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EXECUTIVE SUMMARY

An Essential Health Benefit (EHB) is a policy intervention defining the service benefits (or benefit package) in order to direct resources to priority areas of health service delivery to reduce disease burdens and ensure health equity. Many east and southern African (ESA) countries have introduced or updated EHBs in the 2000s. Recognising this in 2015-2017, the Regional Network for Equity in Health in East and Southern Africa (EQUINET), through Ifakara Health Institute (IHI) and Training and Research Support Centre (TARSC), with ministries of health in Swaziland, Tanzania, Uganda and Zambia, implemented desk reviews and country case studies, and held a regional meeting to gather and share evidence and learning on the role of EHBs in resourcing, organising and in accountability on integrated, equitable universal health systems.
This report synthesises the learning across the full programme of work. It presents the methods used, the context and policy motivations for developing EHBs; how they are being defined, costed, disseminated and used in health systems, including for service provision and quality, resourcing and purchasing services and monitoring and accountability on service delivery and performance, and for learning, useful practice and challenges faced.
Generally, the EHBs in ESA countries apply an analysis of health burdens and cost-benefit or valuefor-money of interventions to identify services for inclusion, while taking on board policy goals and commitments and perceived priorities of stakeholders, including external partners and, to a more limited extent, communities. Despite the diversity in their design methods, the EHBs in the region cover similar services for communicable and non-communicable diseases, maternal and child health and public health interventions, with some inclusion of laboratory, paramedical and allied services. The cost estimates for the EHBs vary relatively widely ($4-$83/capita at primary care level and $22-$519/capita, including referral hospital services) reflecting in part differing assumptions and methods used for capital and recurrent costings.
The design of EHBs was motivated by different policy agendas. The policy agenda of universal health coverage (UHC) and equity in health motivates an aspirational ‘universal health benefit’ that responds to population health needs, clarifies legal or policy entitlements to healthcare, aligns all providers to national health goals, supports social accountability on services and clarifies capacity gaps for health financing.
The funding gap to meet this benefit package has led some countries to explore new revenue sources from innovative financing, linking the EHB to policy dialogue on health financing. Resource constraints and vertical financing have, however, also motivated rationing of scarce resources, reducing the benefit to a smaller subset that can be funded from current budgets. This raises issues of how to set a trajectory to ensure that this ‘minimum’ does not become the maximum and how to address unmet public health needs.
The research raised various areas of good practice in implementing EHBs. In some countries consultative, consensus-building design processes involved experts and implementers and reached out to parliamentarians and the public. Working groups designed and updated the benefits and costings, and used the EHB as a basis for service guidance and to estimate capacity and financing gaps, linked to national health strategy processes and to sector-wide planning. The costings supported mobilisation of innovative financing and resources, while some countries ring-fenced funding of EHB elements. The EHB has been used as a tool for budgeting and planning at local government level, to guide priority setting and budgets and, in some cases, to purchase services from private, not-for-profit services through grants. Health facility reporting on performance on selected indicators of components of the EHB have been used as a basis for public sector resource allocation to districts and facilities; performance contracts in referral hospitals have used EHB outputs; and there is some discussion on the use of the EHB within plans for social health insurance and for direct facility financing. The EHB provides a wider system lens for such purchasing.
Countries also faced challenges in designing and implementing their EHBs: in the breadth and number of EHB interventions versus available resources and capacities; and in economic and health budget constraints versus necessary investments for the EHB. The design and monitoring faced limitations in data quality and adequacy of health information and in-country expertise. There were difficulties accessing information on off-budget and private sector revenue flows for EHB funding, and weaknesses in the involvement of other sectors affecting health and their role in addressing health determinants. There is still limited evidence of monitoring being used to support the role of the EHB and to publicly demonstrate fair process and social accountability on services. At the same time, the EHB is regarded as a tool to ‘correct’ some of these weaknesses.
The findings have already begun to feed into policy dialogue within the countries involved. At national level, setting an EHB as a universal benefit is seen to be consistent with policy goals to build universal equitable health systems and a potentially useful measure to align public and private actors to these goals, if updated every five years and linked to national health strategy processes. It is suggested that greater profile be given to health promotion and prevention in the EHB, that the process be used to engage high-level political actors, other sectors and communities early in its design, to operationalise the interventions and roles for ‘health in all policies’, to leverage intersectoral funding for the EHB and to build public and political support.
The EHB and operational guidelines for its delivery are considered a useful standard for planning, budgeting and allocating resources against which to assess and analyse infrastructure, equipment, staffing and other capacity gaps to deliver services. Policy dialogue on health financing strategies was proposed to be linked to EHB requirements and costings, with a preference for progressive tax financing and pooling of other social insurance and earmarked tax options to avoid segmentation and ensure funds are used for a universal benefit. Beyond such revenue generation strategies, greater attention could be given to ensuring private sector contributions, including through purchasing and performance contracts with non-state services.
Monitoring delivery on the EHB and its system, health, institutional and equity outcomes is observed to build confidence in the design and practice and to inform strategic review and improvement. It is recommended that this be done through strengthening the existing health information and performance monitoring systems. While in part this may call for investment in the system, it also calls for processes to engage the range of actors involved in sharing, disseminating and using information in the processes used to design, cost, implement and review the performance and outcomes of the EHB. These include encouraging non-state and external funders and providers to contribute to and use such evidence.
The exchange across countries in the ESA region highlighted areas where regional co-operation could support national processes and engage globally on the role of EHBs in building universal, equitable and integrated health systems. This includes having regional repositories of publications and information for exchange across countries to inform EHB processes and regional co-operation on training in key skills areas needed to implement EHB. It was proposed that regional guidelines be developed on the roles, design and costing approaches, assumptions and methods, issues to consider in implementing EHBs, methods for assessing service readiness and capacity gaps and methods and indicators from the health information system and facility surveys for monitoring performance, with links to useful resources. This and regional databases of commodity prices and a pool of multi-sectoral expertise on EHB design and costing would help support national processes, and learning on the operational demands of a universal health benefit could inform global health negotiations.
This research pointed to the evidence within the region for policy dialogue on universal health systems. It raised the usefulness of designing, costing, implementing and monitoring an EHB as a key entry point and operational strategy for realising universal health coverage and systems and for making clear the deficits to be met.
The research also raised knowledge gaps, such as on measures for applying EHBs in the private sector and for community inclusion in EHB processes; the triggers and transitioning processes for moving from ‘minimum’ to comprehensive EHBs; and how to frame EHBs to address social determinants and to engage other sectors on health. Involving ministry of health personnel as researchers, while demanding for already busy personnel, brought a policy and practical lens, pointing to the value of embedded implementation research to inform strategic policy and service processes.