Harmonizing benefit packages toward UHC (services, commodities , equipment )

1. Harmonizingbenefit packages toward UHC (services, commodities, equipment) Dr Laurent MUSANGO, MD, MPH, PhD WHO/AFRO, RegionalAdviserHealthFinancing. 8th March, 2014

2. Outline

3. 1.0 Objectives

4. Objectives Government commitment to provide a benefit packages 2. How do we design benefit packages 3. Using benefit package to move towards UHC

5. 2.0 Background

6. Background • Entitlements and obligations for the population • Enshrined in constitution of countries and articulated in healthpolicies. • Entitlements: services that must be available for the population or defined individuals or groups • Obligations: on the side of the beneficiaries and providers. • Note: this is not only an issue for “insurance” – this is an aspect of any health financing arrangement, and may be implicit or explicit • Harmonizing: to avoid multiples schemes with different benefit packages.

7. 3.0 Key Points

8. Key Points: What’s covered? • Two broad approaches to specifying benefits • Positive lists: explicit listing of what services are covered (specific interventions, diagnoses, levels of service, or a combination) • Negative lists: explicit listing of what services are NOT covered – implication is that everything else IS included

9. What priority setting criteria? • There should be 3 objectives in any priority setting effort in health: • Maximize health status (level and equity). • Protect people financially against financial catastrophes from unpredictable and expensive health events. • Maximize consumer satisfaction. How can benefit design help to achieve these policy objectives?

10. What priority setting criteria?Maximize health status • Two questions need to be answered to identify those health services that provide greatest health gain for the population with available resources: • What are the prevalent health problems and what loss do they represent for the society? • How effective are existing interventions in dealing with major health problems, and how much do they cost? • Who benefits – Benefit Package for all or for some? • How to address current inequities in service use or ensure that policies don’t exacerbate differences?

12. What priority setting criteria?Provide financial protection Consequences of lack of financial protection • Protect households from catastrophic health expenditures • Cost-effectiveness alone, may exclude many impoverishing treatments • Capacity to pay varies across the population – what is “catastrophic” is not the same for everyone Within the NHI we share risk, those who are more healthy pay for those who are sickly and the rich share with the poor. To raise money for health care; some household have sold house or land... taken children out of school, or foregone food.

13. What priority setting criteria?Provide financial protection Often, inpatient services are prioritized over ambulatory/outpatient care for this purpose. But… In many countries, outpatient expenditures, especially for drugs and for those with chronic conditions, are also key drivers. Focusing on hospital cost coverage can create barriers for developing the primary health care sector because demand is shifted towards hospital care. It can potentially increase costs in long term.

14. What priority setting criteria?Maximize consumer satisfaction “Maximize consumer satisfaction” is a somewhat elusive term, This is important as a package designed on technical criteria only may not respond to a society’s desires or wishes.

15. What priority setting criteria? How to combine these criteria? Relative importance of the criteria depends on each society Trade offs exist between maximizing health status, financial protection and taking into account consumers’ preferences There is no magical mathematical formula This is not easy – choices will create losers as well as winners (why many politicians don’t like being explicit)

16. Design a benefit package: example of Rwanda. Prostheses coverage added under MMI Excluded : lenses and braces cosmetic surgery for purely aesthetic reasons Subsidized preventative care through the MPA CPA benefits package was extended to cover select services in national hospitals. Reference from the health centers to district or national level hospitals is mandatory CPA Cost of hospitalization, caesarean operations, minor and major surgical operations, medical imaging, and all diseases afflicting children ages 0 to 5 years MPA Pre- and post-natal care, vaccinations, family planning, minor surgical operations, and essential and generic drugs

17. Design a benefit package: example of Taiwan Orthodontics and lab tests that are not medically necessary. Abortion services are covered in the case of sexual assault and 60 days of end-of-life care is included either in a hospice or hospital. Curative services Prescription drugs, dental service, Chinese medicine, home nurse visits, inpatient care, and ambulatory care, among others HIV/AIDS and organ transplants are also covered Preventative services Paediatric immunizations, adult health exams, prenatal care, etc

18. 5.0 Recommended Actions

19. Recommended Actions

20. 6.0 Summary

21. Summary What policies are in place with regard to benefits? Its important that our words are translated to actions. Are these considered for the entire population or just certain groups? How do westrengthen the HSS to deliver the benefit package? Do we have a health financing strategy in place?

22. Thankyou for your attention