1. A tisket, a tasket, is MNCH in your benefits basket? March 2, 2015

2. Abt Associates | pg 2 Learning objectives  Define benefits packages  Recognize factors that influence the prioritization of services offered by health systems  Recognize potential trade-offs that exist when designing benefits packages  Identify criteria for designing benefits packages that support Ending Preventable and children Child and Maternal Deaths (EPCMD)

3. Abt Associates | pg 3 Session overview  Overview of health benefits “baskets” (benefits package) design  Small group discussion of 2 country examples  Plenary discussion of implications for EPCMD countries  Concluding remarks

4. Abt Associates | pg 4 What is a “benefits package”?  Benefits: set of health services covered through some type of health financing arrangement (like insurance)  Package or basket: –A limited subset of all health care interventions –Determined through a prioritization process Explicit: List of covered services and financial benefits for specific population groups, with associated financing flows (sometimes linked to “insurance”) Implicit: Services (and supplies/drugs) are available to those who come to health care facilities until they run out – first come, first served Source: Adapted from Wong and Bitran (1999)

5. Abt Associates | pg 5 Defining a “benefits package”  Defining a benefits package is a way to prioritize what services will be offered, to whom, and at what price BEFORE resources are allocated. –Allows for deliberate and scientific decision-making about spending a country’s health funds –Allows for increased transparency and accountability for what services are offered –“EXPLICIT PRIORITIZATION”  Otherwise, services are rationed across the population – by timing, distance, social class, and chance –Services (and supplies/drugs) available to those who come to health care facilities until they run out – first come, first served –“IMPLICIT RATIONING”

6. Abt Associates | pg 6 Why do benefits packages matter for EPCMD?  They influence which services will be available –Are the services cost-effective, given limited resources? –Do they address the main causes of child and maternal deaths?  They influence which people will get services –Are the services covered mainly needed by women and children, poor and vulnerable groups, vs. services desired by the elite? –Who is guaranteed coverage – full population or only certain groups?  They influence how much governments, and citizens, pay for health care –Can the government afford to provide the services in the benefits package? –How much will people have to pay out-of-pocket for covered services?  They increase accountability for EPCMD –Can be used to hold the government, providers, and insurance companies accountable for service availability and quality

7. Abt Associates | pg 7 Technical considerations for EPCMD benefits package design 1.Economic evaluations Cost-effectiveness analysis Financial protection analysis 2.Disease burden What are the main causes of ill health and mortality? 3.Target population and equity Formal or informal sectors? Women? Men? Children? Elderly? 4.Service readiness and accessibility Is the capacity of health facilities and supply of staff and supplies sufficient? 5.Resource envelope Source: Adapted from USAID presentation by A.K. Nandakumar and Scott Stewart

8. Abt Associates | pg 8 Other considerations  Social preferences: What does the population say that it wants to have covered?  “Rule of rescue”

9. Abt Associates | pg 9 Historical and Political Considerations  The status quo matters. –Design process doesn’t start with a blank slate.  Role of political processes and stakeholder engagement –Political institutions and culture –Population’s awareness of rights and ability to make demands –Strength of civil society, medical associations, and others  Who has real political power? –Desire to target poor or achieve technically efficient outcomes may hit barriers if system is dominated by wealthy constituents

10. Abt Associates | pg 10 Benefits Package Design Tradeoffs To prioritize services covered, should a country …  Rely on cost-effectiveness analysis  vs. rely on social preferences?  Cover more population groups  vs. provide more kinds of services?  Satisfy immediate political goals  vs ensure sustainability?

11. Abt Associates | pg 11 Group Activity Instructions  Get into your groups and select a rapporteur  Read over the handout with country’s experience covering MNCH services  Discuss questions on handout about trade-offs the country made. Prepare to report to plenary group: –What criteria/what trade-offs did your country prioritize when designing its benefits package for MNCH? –What is one pro and one con of this choice? –Would you advise EPCMD countries to make the same trade-offs? Why or why not?

12. Abt Associates | pg 12 Comparison of Benefit Packages for MNCH Services Chile  Who benefits? –97% of the population  What does it cover? –A list of 80 prioritized conditions, including some MNCH services  Who pays? –Copays and premiums, linked to ability to pay, with exemptions for low income households Argentina  Who benefits? –Women and children in informal sector  What does it cover? –Comprehensive set of primary care (treatment and preventive) services for women and children, including MNCH services  Who pays? –Public tax funds

13. Abt Associates | pg 13 Key Takeaways  There are many approaches for covering MNCH services and improving access and equity  Countries can’t cover all costs for all services for everyone right away. They must prioritize.  Prioritizing technical criteria should help enhance the health and poverty impacts of a benefits package, and support EPCMD –Where is the bulk of the disease burden? –What services are most cost-effective? –What costs might be most impoverishing?  But prioritization process will always be shaped by historical and political factors.  Prioritization requires making trade-offs!

14. Abt Associates | pg 14 Additional Resources  USAID-funded Health Finance and Governance Project: www.hfgproject.org www.hfgproject.org  Joint Learning Network for Universal Health Coverage: jointlearningnetwork.org jointlearningnetwork.org  Center for Global Development’s Priority-Setting Technical Working Group: www.cgdev.org/working-group/priority-setting- institutions-global-healthwww.cgdev.org/working-group/priority-setting- institutions-global-health  Inter-American Development Bank. 2014. Health Benefit Plans in Latin America: A Regional Comparison