Health Benefit Packages Survey 2020/21
Main findings
The path to Universal Health Care (UHC) varies from country to country and there is no one-size-fits-all approach. However, many countries have found it useful to define an explicit package of health services that form the core of what should be made available to all citizens from public funds.
When such a package is mandated and linked with a health financing scheme, it is often referred to as a health benefits package (HBP) – a set of services that can be feasibly provided given a particular country or area’s health systems characteristics and financial situation.
To understand more on the existence of HBPs, and the related development and design processes for countries and areas, a global survey on HBPs was administered by the World Health Organization in conjunction with a survey on health technology assessment (HTA) in 2020/2021. The HBP component was a new addition to the 2020/2021 survey that was included in order to understand the linkages between HTA processes and HBP design.
Responses to the survey were received from 115 countries and areas, giving a global response rate of 59% amongst all WHO Member States.
This is a summary of the key takeaways from the 2020/2021 HBP survey.
Health Benefit Package identification
Respondents were asked to identify the largest government health financing schemes in order to give answers related to its HBP. The term “largest” was defined as having the highest total population eligible to receive services, while the term “government” was defined as including any public sector scheme for health service provision, including coverage for groups such as the general population, public sector employees and/or the military.
Respondents were permitted to answer for either national-level or subnational-level schemes.1 Overall, 106 respondents reported for national schemes and six respondents reported having subnational schemes. Out of the 106 national-level schemes, only those that had coverage levels greater than 50% of the population are presented in this Visual Summary to be able to draw conclusions about HBPs that are applicable to a majority of a country or area’s population. These 87 responses serve as the sample for the analyses in this visual summary.
Linkages between HBP and HTA
In order to establish a link between a systematic, formal decision-making process and HBP design, respondents were asked to report if their decisions on benefit package coverage were linked to an HTA process. Only 39% of countries/areas reported that such a linkage exists, while 49% of countries/areas responded that this was not the case.2
Alternatively, from a related question in the HTA section of the survey, 48% of respondents reported having legislative requirements to consider the results of HTA while making coverage decisions or decisions to include an intervention in a benefit package. As most countries/areas had reported that their benefit package decision-making process is not linked to an HTA process when asked in the HBP section, this shows that there is more perceived linkage from the angle of HTA.
How is the range of covered technologies established
Respondents were asked to indicate the manner in which the range of covered technologies is established for different categories of interventions/technologies. This question allowed respondents to indicate multiple options if they existed.
The options available to respondents were:
- “a positive list is established at the central level”
- “negative list (of non-covered technologies) is established at the central level”
- “providers under budget constraints establish their own lists at the local level”
- “the range of benefits covered is not defined, providers give services until resources are consumed”
The results were then examined to see which countries/areas exclusively used which method(s) to establish the range of covered technologies.
There were over 62% of countries/areas that reported exclusively using positive lists and 8% of countries/areas that reported exclusively providing services until resources are consumed for Pharmaceuticals/Medicines.
Similarly, for the alternate categories of interventions, we see that countries/areas typically define the range of covered technologies either through a positive list or without any list at all and provide services until resources are consumed. In fact, for all intervention categories, well over 40% of respondents reported exclusively using positive lists and around 23% of respondents reported exclusively not using a list for the categories of: Medical Procedures, Medical Devices, and Diagnostic tests.
Therefore, only a small number of countries/areas indicated exclusively using negative lists or exclusively using lists defined by providers at the local level.
How are the covered technologies established in the HBP?
Note: This question allowed for multiple answers. Responses for ‘Positive list’ show those answering exclusively for a positive list at the central level. ‘Range of benefits not defined’ implies that respondents answered exclusively for providing services until resources are consumed without defining a range of benefits. For full results, please refer to the survey database.
Conditions on coverage of interventions
HBPs often include conditions of coverage as a way of managing service provision. The most commonly reported coverage condition was providing services only to select population groups (e.g. based on age, geography, socioeconomic status), which was indicated by 84% of countries/areas.
The second most common coverage condition was where interventions can be delivered (e.g. physician gatekeeping or level of service delivery), which was reported by 75% of countries/areas. Cost-sharing arrangements (e.g. co-payments, deductibles, caps, cost recovery) was the third most popular coverage condition.
Countries and areas were allowed to indicate multiple mechanisms to condition coverage in the survey. Indeed, 83% of the respondents reported including more than one coverage condition in their benefit package scheme and 37% of countries/areas include as many as five coverage conditions in their benefit packages.
Coverage conditions for interventions in the HBP
Revisions to Health Benefit Packages
Understanding whether and how often countries/areas revise their HBPs is also important. The survey data shows that 59% of countries/areas report having periodic revisions to the benefit package, with almost 40% of those countries/areas conducting periodic revisions between one and three years.
Time period between revision to the HBP
Note: 51 countries/areas reported having regular revisions to their HBPs. Ten of these countries/areas did not respond to this question.
The most common form of revision was additions to the benefit package, reported by 54% of countries/areas; however, 31% of countries/areas also reported withdrawals from the benefit package as a common revision. The second most common form of revision was a change to the intervention coverage conditions, with around 36% of countries stating that this was employed.
Most common forms of revision to the HBP
Financial arrangements for general interventions
Countries were asked to indicate the financial arrangements for a variety of general categories of interventions including acute inpatient care, ambulance services, critical care, emergency unit care, general outpatient consultation, and specialist outpatient consultation.
The financial arrangement options were:
- “free at point of care”
- “fixed co-payment”
- “percentage co-payment”
- “other”
Many countries/areas reported providing services free at point of care, with around 66% of the countries/areas selecting this for general outpatient consultation. A similar number of countries/areas also reported providing interventions in alternate categories as free at point of care. However, as may be expected, this was seen more often for emergency services and less often for specialist outpatient consultations.
Coverage boundaries for specific interventions and across income classifications
In order to understand coverage boundaries, respondents were asked to report on the inclusion of various proxy interventions across 37 different disease categories. The proxy interventions were a list of four interventions, identified by experts at WHO headquarters and ordered from the least costly and least complex intervention (intervention A) to the costliest and most complex intervention (intervention D).
Focusing on two categories, that of maternal health and cardiovascular disease, shows how the results can provide important HBP information. For the cardiovascular disease interventions, there is a clear coverage gradient in low-income and lower middle-income countries/areas across the proxy interventions (seen by the orange and green dots in the lower panel), while the same finding is not seen for maternal health.
This insight could potentially be due to differences between the range of interventions chosen for the two categories, or due to different priorities featured in the scheme. Further investigation can be conducted to understand such differences in detail. For both categories however, there is no such gradient in the upper-middle- and high-income groups for either of the disease categories.
Coverage boundaries for specific interventions
Note: ‘Two antihypertensives’ refers to the following: i) amlodipine; ii) enalapril or other angiotensin converting enzyme inhibitor (ACEI); iii) hydrochlorothiazide or chlorthalidone; or iv) bisoprolol or alternative beta blocker (atenolol or carvedilol or metoprolol only).
Footnotes
1 Disclaimer: The term “national” should be understood to refer to countries and areas. The designations employed and the presentation of the material in this platform do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city, or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
2 An additional 10 respondents did not provide an answer.