} fft'1tl·'}'} ft-(}·'} month the contribution of the member and that
mCl/'e oo<p(;fi" Oft'}~ OJC 7.1t OJ·11'1' of itself as prescribed under sub-article (1) or
tln,;e:'}t'LOJ' OTJII'r"'tl~ fttlf1'}·:: (2) of this Article.

QI Otl.U ft14>7\' 'W'II ft14>7\' (r) O'rootlh't'OJ' 41 If the employer or the relevant social security
agency fails to transfer monthly contributions in
flit 7Y..-f10:>'11'1' OJC'! 'e oo<p(;lib'}. .f''''II't''''tl.{.
accordance with sub-article (3 )of th~s Article, it
ftLPt OJ,e.9" rOTJunt-'e <pM·'} n,:e:1t'L
shall be liable to a fme of 2% of the amount of .
tltl7r01' tlh.f''}.'n~ OJC .f't'U'l't''''(\'{' OJ.1 contribution not transferr~d, for each delayed
ao<p(;lib ~ noo.'f. 004>6l'l. .eh~"'t\:: month.

l;/ n,;e: 'M..OJ' r OTJu 0t- <e mS ft 71:\ "7 t\o ,}. 51 The Agency may, to strengthen the financial
;»CC},~,} r4.,f'S'}1I 9"'}Ii};" tlOTJ1t\O'}'
sources of the Social Health Insurance Scheme,
hooCP(;libOJ' 7'}t1-f1 h9":"f:" "'.e, tloom'10-eY
invest, pursuant to directive of the government,
rOTJ..e,tIOJ·'} 4>'}('l 4>tOJ"} 00,}"7p,).
accumulated . contribution remaining after
OOTJ.l'ImOJ·ooOutJ' ooLPd' ft.'Hlil'}· tl.YY.C"7
deducting reserve funds .
.e1·t\t\::
 'f,1 un <pC""(J)' fm'l n7N'lfr")' (J)CbUD:r·'} 61 If the prevailing contribution is found to be
insufficient to cover the health service
tt un i'it.'} fA· t\
I' <T<J If' C;' t'L71 .e
(J) 9"
expenditures or if it is in excess of the amount
(J)r.n.9J~'} ttooi'it. '} hUTJ.Yflt.t\ tar O'l.e If'l)' required to cover the health service
t'L71 I'un<PC"" unm~' h VtmunC (J).e9"" expenditures, the Agency shall undertake
f~u n1~~ 1~fl n1~~ ~) ~1~1 studies and recommend to the government to
increase the amount of contribution or, without
h'H'.'rmO~ If'l)' fun<PC"" unm~' h'}-'t~~fl
prejudice to the provisions of sub-article (5) of
h.~1t'Lar n'1'1f· ttunT'lfl')' f(J)·I'\'l. '11'\'0 this Article, to decrease the amount of
Y~Ctlt\;: contribution.

?"". f;P'O'Ott~7i ;--UCa,1' 5. Referral System

M <T<J'}~(J)'9"",rm,!/'UTJ. h~'}7'r~ I'fhh9""'l 11 Any beneficiary shall follow the referral

hC~;r nfl'r~C OH.u Y:}'O n1~~ r system, except for emergency cases, to get
unIP c'3' I'm 'l n7t\ '1tt~,)· tt<T<J'11')' health services provided under Article 3 of this
f;Hl'Ott 71 ;--UCa,,~'}unh'rt\ nttO')':;
u
Regulation.

!U I'1>'0'0tt 71 u ;--uca"p'} 'r'lt\G: 1"1'71 21 A beneficiary who by-passes the referral system
,rm:PUTJ. hm1''I'I fthh9""'l (J)mar (J)·fl'1' :1 shall be liable to pay 50% of the total medical
Ounf' h '}-'th~t\ .eY.t.~t\:: expense.

'j" fl tt m'l 'I' 2.' 9"" '1S!o;J= 9J l' 6. Obligations of Health Facilities

fil <T<J'}~ar9"" -r;:9"" Y.t. Jl(l).'}

I'm, 'l II Any health facility shall provide services to
fm'l n7t\'1tt~')· h~b~'}t'L(J)· ~C beneficiaries in accordance with the required
(l).t\ O'r'run~(l)' <P~ unIPL1' quality standards, and with the tariff stated in
:p<T<J.9J:r unflm')' ntln')·:: the contractual agreement entered with the
Agency.
!U fm'l -r2.'<T<J')' Y.t.p.ro·'} fmn~ n'/t\ '1fr")' 21 Health facilities shall, for periodic evaluation of
nttunnm;Ff(J)''l t\.tt :1" u 1''1'&-,). the Agency, make accessi01e information on the
unnt.C ,y. i'·'} fltt<T<J'ry.'I;rr(J)' o f7. 11.(J)' provision of their services as per the required
tt <T<J.Y.t.
OJ '19°7<T<Junt.p.9Jr'} tt h.~'}t'LOJ. quality standards' and their fulfillment of other
'I'Y.&-7i<T<J
Y: t. '1 ntttl rOJ.:: quality requirements.

u O~U n'}4'~ '}D·fl n'}~7\ (fi) f-r$'.~77(J)·'} 31 Any health facility which contravenes sub-
f-r'lttt. <T<J'}~OJ.9"" fmS '1'2.'9"" n'1tl'O article (l) of this Article shall be subject to
tltt(J)' U'1 unIPL1' n(J)1~t\'l Ott:'hh 'Orh.C criminal and c~vil liability on the basis of
'rmyee .elf''lt\:: relevant law.
Settlement of Health Service Bills
't. ntt Uh9""'l (J)ffi9J1' htt:Y
11 Any health facility shall submit its aggregate
fil <T<J1~(J)'9"" fm'l n7t\'1fr")' '1';:9" fhtt:y health service bills to the Agency within 45
unmfc/~Y 1'I~f'';F'} n7t\'1tt~')· fl'lm01' (l)C days after the end of the month in which the
tltt~ O~l; ~'} OJ.fl'1' nm,!/'fr' tth.~'}(\.(J)' service is provided.
<T<Jq,t.'Ontln')·::
21 The Agency shall verify and pay the amount of
fl.1 h.~'}I'I,(J)' fhfj~Y unmf~Y I'I~~ hY.t.l'lcu
the health service bills to the health facility not
01.'1 0.011 O(lfl')' (J)C arfl'1' '1.I'\O·'}nfTJCf· later than three months from submission of the
ttm'l ,r;:un· unht.t\ nttO')·:: bill.

EI <T<J'}~(J)'9"" fmS n7t\'1fr")' '1';:9° fhtj~Y 31 Any health facility which has failed to submit
unmfeey 1'I~f'.~'} O~U n'}~7\ '}D·fl n'}~7\ health service bills in accordance with sub-
(fi) O-runtthtar f7,11. 7Y.'O (J)'fl'1' t-t'l~t.0
article (l) of this .Article shall be liable to a fine
1.11.tlttt.tlr(J)· fhtt:Y '1'y<t 9J':f''I.e fi Oun'Y·
of 1% of the amount of late claim.
un~6li1. .e;rI'l'OO;rt\::

ill h.:e:'}t'L(J)' ')'hhtt~ fhtt:y unmfeey I'I~Y: 41 If the Agency, having receiyed accurate

~C(lt\,)· O~U n'}~7\ '}D·n ~\'}C/'7\ (i0 health service bills, fails to settle the bills in
O'runtlh'rar f7.lt 7Y.'Oarn'1' htt:Y(J)·1 oee accordance with sub-article (2) of this Article
tlt\Lf~ 9""h'}y')' Yt\t.'l-.un h1Y.If'~ tttl7fOJ. without good cause, it shall be liable to pay
htj~Y O(J)O/'~ftl'}h <T<JM.tY (J)ttY: 'run'} interest on the unpaid amount at the
unIPd· un~6li1. m9"C' .ehtt:'It\::
prevailing bank lending interest rate.
 ?;/ f:P5':t7D A1N?tlor). ntj::f flTlJ.5'.L,?I\TOJ· 51 The health faci lities and types of health services
fme;' rr9:uYf1'e;' fme;' A1t\'?tlo.). 'HJ,~'f'1' to which advance payments may be effected
shall be determined by directive to be issued by
A.:e:·}C\.OJ·oaoz.fOJfT]OJ·t7Dt7Dtf .eOJAe;'tI,::
the Agency.
t.. ()tI{),?'). -r 21\6f,b~'1' A{)rr~.l'.C 8. Risk Management
A.:e:·}O.OJ· fuYfUOt.'e me; t7D5':U'} PC'}rp'} To protect the social health insurance scheme from
f4.,eS1{) A9:r' /l{);J')' rr ;JI\~~')' tlt7DmO:P:- financial risks, the Agency shall:
§/ 'r m:P uYf.9J l' tIrr t7D"1\ 7i un r' e;' l; 0 t7Dl' II cause 5% co-payment for outpatient care to
cp1"rl1 l1tj::f hVt&..~'oo- OuYf5':L'?
prevent misuse of the Social Health Insurance
OuYfUOt.'e me;' t7D5':U'} PC'}rp ftlA'7f\'O
ft7Dmcpr' 5':C1.')·h'}~.eb.~r' .eMMt\ i
Scheme;

~/ fme;' '1'9:9" fCPLOOJ' fnfj~J" 1'.f'</? 21 conduct necessary checking before effecting
/l'rAmOJ' f(nS A1t\'7t1o.). ;JC C\.~'18C payment, if the bills submitted by a health
f'r ;J~~ if)' A.T~. n(J~fOJ"} nt7D&..7,t7D·
facility seems exaggerated as compared to the
0'<")' A{)&"t'\1. fuYffllt.·), Pt.9J'l··'}
fl-j'L~t\[ service provided;

E/ h1.l'.A{)&..I\1.~'P fmM, 'P{)'~'e;"} mr'C'

tbfto r f{);J')' rr ;JI\~~1' t7Dcp~7i H>'o9J1"}
rr'7f\t.'e f.r.C;Jt\::

fj • () tIl' m ,!p uYf. t7D;:1=

OJ4;.f' .r.'0 rr C

uYf1l1OJ'r' fuYfUOt.'e me; t7D5':U'} PC'},)·

rrm:l'lTIJ. OH.u .r:}'O t7DfJJL1' fme;' A1t\'7t1or).

accordance with directive of the Agency to get

t7DfJJL')' f'rAm ft7DTOJt£f .l'.'O,rC t7Df11
health services provided under this Regulation.
AM')'::

A.:e:'} C\.OJ· .e In .r:}'0 tIuYf()&.. ~ r' f uYf.J" () &..t\ l' The Agency may issue directives necessary for the
UOt7Dtf9J1"} uYfOJ-fT]1' .ert\t\:: implementation of this Regulation.

Hi . .r:Hl· fuYf.~e;'01· 1,ti

~,U .l'.1'O /l•..hr'tb § <f>'} ~7i.l; '}.r' :e:r'C' fBe;'

.eife;' t\:: of July, 2013 .

A"t{) Aflf\ U~C II! cp'} ~7i.l; '}.9° Done 'at Addis Ababa, this 28
th
day of November, 2012.

') .e tIuYfC f r' .r.t\ tI '5

HAILEMARIAM DESSALEGN
f ?d'\"~'f &v.l'.t-I\'l? "t 'Fnt.C\.f'e t T'OtI.n PRIME MINISTER OF THE FEDERAL
m :Pt\;i? mz. 'l.{)')·C DEMOCRA TIC REPUBLIC OF ETHIOPIA