Front Cover

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Title Page, Copyright Information

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pp. i-iv

Table of Contents

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pp. v-viii

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Foreword

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pp. ix-x

This book, a multiyear effort by leading applied academics, frontline practitioners, and policymakers from around the world, is the first-ever “howto” guide to addressing one of the most overlooked practical, methodological, and moral questions in nations’ journeys to universal health coverage (UHC): What do we pay for in our healthcare systems and how do we decide to pay for it?...

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Acknowldgments

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pp. xi-xii

Many, many thanks are due to our chapter authors who contributed the content of much of this book and patiently waited for and made revisions based on edits and suggestions. Each is listed in the contributors’ section.
We offer profound gratitude to the participants in and contributors to three roundtables with policymakers from low- and middle-income countries...

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Preface

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pp. xiii-xiv

Healthcare systems in low- and middle-income countries are undergoing major changes. Countries are growing richer and losing aid eligibility, and disease burdens are shifting to noncommunicable chronic diseases. Technological and knowledge breakthroughs mean more and more of a country’s disease burden is preventable, and increasingly well-educated citizens are more knowledgeable and demand more and better healthcare....

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About This Book

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pp. xv-xx

Vaccinate children against deadly pneumococcal disease, or pay for cardiac patients to undergo lifesaving surgery? Cover the costs of dialysis for kidney patients, or channel the money toward preventing the conditions that lead to renal failure in the first place? How much to do of each? Policymakers who deal with the realities of limited healthcare budgets face tough decisions like these regularly. And for...

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The Health Benefits Package: Bringing Universal Health Coverage from Rhetoric to Reality

Amanda Glassman
Ursula Giedion
Peter C. Smith

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pp. 1-18

There is immense interest worldwide in the notion of universal health coverage (UHC): the idea of providing a core set of good-quality health services to which all citizens are entitled regardless of their circumstances. After the political commitments are made, however, many policymakers are left to grapple with the central issue: what services should be made available, and under what conditions? This book aims...

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Revisiting and Reformulating: How Explicit Benefit Packages Have Helped Mexico Move toward Universal Health Coverage

Eduardo González-Pier

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pp. 19-22

For more than 20 years, defining explicit health benefits packages (HBPs) has been a core strategy to guide efforts to increase healthcare coverage in Mexico, especially for the poor. The landmark 1994 study Economía y Salud, led by the nonprofit healthcare organization Funsalud, introduced the concept of a national healthcare plan using what were then novel cost-effectiveness tools to choose interventions...

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Part I: Goverancne and Process: The Foundation of a Health Bene ts Package Policy

Ursula Giedion

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pp. 23-29

Creating a health benefits package (HBP) involves much more than a technical, evidence-based exercise that identifies the services that will be financed with available public resources while moving toward universal health coverage (UHC). It includes not only the work of designing a technically sound benefits package, but also updating, monitoring, evaluating, and implementing it. This HBP “production...

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Defining the Rules of the Game: Good Governance Principles for the Design and Revision of the Health Benefits Package

Ursula Giedion
Javier Guzmán

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pp. 30-60

Designing and adjusting a health benefits package (HBP) not only requires the use of robust methods and high-quality data (as outlined by Katharina Hauck, Ranjeeta Thomas, and Peter C. Smith in chapter 9) but also sound processes and adequate institutional and legal frameworks to be sustainable. The term “governance” describes the process and structure by which the benefits package is designed...

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Tracking the Benefits Package from Paper to Practice: Monitoring and Evaluation

Ricardo Bitrán

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pp. 61-87

Low- and middle-income countries are increasingly adopting health benefits packages (HBPs) as core elements of their national policies to achieve universal health coverage (UHC). For example, Mexico’s Seguro Popular (Popular Insurance), which offers coverage to low-income citizens without social health insurance, has two HBPs: one for common ambulatory and hospital services and another for...

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Managing the Money: Fiscal and Budgetary Consideration for the Benefits Package

Amanda Glassman

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pp. 88-104

Once the decision to adopt a health benefits package (HBP) has been made, four key financerelated challenges must be considered and aligned if the plan is to be an effective instrument for setting and delivering on health priorities: fiscal space, budgetary structures, provider payment arrangements, and external funding sources. These cross-cutting finance issues touch on steps 7 (make recommendations...

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Aspiring to National Health Insurance, South Africa Considers Its Benefits Package

Mark Blecher
Yogan Pillay

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pp. 105-108

When South Africa first endeavored to develop its National Health Insurance (NHI) system, the Department of Health and the National Treasury struggled to find common ground on an approach to defining the health benefits package. The National Treasury believed that leaving the benefits largely undefined would lead to low-value but high-cost interventions being included in the package; the...

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Part II: Putting Pen to Paper: Methods to Select a Bene ts Plan That Works

Peter Smith

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pp. 109-114

In the first chapter of this book, Amanda Glassman, Ursula Giedion, and Peter Smith explain the powerful reasons for setting a health benefits package (HBP) as a key foundation for moving toward universal health coverage. A key question then arises: how is this to be done? It is important to distinguish between explicitness in stating the contents of the benefits package and consistency and rigor in selecting the...

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How Much Health for the Money? Using Cost-Effectiveness Analysis to Support Benefits Plan Decisions

Mark Sculpher
Paul Revill
Jessica M. Ochalek
Karl Claxton

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pp. 115-140

Any collective financial arrangement in healthcare requires decisions to be made about which medical interventions and healthcare programs will be funded from the resources available, which inevitably are finite. Some low- and middle-income countries (LMICs) have made progress in defining those collectively funded interventions and programs to which particular individuals have access. Whether in...

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Benefits beyond Health: Evaluating Financial Risk Protection and Equity through Extending Cost-Effectiveness Analysis

Stéphane Verguet
Dean T. Jamison

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pp. 141-153

Multiple criteria are involved in decisionmaking and prioritization of health policies.1 The trade-offs between efficiency and equity are among these criteria, and have long been emphasized in the field of HIV/AIDS treatment and prevention, for example.2 Notably, several mathematical frameworks, including mathematical programming, have been proposed to incorporate equity considerations into resource allocation in the public sector.3...

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Comparing Apples and Oranges: Strategies to Weigh Health against Other Social Values

Alec Morton
Jeremy A. Lauer

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pp. 154-174

The 2 management of health services presents a unique difficulty: although some services are highly effective, in that they can deliver significant value to some patients, at least some of the time, identifying which services deliver such value is a difficult and costly undertaking. Since patients in general are unable to assess, on a treatment-by-treatment basis, which services (if any) they may benefit from,...

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Square Pegs, Round Holes: Addressing Health Sector Interventions with Non-Health Benefits

Rachel Silverman

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pp. 175-184

Intuitively, interventions delivered by the health sector are expected to improve the health of users—and in most cases, better health, as measured through quality-adjusted life years (QALYs) gained or disability-adjusted life years (DALYs) averted, is indeed their main outcome of interest. However, some subset of interventions delivered through the health sector—that is, provided in health facilities;...

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At What Price? Costing the Health Benefits Package

Cheryl Cashin
Annette Özaltın

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pp. 185-200

Throughout this volume, contributors emphasize that a key principle underlying the selection of the health benefits package (HBP) should be to select services according to the “value” they offer, in terms of satisfying social objectives, given the costs of providing the services. Financial resources are limited, and governments committed to making progress toward universal health coverage (UHC) face an...

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Beyond Cost- Effectiveness: Health Systems Constraints to Delivery of a Health Benefits Package

Katharina Hauck
Ranjeeta Thomas
Peter C. Smith

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pp. 201-213

Cost-effectiveness analysis (CEA) of healthcare 3 technology has been extensively applied to evaluate interventions, and is a key input in developing evidence-based clinical guidelines and care quality standards. These guidelines and standards offer systematic guidance on how healthcare professionals should care for individuals with specific conditions....

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See the Bigger Picture: Resources Optimization Tools to Inform HBP Design

Marelize Görgens
Janka Petravic
David J. Wilson
David P. Wilson

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pp. 214-234

Working within a limited budget means that not all health services will be available for everybody. A challenge faced by decisionmakers is how to use limited funds optimally across the large set of health technologies, healthcare programs, and patient groups, targeted to the right people, in the right locations, in the right time, and in the right ways to achieve the greatest population health gains while...

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Reliable Sources? Generating, Selecting, and Applying Evidence to Inform the Health Benefits Package

Neil Hawkins
Robert Heggie
Olivia Wu

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pp. 235-246

Decisionmakers need to determine, based on currently available evidence, which interventions should be included in a health benefits package (HBP). They may also need to decide whether additional research should be required or funded. Quantitative economic evaluations can aid these decisions. The challenge is to conduct useful evaluations given typical limitations in both the available...

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Confronting Tight Fiscal, Human Resource, and Evidence Constraints, Malawi Revises Its Benefits Package

Gerald Manthalu
Dominic Nkhoma
Jessica M. Ochalek
Andrew Phillips
Paul Revill

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pp. 247-252

All Malawians have experienced the death or undue suffering of loved ones from ill health, knowing that their conditions could have been prevented or treated with medications widely available in other, wealthier parts of the world. By some measures Malawi is the poorest country on earth, with 2013 annual per capita income of US$2261 and total healthcare spending of only $38 per person...

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More than a List: Reforming a Country's Health Benefits Package—A Rigorous Approach to Tackling Costly Overutilization

Yot Teerawattananon
Waranya Rattanavipapong
Benjarin Santatiwongchai
Thanaporn Bussabawalai
Kittiphong Thiboonboon
Saudamini Dabak

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pp. 253-267

Prioritizing the health services guaranteed by the government is one challenge in implementing universal health coverage (UHC). Some countries with established UHC systems such as Australia, England and Wales, and Thailand have made significant investments in priority-setting institutions such as, respectively, the Pharmaceutical Benefits Advisory Committee (PBAC), the National Institute for...

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Starting with the Essential Medicines List: How New Zealand's PHARMAC Prioritizes and Purchases Pharmaceutical Benefits

Thomas Wilkinson

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pp. 268-272

Although the shape of a health benefits package (HBP) will be unique to a country’s needs, the way that pharmaceutical benefits are managed as part of the package will be critical for sustainability and maintaining universal access. Many countries have some form of Essential Medicines List or schedule of medicines that are fully or partially funded for particular indications or groups of people, and globally...

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Part III: Tough Choices: Considering Ethics, Rights, and Political Economy in Defi ing Bene ts

Amanda Glassman

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pp. 273-276

Political, ethical, and rights issues are intrinsic to all aspects of the design and adjustment of health benefits packages (HBPs), and their adequate analysis and management is central to a policy’s eventual effectiveness for universal health coverage. People who decide how to spend health budgets hold the lives and livelihoods of many other people in their hands, and they must literally make life-or-death...

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Priority-Setting as Politics: A Political Economy Framework for Analyzing Health Benefits Package Decision

Jesse B. Bump
Angela Y. Chang

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pp. 277-289

Designing health benefits packages (HBPs) is far from simple because it raises politically difficult and economically significant issues, such as what services will be provided, to whom, under what circumstances, and at what cost. HBP decisions are increasingly important and complex as more countries embrace the goal of universal health coverage (UHC), more low-income countries reach...

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A Matter of Morality: Embedding Ethics and Equity in the Health Beneftis Policy

Carleigh Krubiner
Ruth Faden

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pp. 290-326

Health benefits packages (HBPs) have become an increasingly popular approach to setting priorities and allocating resources for health, in both lowand high-income settings.1 A HBP lays out an explicit set of services, activities, and goods that will be covered in the package, and specifies which populations and what proportion of the costs will be covered. The...

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The Right to Health and the Health Benefits Package: Accounting for a Legal Right to Health When Designing a HBP

Rebecca Dittrich
Leonardo Cubillos
Lawrence O. Gostin
Kalipso Chalkidou
Ryan Li

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pp. 327-344

When designing health benefits packages (HBPs), 4 decisionmakers must consider how to make packages fair, ethical, efficient, and affordable—and those decisions sometimes include difficult tradeoffs. Important to the design of a well-balanced HBP is whether the inclusion or exclusion of a certain benefit aligns with the right to health of each...

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Chile's Guaranteed Package of Health Benefits Navigates Poiltical Challenges

Antonio Infante

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pp. 345-354

At the turn of the century, many Chileans expressed dissatisfaction with the country’s two-tiered system. A minority (about 15  percent) of relatively wealthy and healthy Chileans received care through private insurance and providers, known as ISAPREs (Instituciones de Salud Previsional; Health Insurance Institutions), while most others (about 75  percent of the population)...

Contributors

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pp. 355-362

Glossary

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pp. 363-366

Index

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pp. 367-376

Back Cover

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