WHAT’S IN, WHAT’S OUT? This is a preliminary edition of a work in progress—please do not base any citations on this uncorrected proof WHAT’S IN, WHAT’S OUT? Designing Benefits for Universal Health Coverage Edited by Amanda Glassman, Ursula Giedion and Peter C. Smith Copyright © 2017 center for global development 2055 L St. NW Washington DC 20036 www.cgdev.org All rights reserved. No part of this publication may be repro- duced or transmitted in any form or by any means without per- mission in writing from the Center for Global Development. Library of Congress Cataloging-in-Publication Data Names: Glassman, Amanda, 1970– editor. | Giedion, Ursula, editor. | Smith, Peter (Peter C.), editor. | Center for Global Development, issuing body. Title: What's in, what's out : designing benefits for universal health coverage / edited by Amanda Glassman, Ursula Gie- dion, and Peter C. Smith. Description: Washington DC : Center For Global Develop- ment, [2017] | Includes bibliographical references and index. Identifiers: LCCN 2017019856 (print) | LCCN 2017021073 (ebook) | ISBN 9781944691059 | ISBN 9781933286891 (pbk.) Subjects: | MESH: Universal Coverage—economics | Insurance Benefits—economics | Universal Coverage—ethics | Insur- ance Benefits—ethics | Cost-Benefit Analysis Classification: LCC RA412 (ebook) | LCC RA412 (print) | NLM W 225.1 | DDC 368.4/2—dc23 LC record available at https://lccn.loc.gov/2017019856 9 8 7 6 5 4 3 2 1 CONTENTS Foreword ix Lord Darzi of Denham and Kalipso Chalkidou Acknowledgments xi About This Book xiii INTRODUCTION The Health Benefits Package: Bringing Universal Health Coverage from Rhetoric to Reality 1 Amanda Glassman, Ursula Giedion, and Peter C. Smith Policymaker Commentary Revisiting and Reformulating: How Explicit Benefit Packages Have Helped Mexico Move toward Universal Health Coverage 19 Eduardo González-Pier PART I GOVERNANCE AND PROCESS The Foundation of a Health Benefits Package Policy Introduction 23 Ursula Giedion 1 Defining the Rules of the Game: Good Governance Principles for the Design and Revision of the Benefits Package 30 Ursula Giedion and Javier Guzmán 2 Tracking the Benefits Package from Paper to Practice: Monitoring and Evaluation 61 Ricardo Bitrán 3 Managing the Money: Fiscal and Budgetary Considerations for the Benefits Package 88 Amanda Glassman Policymaker Commentary Aspiring to National Health Insurance, South Africa Considers Its Benefits Package 105 Mark Blecher and Yogan Pillay vi CONTENTS UNPROOFED ADVANCE EDITION PART II PUTTING PEN TO PAPER Methods to Select a Benefits Plan that Works Introduction 109 Peter Smith 4 How Much Health for the Money? Using Cost-Effectiveness Analysis to Support Benefits Plan Decisions 115 Mark Sculpher, Paul Revill, Jessica M. Ochalek, and Karl Claxton 5 Benefits beyond Health: Evaluating Financial Risk Protection and Equity through Extended Cost-Effectiveness Analysis 141 Stéphane Verguet and Dean T. Jamison 6 Comparing Apples and Oranges: Strategies to Weigh Health against Other Social Values 154 Alec Morton and Jeremy A. Lauer 7 Square Pegs, Round Holes: Addressing Health Sector Interventions with Non-Health Benefits 175 Rachel Silverman 8 At What Price? Costing the Health Benefits Package 185 Cheryl Cashin and Annette Özaltin 9 Beyond Cost Effectiveness: Health Systems Constraints to Delivery of a Health Benefits Package 201 Katharina Hauck, Ranjeeta Thomas, and Peter C. Smith 10 See the Bigger Picture: Resource Optimization Tools to Inform HBP Design 214 Marelize Gorgens, Janka Petravic, David J. Wilson, and David P. Wilson 11 Reliable Sources? Generating, Selecting, and Applying Evidence to Inform the Health Benefits Package 235 Neil Hawkins, Robert Heggie, and Olivia Wu Policymaker Commentary Confronting Tight Fiscal, Human Resource, and Evidence Constraints, Malawi Revises Its Benefits Package 247 Gerald Manthalu, Dominic Nkhoma, Jessica M. Ochalek, Andrew Phillips, and Paul Revill Policymaker Commentary More than a List: Reforming a Country’s Health Benefits Package— A Rigorous Approach to Tackling Costly Overutilization 253 Yot Teerawattananon, Waranya Rattanavipapong, Benjarin Santatiwongchai, Thanaporn Bussabawalai, Kittiphong Thiboonboon, and Saudamini Dabak Policymaker Commentary Starting with the Essential Medicines List: How New Zealand’s PHARMAC Prioritizes and Purchases Pharmaceutical Benefits 268 Thomas Wilkinson UNPROOFED ADVANCE EDITION CONTENTS vii PART III TOUGH CHOICES Considering Ethics, Rights, and Political Economy in Defining Benefits Introduction 273 Amanda Glassman 12 Priority-Setting as Politics: A Political Economy Framework for Analyzing Health Benefit Package Decisions 277 Jesse B. Bump and Angela Y. Chang 13 A Matter of Morality: Embedding Ethics and Equity in the Health Benefits Policy 290 Carleigh Krubiner and Ruth Faden 14 The Right to Health and the Health Benefits Package: Accounting for a Legal Right to Health When Designing a HBP 327 Rebecca Dittrich, Leonardo Cubillos, Lawrence Gostin, Kalipso Chalkidou, and Ryan Li Policymaker Commentary Chile’s Guaranteed Package of Health Benefits Walks a Political Tightrope 345 Antonio Infante 349 Additional Resources 350 List of Contributors 359 Glossary 361 Index UNPROOFED ADVANCE EDITION FOREWORD Lord Darzi of Denham Kalipso Chalkidou his book, a multiyear effort by leading applied guidance must be both methodologically rigorous academics, frontline practitioners, and policy- and grounded in the practical challenges that they Tmakers from around the world, is the first-ever “how- likely will face. to” guide to addressing one of the most overlooked This book was developed for and to a large extent practical, methodological, and moral questions with these audiences in mind. It distills practical in nations’ journeys to universal health coverage experiences and in-depth understanding of the (UHC): What do we pay for in our healthcare systems theory and the realities of evidence-informed policy- and how do we decide to pay for it? making. Alongside chapters on economic evaluation This guide comes at the right time. With the cur- methods and ethical, legal, and governance frame- rent squeeze on aid budgets in high-income countries works, it features case studies and testimonials from and a persistent skepticism in emerging economies national treasuries and health insurance funds, think about the return of investing in healthcare compared tanks, and university groups working closely with with other priorities such as education or the envi- governments such as those of Malawi, South Africa, ronment, policymakers need guidance on how to and Vietnam. design affordable, equitable, good-quality packages The book has been developed under the aus- of care for their populations. These packages of care pices of the International Decision Support Initia- must address specific needs, be able to be delivered in tive (iDSI), which was launched in 2012 following a realistic framework, and be costed and shown to be the publication of a report by the Center for Global feasible within available resources. To be relevant and Development on priority-setting institutions for useful to healthcare policy creators and drivers—the better spending on health. Led by the Institute politicians, budget holders, and regulators in devel- of Global Health Innovation at Imperial College oping countries that are committed to UHC—such London, iDSI stands for “better decisions for better ix x FOREWORD UNPROOFED ADVANCE EDITION health.” Because UHC can be a unique mechanism whether in the form of clinical and economic evi- for redistribution of health resources, and such redis- dence; evidence on feasibility, including the total tribution is more readily achieved through locally bill with regard to available funds; assessments of relevant, fair, and evidence-informed processes, iDSI cultural acceptability; evidence on government pri- has been designed as a multicountry, multidisci- orities, and an awareness of opportunities to make plinary partnership of practitioners and researchers things happen on the ground. from around the world. It is supported by the United The work is hardly over. The iDSI team is plan- Kingdom Department for International Develop- ning to use the material for courses, including mas- ment and the Bill & Melinda Gates Foundation, with sive open online courses, or for simulation games lead partners in Thailand’s Ministry of Public Health using hypothetical and real budgets; for real-time and its Health Intervention and Technology Assess- links to GEAR, an innovative database for sourcing ment Program, South Africa’s Wits University, Chi- and addressing policymakers’ questions on the eco- na’s National Health Development Research Center, nomic evaluation of healthcare interventions; and and the Center for Global Development in Washing- for postings to F1000 Research’s iDSI gateway, a new ton, DC. open-access knowledge-sharing platform. Informa- iDSI has supported the government of India in tion from this book has made it possible to deliver its assessment of the value of medical technology for training in South Africa to colleagues from six its national and state health insurance schemes, and sub-Saharan Africa countries, including policymak- advised China’s National Health and Family Plan- ers from the Republic of South Africa, and the team is ning Commission on setting up a network for health planning to do more in India and West Africa. Team policy research and technology evaluation com- members also will develop a case study compendium prising 30 universities and more than