On October 25, the Health Benefits Policy (HBP) Collaborative hosted a webinar, “Health Benefits Policies: Lessons, Country Assessments and Guide.” The webinar focused on taking a health systems approach to designing and implementing a health benefits package. The event was moderated by JLN Primary Health Care (PHC) Initiative facilitators Aaron Pervin, Results for Development, and Dr. Kamaliah Mohd Noh, Cyberjaya University Malaysia, and featured video presentations from country practitioners in Indonesia, Kenya, and Malaysia.
Countries dedicated to achieving universal health coverage want a scheme that covers all individuals but covering a full suite of medical services for the entire population is often impractical and would exceed available resources. Tradeoffs are inherent in all coverage schemes, including which services to cover, which populations to cover, and how much covered individuals should pay out of pocket for services.
Because all countries have resource limitations, the design of the health benefits package must take into account the financial, technical, and economic capabilities of the country’s health system. Failure to account for country capacity can lead to implicit rationing that does not align with country priorities. Not only should the benefits package be scaled to available resources and capacities, but the health system that implements the package should be coordinated in a way that enables covered services to be accessed by beneficiaries—either through providers or through public health interventions. These coordinating policies or regulations are what we refer to as health benefits policies.
Participants within the JLN have noted that there is a critical knowledge gap between theory and practice with regards to designing these health benefits policies. To fill this knowledge gap, the HBP Collaborative created the HBP Assessment Guide which helps to document the strengthening policies and regulations that ensure the health benefit package is meeting system targets.
Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam piloted these assessment guides which uncovered common challenges and innovations that aligned (or misaligned) the health system during the implementation of a new or revised benefits package. These 11 lessons for improving or strengthening a country’s health benefits policies are:
Mobilizing and Pooling Resources
- Consolidating multiple social insurance schemes into a single payer can improve health system alignment with health objectives
- In decentralized countries, the central government can define coverage guidelines while subnational governments innovate with different package offerings
- Some countries are considering using strategic purchasing to ensure that payment mechanisms are aligned with benefit package objectives
- Inadequate funding for providers (either through fixed budgets or output-based payments) can lead to excessive formal payments to providers for care
- How a government enrolls beneficiaries and generates demand for services has downstream effects on access to health benefits packages and on risk pooling
Supply Side Strengthening
- Some countries are experimenting with task shifting to increase facility capacity to provide services to new and expanded patient populations
Protocols and Pathways
- Several countries see a need to strengthen the gatekeeping role of PHC staff
- Most countries that rely on public facilities for PHC have defined catchment regions that automatically link enrollees with a provider
- Some countries want to use information and communications technology (ICT/IT) to improve private and public sector data sharing
- A few countries have created an M&E framework with a data collection mechanism to assess beneficiary access to benefit package services
- All six countries used a deliberative process, with a governance group comprising health system stakeholders, to make decisions about health benefits policies
Makueni County in Kenya, Indonesia, and Malaysia all recorded videos presenting their innovations and challenges.
Jaminan Kesehatan Nasional