A tisket, a tasket, is MNCH in your benefits basket?

March 2, 2015

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Learning objectives

Define benefits packages

Recognize factors that influence the prioritization of services offered by health systems

Recognize potential trade-offs that exist when designing benefits packages

Identify criteria for designing benefits packages that support Ending Preventable and children Child and Maternal Deaths (EPCMD)

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Session overview

Overview of health benefits “baskets” (benefits package) design

Small group discussion of 2 country examples

Plenary discussion of implications for EPCMD countries

Concluding remarks

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What is a “benefits package”?

Benefits: set of health services covered through some type of health financing arrangement (like insurance)

Package or basket:

– A limited subset of all health care interventions

– Determined through a prioritization process

• Explicit: List of covered services and financial benefits for specific population groups, with associated financing flows (sometimes linked to “insurance”)

• Implicit: Services (and supplies/drugs) are available to those who come to health care facilities until they run out – first come, first served Source: Adapted from Wong and Bitran (1999)

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Defining a “benefits package”

Defining a benefits package is a way to prioritize what services will be offered, to whom, and at what price BEFORE resources are allocated.

– Allows for deliberate and scientific decision-making about spending a country’s health funds

– Allows for increased transparency and accountability for what services are offered

– “EXPLICIT PRIORITIZATION”

Otherwise, services are rationed across the population – by timing, distance, social class, and chance

– Services (and supplies/drugs) available to those who come to health care facilities until they run out – first come, first served

– “IMPLICIT RATIONING”

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Why do benefits packages matter for EPCMD? They influence which services will be available

– Are the services cost-effective, given limited resources?

– Do they address the main causes of child and maternal deaths?

They influence which people will get services– Are the services covered mainly needed by women and children, poor and

vulnerable groups, vs. services desired by the elite?

– Who is guaranteed coverage – full population or only certain groups?

They influence how much governments, and citizens, pay for health care

– Can the government afford to provide the services in the benefits package?

– How much will people have to pay out-of-pocket for covered services?

They increase accountability for EPCMD– Can be used to hold the government, providers, and insurance companies

accountable for service availability and quality

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Technical considerations for EPCMD benefits package design

1. Economic evaluations• Cost-effectiveness analysis

• Financial protection analysis

2. Disease burden • What are the main causes of ill

health and mortality?

3. Target population and equity• Formal or informal sectors?

• Women? Men? Children? Elderly?

4. Service readiness and accessibility• Is the capacity of health facilities and supply of staff and supplies sufficient?

5. Resource envelopeSource: Adapted from USAID presentation by A.K. Nandakumar and Scott Stewart

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Other considerations

Social preferences: What does the population say that it wants to have covered?

“Rule of rescue”

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Historical and Political Considerations

The status quo matters.

– Design process doesn’t start with a blank slate.

Role of political processes and stakeholder engagement

– Political institutions and culture

– Population’s awareness of rights and ability to make demands

– Strength of civil society, medical associations, and others

Who has real political power?

– Desire to target poor or achieve technically efficient outcomes may hit barriers if system is dominated by wealthy constituents

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Benefits Package Design Tradeoffs

To prioritize services covered, should a country …

Rely on cost-effectiveness analysis vs. rely on social preferences?

Cover more population groups vs. provide more kinds of services?

Satisfy immediate political goals vs ensure sustainability?

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Group Activity Instructions

Get into your groups and select a rapporteur

Read over the handout with country’s experience covering MNCH services

Discuss questions on handout about trade-offs the country made. Prepare to report to plenary group:

– What criteria/what trade-offs did your country prioritize when designing its benefits package for MNCH?

– What is one pro and one con of this choice?

– Would you advise EPCMD countries to make the same trade-offs? Why or why not?

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Comparison of Benefit Packages for MNCH Services

Chile

Who benefits?– 97% of the population

What does it cover?– A list of 80 prioritized conditions,

including some MNCH services

Who pays?– Copays and premiums, linked to

ability to pay, with exemptions for low income households

Argentina

Who benefits?– Women and children in informal

sector

What does it cover?– Comprehensive set of primary

care (treatment and preventive) services for women and children, including MNCH services

Who pays?– Public tax funds

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Key Takeaways

There are many approaches for covering MNCH services and improving access and equity

Countries can’t cover all costs for all services for everyone right away. They must prioritize.

Prioritizing technical criteria should help enhance the health and poverty impacts of a benefits package, and support EPCMD

– Where is the bulk of the disease burden?– What services are most cost-effective?– What costs might be most impoverishing?

But prioritization process will always be shaped by historical and political factors.

Prioritization requires making trade-offs!

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Additional Resources

USAID-funded Health Finance and Governance Project: www.hfgproject.org

Joint Learning Network for Universal Health Coverage: jointlearningnetwork.org

Center for Global Development’s Priority-Setting Technical Working Group: www.cgdev.org/working-group/priority-setting-institutions-global-health

Inter-American Development Bank. 2014. Health Benefit Plans in Latin America: A Regional Comparison