JLN Knowledge Product Showcase Series – Spotlight on JLN Revision of Health Benefit Package Guide

Authors:Vrishali Shekhar, Leon Bijlmakers, Jeanne-Marie Tucker

The Joint Learning Network for Universal Health Coverage (JLN) is uniquely positioned in the global health space as an innovative community of country practitioners and policymakers from around the world actively engaged in exchanging tacit knowledge on challenges faced and co-developing pragmatic solutions to implementing universal health coverage (UHC) reforms. The co-created knowledge attempts to harnesses the in-field practitioner’s experience and expertise to develop the how-to’s of designing and refining efficient, equitable and sustainable healthcare systems, while contributing to the global knowledge resource for achieving UHC.

The JLN proudly hosts a growing community of 39 member countries across the globe. Over the last 14 years, JLN has had at least 8,000 practitioners and policymakers interact on 50 technical initiatives or thematic groups resulting in over 65 knowledge products. The JLN technical offerings are used both by the member countries and non-member countries driving change in their health systems by helping address issues related to advocating for more health for money and more money for health; costing for provider payments; undertaking medical audits, designing IT systems, and how to assess primary care and integrating care, where appropriate.

In this regard, the JLN is delighted to initiate the JLN Knowledge Product Showcase Series (JLN- KPSS), with the objective of providing the JLN community with greater exposure to JLN’s recently concluded and ongoing work.  The JLN KP Showcase Series provides an opportunity for the key decision and policy makers to get better acquainted with available products and approaches for development and scaling of sustainable innovations for the attainment of UHC priorities in their respective countries. It also aims to develop a thriving ecosystem by providing a platform to JLN member countries to share their experiences of documented successes and challenges in the adaptation and implementation of JLN Knowledge Products, hence fostering collaboration and knowledge sharing within the JLN community.

Making explicit choices on the path to UHC – JLN Health Benefits Package (HBP) Revision Guide, the latest product of the JLN Efficiency Collaborative under the umbrella of the Health Financing Technical Initiative, was developed based on experiences from 18 countries, featured in the first event of the JLN-KP series. The event was aimed at introducing the technical aspects of the knowledge product as well as illustrating successful examples of adaptation and implementation of the Guide by highlighting country stories of Ghana, Ethiopia, South Africa and Kenya.

About the Guide:

The lead technical facilitator, Dr. Leon Bijlmakers highlighted the universal quest for countries to explicitly define publicly funded essential services given their fiscal constraints to create a sustainable system of UHC as the motivation behind the development of the knowledge product. The dynamic nature of the HBP is on account of the evolving nature of disease burdens and epidemiological patterns; economic cycles and their impact on fiscal budgets; availability of innovative service delivery mechanisms; and overcoming implementation challenges. Such trends compel regular revisions of the HBP to ensure efficient allocation of fiscal and human resources for the delivery of healthcare. Experiences from countries suggest that any HBP revision is reflective of local circumstances and the prioritization of services needs to be evidence based to make it a rigorous and transparent process. It goes without saying that countries face various challenges during the process of HBP revision and the Guide offers a basket of tailored methodological approaches (e.g., whole package review, partial review, incremental analysis, or a rapid review) for countries to choose from to overcome implementation concerns related to affordability and efficiency of HBP revisions.  The Guide also offers guidance on how to go about collecting and interpreting different sets of data and evidence that is crucial for achieving high quality of HBP revision related decision-making. Finally, the Guide underscores the importance of maintaining policy dialogue, establishing communication and appeal mechanisms to warrant that all stakeholders (particularly the Ministry of Finance) are aligned in the process, as well as conducting regular monitoring and evaluation of all revisions, once implemented.

Customizing the HBP revision process in local country contexts is an ongoing challenge, hence it becomes imperative for countries to learn from other countries which face similar challenges and have a comparable decision-making context. In this respect, the session provided inspiration and practical guidance from the experience of four countries on how to organize the HBP process; the analytical approaches and the types of data and evidence used in the decision- making process; how to engage in effective and sustaining policy dialogue; and institutionalizing periodic HBP revisions.

 Country Spotlights:

The Ghanaian experience with the Guide elaborated on the process of reviewing the 5% explicitly excluded diseases conditions from the benefits package designed by the National Health Insurance Scheme. The National Health Insurance Authority (NHIA) which manages the scheme is mandated by law to review the implicit benefit package that currently covers 95% of the diseases on a periodic basis. Ghana’s story underlines the importance of documentation of the revision process for standardization, ease of reference, transparency and avoiding ad-hoc changes to the benefits packages. Additionally, the cost-effectiveness of inclusion requests is assessed to ensure the sustainability of the scheme. Going forward, NHIA is looking to implement an important recommendation of the Guide by establishing a priority setting mechanism to assess inclusions by leveraging the existing structure and outputs of the Health Technology Assessment in the Ministry of Health.

Ethiopia’s illustration of the adaptation and implementation of the Guide highlighted the need to conduct a fiscal space analysis for the effective implementation of the Ethiopian Essential Health Services Package Revision. Ethiopia applied the seven principles as outlined in the JLN Guide to revise their benefits package including disease burden, cost effectiveness, equity, financial risk and protection, budget impact, public and political accountability and acceptability hence making the process participatory, inclusive, and evidence based. The process identified 1,018 health interventions from an initial list of 1,749 and ranked around 56% of them as high-priority interventions. Cost estimation of the interventions recognized a 30% budget gap in the fiscal space, rendering it as one of the biggest challenges in the implementation of the revision of HBP. The process emphasized the need for a continuous dialogue between the MoH and MoF, involving parliamentarians, leaders from both ministries and regional offices, to bring stakeholders on the same page. Recognizing the evolutionary nature of the HBP, Ethiopia is in the process of designing a roadmap for the institutionalization of the HTA/HBP revision process.

With strong political support, the health system in Keyna has been identified as a prioritized agenda in the country’s economic transformation plan. The strengthening of health information systems which focusses on the use of digital platforms to deliver healthcare is one of the foundational pillars of the health sector. One of the key reforms is the design of the essential benefit package and the institutionalization of the benefits design in a separate body. The Advisory Council adheres to the principles outlined in the Guide to inform the Ministry about necessary revisions in the package design. The Council recognizes the major role played by the private sector and faith-based organizations in the delivery of health services in the country, hence engaging them in tariff design and reimbursement rate discussions.

Finally, the approach to the design of the National Health Insurance Service benefits in South Africa is influenced by the fragmented nature of health packages in the public and private sector. A policy- based data structure largely underpins the thinking behind the country’s service benefits framework (SBF) by listing and describing examples of (normative) services available at any one time, providing the baseline against which the Benefits Advisory Committee reviews and revises the benefits. The SBF does not replace existing clinical & policy guidance; it in fact confirms their consistency/coherence at service delivery level. It does this by making explicit the service delivery assumptions that underpin national planning and impact on quality of care, thereby strengthening capacity for stakeholder engagement and good governance. The recent passing of the NHI Bill in the National Parliament and National Council of Provinces, with the possibility of it being signed by Law, are significant developments in the process of HBP revision in South Africa.

Key Takeaways:

The session underlined the following key messages from the Guide that deserve consideration for countries revising their health benefits packages. Firstly, each country context varies tremendously reflecting differences in socioeconomic, cultural and political context, hence there is no one-size-fits-all solution. Countries are encouraged to benefit from shared peer-learning experiences to adapt from comparable decision-making contexts. Countries must account for available financial, human and material resources to provide all included health services at desired coverage levels to avoid practical challenges in the implementation of aspirational packages. The Guide also strongly recommends transitioning towards an evolutionary explicit package, i.e., a well-defined and affordable set of services that is clear on benefits and promotes equity, requiring the institutionalization of a systematic, rigorous, transparent, and evidence-informed process with meaningful deliberation and stakeholder involvement. Crucially, the Guide clearly endorses universal coverage of existing high-priority services before expanding the package; and freeing resources by disinvestments from low-value services.

About the Authors: Vrishali Shekhar, Focal Point for Country Core Groups and Country Engagement, World Bank. Dr. Leon Bijlmakers, Assistant Professor, Radboud University Medical Centre Nijmegen, Netherlands. Dr. Jeanne-Marie Tucker, Development Economist, Health Policy and Systems for UHC, South Africa.

Contributors: Dr. Ruby A. Mensah Annan Ag. Director, Strategic Health Purchasing Directorate, National Health Insurance Authority, Ghana. Dr. Samson Kuhora, Head, Benefits Design and Claims Management, National Health Insurance Fund, Kenya. Dr. Alemayehu Hailu, Assistant Professor, Department of Global Public Health and Primary Care Bergen Centre for Ethics and Priority Setting (BCEPS), Western Norway University of Applied Sciences.