Designing a health benefits package (HBP)—an explicit list of health services provided using public funds is considered essential to achieving universal health coverage (UHC). It involves a multi-disciplinary process and requires setting up a governance structure; defining the budget and clear prioritization criteria; scoping, assessing, and appraising the potential interventions to be covered; deliberating and decision making; and implementing the package. It implies moving from aspirational and implicit approaches where everything is covered in theory to explicit packages which specify what services are provided to whom, and at what price.
Often, countries initiate the process by reviewing long lists of interventions either provided historically or categorized as essential and cost-effective by reference bodies such as the World Bank, World Health Organization, or Disease Control Priorities. Then, as priority setting mechanisms mature, countries typically move to making only incremental adjustments to their HBP, usually involving individual interventions. This is not a linear or prescriptive process, and countries can move from implicit approaches to explicit HBPs, skip straight from implicit HBPs to incremental adjustments, or in some instances like the UK, never have an HBP at all and only make incremental adjustments.
Figure 1: HBP Stages
In the last decade, many countries have worked to make their benefits packages explicit (e.g. Pakistan, Malawi, Ethiopia, Ghana, and currently, Rwanda), while others are working on incremental adjustments (e.g. Indonesia and Philippines).
In this blog, we look at how to strengthen HBP design to catalyze sustainable priority setting processes, leveraging lessons learned by partners and Advisory Board members of the international decision support initiative (iDSI).
Political, procedural, and technical challenges—the three key issues to solve when designing HBPs
Overall, developing and maintaining an affordable HBP can be challenging in a myriad of ways. We have bucketed these into three key themes: sustaining political buy-in, navigating procedural complexities, and managing globally fragmented technical resources.
1. Political buy-in is critical, but underemphasized
Prioritizing benefits packages for UHC is an inherently political process which needs to carefully manage a range of competing interests. Often, countries initially have high-level political drive for HBP (re)design (e.g. see Rwanda and Kenya), and this must be sustained for the full duration of HBP development and implementation. Working to ensure that the right stakeholders—including civil servants and relevant representatives from Ministries of Health and Ministries of Finance—are at the table for the entire HBP process can be more challenging. The process can take a year or longer and can sometimes be perceived as going against original political promises that everything would be provided for. While it can be easier to engage technocrats in the technical process of HBP design, it can be more difficult to create, sustain and seize political buy-in of the process, while at the same time managing the political economy of sensitive issues in designing the benefits packages. Though this distinction is not well articulated in the public domain, the latter is crucial to ensure that the HBP design process is linked to live decisions and to ensure the translation of the benefits package to practice.
2. HBP updating process remains complex
Ensuring explicit procedural mechanisms are in place to determine how the HBP will be financially sustainable and updated over the years is too often neglected. If prioritization is undertaken but there is no process to align it with the budget, it can lead to an unaffordable package (e.g. Ethiopia and Kenya). If there is no mechanism in place to revise packages at all, they can become outdated and lose their legitimacy. Both risk a return to implicit rationing approaches where decisions are made ad-hoc. If packages are finally reviewed, it may leave countries with hundreds of interventions to review, as in the case of Argentina. One way around these challenges is to skip straight to institutionalizing structures, processes, and procedures to make incremental adjustments to the HBP. While there are many books and guides on HBPs (see here, here, here, and here) some may not be specific enough to help countries overcome these challenges and thus require input from HBP experts. There is then, a need for more specific, applied guidance on HBP design, as well as explicit mechanisms for using HBP processes as a catalyst for institutionalized priority setting.
3. Global resources to support technical analysis are fragmented
HBPs are notoriously technically challenging, starting out with long lists of prioritization criteria (e.g. cost-effectiveness, financial risk protection, feasibility, equity, to name a few) which need to be evaluated for each intervention (sometimes up to 1,000 services) in a long HBP list. It would be impossible for countries looking at their entire HBP to do tens or hundreds of assessments at once, and so many draw on international data sources. However, these sources are fragmented and may not be contextually relevant. Determining which sources to use based on how transferable they are to the local setting demands difficult decisions about where best to ‘cut corners’ in a limited time to ensure estimates are maximally relevant. Additionally, tools and datasets (e.g. HiPTool, OneHealth Tool, DCP-3, Tufts, WHO-CHOICE) have been developed to support HBPs and have been applied in various contexts (e.g. HiP and DCP-3 in Pakistan, Tufts and WHO-CHOICE in Malawi and Kenya). However, there is no common resource which outlines their functionality, strengths, and limitations to help guide countries on which to use. Furthermore, some data and models, including their assumptions, are not open source. This fragmentation, coupled with a limited supply of health economists to navigate the options risks that the analytical approach is driven by a tool’s functionality, rather than the needs of policymakers. There is a need for improved and consolidated guidance to empower policymakers to choose their technical approach and accompanying tools.
Recommendations
Many of the lessons outlined here are independent reflections of iDSI’s advisory board and network members, but are not widely available in the published literature or public domain, which is a challenge in itself. We suggest the following approaches to strengthen HBP design:
HBP experts should develop applied guidance on HBP design, drawing on lessons learnt from countries’ experience.
A survey of the characteristics of HBP experiences in ten countries presented at our latest iDSi board meeting shows that although countries work in silos to develop HBPs, they follow similar HBP processes (Baltussen, forthcoming). There is a need to fill gaps in existing resources by developing ‘applied’ guidance that focuses on guiding policymakers through options, strengths, and weaknesses of different procedural approaches. These gaps should be identified by HBP experts, but a few examples include articulating: options for HBP governance structures that support long-term priority setting; how to ensure there are mechanisms for the budget for the HBP to be specified and allocated early on; how to select prioritization criteria based on local needs and available evidence to inform the criteria; and how to modify the assessment of many interventions to ensure using the best possible evidence within the available time for prioritization. Gaps in current HBP guides and resources should be filled by new resources that can be used directly by policymakers such as new guidance, regional workshops, and/or massive open online courses on HBPs.
Improve and consolidate technical guidance on HBP design and update including data, evidence tools and models.
There are more resources, tools, and sources of information to support evidence-based HBP design available now than in the 1990s. However, more work needs to be done to put countries in the driving seat of deciding the optimal approach to HBP design for their local context. This could be done by developing an index of critically appraised HBP tools and datasets, collating the functionality, strengths and limitations of wide-ranging sources. Additionally, databases, models, and technical manuals that exist for various criteria should be made open source and publicly available, and experiences of using these published and shared.
Policymakers should use HBP processes as a catalyst for building priority-setting foundations.
In HBPs design, it’s tempting to get caught up in the outputs–namely, a revised HBP. Arguably, the more important objective of HBP design is to use the policy window to strengthen national priority setting systems as a means to continually improve population health in the quest for UHC. This can be done through mapping and building local capacities (including specialists in epidemiology, (evidence-based) medicine, systematic reviewing, etc.), developing sustainable and replicable processes, and building a formalized governance infrastructure to sustain evidence-based priority setting going forward.
Disclaimer
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.
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