Designing Health Benefits Policies

Transcription

1 JLN Primary Health Care Initiative HEALTH BENEFITS POLICY COLLABORATIVE Designing Health Benefits Policies Lessons from Six JLN Countries

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3 JLN Primary Health Care Initiative HEALTH BENEFITS POLICY COLLABORATIVE Designing Health Benefits Policies Lessons from Six JLN Countries

4 Technical Facilitators Aaron Pervin, Results for Development Daniela Gutierrez, Results for Development Emma Willerton, Results for Development Marty Makinen, Results for Development Cicely Thomas, Results for Development Kamaliah Mohd Noh, Cyberjaya University College of Medicine Sciences Ricardo Bitran, independent consultant Nathan Blanchet, Results for Development Authors Kenya Omar Ahmed Omar Mohammed, Ministry of Health Matheka W. Cyrus, Department of Health, Government of Makueni County Esther Wabuge, JLN Kenya Indonesia Atikah Adyas, Ministry of Health Yusuf Kristanto, Forum Dentist Association Ede Surya Darmawan, University of Indonesia Ali Ghufron Mukti, University of Gajah Mada, Center for Financing Policies and Health Insurance Management Malaysia Noridah Binti Mohd Saleh, Ministry of Health Nazrila Hairizan Nasir, Ministry of Health Nor Idawaty Ibrahim, Ministry of Health Mali Plea Boureima, National Directorate of Health M. Konare Yaya Zan, Ministry of Public Health and Hygiene Sogo Coulibaly, National Management of Social Protection and the Interdependent Economy (DNPSES) Ousmane Ly, Ministry of Public Health and Hygiene Hammadoun Dia, Ministry of Public Health and Hygiene Sissi Dakouo, Ministry of Public Health and Hygiene Morocco Hassan Semlali, Ministry of Health Rihani Anas, Ministry of Health Chakib Boukhalfa, National School of Public Health Vietnam Nguyen Khanh Phuong, Health Strategy and Policy Institute Tham Chi Dung, Ministry of Health Khuong Anh Tuan, Health Strategy and Policy Institute Acknowledgments The editors gratefully acknowledge the generous funding from the Bill & Melinda Gates Foundation that made possible the production of this report and the accompanying country health benefits policy assessments. Other partners contributed valuable technical expertise and created opportunities for exchange that greatly enriched this report. In particular, the editors would like to thank the Joint Learning Fund, the Ministry of Health and Badan Penyelenggara Jaminan Sosial of the Government of Indonesia, and the National Health Insurance Service and Health Insurance Review and Assessment of the Government of South Korea, all of whom helped support joint learning exchanges that informed the information presented here. The editors would also like to thank the many individuals from JLN countries and international partner organizations who provided specific contributions to the report by participating in virtual and in-person meetings, writing sections, conducting technical reviews of early outlines and drafts, and developing the health benefits policy assessments that informed the outline of this report. Finally, the editors acknowledge the health system stakeholders who are working to develop or reform PHC benefits policies in their countries. Their experiences form the basis of this report. This report was produced by the Joint Learning Network for Universal Health Coverage ( JLN), a community of policymakers and practitioners from around the world who jointly create practical guidance to accelerate country progress toward universal health coverage. This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License (CC BY-SA 4.0). To view a copy of this license, visit creativecommons.org/licenses/by-sa/4.0/ legalcode. The content in this document may be freely used and adapted in accordance with this license, provided it is accompanied by the following attribution: Designing Health Benefits Policies: Lessons from Six JLN Countries, Copyright 2018, Joint Learning Network for Universal Health Coverage, Bill & Melinda Gates Foundation, Results for Development. For questions or inquiries about this report or other JLN activities, please contact the JLN Coordinator Team at jln-nc@r4d.org. Funded by Produced by

5 Contents Abbreviations and Acronyms....2 Key Terms....3 Introduction...5 Designing Health Benefits Policies....6 Country Health Systems and Packages Assessment Findings Lessons from the Country Assessments...24 Concluding Thoughts Annex A: The JLN s Joint Learning Process...35 Annex B: Country Assessment Reports...37 Endnotes...38 References...39

6 Abbreviations and Acronyms AMO BHSP BPJS-K CHE DJSN EnPHC GDP ICT JKN JLN MOH NCD NGO NHIF PHC RAMED UHC VSS l Assurance Maladie Obligatoire (Morocco s mandatory medical insurance) Basic Health Services Package (Vietnam) Badan Penyelenggara Jaminan Sosial Kesehatan (Indonesia s social security agency for health) current health expenditure Dewan Jaminan Sosial Nasional (Indonesia s national social security council) Enhanced Primary Health Care (Malaysia) gross domestic product information and communications technology Jaminan Kesehatan Nasional (Indonesia s national health insurance) Joint Learning Network for Universal Health Coverage Ministry of Health noncommunicable disease nongovernmental organization National Hospital Insurance Fund (Kenya) primary health care Régime d Assistance Médicale (Morocco s medical assistance scheme) universal health coverage Vietnam Social Security page 2

7 Key Terms accreditation. A formal process by which a recognized body, usually a nongovernmental organization (NGO), assesses and recognizes that a health care facility meets applicable predetermined and published standards.1 capitation. Payment to a health care provider based on an agreed-upon amount per person covered or enrolled for a specified package of covered services. 2 contact rate. The proportion of enrolled patients who had some contact with the provider. cost sharing. The share of service payment covered by insurance that individuals have to pay out of their own pocket. This generally includes deductibles, coinsurance, and copayments or similar charges but does not include premiums. cost-effective. In terms of medical treatment or health policy, achieving better or the same outcomes at a lower marginal cost. See also efficiency. credentialing. The process of obtaining, verifying, and assessing the qualifications of health care providers to authorize them to provide specific patient services.3 diagnostic or bundled payment. A fixed payment to a health care provider to cover aggregate costs over a specific period to provide a set of services that have been broadly agreed upon. The payment may be based on inputs, outputs, or a combination of the two. efficiency. In health care, usually improved cost-effectiveness of care. This can be measured by indicators such as avoidable hospitalizations or unnecessary C-sections. See also cost-effective. enrollment. The process through which an approved applicant is signed up for coverage with a health insurance provider. health benefits policies. Policies that facilitate the development or reform of a health benefits package. health benefits package. A set of basic health services that can be feasibly financed and provided within a country. 4 out-of-pocket costs. Consumer spending for medical care that is not covered by insurance. These costs include deductibles, coinsurance, and copayments for covered services, as well as all charges for services that are not covered. patient choice. The ability of individuals to choose a primary care provider. Patient choice has implications for referrals when needed. phc benefits framework. The JLN HBP Collaborative s framework to guide policymakers in considering the potential objectives of benefits package creation and the complementary policy domains that enable the benefits policies. The framework is based on global best practices for creating and implementing health benefits packages that are appropriate to each country s unique health system. page 3

8 pooling. The collective transferring of health revenues to purchasing organizations. Pooling ensures that risks related to financing health interventions for which the need is uncertain are borne by all the members of the pool, not by individual contributors. 5 referral network. A structured, multidisciplinary care plan that details essential steps and the appropriate facility level for each step in caring for patients with a specific clinical problem. Referral networks have been proposed as a way to translate national care guidelines into local protocols for clinical practice. 6 Also known as an integrated care pathway. standard treatment guidelines. Documented courses of action for providers to follow in treating specific clinical problems. The guidelines usually reflect medical consensus on the optimal treatment options within a health system and aim to influence provider behavior at all levels of care. task shifting. The delegating of tasks, where appropriate, to less specialized health workers. Task shifting can lower the cost of care by allowing lower-salaried medical practitioners to care for lower-risk patients or participate in less complicated interventions. vulnerable populations. Demographic groups that are at risk for poor health access and outcomes. These populations can include racial and ethnic minorities, children, the elderly, socioeconomically disadvantaged groups, the underinsured, and people with chronic, serious medical conditions. 7 page 4

9 Introduction Many low- and middle-income countries are strengthening access to high-quality primary health care (PHC) services as part of a move toward universal health coverage (UHC). A key step in this process is defining a PHC benefits package. A health benefits package is the set of health or medical services that beneficiaries are entitled to. Health planners must think about more than just the package itself, however. They must find ways to orient the entire health system to improve beneficiary access to PHC services. The policies that facilitate the development or reform of the benefits package are known as health benefits policies. In 2016, a group of committed country practitioners in the JLN PHC Initiative joined together to share knowledge on how to create effective health benefits policies as well as to address the lack of international guidance in this area. (For more on the joint learning process, see Annex A.) These practitioners formed the JLN Health Benefits Policy (HBP) Collaborative and began sharing experiences and compiling practical advice for use by other low- and middle-income countries. As part of this effort, six countries Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam conducted assessments to evaluate their own efforts to implement a new or revised benefits package within a comprehensive health benefits policy. (The resulting assessment reports are available at and via the QR code in Annex B.) DESIGNING HEALTH BENEFITS POLICIES IN DESIGNING MOROCCO HEALTH (RAMED) BENEFITS POLICIES IN A COUNTRY DESIGNING MALI HEALTH (MUTUELLES) ASSESSMENT REPORT BENEFITS POLICIES IN A COUNTRY DESIGNING MALAYSIA HEALTH (EnPHC) ASSESSMENT REPORT BENEFITS POLICIES IN DESIGNING HEALTH A COUNTRY KENYA (MakueniCare) BENEFITS POLICIES ASSESSMENT IN REPORT INDONESIA A COUNTRY (JKN) ASSESSMENT REPORT A COUNTRY ASSESSMENT REPORT This report synthesizes lessons and insights from these country assessments. It outlines the HBP Collaborative s framework for applying global best practices 8 when creating and implementing a health benefits package, 9 presents an overview of each country s health system and the benefits package it assessed, describes each country s experience in implementing its package, and offers guidance for other JLN countries as well as countries outside the JLN. Defining Primary Health Care In this report, primary health care refers to the delivery of high-quality outpatient (nonsecondary and nontertiary) preventive, promotive, and curative care, with a particular focus on interventions that countries and the global health community consider a high priority because they address diseases with the highest burdens. 10 Preventive services protect against illness or disease and include family planning, prenatal care, and immunizations. 11 Promotive services encourage well-being and healthy living and include sanitation, nutrition, smoking deterrence, and mental health. 12 Curative services treat and reduce the probability of disability and death due to entry-level and common high-burden diseases. They include deliveries, respiratory illnesses, and childhood illnesses. 13 page 5

10 Designing Health Benefits Policies Countries that are dedicated to achieving UHC want a scheme that covers all individuals, but covering a full suite of medical services for the entire population is often impractical and would exceed available resources. Tradeoffs are inherent in all coverage schemes, and for countries in the HBP Collaborative, these tradeoffs have included which services to cover, which populations to cover, and how much covered individuals should pay out of pocket for services. (See Figure 1.) Because all countries have resource limitations, the design of the health benefits package must take into account the financial, technical, and economic capabilities of the country s health system. Failure to account for country capacity can lead to implicit rationing that does not align with country priorities. 14 Not only should the benefits package be scaled to available resources and capacities, but the health system that implements the package should be coordinated in a way that enables covered services to be accessed by beneficiaries either through providers or through public health interventions. Figure 1. Dimensions of Universal Health Coverage reduce cost sharing and fees include other services financial protection: What do people have to pay out of pocket? extend to non-covered coverage mechanisms services: Which services are covered? population: Who is covered? Adapted from World Health Organization, 2010 page 6

11 JLN Summary Report Joint Learning Network for Universal Health Coverage: 1 Helpful Resources COSTING Of HEALTH SERVICES for PROVIDER PAYMENT A Practical Manual Based on Country Costing Challenges, Trade-offs, and Solutions Costing of Health Services for Provider Payment: A Practical Manual Based on Country Costing Challenges, Trade-Offs, and Solutions What s In, What s Out: Designing Benefits for Universal Health Coverage UHC PRIMARY HEALTH CARE SELF-ASSESSMENT TOOL Summary Report from Five Country Pilots June 2016 UHC Primary Health Care Self-Assessment Tool Primary Health Care Technical Initiative The PHC Benefits Policy Framework The PHC Benefits Policy Framework, shown in Figure 2, offers a way to understand the considerations involved in designing a PHC benefits package and the overall health benefits policies. At the center of the framework is the benefits package. The choice of services to include in the package is the common starting point for countries that want to improve access to PHC services. The outermost circle shows the objectives commonly stated by policymakers for PHC-oriented reforms. The inner circle lays out the complementary policy domains that enable implementation of the benefits package to advance PHC objectives. Equity Figure 2. PHC Benefits Policy Framework Health Ben Sustainability Accountability Mechanisms Protocols & Pathways Efficiency Financing: Mobilizing & Pooling Resources PHC Benefits Package Generating Demand work Health Outcomes Financing: Payment Mechanisms Supply-side Strengthening Quality Financial Protection page 7

12 Objectives of PHC-Oriented Reforms A country s specific objectives will inform how the package is formulated and implemented. The HBP Collaborative identified six of the most common objectives of PHC benefits package reforms: Health Outcomes: improving population health Financial Protection: limiting the burden of health care costs borne by patients Quality: improving the quality of care Efficiency: improving the cost-effectiveness of health care services Sustainability: improving the health system s financial viability by ensuring alignment between the services covered and available financing streams and by lowering long-term health expenditure growth Equity: ensuring that priority health services of good technical quality are available for all those in need, irrespective of economic, geographic, gender, ethnic, or other characteristics Countries will have different priorities with respect to the six policy objectives. For example, some countries may place a greater emphasis on equity while others may ascribe more importance to quality of care. Health benefits policies should be consistent with each country s stated policy objectives. Policy Domains To accomplish PHC objectives, policymakers not only need to define the benefits package, but they also need to implement the package through a set of enabling policies. The PHC Benefits Policy Framework groups these policies into six domains: Financing: Mobilizing and Pooling Resources Financing: Payment Mechanisms Supply-side Strengthening Generating Demand Protocols and Pathways Accountability Mechanisms Table 1 describes each domain and provides policy examples. page 8

13 Table 1. PHC Benefits Policy Domains Policy Domain Definition Policy Examples Financing: Mobilizing and Pooling Resources Financing: Payment Mechanisms Supply-side Strengthening Generating Demand Protocols and Pathways The strategy for generating adequate financial resources to finance service delivery Mechanisms that create incentives for providers to offer PHC services Government spending to improve provider capacity to deliver high-priority PHC services The strategy for educating the public about the health advantages of enrolling in the scheme and seeking PHC services The treatment protocols and referral pathways that improve the quality and efficiency of service delivery Introduce premiums (monthly, quarterly, or annual contributions from beneficiaries of the benefits package) into the coverage scheme for PHC services Earmark a tax or a portion of a tax to finance PHC services Allocate a share of government health spending to fund PHC services Use a blended provider payment mechanism for PHC to achieve desired objectives Introduce consumer cost sharing for lower-priority care Consolidate multiple payers to harmonize purchaser rate setting Modify laws to change the scope of practice for various medical specialties to enable task shifting Assess provider readiness to deliver PHC services and fill gaps in training, staffing, and equipment Build, equip, and staff new PHC facilities in places with limited physical access to care Offer private providers payment for delivering benefits package services Conduct outreach and education campaigns to inform the population about benefits package services and enrollment Create and fund mechanisms to promote enrollment in the scheme Engage civil society organizations when determining the composition of the benefits package in order to promote awareness of the new or modified set of services Develop or update standard treatment guidelines Create primary, secondary, and/or tertiary referral networks Link payment with provider adherence to protocols and pathways Develop and implement portable electronic medical records Accountability Mechanisms The institutional framework for measuring access and evaluating provider delivery of covered services within the PHC benefits package Provide oversight of accreditation Ensure a transparent process for setting priorities in the benefits package Provide government funding for program evaluation grants Provide government oversight of compliance with treatment guidance Publish data on public websites on the use, cost, and quality of benefits package services and on benefits policy performance indicators page 9

14 Country Health Systems and Packages All countries within the HBP Collaborative were invited to participate in the assessments of benefits package implementation, and Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam responded with interest. The assessment applied the PHC benefits policy framework to each country s benefits policy and identified necessary policy changes to improve access to services within the package. Each country created an assessment team consisting of consultants and representatives from the Ministry of Health and the main health purchaser. Each team analyzed a recent health benefits package reform in that country that offered a new scope of coverage, either through different services or through coverage of additional populations. The six countries vary in their income level and the organization of their health system. For example, the level of wealth as measured by per capita income ranges from US$779 in Mali to almost US$10,000 in Malaysia. Out-of-pocket spending on health also varies as a proportion of total income, from US$20 in Mali to US$141 in Malaysia. Tables 2 and 3 describe the economic and population health indicators in the six countries; Table 4 provides a brief overview of each country s health system. Table 2. Demographic and Health Outcome Indicators Country Population (World Bank, 2016) Rural Population (World Bank, 2017) Infant Mortality Rate (per 1,000 live births) (World Bank, 2016) Maternal Mortality Ratio (modeled estimate, per 100,000 live births) (World Bank, 2015) Indonesia 261 million 46% Kenya 49 million 74% Malaysia 31 million 25% 7 40 Mali 18 million 59% Morocco 35 million 39% Vietnam* 95 million 66% * Vietnam defines the numerator and denominator of some of these indicators differently than the World Bank does. Vietnam MOH data show a total population of 93 million that is 65% rural (2016), an infant mortality rate of 15 per 1,000 live births (2015), and a maternal mortality ratio of 69 (2015). page 10

15 Table 3. Health System Indicators Country GDP per Capita (in current US$) (World Bank, 2016) Current Health Expenditure (CHE) per Capita (in Current US$) (World Bank, 2015) General Government Health Expenditure (GGHE) per Capita (in current US$) (World Bank, 2015) CHE as a % of GDP (World Bank, 2015) GGHE as a % of CHE (World Bank, 2015) Out-of- Pocket Expenditure per Capita (in current US$) (World Bank, 2015) Indonesia $3,570 $112 $43 3.3% 38% $54 Kenya $1,455 $70 $23 5.2% 33% $23 Malaysia $9,508 $386 $ % 52% $141 Mali $779 $42 $7 5.8% 17% $20 Morocco $2,892 $160 $69 5.5% 43% $85 Vietnam* $2,170 $117 $49 5.7% 42% $51 * Vietnam defines the numerator and denominator of some of these indicators differently than the World Bank does. Vietnam national health accounts data (2015) show US$42 GGHE per capita and CHE at 5.96% of GDP. page 11

16 Table 4. Overview of Country Health Systems Country Indonesia Kenya Malaysia Mali Morocco Vietnam Indonesia has an integrated health system with a single benefits package, Jaminan Kesehatan Nasional (JKN), that is comprehensive and includes primary, secondary, and tertiary levels of care. It is managed by a single payer, Badan Penyelenggara Jaminan Sosial Kesehatan (BPJS-K), the social security agency for health. Quality of service delivery within the public and private health sectors is overseen by the MOH, which develops the accreditation process for both primary care facilities and hospitals. JKN services are provided by local government health clinics (puskesmas) and hospitals, national government facilities, and private facilities that contract with BPJS-K. BPJS-K pays providers for PHC through capitation and pays for higher-level hospital services through case-based bundled payments (Indonesia Case-Based Groups, or INA CBGs). Kenya has a highly decentralized health system in which 47 county governments provide health services that are different and separate from those offered by the national government. All providers owned by the national government must adhere to the Kenyan Essential Health Services package; counties can add additional coverage depending on regional financing and priorities. Services are delivered through the public sector, private sector, and faith-based organizations. Health services are financed through user fees, public taxes, donor funds, and premiums within public and private health insurance. Health facilities are classified into six levels based on the level of services offered and the geographic coverage. PHC services are free at health centers (level 3) and dispensaries (level 2). The National Hospital Insurance Fund (NHIF) is a mandatory social insurance program for the formal private sector. There are also schemes for 1) civil servants, police, and the military; 2) the poor, the elderly, and people with severe disabilities; and 3) women and children under age 5. Malaysia has a PHC-focused health system that includes a mix of public and private financing and service delivery. Health services are financed by 1) the public sector, through direct and indirect taxes and nontax revenues, and 2) the private sector, through out-of-pocket spending, private health insurance, and employer health benefits. Nationwide, 60% of PHC utilization is through the public sector and 40% is through the private sector. Mali s health system is highly decentralized, with local authorities involved in management. The largest health insurance scheme (Mutuelles) is voluntary; there are also schemes for employees and the indigent population. The PHC package is financed through general contributions, national government subsidies, taxes on tobacco or alcohol, payroll taxes, individual premiums, and out-of-pocket payments, among other mechanisms. Morocco s health system has a mix of public and private financing and service delivery. The government oversees the basic public health programs, hospital services, and regulation of the health sector. Health care is financed by a combination of general government revenues (via line-item budget), social health insurance, and private out-of-pocket spending. Two main national health insurance schemes cover the population: 1) a mandatory scheme (AMO) that covers public-sector employees, formal private-sector employees, retired pensioners, and students, and 2) a scheme targeted at poor and vulnerable populations (RAMED). The AMO covers 35% of the population, while RAMED covers an additional 28%. Vietnam s health system includes a mix of public and private financing and service delivery, but 96% of inpatient care and 70% of outpatient care is provided by the public sector. The MOH develops the health benefits policy, which is then implemented at the local level. The health care system is divided into preventive care and curative care. Preventive care is funded through the national budget, while health insurance is used to for curative care. Commune-level health centers deliver curative and preventive PHC. page 12

17 The countries benefits packages have varying levels of coverage and have been implemented according to each country s governance structure. (See Table 5.) For example, Indonesia, Kenya, Mali, and Vietnam have decentralized health care systems that place most of the responsibility on subnational entities, while Malaysia and Morocco have centralized systems in which the responsibility for benefits package implementation is at the national level. For an explanation of how decentralized governance can affect the benefits package, see the upcoming sidebar. All of the health benefits packages analyzed in the assessments were implemented at the national level except Kenya s MakueniCare. In each country, the assessment served a different purpose because the countries are at different stages of reform. Indonesia, Mali, and Morocco each evaluated a benefits package revision that occurred before 2014 and are looking toward strengthening the implementation and performance of the revised benefits package. MakueniCare entered its second year in 2018, so the assessment was one of the first evaluations of its benefits package. Malaysia s assessment evaluates the government s implementation plan for a new benefits package, which is still being rolled out. Vietnam s assessment was written in the primary care priority-setting phase for its Basic Health Services Package, so the analysis informed the government s implementation plan. The differences in the scope of the assessments are reflected in this report s analysis. While each country s health system, benefits package, and stage of reform are unique, each assessment has yielded practical guidance and tangible examples of ways to design or modify a benefits package and align and strengthen the health system to facilitate implementation of that package. Benefits Package Health Objectives in Decentralized Countries In highly decentralized countries, health objectives are likely to vary by unit of governance. For example, Kenya and Indonesia are strengthening governance at the local level, so local government has significant involvement in setting benefits package offerings. Makueni County in Kenya, which is considered a leader in health system strengthening, recently implemented a UHC scheme called MakueniCare, which is partially funded by the county and offers an additional layer of coverage on top of the package offered by Kenya s National Hospital Insurance Fund (NHIF). The success of MakueniCare in increasing coverage and lowering out-of-pocket spending for residents of the county has encouraged health system leaders in Kenya to analyze the scheme to inform other subnational coverage efforts and to seek ways for the program to work with NHIF in advancing Kenya s UHC agenda. Indonesia s national UHC scheme, JKN, has a national purchaser, but many districts and municipalities have developed local health financing in order to improve service delivery. The Indonesia assessment team cited studies showing that 45% of Indonesian provinces have modified the services in the benefits package. Some provinces use JKN as a coverage floor and guarantee additional services, while others have reduced the scope of services covered because of inadequate provider capacity to deliver all of the guarantees within the JKN package. In both Kenya and Indonesia, this decentralized governance structure means that health priorities will vary depending on local government health objectives. For example, in poorer areas of Indonesia, subsidies for lower-income families might be paramount, while in wealthier areas, high demand for services may lead to health inflation and thus financial sustainability concerns. page 13

18 Table 5. Country Health Benefits Packages Scheme and Implementation Date Mission Beneficiaries Indonesia Jaminan Kesehatan Nasional (JKN)* 2014 To guarantee health care and protection to meet basic health needs, as mandated by the constitution, to all individuals who have paid their contribution to the government All enrollees within publicly financed insurance schemes and voluntary enrollees who account for a large share of the previously uninsured Makueni County (Kenya) MakueniCare 2016 (in progress) To improve the socioeconomic well-being of the people of Makueni County by expanding access to equitable, affordable, and quality health care Residents of Makueni County and their dependents who voluntarily register for the program Malaysia Enhanced Primary Health Care (EnPHC) 2017 (in progress) To develop a people-centered PHC system that is efficient, effective, equitable, more responsive, and better able to address the high burden of noncommunicable diseases (NCDs)** Adults with NCDs (diabetes, hypertension, and hyperlipidemia) or adults at risk for NCDs Mali Mutuelles 2014 To provide a range of essential preventive, curative, and promotive health care that is universally accessible for all individuals and all families De facto coverage of the entire population within the service area of a community health center (radius of 5 to 15 kilometers) Morocco Régime d Assistance Médicale (RAMED)* 2012 To enable poor and vulnerable populations to access care with dignity and to put an end to the certificates of indigence system in state public facilities Poor and vulnerable populations Vietnam Basic Health Service Package (BHSP) In progress To ensure sustainability of the health insurance fund, provide financial protection, expand insurance coverage, and ensure accessible, equitable, and goodquality services to all beneficiaries Enrollees in the national insurance scheme (generally the poor and vulnerable and all of the formal sector) * These countries looked at more than PHC. ** A pilot package is being rolled out in 20 facilities across the country. page 14

19 Table 5. cont'd Service Package Purchaser Providers Indonesia Nonspecialty services such as administrative services, promotive and preventive services, medical exams, treatment and consultation, nonspecialist medical procedures, medical supplies, and lab diagnostics. Advanced-level services such as casualty services, pharmaceuticals, health screenings, midwifery and neonatal services, and family planning services. BPJS-K, Indonesia s social security agency for health Public and private-sector PHC clinics and hospitals Makueni County (Kenya) Services within the Kenya Essential Package for Health, plus additional services and items such as clinical services, mortuary services, medicines, and some specialty services. Makueni County government County-owned public facilities Malaysia Cardiovascular disease care bundle (diabetes, hypertension, and hyperlipidemia) through separate integrated care pathways that include health promotion and prevention activities, risk detection, screening, early treatment, management of the disease and complications, rehabilitation, and referrals and counterreferrals to secondary and tertiary care. MOH Piloted in 20 PHC facilities Mali Includes treatment of routine diseases, prenatal and postnatal consultations, normal deliveries, vaccinations in the expanded vaccination program, and more. Malian Social Security Fund Public community health centers Morocco Includes preventive services, general and specialized medicine, surgical hospitalizations and reconstructive therapy, X-rays and imaging services, medicines and other pharmaceutical products, necessary medical devices and implants, and more. MOH Primarily public providers, with some specialty services provided in the private sector Vietnam PHC services, including management and treatment of diseases such as hypertension, diabetes, and acute respiratory infections. MOH and Vietnam Social Security (VSS) Predominantly public providers, with private providers playing a small role page 15

20 Assessment Findings This section outlines the findings from each country s assessment. It reviews each country s health objectives and reasons for the benefits package revision, and how policymakers coordinated the health system to strengthen service delivery and access. (The assessment reports are available at Annex B includes a QR code that you can scan to access the reports.) Health Objectives Each country team began by defining the country s health objectives and how those objectives informed the services included in the benefits package. The process used to define health objectives has differed by country, and those objectives can change over time. For example, Malaysia has experienced declining maternal mortality since the 1960s and increases in noncommunicable diseases (NCDs), so the country s benefits package reflects those trends. (See the sidebar on the next page.) In most of the participating countries, such as Malaysia, health objectives are defined either by the executive branch (usually the Ministry of Health) or in government or political party planning documents as in Indonesia, Kenya s Makueni County, Mali, Morocco, and Vietnam. Each country team ranked the six possible health objectives in the PHC Benefits Policy Framework; every team noted that all six objectives were important, despite having different levels of priority. (See Table 6.) Financial protection was the most common high priority, followed by health outcomes and quality. Efficiency and equity were high priorities only for Vietnam. Health outcomes were a secondary priority for four countries, equity was a secondary priority for two countries, and quality and efficiency were secondary priorities for one country. Every objective was considered a factor for benefits package design in nearly all of the countries. page 16

21 Malaysia: Changes in Health Objectives over Time Malaysia is among the countries in which health objectives have changed as the country s demographics have shifted and the economy has matured. The figure below shows how Malaysia s PHC focus has expanded as provider capacity has grown and the burden of disease has changed. Malaysia s status as a middle-income country with adequate public health spending and growing per capita income means that PHC services are typically affordable for the community. The benefits package has expanded accordingly, with greater focus on services that improve chronic disease health outcomes (including for NCDs) Mother & Child Family Planning Outpatient Environmental School Blue = added priorities Mother & Child Family Planning Outpatient Environmental School Dental Pharmacy Lab Mother & Child Family Planning Outpatient Environmental School Dental Pharmacy Lab Child with Special Needs Adult Health Elderly Cardiovascular Disease Mental Health Adolescent Sexually Transmitted Infection Tuberculosis/Leprosy Occupational Health Emergency Health Informatics Mother & Child Family Planning Outpatient Environmental School Dental Pharmacy Lab Child with Special Needs Adult Health Elderly Cardiovascular Disease Mental Health Adolescent Sexually Transmitted Infection Tuberculosis/Leprosy Occupational Health Emergency Health Informatics Rehab Dietary HPV Needle and Syringe Exchange Program / Methadone Management Therapy / HIV Dialysis page 17

22 Table 6. Priority of Health Objectives Objective High Priority Secondary Priority Health Outcomes Financial Protection Quality Makueni County (Kenya) Malaysia Indonesia Makueni County (Kenya) Mali Morocco Makueni County (Kenya) Malaysia Vietnam Indonesia Mali Morocco Vietnam Indonesia Efficiency Vietnam Morocco Equity Vietnam Malaysia Mali Sustainability Indonesia Defining the Benefits Package All of the countries except Vietnam reformed an existing benefits package based on the burden of disease and what was missing from the existing package. Vietnam is reforming its current package due to sustainability concerns and is considering removing services that are not cost-effective (according to international medical evidence) to make better use of health spending. All of the countries used a similar process for package formulation. They first created a technical working group with representatives from across the health sector including the major health purchaser and the health system s quality steward to determine the composition of the package. Table 7 lists the types of participants who were involved in the benefits package decision-making process. Malaysia, Mali, Morocco, and Vietnam included civil society representatives who spoke on behalf of beneficiaries, while other countries limited their technical working group to providers and government stakeholders. The time needed for the process depended on the scope and scale of reform. In Indonesia and Morocco, the health system reform took about five years. In Malaysia, intensive deliberations on the relatively small EnPHC package (for use in 20 facilities across the country) took place over six weeks. page 18

23 Table 7. Technical Working Group Composition Country Participants Indonesia Kenya Malaysia Mali MOH, health purchaser (BPJS-K), national social security council (DJSN), medical associations, hospital associations, professional associations, and academia County government, county health department, health facilities, county/subcounty health management boards, and the governor s administration Prime minister s Performance and Delivery Unit, community NGOs, MOH, private- and public-sector providers Civil society representatives (on behalf of consumer associations and the National Federation of Community Health Associations), NGOs (on behalf of technical and financial partners), and the national government Morocco Vietnam MOH, labor unions, employers, Parliament, National Agency for Health Insurance MOH, Ministry of Finance, social security administration (VSS), health regulatory bodies, medical associations, health facility administrators at all levels, and technical experts Vietnam s priority-setting process is emblematic of how technical working groups can be used to determine what services to include in or exclude from the benefits package. Vietnam used medical and cost-effectiveness evidence to create a new list of services that excludes unsafe and cost-ineffective services, and it created the National Health Insurance Policy Advisory Council whose members represent beneficiaries, providers, and payers to review and debate the merits of the various services and interventions. This kind of process encourages communication among all parts of the health sector and can lead to a consensus decision on the scope of the benefits package. For more on Vietnam s priority-setting process, see the accompanying sidebar. page 19

24 Vietnam: Reviewing the Basic Health Services Package Vietnam Social Security (VSS) covers a generous benefits package, including 17,216 services and 1,064 pharmaceuticals for all levels of care. The list has grown organically, in the absence of a specifically defined package. To improve the financial feasibility of VSS, Vietnam reviewed all of the covered interventions to determine which ones to include in the Basic Health Services Package (BHSP). The proposed process for reviewing the current list of reimbursable services and defining the BHSP is depicted in the following figure and described below. 1 Selection for Assessment (from 17,000+) Highest-cost and highest-frequency services prioritized for review Low-cost and low-frequency interventions pass without intensive scrutiny (for now) 3 Deliberation + Decisions 2 In-Depth Assessment Selected services evaluated for:»» Safety»» Clinical effectiveness»» Cost-effectiveness Analysis to include estimated savings from recommended exclusions, reimbursement conditions, and revisions to standard treatment guidelines. Council to decide based on assessment criteria and additional considerations, including:»» Health needs»» VSS budget impact»» Delivery feasibility»» Political issues (equity, social preferences, vulnerable populations) Evidence compiled for the council 1. Select the interventions to review. All countries are limited in the amount and types of health services they can afford financially and can deliver to their populations. Thus, all countries must identify the highest-priority health interventions and match available resources with health needs. Vietnam s first step in refining its benefits package is to create a list of services for an in-depth review, focusing on the highest-cost and highest-frequency services. As in many other countries, relatively few services and medicines account for a large proportion of social security spending. 2. Conduct an in-depth assessment of the selected interventions. Vietnam has selected a subset of the many high-cost interventions 14 pharmaceuticals, three diagnostic devices, and screening protocols for two leading forms of cancer to assess, using the criteria of safety, clinical effectiveness, and cost-effectiveness. 3. Deliberate and decide on the benefits package. In the final stage of the review process, a national advisory council for health insurance policy will be presented with a number of potential benefits package designs that vary in the services offered and the service eligibility criteria. The council will make a choice based on Vietnam s health needs, the budget impact on the VSS, impact on out-ofpocket expenditures, alignment with service delivery capacity, and political priorities. page 20

25 Health System Coordination All six countries have made efforts to strengthen policies in at least some of the domains in the HBP Framework to facilitate implementation of their benefits package. Table 8 describes the policy changes each country has made in various domains, as well as which domains they have not addressed. For Vietnam, which is still determining its BHSP and corresponding policies, the table lists proposed policies. Table 8. Policy Changes Made to Facilitate Benefits Package Performance Domain Indonesia Makueni County (Kenya) Malaysia Mali Morocco Vietnam High-Priority Health Objectives Financial Protection, Sustainability Health Outcomes, Quality, Financial Protection Health Outcomes, Quality Financial Protection Financial Protection Quality, equity, and efficiency Mobilizing and Pooling Resources Governmentsponsored insurance plans have been consolidated into a single purchaser. Scheme is funded through a mix of payroll taxes, premium payments, and general revenue. Funding sources: General county revenue Budget transfers from the central government to Makueni County Donor funding User fees from non-makuenicare beneficiaries Not a high-priority domain, but the MOH provided a small budget for providers who participated in the EnPHC pilot. If the program is scaled up, the amount of resources per provider will need to increase. Funding sources: Personal contributions Payroll tax Federal budget transfers Private donor funding Sin taxes Transportation levies Funding comes from general revenue; no new revenue streams were established to implement the program. The current social health insurance scheme has different budgets for curative services and for preventive/ promotive services, both funded from general revenue, individual premiums, subnational budget transfers, and donor support. Vietnam s strategic plan for the BHSP involves a costing exercise to estimate the total per-person cost of the new package and determine any changes needed to the package s financing apparatus. Payment Mechanisms Blended payment model with capitation for primary care, bundled episode payments (casebased groups known as INA CBGs) for all inpatient and some outpatient care, and feefor-service for high-priority populations such as pregnant women and newborns. MakueniCare services are reimbursed using fee-for-service. Public providers are typically funded through fixed budgets, but the fixed budgets are not changing due to the pilot. The government acknowledges that changes in provider payment such as increases in facility budgets will have to be considered if the pilot is scaled up. Providers are paid by the visit or through fee-forservice, depending on the service. Providers are paid through a fixed budget or through block grants from the central government, but there continues to be out-ofpocket spending within vulnerable populations targeted by the health law. The MOH is working with stakeholders to develop a capitated payment structure for BHSP services. VSS has historically paid for SHI services through fee-for-service. page 21

26 Table 8. cont d Domain Indonesia Makueni County (Kenya) Malaysia Mali Morocco Vietnam Supply-side Strengthening Credentialing for all providers and accelerated accreditation for public and private providers that meet quality assurance standards. Makueni County has allocated 30% of its UHC budget to invest in facility infrastructure and staff to increase their technical capacity to deliver the full list of MakueniCare services. The county increased the number of health care workers by 54% from 2013 to The county is addressing staff shortages for some medical specialties by adding training at other staff levels (such as nurses and clinical officers) in treatments and interventions that are typically provided by those with additional schooling (such as anesthesia, psychiatry, and ophthalmology). Malaysia has increased investment in technology to improve patient risk profiling. Community volunteers are trained to use basic screening kits to measure blood pressure, glucose, and body mass index. Governmentemployed community health coordinators analyze patient risk profiles to determine the initial setting of care for patients with differential risk scores. All levels of government, from the national to the community level, recruit physicians. In some communities, medical associations and NGOs also conduct physician recruitment. The private sector is contracted to provide care that is unavailable or underprovided within the public sector. Current measures include task shifting, investing in providers, and private-sector engagement, but there are not enough resources to do this adequately. Some of the funding for public provider investment will come from the social health insurance fund. The MOH is developing a strategic plan to address gaps in provider capacity to deliver the full suite of services within BHSP. Implementation of the BHSP will require more funding for these program components. Generating Demand Previously uninsured and informal-sector workers are (voluntarily) enrolled at regional enrollment centers. Previous enrollees within governmentsponsored insurance schemes poor/ near-poor, formal sector, and government employees are automatically enrolled in JKN. Voluntary enrollment is done at the point of service (hospitals or PHC facilities). Enrollment is carried out by community NGOs; the government offers nonfinancial incentives for enrollment work, such as giving enrollment NGO employees higher priority when they seek treatment at participating facilities. The National Center for Information, Education and Communication in Health (CNIECS) the MOH department in charge of communications and behavior change efforts runs public awareness campaigns to publicize the health benefits package. Government conducts public awareness campaigns. Community enrollment centers are responsible for encouraging beneficiary enrollment. Vietnam plans to conduct a public awareness campaign to improve enrollment. Evidence from past enrollment campaigns shows mixed success. page 22

27 Table 8. cont d Domain Indonesia Makueni County (Kenya) Malaysia Mali Morocco Vietnam Protocols and Pathways JKN ties the provider s capitation rate to provider referral pathways and wellness club participation. The referring facility must receive prior authorization from the referral facility. If the referral facility does not believe the case has merit, it will offer support over the phone. However, bypassing of county-owned PHC centers by beneficiaries is still an issue. During enrollment, Malaysia collects patient information such as socioeconomic status and family and personal medical history. Information is used to group all adults into risk tiers. Malaysia is strengthening the system s referral network to improve continuity of care, including clinical and prescribing audits and organizational feedback mechanisms to update antiquated systems. The MOH publishes referral guidelines. Government is creating standard care guidelines for conditions including cancer, hypertension, diabetes, hepatitis C, mental health, dialysis, thalassemia, and hemophilia. Under the current package, standard treatment guidelines are not strictly followed. BHSP is attempting to improve adherence to the medical guidelines and referral pathways, which will decrease bypassing of the PHC system. Accountability Mechanisms Indonesia is using electronic medical records and billing data to oversee providerlevel service utilization. Capitation payment for PHC is linked to facility-level performance benchmarks. MakueniCare plans to contract with the private sector to increase the supply of providers in regions with limited access to care. The county is strengthening its IT system to improve data sharing among facilities and enable better reporting and monitoring of service delivery. Three-step M&E plan: 1. Community survey to measure the effectiveness of EnPHC s screening techniques and changes in NCD prevalence and case detection. 2. Facility survey to evaluate EnPHC at the clinical level using process measures and clinical outcomes to measure improvements in NCDs. M&E is conducted by multiple agencies, including the MOH, National Agency for Evaluation of Hospitals, and Central Health Laboratory. Legal agreements between the national health insurance scheme and professional medical associations monitor how care is delivered by public providers. The General Inspection Unit within the MOH will investigate providers if there are excessive requests or complaints by civil society. Vietnam is currently preparing a regulation that provides guidance on monitoring providers to ensure proper care delivery. 3. Focus groups to evaluate staff and assess facility experiences in implementing the program. page 23

28 Lessons from the Country Assessments Some common themes emerged from the country assessments, all related to how countries have attempted to align their health systems with the benefits package. This section discusses those themes, grouped by health benefits policy domain. Mobilizing and Pooling Resources Consolidating multiple social insurance schemes into a single payer can improve health system alignment with health objectives. Health financing streams can include many actors such as private health insurance companies and donors in addition to government purchasers each with service priorities that are tied to different payment mechanisms. When various purchasers do not agree on the highest-priority services, the health system s efforts to improve overall population health and financing protection can be compromised. Some countries might also have funding streams that are earmarked for specific vertical programs, such as tuberculosis or HIV. For example, Kenya s MakueniCare and Morocco s RAMED are funded by multiple county and national-level revenue streams, such as donor support, subnational taxes, and a national general pool. MakueniCare s assessment studied the risks that this fragmentation poses to the scheme s sustainability if the organizations in charge of the different funding streams were to shift their priorities. To help address these sorts of issues and strengthen its sustainability, Indonesia s JKN program consolidated many government-sponsored packages and pooled resources under a single payer. (See Figure 3.) Before JKN, the Indonesian government funded a national coverage scheme for those living near the poverty line ( Jamkesmas) and subnational agencies added a layer of additional coverage based on regional priorities ( Jamkesda). Indonesia also had a coverage scheme for government employees (Askes) and one for formal-sector companies ( Jamsostek). JKN consolidated all of these schemes while expanding coverage to the previously uninsured and created a single payer (BPJS-K). Having a single payer can have disadvantages, such as if the purchaser is corrupt or inefficient, but the potential advantage is that the institution can align the disparate funding streams and packages and ensure that all of the provider payment mechanisms contribute to ensuring access to high-priority services. In decentralized countries, the central government can define coverage guidelines while subnational governments innovate with different package offerings. Indonesia, Kenya, and Mali all have a centrally defined benefits package but allow subnational governments to modify the package based on local priorities and resources. Makueni County treats the Kenyan Essential Package for Health (KEPH) as a coverage floor and offers additional coverage to enrollees for care in county-owned facilities. Before the advent of JKN in Indonesia, the country had a package coverage floor for the poor and near-poor ( Jamkesmas) but allowed subnational governments to expand on that package using local financing ( Jamkesda). Indonesia and Mali have packages that can be modified depending on regional provider capacity. This can have positive and negative effects. On the one hand, the package can be aligned with provider capacity to deliver the defined service, but on the other hand subnational governments could weaken the package to such an extent that UHC is no longer feasible. page 24

29 Figure 3. Indonesia s Financial Pooling and Provider Payment Mechanisms for PHC Government employer/ employee contributions (formerly under Askes) Payroll tax on private- and formalsector employers and employees (formerly under Jamsostek) Ministry of Finance contributions for the poor and near-poor (formerly under Jamkesmas and Jamkesda) Informal sector and other previously uninsured Personal contribution varies only by preferred inpatient bed type (personal room, shared room, ward). PHC coverage is the same regardless of contribution amount. Central BPJS-K Fund 5% to JKN administration 95% to BPJS-K regional offices PHC facilities (puskesmas and private clinics) Capitated payment and some fee-for-service Hospitals Case-based bundled payments or fee-for-service Adapted from JLN/GIZ, 2017 Payment Mechanisms Some countries are considering using strategic purchasing to ensure that payment mechanisms are aligned with benefits package objectives. It is critical to understand how a particular payment mechanism may affect delivery of the benefits package. All of the participating countries use a mix of fee-for-service, capitation, and fixed budgets to pay for services in the benefits package, but some countries, such as Kenya and Vietnam, are contemplating moving to a payment structure that shifts additional financial risk from the purchaser to the provider. Table 9 shows the payment mechanisms in use for each health benefits package and the extent of financial risk that each payment system shifts to the provider or payer. (Malaysia is omitted because EnPHC does not introduce new provider payment mechanisms.) Each country is grappling with the effects of payment mechanisms on service utilization. Makueni County and Mali are using payment mechanisms that minimize incentives for providers to underprovide necessary care. These mechanisms reimburse costs that providers incur or use fee-for-service to encourage service utilization. To build in some level of accountability, however, Makueni County has created an extensive payment tracking system to ensure that the payments are medically justifiable. (See Figure 4.) Historically, Vietnam has paid for social health insurance services on a fee-for-service basis. But this has led to concerns about overprovision of care, putting the financial sustainability of the social health insurance fund managed by VSS at risk. This is why policymakers in Vietnam are reviewing the benefits package to determine which of the page 25

30 17,261 currently covered services should be included in the new BHSP for each level of care. Health governance stakeholders are trying to shift to a capitated payment for primary and secondary BHSP services so the payer can better predict future spending. Unlike with pure fee-for-service, JKN in Indonesia and RAMED in Morocco reimburse for services in the basic PHC package through capitation or through budget appropriation and block grants. Both countries are concerned about the effect of this payment mechanism on access to care. Indonesian policymakers are concerned about underprovision of certain services that are included in the capitated payment or fixed budget allocation, such as TB treatment at the PHC level, while technical experts in Morocco are concerned that fixed budgets may fail to reduce inequities in access to care. For some priority services such as maternal and newborn care JKN uses a blended payment model that includes fee-for-service and payments bundled at the inpatient or outpatient level. This lowers the probability that providers will stint on care for priority diseases or diagnoses. Table 9. Provider Payment Risk Sharing Greater risk to the provider Greater risk to the payer Country Coverage Scheme Budgets or Block Grants (per Year) Capitation (per Enrollee per Year) Diagnostic or Bundled Payment (per Episode) Per Visit Per Service Reimbursement for Unit Costs Indonesia JKN X X X X X Kenya MakueniCare X X Mali Mutuelles X X Morocco RAMED Vietnam BHSP page 26

31 A Toolkit for Countries Working Toward Universal Health Coverage SERIES SUMMARY JLN/GIZ Case Studies on Payment Innovation for Primary Health Care In most countries, primary health care (PHC) providers are the first point of contact that people have with the health care system. This part of the system sees the most use and can therefore have the greatest impact on health, particularly among vulnerable populations. International evidence confirms that a stronger PHC sector is associated with greater equity and access to basic health care, higher patient satisfaction, and lower aggregate spending for the same or better outcomes. The role of the PHC sector also determines many of the interactions among the government, purchasers, providers, and the population throughout the health system. Financing and payment models for PHC can be important tools for addressing issues of access, quality, and equity in health care. Financing and payment models for PHC should allow adequate resources to flow to the primary care level and make priority interventions accessible to the entire population. These models should also create incentives across the health system to manage population health, use resources efficiently, and avoid unnecessary services and expenditures at the secondary and tertiary levels. In many countries, financing and payment models do not help strengthen PHC; in fact, they tend to exacerbate imbalances that favor expensive tertiary hospitals. This hinders efforts to improve population health and imposes financial burdens on households. Financing systems are often fragmented and involve many different agencies (including national and local governments, insurers and purchasing agencies, development partners, faith-based organizations, and nongovernmental organizations), each with their own funding and payment mechanisms. Countries find it challenging to develop financing and payment systems for PHC that align with payment systems at other service delivery levels IN-DEPTH COUNTRY CASE STUDIES The series includes case studies on these three countries: ARGENTINA CHILE INDONESIA and create both opportunity and incentives to provide better primary care, ensure more equitable access, and shield families from impoverishing out-of-pocket payments. Little evidence is available on effective payment models for PHC that help shift the balance of resources and services toward primary care and prevention to improve population health. Many countries, including those in the Joint Learning Network for Universal Health Coverage 1 (JLN), have tried a wide variety of approaches and models for PHC financing and payment, but few of those experiences have been evaluated or their lessons well documented for an international audience. The JLN/GIZ Case Studies on Payment Innovation for Primary Health Care aim to help fill this gap by sharing the experiences of three countries Argentina, Chile, and Indonesia so peer countries can extract lessons about implementing innovative payment models for PHC. Each case study describes the context, objectives, and governance structure of the PHC payment innovation, the design of the payment model, and how effectively the payment innovations have achieved their objectives. The Argentina case highlights the effective use of financing and payment for PHC to achieve national health objectives in a highly decentralized context. Chile offers an example of how a country can incrementally introduce major payment reforms during a political transition and then refine the model over time. Indonesia highlights the experience of scaling up a PHC payment innovation in the context of integrating multiple public health insurance schemes. The following table summarizes each country s payment innovation and how well it has met the country s stated health objectives. 1 The JLN is an innovative, country-driven network of practitioners and policymakers from around the globe who co-develop global knowledge products that help bridge the gap between theory and practice to extend coverage to more than 3 billion people. PAGE 1 Figure 4. Public Financial Management Accountability in Makueni County Department of Health presents to cabinet proposed utilization of budget for the whole year Hospital submits invoice to Department of Health. Accountant and UHC administrator receive and verify data and submit to Director of Health Planning Director verifies data and forwards to the Office of Chief Officer (accounting officer) for approval Accountant signs requisition and forwards to accountant in charge of vote book, who verifies availability of funds and signs Returns to Chief Officer, who signs and approves according to the guidelines issued by the Cabinet and Public Finance Management Act and forwards to Minister of Health for signing Minister signs, approves, and forwards to County Treasury Invoices IFMIS for approval and payment to hospital accounts Helpful Resources Using Data analytics to Monitor HealtH ProviDer PayMent systems Using Data Analytics to Monitor Health Provider Payment Systems FINANCING AND PAYMENT MODELS FOR PRIMARY HEALTH CARE SIX LESSONS FROM JLN COUNTRY IMPLEMENTATION EXPERIENCE Financing and Payment Models for Primary Health Care: Six Lessons from JLN Country Implementation Experience JLN/GIZ Case Studies on Payment Innovations for Primary Care page 27

32 Understanding how payment mechanisms affect access to entitlements is critical. Shifting to capitation payment can lower the growth of health spending but also create an incentive for providers to withhold necessary care to keep their costs low and retain more of the capitated amount. Shifting to fee-for-service can lead providers to increase the amount of services they provide but also increase the use of cost-ineffective services, thereby increasing purchaser costs. Each payment mechanism should be evaluated based on how it aligns with the benefits package s objectives. Inadequate funding for providers (either through fixed budgets or output-based payments) can lead to excessive informal payments to providers for care. Expanding the list of services in health benefits packages that are not adequately financed can lead to providers accepting informal or illicit payments for primary care, which can create a barrier to patient access to services. In addition, offering services in a benefits package but not accurately costing them for adequate service provision can lead to implicit rationing of care. Inadequate health financing can manifest in many ways, from lack of staffing for delivering new services to inadequate capitated payment that does not reflect the expected total cost (utilization rate times cost) of line items in the benefits package. Indonesia and Morocco are concerned that the financial analysis used to determine the level of provider funding may have underestimated the amount of revenue needed to cover the cost of new services. If new entitlements increase total costs but funding for staffing or provider payments does not increase accordingly, providers will likely request illicit out-of-pocket payments from patients to cover their losses. Helpful Resource COSTING Of HEALTH SERVICES for PROVIDER PAYMENT A Practical Manual Based on Country Costing Challenges, Trade-offs, and Solutions Costing of Health Services for Provider Payment: A Practical Manual Generating Demand How a government enrolls new beneficiaries and generates demand for services has downstream effects on access to health benefits packages and on risk pooling. Some UHC schemes that are partially funded through annual or monthly premiums enroll beneficiaries at the provider level or conduct voluntary enrollment at registration centers. This kind of enrollment can cause adverse selection and lead the risk pool to consist of individuals who seek medical help and are sicker than the general population. In Makueni County, 70% to 80% of individuals who visit facilities are enrolled in the program, but only 15% of county residents are enrolled, leading to concerns about adverse selection and risk pooling. In Indonesia, the JKN purchaser, BPJS-K, has regional enrollment centers that do community outreach to bring in new enrollees. All six countries rely on community-level awareness campaigns to improve pooling. However, Makueni County and Indonesia are reevaluating the voluntary enrollment mechanism and are investigating ways to enroll healthy individuals to spread out medical risk. page 28

33 The countries have not considered other mechanisms for spreading medical risk, such as making enrollment compulsory for all uninsured people or requiring group enrollment (family, farm cooperative, or professional association group). These could improve risk pooling by increasing healthy patient enrollment within the UHC scheme. Supply-side Strengthening Some countries are experimenting with task shifting to increase facility capacity to provide services to new and expanded patient populations. Relaxing the scope of practice laws while expanding regulatory oversight of lower-skilled medical workers can help increase health care staffing. One approach is to start small and focus on training community-level staff or volunteers to do risk profiling, health screening, and assisting with referrals similar to what Malaysia is currently doing through its EnPHC program. Larger task-shifting reforms such as in Makueni County include training nurses and physician assistants in treatments and interventions that typically require additional schooling. This has allowed MakueniCare to increase its coverage of services that are in short supply, such as anesthesia, psychiatry, and ophthalmology, in regions where demand for such services outpaces supply. Protocols and Pathways Several countries see a need to strengthen the gatekeeping role of PHC staff. Empowering PHC staff to steer the referral process can improve benefits package performance. All six countries have issues related to inappropriate use of expensive hospitals by patients who bypass lower-level, less costly PHC clinics. In some schemes, such as Indonesia s JKN and Kenya s MakueniCare, PHC providers sometimes refer patients to hospitals because of concern about the cost of treating a complicated case. In Mali and Vietnam, patients sometimes bypass primary care and go straight to secondary or tertiary hospitals. There are many ways to strengthen gatekeeping across the domains in the HBP Framework. Indonesia uses performance-based payments that are tied to benchmarks for nonspecialty referrals. If a PHC provider refers more than 5% of patients to hospitals for services within their capitation payment contract, the capitation payment is lowered by 5%. (See the sidebar on Indonesia on the next page.) This accountability mechanism encourages providers to provide benefits package services within their own facility. page 29

34 Indonesia: Using Performance-based Payment to Reduce Inappropriate Referrals Indonesia is working to strengthen the gatekeeping role of primary care facilities and linking primary care capitation payment to referral, access, and quality benchmarks. Capitation rates are tied to a PHC provider s performance against three benchmarks: Contact rate. This benchmark discourages underserving of enrolled populations. The contact rate is the proportion of enrollees who have had some contact with the provider. To receive the full capitated payment, a facility must have a contact rate higher than 1.5%. Referral rate. This benchmark reduces inappropriate referrals. The referral rate is the proportion of referrals to specialists that are for a primary care diagnosis. To receive the full capitated payment, a facility must have a referral rate lower than 5%. Chronic Disease Management Program (PROLANIS) measures. These measures were developed to prevent worsening of chronic conditions. They are defined as the proportion of individuals with hypertension or diabetes who participate in a facility s fitness and wellness club. To receive the full capitated payment, a facility must have more than 50% participation among patients with these chronic conditions. Capitated payments are lowered if a facility fails to meet these benchmarks. As of March 2017, almost all public primary care centers had committed to participate in the performance-based payment program; expansion to private facilities is planned for Malaysia has instituted the Family Health Team, which coordinates care for individuals with cardiovascular disease, starting at enrollment. The team funnels patients with multiple co-morbidities into the primary care system. (See the sidebar on the next page.) This strategy ensures that the primary care facility is the patient s first point of contact and increases preventive care for patients with high medical risk. page 30

35 Malaysia: Managing Patient Care from Enrollment to Discharge EnPHC in Malaysia is piloting a new way for providers to manage NCDs, starting with diabetes and cardiovascular disease. Central to the EnPHC package is a multidisciplinary care team called a Family Health Team. Clients in the community with identified health risks are referred to nearby health clinics or hospitals for further diagnostic tests. A standardized process ensures continuity of care as the patient moves between facilities; it includes a full patient history that is available to all participating facilities as well as electronically linking the patient to available appointment times with appropriate specialists. Upon arrival at a PHC clinic, the patient is assigned to a Family Health Team led by a specific doctor; the patient will see this same team at each subsequent visit. A quick screening by the Family Health Team helps reduce congestion and wait times. A clinic manager coordinates the patient s care pathway, which might include appointments with dietitians, NCD educators, or physiotherapists as well as links to community-based programs. The following figure shows how this care pathway works with patients diagnosed with diabetes, from the initial community screening to referrals to higher-level facilities. Integrated Clinical Pathway for Diabetes Mellitus Screening Confirmation of Diagnosis Risk Stratification Level of Management Referral Screening programs (community/ PHC/dental) Refer to secondary level, as per specific conditions Opportunistic screening Symptom presentation Diagnostic investigations: FPG, OGTT, A1C DM Management at PHT Education, diet, exercise therapy Pharmacotherapy Management of concomitant clinical conditions Hypertension Dyslipidaemia Mangement of co-morbid conditions (smoking/obesity) Dental referral for assessment Confirmation of diabetes A1C basic investigations DM Control <6.5% short duration of DM, no co-morbidities 7 8% longer duration of DM, elderly, with co-morbid conditions With complications? no yes Early-stage complications? yes Well controlled? yes Follow up and review on scheduled basis no no Nephropathy Retinopathy Neuropathy CVD complications CVA complications Consider referral to secondary care / endocrinologist Enabling client-centric approach to NCD care management in DM cases Sources: CPG Management of Diabetes 5th Edition, 2015 CPG Management of Hypertension, 2013 CPG Management of CKD, 2011 CPG Management of Stable Angina, 2010 CPG Management of Heart Failure, 2014 CPG Management of Ischaemic Stroke, 2012 CPG Management of Diabetic Retinopathy, 2011 page 31

36 joint learning network for universal health coverage primary health care technical initiative Helpful Resource engaging the private Sector in primary health care to achieve universal health coverage: Advice from Implementers, to Implementers Engaging the Private Sector in Primary Health Care to Achieve Universal Health Coverage: Advice from Implementers to Implementers Most countries that rely on public facilities for PHC have defined catchment regions that automatically link enrollees with a provider. Mali, Morocco, and Indonesia have public facilities with catchment areas that automatically register or link an enrollee with a provider. This enables immediate patient access to a primary care physician. These catchment areas help health planners determine which regions might have a shortage of health care staff and either invest in additional providers or engage with the private sector. Clearly defined catchment regions ensure that people can access primary care the moment they are enrolled within the UHC scheme. Some countries want to use information and communications technology (ICT) to improve private- and public-sector data sharing. In countries with a growing private health sector, such as Indonesia, beneficiaries increasingly want patient choice in determining their primary care physician and choosing between a public or private-sector provider. Indonesia and Kenya s Makueni County have an ICT system that allows private and public facilities to record a patient s medical history to improve care coordination and chronic disease management. However, neither health system allows for that data to be shared between facilities. Having an integrated ICT system would allow private and public facilities to share patient records to enable better care coordination across facilities. To improve the ability of providers to coordinate care and share data, Makueni County is investing in ICT to make the patient s medical history portable across providers and facilities. Accountability Mechanisms A few countries have created an M&E framework with a data collection mechanism to assess beneficiary access to benefits package services. When a revised or new benefits package is implemented, national or local governments must have a way to hold providers accountable for the entitlements within the benefits package. To ensure accountability, authorities must be able to collect, organize, and use health services data. A robust M&E framework will ideally be closely linked with the health system s ICT system and allow for ongoing data collection. It will also allow authorities to modify the benefits package as needed, identify physician difficulty in providing some of the package services, and understand barriers to accessing services. Malaysia s EnPHC uses process indicators to evaluate provider adherence to treatment guidelines. (See the sidebar on the next page.) Kenya s MakueniCare uses its billing system to monitor service utilization. Both kinds of monitoring allow for regular reassessment and retooling of the benefits package. page 32

37 Helpful Resource MEASURING THE PERFORMANCE OF PRIMARY HEALTH CARE A Practical Guide for Translating Data into Improvement Measuring the Performance of Primary Health Care: A Practical Toolkit for Translating Data into Improvement Malaysia: EnPHC s M&E Indicators EnPHC has a complex integrated care delivery model that combines community-based screening and chronic disease management. Additional services have been added to the benefits package with minimal additional funding, necessitating a complex monitoring plan to ensure that providers are adhering to package entitlements instead of rationing care. To fully reflect the three components of the treatment pathway community enrollment, Family Health Teams, and integration with hospital referral systems EnPHC uses eight key indicators to measure success: 1. Percentage of the population enrolled 2. Percentage of the population screened 3. Number of newly diagnosed cases of hypertension 4. Number of newly diagnosed cases of diabetes mellitus 5. Number of newly diagnosed cases of hyperlipidemia 6. Number and percentage of prescription refills 7. Number and percentage of clinic appointment defaulters 8. Number and percentage of hospital referral defaulters Malaysia will measure the outcomes of the program in All six countries have used a deliberative process, with a governance group comprising health system stakeholders, to make decisions about health benefits policies. The participatory process has allowed for discussion of the challenges encountered and policy changes to address those challenges and improve benefits package implementation. It has also made the system more accountable to patient advocacy groups and others for failure to achieve the promised benefits. page 33

38 Concluding Thoughts In working to create a universal coverage scheme, all six countries have encountered financial, technical, or geographic limitations on what kinds of health services they can deliver to their population. The HBP Framework helps countries identify these limitations and provides a structure for policymakers to think through policy options for addressing them. The HBP Framework combines global evidence and international best practices with the realities faced by many lowand middle-income countries in creating and implementing a benefits package. A few countries, such as Malaysia, Vietnam, and Indonesia, already apply a health systems approach to benefits package design, while other locales, such as Makueni County in Kenya, Mali, and Morocco, have found that applying the framework in the assessments has helped them think through the components of their health system. Overall, the country assessments have shown that the HBP Framework is a helpful starting point for thinking through benefits package reform and implementation. The countries also found that the framework is adaptable to many different country contexts and benefit packages for example, even though it focuses on PHC, Morocco, Indonesia, and Kenya s Makueni County applied it to inpatient and specialty care to diagnose misalignments in their benefits policies. The next step for the countries in the HBP Collaborative is to disseminate their findings within their own national systems and develop a roadmap for instituting changes within each policy domain to improve access to priority services within the benefits package. page 34

39 Annex A: The JLN s Joint Learning Process The JLN uses a country-led participatory approach that includes identifying a common technical challenge, collectively working to solve it, synthesizing new knowledge, adapting this knowledge within JLN countries, and disseminating it to other countries outside of the JLN. The JLN s Joint Learning Approach 1. Identify Common Problems 2. Collectively Devise Solutions 3. Synthesize New Knowledge 4. Adapt Knowledge Within JLN Countries 5. Disseminate Knowledge to Other Countries The JLN Health Benefits Policy Collaborative came together to address how to define and implement health benefit packages to provide PHC. In the process, the group drew on lessons from in-person discussions and the country assessments to create this report. This knowledge will be disseminated to JLN countries as well as countries outside the JLN. Designing the Country Assessments The HBP Collaborative solicited country interest in participating in the assessments, and Indonesia, Kenya, Malaysia, Mali, Morocco, and Vietnam applied. The collaborative brought these countries together in Yogyakarta, Indonesia, in March 2017 to share their experiences with health benefits package design and implementation, discuss existing global resources on this topic, and review and discuss drafts of the country implementation assessments. At the meeting, participants suggested that a style and qualitative methods guide be developed to help the country assessment teams conduct their research. Participants also agreed on a timeline for implementing the assessments. (A final version of the guide for broader use by other countries is available at page 35

40 Based on the discussions in Yogyakarta, the PSE Collaborative set out the following scope for the country assessments: Focus on health benefits policies. Health benefits policies are government policies that facilitate the development or reform of the health benefits package that provides access to PHC services. An effective health benefits policy clearly articulates the objectives of PHC coverage, uses those objectives to define the benefits package, and deploys a range of complementary policies to ensure coverage of services in the package. Focus on PHC. The assessments may inevitably touch on secondary and tertiary care because health benefits packages often provide those health services without specifying the level of care, but the focus should be on PHC. Document unique country experiences. Lessons learned both positive and negative through country experience may apply to other country contexts. Implementing the Country Assessments With support from the PHC Initiative technical facilitation team, the six countries began implementing the assessments in June 2017 by first identifying institutions and individuals to carry out the assessments. The process included designating a principal investigator, assembling a team of researchers, informing the team about the background and objectives of the assessments, and delegating tasks. Once countries identified their primary research teams, the teams prepared for the data collection process, which involved two distinct phases: 1) document review (secondary data collection) and 2) interviews (primary data collection). Countries determined how to structure and format the interviews based on their unique context. Some countries used focus group interviews and in-depth interviews with stakeholders for primary data collection, and others used workshops. Many country teams did the data collection themselves, only outsourcing work for the assessment report drafting. Throughout this process, the JLN technical facilitation team was available to provide support on data collection methods and techniques, review the assessment guide, and answer any questions. Countries that were further ahead in the data collection process were able to share tools with other countries and answer questions. Sharing the Findings In November 2017, the six countries participated in a virtual learning exchange to discuss lessons learned from the data collection process as well as initial findings. All of the countries completed data collection by the end of November The teams met in person in Seoul, South Korea, in December 2017 to share findings, conclusions, and recommendations from the country assessments. Each team brought a poster that detailed their data collection methodology, findings, and early recommendations. The meeting in Seoul brought together multiple JLN collaboratives, including the Private Sector Engagement Collaborative and the Domestic Resource Mobilization Collaborative, to view the posters and provide additional input. In early 2018, the countries drafted their assessments with feedback and additional support from the technical facilitation team. In partnership with the technical facilitation team, the HBP Collaborative extracted lessons and guidance from the individual country assessments to inform this report. page 36

41 Annex B: Country Assessment Reports The country assessment reports from the members of the HBP Collaborative are available on the JLN website at The QR code shown here can be scanned for quick access to the main webpage for the reports. DESIGNING HEALTH BENEFITS POLICIES IN INDONESIA (JKN) A COUNTRY ASSESSMENT REPORT Designing Health Benefits Policies in Indonesia ( JKN) DESIGNING HEALTH BENEFITS POLICIES IN MALI (MUTUELLES) A COUNTRY ASSESSMENT REPORT Designing Health Benefits Policies in Mali (Mutuelles) A COUNTRY ASSESSMENT REPORT A COUNTRY ASSESSMENT REPORT DESIGNING HEALTH BENEFITS POLICIES IN KENYA (MakueniCare) A COUNTRY Designing Health Benefits Policies in Kenya (MakueniCare) DESIGNING HEALTH BENEFITS POLICIES IN MOROCCO (RAMED) A COUNTRY Designing Health Benefits Policies in Morocco (RAMED) ASSESSMENT REPORT A COUNTRY ASSESSMENT REPORT ASSESSMENT REPORT A COUNTRY ASSESSMENT REPORT DESIGNING HEALTH BENEFITS POLICIES IN MALAYSIA (EnPHC) A COUNTRY ASSESSMENT REPORT Designing Health Benefits Policies in Malaysia (EnPHC) A COUNTRY ASSESSMENT REPORT page 37