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BENEFIT PACKAGES
Principles of health benefit packages
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PRINCIPLES OF HEALTH
BENEFIT PACKAGES
Acknowledgements
This publication was produced under the overall guidance of the World Health Organizations Technical Advisory
Group on Health Benefit Packages. The members of the Technical Advisory Group who contributed to the writing
of this document are Ole Norheim (Chair), Rob Baltussen, Kalipso Chalkidou, Yingtao Chen, Alemayehu Hailu, Inaki
Gutierrez Ibarluzea, Mouna Jaeleddine, Lydia Kapiriri, Margaret Kruk, Di McIntyre, Francois Meyer, Yot Teerawattanon,
Anna Vassal, J eanette Vega, Alicia Yamin.
World Health Organization staff Melanie Bertram, Tessa Tan Torres Edejer and Agnes Soucat contributed to the
writing of the document.
ii
Introduction
Figure 1: The “UHC Cube” representing the three dimensions of improvement required for Progressive Realization of UHC
Include
other
Reduce cost Direct costs:
services
sharing and fees Proportion of the
costs covered?
Extend to
non-covered
Current
pooled funds
Services:
Which services
Population: who is covered? are covered?
1
Define and scale
up essential health
services, include more
people until there is
universal access.
Countries must define and scale up essential health ser- Most countries have historically defined high priority
vices, include more people until there is universal access, services through national planning documents, five-year
and reduce or eliminate out-of-pocket payments for all strategic plans and annual budgets. National priorities
essential services. Without defining which services are es- have often been sound and reasonable, although some-
sential and where and by whom they should be provided times ad hoc and sometimes with lack of clarity. Today,
to have a health impact, it is hard to scale up all possible many countries are now in the fortunate position that there
services with sustainable funding. No country in the world is more evidence available than ever before for better
is able to provide everything to everyone from public priority setting. Whilst not yet the case for every coun-
funds. Choices must be made on the path to UHC. try, in many cases as investments in strong data systems
intensify, ministries of health and finance increasingly
Within every health system, current service provision have access to databases, reports, national and interna-
contains a health benefit package, which may be explicit tional research that can help them make better decisions
in some cases, or implied in others. By creating an explicit informed by evidence on the burden of disease in their
health benefit package, countries can begin to establish country, which programs and services are most effective,
guarantees for service access. Citizens should be aware of and at what cost.
what they are entitled to receive, and what responsibilities
they have for accessing services. In order to select the By changing from ad hoc or implicit priority setting and
health benefit package, difficult decisions must be made rationing of services, to systematic, evidence-based and
about what the country can afford to deliver through pub- transparent priority setting, countries can substantially
lic funds. This involves a series of trade-offs, whereby dif- improve health outcomes, improve access to important
ferent, often opposing, priorities and criteria are balanced high-quality services and achieve national and global
against each other in order to develop an explicit package. SDG targets. Countries can move towards a health system
For example, a country may need to choose whether to where there is universal access to services that improve
spend its limited resources on scaling up HIV screening health the most, for those with greatest needs. Countries
and testing or second-line HIV treatment. If the country that have made systematic priority setting a key compo-
considers maximisation of population health as its main nent of their health system include New Zealand, Austra-
criterion, it may prioritise the former service (other things lia, Thailand, the Philippines, The Netherlands, Sweden,
equal). In contrast, if the country considers it more import- Norway, England, Ethiopia, Chile and Mexico (see table 1).
ant to take care of the worst-off segments of its population
(here: severely ill HIV patients), it may prioritise the latter
service.
2
Table 1: Examples of systematic priority setting processes in countries (note list non-exhaustive)
Developing a health benefit package is not a one-off This note explains guiding principles for the process of
action – it is a dynamic process, with the package chang- selecting essential health care services. This can serve
ing over time as countries develop. As fiscal space grows, as useful input to the planning process. A more practical,
epidemiological profiles change and more information step-by step guidance is under development and will be
about interventions becomes available, a process to revise available later. Additional resources can be found in the
decisions should be in place. reference list. 4-10
Reduce or eliminate
out-of-pocket
payments for all
essential services!
3
Principles of health benefit package
The 8 principles
4
1. E ssential benefit package design
should be impartial, aiming for universality
5
2. E ssential benefit package design should
be democratic and inclusive with public
involvement, including from
disadvantaged populations
6
3. E ssential benefit package design should
be based on national values and
clearly defined criteria, including
explicit reference to trade-offs
7
Table 2: Possible criteria for essential health benefit package decision making
Burden of disease The health loss from diseases, injuries and risk factors at the population level;
it is usually expressed in a measure that combines morbidity, mortality and
disability
Balance of benefits and The balance of health benefits and harms reflects the health impact of an
harms intervention on individuals or populations
Equity and priority to A qualitative or quantitative measure of the ability of the intervention to
the worse off address existing inequalities in the health system
Financial risk protection The extent to which individuals, households or communities can afford
the cost of the intervention and are protected from catastrophic health
expenditure and health-related financial risk
Budget impact and A measure of the resources needed to implement the intervention. For
sustainability budget impact this is the overall financial implications of implementing the
intervention for the available national health budget
Feasibility The extent to which the intervention can be delivered through the existing
health system taking into account available human resources, infrastructure
and other resources and whether it is socio-culturally acceptable to the public
Social and economic The societal consequences resulting from the intervention, for instance
impact in terms of stigma, societal cohesion; as well as the broader economic
consequences, such as national development and poverty reduction goals.
Trade-offs between conflicting goals and values may be budgetary allocation carries an opportunity cost; i.e. allo-
necessary, and the selection of different criteria can lead cating funds to one intervention means that other services
to different decisions. Explicit priority-setting makes these which may well have produced more health, protected the
trade-offs transparent and enables all stakeholders to most vulnerable from impoverishment or improved access
understand the justification for such decisions. for the least advantaged, will not be provided.
All countries must ensure through their benefit package The epidemiological characteristics of the society and the
selection process that available resources are used in cultural and social aspects are changing over time and
the most efficient manner, by ensuring that the greatest that means that not only new technological solutions and
possible health benefits are achieved within the budget new innovative frameworks of organisation should be con-
constraint. Where alternative criteria are prioritized, clear sidered for inclusion in health benefit packages, but also
communication of the health loss resulting from the trade- new pathologies, new cultural paradigms and evolving
off must occur. Every decision within a finite (whether epidemiological profiles.
growing, stable or diminishing in absolute or relative terms)
8
4. E ssential benefit package design
should be data driven and evidence-based,
including revisions in light of new evidence
and changing epidemiological profiles
9
the
three
10
6. E ssential benefit package design should
be linked to robust financing strategies
This final decision is political in the sense that those who are
assigned responsibility to approve the essential package are held
accountable by political mechanisms, and in the end by all citizens.
11
7. E ssential benefit package design
should include an effective service delivery
mechanism that can promote quality care
Quality of health delivery depends upon effective regula- Opportunities to invest in health system quality that can be
tion that does not: (1) leave “gray zones” where it is unclear linked to introduction of UHC include: strengthening gov-
to some or all actors what is included and what is not (e.g. ernance and learning health systems, reorganizing service
the prosthetic as well as the surgery); or compliance gaps delivery to maximize outcomes and efficiency, moderniz-
in program implementation, especially in decentralized or ing pre-service education, and involving users in providing
fragmented health systems system feedback and informing service design.
12
8. E ssential benefit package design should
be replicable, open and transparent in
all steps of the process, and decisions
should be clearly communicated
13
Where to start?
Reference list:
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Targets and Indicators. Geneva: WHO; 2018.
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coverage. Washington DC: Center For Global Develop ment; 2017.
5. Chalkidou K, Culyer AJ. Making Choices on the Journey to Universal Health Care Coverage: From
Advocacy to Analysis. Value Health 2016; 19(8): 910-2.
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World Health Organ 2016; 94(6): 462-7.
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Lancet 2013; 382(9910): e48-9.
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guide for HTA agencies to enhance legitimate decision making. Version 1.0. Nijmegen, Radboud
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universal health coverage: what are the required processes and evidence? BMJ Glob Health 2017; 2(3):
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