HSS Resource Menu
- How to Accelerate Health Systems Strengthening and Promote Health Equity
- Next Generation Technical Assistance
- Integrating Priority Health and Disease Programs
- Strengthening Primary Health Care and Community Health
- Designing Health Benefits Policies for UHC
- Incorporating Equity, Resilience, and Social and Behavioral Change
Health benefits policy — the defined set of health services and commodities to be funded with pooled public funds and the rules for accessing them — is a critical way for governments to support universal health coverage (UHC). Resources are always limited, so benefits policy design is, at its core, a priority-setting exercise, one that must align with financing systems and how services and commodities are purchased from providers. Purchasing can, in turn, create efficiencies that allow for more benefits.
A growing body of guidance supports the technical aspect of benefits policy design, but such designs are also highly political and require achieving consensus on trade-offs and who benefits from public funds.
In Ethiopia, Georgia and Ghana, the Health Systems Strengthening Accelerator provided technical and facilitation support to translate global evidence into practical steps to strengthen financing for essential health services to be included in benefits packages.
The experience in these countries demonstrates that a combination of inclusive stakeholder processes, effective policy advocacy and communication, and locally generated and contextualized regional or global evidence can move governments to incrementally expand health services despite fiscal challenges and highly constrained resources.
Getting expanded benefits on the health policy agenda
Although it’s challenging, it is possible to expand benefits packages in a highly constrained fiscal environment — as was the case in Ethiopia, Georgia and Ghana. Different factors triggered each expansion, but all included advocacy demonstrating that current UHC commitments required expanding benefits, combined with locally generated evidence supporting other arguments such as value for money.
In Ethiopia, a decline in donor funding and a potential crisis in the availability of essential commodities, threatening commitments to reduce maternal and child mortality, sparked action. In Georgia, the expansion of benefits gained traction through the combination of global advocacy drawing attention to the unmet need for rehabilitation services and locally generated analysis of return on investment. In Ghana, the benefits expansion was driven by analysis that showed the commitments in the UHC roadmap would only be met with health promotion and prevention services.
Establishing effective stakeholder processes
In all three countries, consensus on expanding benefits was reached through highly inclusive, facilitated stakeholder processes. In Georgia, for example, the Accelerator supported stakeholder engagement and the inclusion of many voices at key decision points, including different government agencies, provider associations, and representatives of the community and disabled populations. A household survey also aided in understanding the barriers to accessing rehabilitation services.
Selecting and applying criteria to prioritize health services and commodities
Once consensus was reached to expand benefits in the three countries, further prioritization of services and commodities within the area of expansion was necessary to align with available financing. Stakeholders developed criteria to prioritize the benefits, including value judgments in each context, but with some variation of disease burden, cost-effectiveness, and utilization (higher utilization signifying higher need). The Accelerator supported using a combination of global evidence and locally generated data to apply the criteria.
Estimating budget impact and exploring purchasing arrangements
All three countries aligned benefits expansion with financing from the start, with up-front analysis to estimate the budget impact and identify options for purchasing through different provider payment methods and rates. With the Accelerator’s support, policymakers took multiple steps to manage risk and ensure that commitments did not exceed available resources, including scaling back the initially defined expansion and agreeing to incrementally expand based on experience (all three countries), costing and preparing to pilot the new package to get better estimates of budget impact at scale (Ghana), and putting in place other purchasing mechanisms like bundled provider payment and utilization management (Georgia).
Ethiopia’s experience strengthening domestic financing for family planning and maternal child health commodities
Ethiopia faces declining donor funding for family planning and maternal, newborn, and child health (MNCH) commodities, requiring a larger domestic role in financing and procurement. The threat of decreased funding for essential commodities prompted a discussion about sustainable financing and an effort to prioritize which services and commodities should continue to be provided free of charge. The MOH convened a technical working group (TWG) to identify the commodities to prioritize for domestic funding and to identify sustainable sources of financing. The TWG analyzed commodity needs with facilitation support from the Accelerator. This informed priority-setting, decisions about trade-offs and ultimately a consensus on which commodities the government would fund from domestic sources.
Key resource from Ethiopia’s experience
Georgia’s experience adding rehabilitation to its essential health benefits package
Georgia recognized the need for greater access to rehabilitation services amid a limited supply of outpatient rehabilitation facilities, health workers and standards of care. This unmet demand rose on the country’s health agenda following the World Health Organization’s 2021 report on rehabilitation, which galvanized political commitment to provide these services for high-need populations. Georgia’s Ministry of Health initiated a process to add outpatient rehabilitation services to its benefits package, with the Accelerator providing support to sensitize policymakers and provide evidence on the need for rehabilitation services to improve productivity and quality of life for all (not just the disabled) and the value-for-money from doing so — adding rehabilitation services also increases the value of other health investments. Consensus was reached on a prioritized list of services to be gradually introduced, starting with rehabilitation for spinal cord injuries and stroke. The Accelerator further supported the costing and budget impact analysis for the new package using benchmarked payment rates for comparable services in Estonia.
Key resource from Georgia’s experience
Ghana’s experience expanding essential benefits to include health promotion and prevention services
Ghana’s “UHC Roadmap” prioritized health promotion and prevention, but the benefits initially included in the National Health Insurance Scheme (NHIS) were largely curative. So the country aimed to prioritize a health promotion and prevention benefits package (HPPBP) to add to NHIS benefits. Ghana was also working to scale up primary care networks (“networks of practice”) and link them to financing from NHIS, which required clarifying which services the networks would provide and how to pay providers to deliver them. The Accelerator helped facilitate the process of designing the HPPBP (as a subset of the Essential Health Services Package) and analytics to operationalize it. Due to NHIS concerns, the full package will not be offered immediately, but rather, a short-term strategy will start by providing a small subset of the 68 services identified for the HPPBP covered through an “annual health check.” Part of the annual health check package will be piloted nationally and paid for by the NHIS through a new payment mechanism. Stakeholders will learn from this experience and determine how more HPPBP can be offered to the population through NHIS benefits expansion.