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Designing and implementing explicit health benefits packages in Latin America Ursula Giedion, IDB consultant Roundtable discussion on UC and BPs Washington D.C, December 2013 - 1 - Slide 2 Structure Context What are we talking about? Benefits packages: Fashion long gone by? Why do LAC countries adopt explicit benefits packages? Comprehensive or focused? Trends Challenges Giedion, U. Workshop DC Washington DC, Dec. 2013 - 2 - Slide 3 Context: regional IDB activities around BPs and priority setting Giedion, U. Workshop DC Washington DC, Dec. 2013 - 3 - Slide 4 Knowledge exchange - Virtual platform www.redconocimientopbs.org Members: 470 Countries: 27 Average number of visits/month: 500 Profile of participants: mix of public and private institutions Members: 470 Countries: 27 Average number of visits/month: 500 Profile of participants: mix of public and private institutions Giedion, U. Workshop DC Washington DC, Dec. 2013 - 4 - Slide 5 Monthly webinars on explicit priority setting and BPs. Assistants: Up to 60 Focus of presentations: Exchange of experiences with the design and implementation of BPs Institutional aspects, not methods. Presentations and audios available on the web The best are transformed into policy briefs - 5 - Knowledge exchange : Webinars Giedion, U. Workshop DC Washington DC, Dec. 2013 Slide 6 Regional Studies BP design and implementation Name PBS Gasto en salud (GS) per capita, US$ PPP (constantes2 005 Arg.Plan Nacer $ 1.235 ChilePlan AUGE/GES $ 1.172 Col.POS $ 569 Hond.Basic Benefits Package $ 230 MexicoCAUSES/ plan FPGC $ 846 PeruPEAS $ 400 UruguayPIAS $ 979 Giedion, U. Workshop DC Washington DC, Dec. 2013 - 6 - Slide 7 Target population of BPs: From narrowly defined and limited to vulnerable population groups (Argentina, Per, Honduras, Mxico) To universal coverage (Chile, Uruguay, Colombia) Scope of services: Narrow set of maternal child health services Subgroup of key health problems (Chile) Universal coverage (Colombia, Mexico, Colombia)-one or several packages. From veterans (Colombia) to newcomers (Peru, Uruguay) Regional Studies BP design and implementation Giedion, U. Workshop DC Washington DC, Dec. 2013 - 7 - Slide 8 Heterogeneity in size/scope of packages from 4 US$ in Argentina to 590 in Uruguay Source: Giedion, Tristao, Bitran, Caon eds., 2013 (forthcoming) Regional Studies BP design and implementation Giedion, U. Workshop DC Washington DC, Dec. 2013 - 8 - Slide 9 9 BPs are mobilizing a growing share of public resources for health and are becoming key determinants of health sector budget allocation decisions in several countries in the region ==> Tool for strategic purchasing Giedion, U. Workshop DC Washington DC, Dec. 2013 Source: IDB, 2013 Notes: Argentina, Honduras does not include fixed cost. Mexico FPGC does not include fixed costs BPs in LAC Slide 10 What are we talking about? Giedion, U. Workshop DC Washington DC, Dec. 2013 - 10 - Slide 11 What are we talking about? Definitions & characteristics What some authors think BPs are (or should be?): No consensus a set of health services that are considered to be essential and which the society wants to guarantee for all (Essential Health Services Packages, WHO, Essential Health Services, Tarimo, 1996) the totality of services, activities, and goods covered by publicly funded statutory/mandatory insurance schemes (social health insurance, SHI) or by National Health Services (NHS).(EU Basket Project, Schreygg, 2005) Giedion, U. Workshop DC Washington DC, Dec. 2013 - 11 - Slide 12 HBPs are much more than a prioritized list of cost effective health interventions BPs Determine what services will be asked for from the provider network Determine the required amount of resources Determines (in part) the legitimacy of the health system Can be a key tool of strategic purchasing Determines what human resources and infrastructure will be required Can be used as a starting point to design contracting and payment mechanisms Picture: center stone Notre Dame, Paris. May be seen as an expression of the human right to health What are we talking about? Definitions & characteristics Giedion, U. Workshop DC Washington DC, Dec. 2013 - 12 - Slide 13 Why do they do it? Giedion, U. Workshop DC Washington DC, Dec. 2013 - 13 - Slide 14 Why do countries adopt explicit benefits packages? Use BPs to move from implicit to explicit Move from promise of universal access to explicit guarantees Use BP to determine resources required for resource mobilization/planning Mobilize resources to reduce equity gap Guarantee a minimum to all for equity reasons and empower the population Equity & accountability Contractual relationships introduced by reforms Purchaser provider split More dollar for the buck Efficiency Giedion, U. Workshop DC Washington DC, Dec. 2013 - 14 - Slide 15 Move from implicit universal access to explicit delimited Explicit benefits packages as an answer to an unfulfilled promise in LAC Where most LAC health systems come from: Promise of universal health care providing all necessary benefits according to need and for free. In practice: Implicit rationing Low quality, Low efficiency. Limited equity (first come, first serve) Violation of to the right to have access to the even most basic care for many, especially the poorest and those living in remote areas. Giedion, U. Workshop DC Washington DC, Dec. 2013 - 15 - Slide 16 Mobilize resources to reduce equity gaps BPs evidence the need for more resources by defining an essential package and determinaning its cost. Example Mexico/Seguro Popular: ..[]The benefits package was meant to help correct this inequity by guaranteeing the allocation of a specific amount of money per person. By establishing the content and cost of the Seguro Popular Benefits Package, it was possible to make the resource requirements evident. This in turn helped to mobilize additional resources. As a result, the differences in percapita spending were reduced to 1.2 x. (Knaul et al, 2012). Per capitas in Mxico, public and social security sector Giedion, U. Workshop DC Washington DC, Dec. 2013 - 16 - Slide 17 Equity A minimum or essential package for all irrespective of a persons ability to pay. Equity and accountability a common denominator in LAC: Peru: In summary, the PEAS was created as a result of a national agreement to create a universal insurance scheme with a health benefits plan guaranteeing a minimum health coverage for all Peruvians(Prieto &Cid)*/ Chile: one of key reasons for adopting AUGE was to reduce inequities (Bitran et al.)*/ Uruguay: Adopting the benefits package meant to adopt a n explicit list of services available to all that can be legally enforced by the population (Buglioli, Mollins, Rodriguez et al)*/ Mexico: There were 3 key reasons behind the creation of CAUSES. One was the empowerment of the population making it aware of its explicit rights (Frenk et al. 2009) Giedion, U. Workshop DC Washington DC, Dec. 2013 - 17 - */IDB, Giedion, Tristao, Bitran eds., 2013. Slide 18 How do they do it? Giedion, U. Workshop DC Washington DC, Dec. 2013 - 18 - Slide 19 Choosing what to finance: Key aspects to decide on Positive or negative list?, What criteria? Who is in charge of what? Etc. Whats the role of the BP in your health system? Giedion, U. Workshop DC Washington DC, Dec. 2013 - 19 - Whats the role of the BP in your health systemt? Option 1: Comprehensive benefits (anything not included is excluded) 100% evidence basedLook at critical issues Option 2: Delimit a subset of VIP priorities + business as usual Source: Giedion, 2012 Examples: Colombia, Uruguay, Mexico Examples: Chile, Argentina (PN), Honduras (sds) Slide 20 Whats the product? Option 1: A comprehensive &scientifically designed Who? Case Colombia, 1993 Top experts (Murray, Frenk, Bobadilla etc.) supporting Colombia in designing a BP based on cost effectiveness analysis. 18 months work Limited information available. Package was NOT accepted as much smaller than what had been previously offered to Social Security Affiliates. End result: Previous tariff manual of the Social Security Institute was adopted as a Benefits Package. Giedion, U. Workshop DC Washington DC, Dec. 2013 - 20 - Slide 21 Case Chile AUGE=PRIORITIZED BENEFITS PACKAGE, DISEASE ORIENTED Identification of 56 (now 80) prioritized health problems (based on multiple criteria), 75% BOD Associated clinical guidelines (446) Associated interventions (8005) Guarantees of access, financial protection, opportunity of care. Rest is still provided but w/o guarantees. Advantage: you never have to say explicitly NO but you still prioritize. Share of public health expenditure related to AUGE/GES, Chile 2011 Whats the product? Option 2: Limited benefit package + business as usual Giedion, U. Workshop DC Washington DC, Dec. 2013 - 21 - Source: Bitran et al., 2013 in BID, 2013. Slide 22 Trends Giedion, U. Workshop DC Washington DC, Dec. 2013 - 22 - Slide 23 Trends - 23 - 1.Increasing request for non essential health services NOT included in the benefits packages (Colombia, Uruguay, Chile, Costa Rica, Brazil) using judicial/administrative mechanisms. 2.Institutionalization of evidence based coverage decisions to adjust BPs (Uru-FNR, Mex, Col, Chile) 3.BPs-much more than lists of services 4.BPs-with guarantees to: - Enforce what is being promised - Access, quality, opportunity, financial protection guarantees Giedion, U. Workshop DC Washington DC, Dec. 2013 Slide 24 Use of judicial/administrative mechanisms for non essential health services excluded from BPs Not a minor issue anymore. Aprox. 20% of all resources of the contributory regime in Colombia in 2010. Growing concern: Why a BP if anything can be obtained anyway? - 24 - Giedion, U. Workshop DC Washington DC, Dec. 2013 Slide 25 PAHO Resolution HTA 2012 Chilean ETESA commission Institutionalization of coverage decision processes A regional trend Giedion, U. Workshop DC Washington DC, Dec. 2013 - 25 - Slide 26 Much more than a list Giedion, U. Workshop DC Washington DC, Dec. 2013 Increasing number of countries are going beyond listing what is being covered to: Define what is being covered under which circumstances : Uruguay, Chile, Colombia (starting) Explicitly linking BP content to protocols and clinical practice guidelines (Chile, Uruguay, Mxico, Colombia (sometimes)) - 26 - Slide 27 Much more than a list Uruguays PIAS List of services covered Category 1: Unrestricted use Category 2: Restricted use according to evidence 2.1 Evidence of benefits available: covered 2.2 Evidence not available: not covered Giedion, U. Workshop DC Washington DC, Dec. 2013 - 27 - Example of specific conditions covered, FNR Uruguay (Rituximab) The clinical conditions for which Rituximab is covered are: Slide 28 Guarantees Chiles AUGE/GES Access Opportunity Financial Protection Quality indicator Protocols / guidelines EXPLICIT GUARANTEES IN CHILES AUGE Copayments according to ability to pay Waiting time for diagnosis and treatments explicitly established Access to services guaranteed Opportunity of care once diagnosed Reference to CPGs and protocols Giedion, U. Workshop DC Washington DC, Dec. 2013 - 28 - Slide 29 Challenges Giedion, U. Workshop DC Washington DC, Dec. 2013 - 29 - Slide 30 Challenges in HBP design and adjustment ChallengeEffects Technical Poor or no local basic data (costs,epi., freq., utiliz.) Limited explicit criteria or method for defining inclusions or exclusions Limited technical capacity FiscalHBP rarely linked to available resources and/or not allocated according to the cost of the plan. Limited budget impact analysis of inclusion decisions InstitutionalConducted as short-term, one-off exercises, ad hoc, no mechanism to update analyses based on new data No consultative, transparent process to consider evidence, design HBP, and make adjustments, or allow for non-quantitative criteria to play a role in coverage decisions Limited documentation (transparency?) PoliticalPlans legislated prior to costing due to political urgency No explicit process to manage competing groups Pressure to include from organized interest groups often stronger than evidence base Pressure to review more than you can 30 Source: Adapted from Glassman, Chalkidou, Giedion et al. 2012 Giedion, U. Workshop DC Washington DC, Dec. 2013 Slide 31 Challenges in implementation It needs much more than choosing smartly to get from paper to practice Enabling factors Making it happen Enabling factors Making it happen Incentives to provide the services included in the BP in pro of the health of population (payment mechanism, monitoring and control, guarantess, information) EnforceabilityM&E frameworks Dissemination of benefits, empowerment of beneficiaries through knowledge Physical and HR capacity to deliver the promise Linking resource allocation to cost of BP Source: Giedion et al., 2006. Giedion, U. Workshop DC Washington DC, Dec. 2013 - 31 - Slide 32 New Regional Study BP design and implementation Available January 2014 In print in English and Spanish Download from www.iadb.org/health www.iadb.org/health Giedion, U. Workshop DC Washington DC, Dec. 2013 - 32 - Slide 33 Thank you! - 33 -