Opinion: Health benefits packages — a vital tool for a 2023 UHC crisis

If 2022 was the year that the world hoped to “build back better” from COVID-19, 2023 will be the year that reality sets in for health systems around the world. The post-COVID-19 global economic stagnation, combined with inflation and rises in debt interest rates, is coming together to severely restrict fiscal space for health in most countries. Ghana, for example, just defaulted on its debt in late December. Thirty-eight countries are actually projected to have lower government revenues in 2027 compared to pre-pandemic levels. And yet the deadline to achieve the United Nations Sustainable Development Goals looms ever closer, populations continue to age, and the burden of noncommunicable diseases is rising. Ministers of health around the world face more and more competing priorities, but with inadequate resources to address them. Difficult choices must be made or progress toward universal health coverage, or UHC, will stall. We encourage policymakers and development partners to make greater use of a key policy route out of this dilemma: Establishing explicit health benefits packages, or HBPs, that re-focus limited resources on the highest priority services for all. This would enable limited resources to go further, saving lives and delivering major strides toward UHC. HBPs are developed by ministries of health or national health insurance agencies to define what services can be provided to whom, and at what cost, as part of UHC programs. They help countries make explicit guarantees to their citizens on what services they can access — whether it is HIV treatment or cataract surgery. HBPs are not new. Many countries developed their first packages in the 1990s, at least in part inspired by the 1993 World Development Report. Recently, 14 countries, all part of the Joint Learning Network for Universal Health Coverage, came together to share their experience of HBP revisions — the process by which countries add or remove services covered, change reimbursement rates for providers, or add new categories of beneficiaries to their scheme. Two key common challenges stood out. Firstly, HBPs are rarely revised and become rapidly out of date, meaning that they can no longer guide health services. In the Philippines, for example, there was a 20-year gap before its first major revision. Still, this is not inevitable. India’s National Health Authority, for instance, has thoroughly revised its HBP three times since its inception in 2018, and Thailand uses Health Technology Assessment, a process to rigorously evaluate the consequences of introducing a new health technology, to routinely review the services it provides. Secondly, HBPs are often aspirational, including a wider range of services than a country can afford. This aspiration is politically understandable but can be harmful — resulting in common distortions to health priorities, such as expensive dialysis treatment provided for a few, while coverage of essential services remains low. Again, there are good practice examples from countries that have committed to costing, appropriately budgeting, and paying their providers for the delivery of services within the HBP. In Chile’s national health plan, or AUGE, every HBP revision is carefully planned for, and fiscal space is considered from the outset, to ensure the financial sustainability and implementation of the program. Part of the challenge is that many governments, development partners, or interest groups see priority setting in health as a rapid technical exercise that can be left to public health experts and medical specialists. This is epitomized by postings many countries and development partners release, for instance, asking for a single consultant to come and revise an HBP in less than a month. We, instead, argue that HBPs should be considered as highly political, and critically, as a policy. Indeed, it should be the beating heart of all universal health coverage policy, guiding everything from service delivery, to procurement, to clinical guidelines, to user fees and provider payment mechanisms. The objective of an HBP should be to ensure that the whole health system is focused on explicitly defined key priorities. To do this, HBPs must have a mandate from the highest level and must be a standard institutionalized process that occurs regularly. Updating HBPs must be done in line with the latest evidence, health needs, technologies, and government strategy. HBPs must seriously consider the latest evidence and relevant ethical factors through an open and transparent deliberative process, which includes all relevant stakeholders. Only through this process will HBPs secure the necessary authority and legitimacy to direct resource allocation in the health system. This effort can bring great rewards — for example, Pakistan estimated that introducing its HBP could reduce under-5 mortality by 30%, neonatal mortality by 33%, and maternal mortality by 35%. 2023 will be a challenging year, with countries and development partners facing far more priorities than they can afford. But with challenge comes opportunity. 2023 can turn the page on an era of aspirational universal health coverage plans and HBPs that cannot deliver on their promises to citizens. The fiscal pressure on health budgets can be an opportunity to commit to a process of rigorous and regular HBP reviews that can help countries achieve their health systems goals and truly move toward universal health coverage.