Implicit & Explicit BenefitImplicit & Explicit Benefit Package: Pros & ConsPackage: Pros & Cons

Dr Rozita Halina Tun HusseinUnit for National Health FinancingUnit for National Health FinancingPlanning and Development Division

Ministry of Health, Malaysiait h li @ hrozitahalina@moh.gov.my

1

OverviewOverviewOverviewOverview

• The context of Malaysia

• Definitions and Scope of Benefit Package (BP)Definitions and Scope of Benefit Package (BP)

• Implicit BP Pros & Cons

• Explicit BP Pros & Cons

• ConclusionConclusion

• References

Acknowledgement – Dr Munizam Abd Majid, Dr MasturaAcknowledgement  Dr Munizam Abd Majid, Dr MasturaMohd Tahir and Dr Zakiah Zainuddin

2

Malaysian Health SystemMalaysian Health System

3

Life Expectancy at BirthLife Expectancy at Birth

Female, 2009 ,76.5

Male,2009 71.7

4SourceSource: Department of : Department of Statistics, Malaysia Statistics, Malaysia

Selected Vital Statistics M l i 1957 2006

Selected Vital Statistics M l i 1957 2006

80.0

Malaysia 1957‐2006Malaysia 1957‐2006

60.0

70.0 IMR

50.0

30.0

40.0

NMR

20.0

CDR

0.0

10.0

1957 1960 1970 1980 1990 1995 1999 2001 2002 2003 2004 2005 2006

TMR

CDR

1957 1960 1970 1980 1990 1995 1999 2001 2002 2003 2004 2005 2006

Source : Department of Statistics, Malaysia

Targeting of Public SpendingTargeting of Public Spending

Source: Rozita Halina, 2000 

6

Poverty Impact of Health ExpendituresPoverty Impact of Health Expenditures

Pre and post OOP payment income, Malaysia 1999

180

200

L

120

140

160

ult

iple

s o

f $1

PL

80

100

120

sum

pti

on

as

mu

40

60

80

per

cap

ita

con

s

0

20

0.00

0.04

0.09

0.12

0.16

0.19

0.23

0.26

0.29

0.32

0.35

0.38

0.41

0.44

0.47

0.50

0.52

0.55

0.58

0.60

0.63

0.65

0.68

0.70

0.73

0.75

0.77

0.79

0.81

0.83

0.85

0.87

0.89

0.91

0.93

0.94

0.96

0.98

0.99

cum. proportion of persons in ascending order of consumption

$1.08 PL Pre OOP consumption Post OOP consumptionSource Ng CW - Equitap 7

Primary Health CareComprehensive Deconcentrated System

Primary Health CareComprehensive Deconcentrated SystemComprehensive Deconcentrated SystemComprehensive Deconcentrated System

Mother and Child

Family Planning

Home Visits

Dental

Outpatient

2000

Mother and Child

Dental

Lab

Pharmacy1980Mother and Child

Family Planning

Outpatient ElderlyAdolescent

Child w Special NeedsReproductive Clinic1960

Mother and Child

Family Planning

O i

Home Visits

Dental

Pharmacy

AdolescentGeriatric

EmergencyHealth informatics

Outpatient

Lab

Pharmacy

Diabetic Clinic

Occupational Health Clinic

8

1Malaysia clinics and Community clinics1Malaysia clinics and Community clinics

9

Health Services at District LevelHealth Services at District Level

DISTRICT  HEALTH OFFICENo. : 139*

OUTREACH SERVICESOUTREACH SERVICES

HEALTH CLINICNo. : 807*

FLYING DOCTORS

COMMUNITY HEALTH CLINICS / KLINIK DESA

• No 2158*

Coverage: 20,000  pop

• No. : 2158*• Coverage: 4,000 population

* DEC 2006 * Dec 2006

MOBILE TEAM10

SECONDARY / TERTIARY CAREFor the regionalized services, FOCUS is given to 26 

SECONDARY / TERTIARY CAREFor the regionalized services, FOCUS is given to 26 For the regionali ed services, FOCUS is given to 6

specialty / subspecialty services:For the regionali ed services, FOCUS is given to 6

specialty / subspecialty services:

1. RESPIRATORY MED.

2. INFECT. DISEASES

10.       NEUROLOGY

11.     ENDOCRINOLOGY

20. UROLOGY

21. PAEDIATRIC SURGERY

3. RHEUMATOLOGY

4. HEPATOLOGY

5 PALLIATIVE

12.     ONCOLOGY

13. UPPER GI SURG.

14 COLORECTAL SURG

22. PLASTIC SURGERY

23. CARDIAC PERFUSION 

ANAES5. PALLIATIVE 

MEDICINE

6. HAEMATOLOGY

14. COLORECTAL SURG.

15. HEPATOBILIARY SURG.

16. BREAST/ ENDOC SURG.

ANAES.

24. NUCLEAR MEDICINE

25. REHABILITATION6. HAEMATOLOGY

7. GASTROENTERO.

8. CARDIOLOGY

17. VASCULAR SURGERY

18. NEUROSURGERY

25. REHABILITATION 

MEDICINE

26. FORENSIC MEDICINE

9. GERIATRIC 19. CARDIOTHORACIC 

SURGERY

11

Other sub-specialisations and areas of competence continue to be developed.

CENTRES OF EXCELLENCECENTRES OF EXCELLENCE

• Collaboration with US

Health System Sustainability Public Private Expenditure on Health 

1997 2009 (2011 l )

Health System Sustainability Public Private Expenditure on Health 

1997 2009 (2011 l )5.0 5.0025.00

1997 – 2009 (2011 value)1997 – 2009 (2011 value)

19.13.73.8

4.44.2

3.9

4.2 4.14.1

4.00

4.50

20.00

15.214.6

12 9

16.1 16.317.3

2.93.1

3.23.3

3.00

3.50

15.00

8.69.5

11.412.0

12.9

10 6

11.6 12.5

13.414.2

14.815.9

2.00

2.50

10.00

7.8 7.7

6.0 6.1 6.8

7.68.2

9.1

10.6

1.00

1.50

5.00

0.00

0.50

0.00

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009Public Exp (RMbill in 2011 RM value) Private Exp (RMbill in 2011 RM value) THE as % GDP

Source – MNHA13

Three Dimensions to Consider When Improving Universal Coverage

Three Dimensions to Consider When Improving Universal CoverageImproving Universal Coverage Improving Universal Coverage 

14Source : Health System Financing, WHO Report, 2010

Components of 1Care for 1Malaysia Components of 1Care for 1Malaysia 

1. Service Delivery Reforms

• Increase quality of care• Public & Private healthcare delivery• Family doctor for each individualFamily doctor for each individual• Gatekeeper to higher level• Defined benefit package

• Mixed financing • Public Sector autonomy

2. Organisational Reforms3. Financing Reforms

SHI (by NHFA)General taxation

• Purchaser Provider Splitl

y• Streamlining MOH

Stewardship Governance

• Relevant PPM• Incentives• Pay for Performance

Public health servicesResearchTraining

15

DEFINITION of BENEFIT PACKAGEDEFINITION of BENEFIT PACKAGE

• BP refers to ‘the totality of services, activities, and P refers to the totality of services, activities, andgoods covered by PUBLICLY FUNDED statutory/mandatory insurance schemes’ – EU Health y/ yBASKET project

• Essential BP aims to concentrate scarce resources on interventions which provide the best 'value for o te e t o s c p o de t e best a ue fomoney'. – often expected to achievemultiple goals:often expected to achieve multiple goals:

improved efficiency; equity; political empowerment, accountability, and altogether more effective care. (WHO 2008)

16

SCOPE of BENEFIT PACKAGE  (BP)SCOPE of BENEFIT PACKAGE  (BP)

• BP ‐ in low‐income country consists of a limited list of services or interventions while, in richer countries packages are often described according to what they exclude. 

• Essential Benefits package (BP) will become the p g ( )standard for health coverage and will be used as the basis for establishing the different benefit levels gof plans that will be offered … the minimum that all new health plans have to cover (Families USA Sept 2009 about Health Reform Legislation – benefits in different health plans in the health insurance exchange) 17

WHAT IS IMPLICIT BP?WHAT IS IMPLICIT BP?

• Broadly defined general categories of care, and then leave themore specific decisions to healththen leave the more specific decisions to health professionals and/or politicians. 

• Utilised in 

New Zealand prior to health reforms in the early– New Zealand prior to health reforms in the early 1990s (Wong & Bitrán 1999)

– Primary Healthcare Services in Britain (Clarkeburn 1998)

– Malaysia’s public health care sectorMalaysia s public health care sector

18

Characteristics of Implicit BPCharacteristics of Implicit BP

i. Rationing without a (single) defined rationing plan

ii. Implicit rationing is implemented by using one or more subtle ways to ration

iii. In an implicit rationing model, no one person or institution takes responsibility for making resource ll ti h i i h lth 'i i ibl ' ti iallocation choices in health care = 'invisible' rationing. 

iv. People directly affected or making these implicit rationing h d k h h h h ll bchoices do not know which choices have actually been taken or on what grounds. 

v. Inclusions of the health service are often publicly known, while exclusions are performed implicitly.

vi. Implicit rationing choices are localized. Health care providers = role as rationing agents.                 (Clarkeburn 1998)19

IMPLICIT ‐ ProsIMPLICIT ‐ Pros

• Increase population coverage by limiting service coverage (Ham & Coulter 2001).

• Allows flexibility (Wong & Bitrán 1999)Allows flexibility (Wong & Bitrán 1999).

• May actually be a better way of dealing with difficult and complex issues (H t 1995)difficult and complex issues. (Hunter 1995)

• Minimize political resistance ‐ No explicit exclusions to serve as a focal point for opposition (Wong & Bitrán 1999).

• Politicians are shielded/praised from the impact of decisions about who not to treat and who to treat (Hunter 1995).

20

IMPLICIT ‐ ProsIMPLICIT ‐ Pros

• Possibility of securing and maintaining the ideal/idea of a health care system that will in all instances do the most for every single individual (Clarkeburn 1998)

• At the point of service maybe more sensitive to – the complexity of medical decisions and p y

– the needs and personal and cultural preferences of patients      (Mechanic 1995)p ( )

I M l i h lth id th kIn Malaysia, health care providers are the key decision‐makers about demand for health care 21

IMPLICIT ‐ ConsIMPLICIT ‐ Cons

l ibili h l h• Places a great responsibility on health care providers 

• Given only minimal guidelines 

• May sacrifice their professional integrityMay sacrifice their professional integrity 

• Uncertainty on actual services covered

• chance of patients receiving most appropriate health care can be influenced by their luck in 

/finding the right healthcare provider and/or by their place of residence, as local health a thorities ma ha e made differing decisions onauthorities may have made differing decisions on the services provided  (Clarkeburn 1998) 22

IMPLICIT ‐ ConsIMPLICIT ‐ Cons

• This approach may not be able to achieve an efficient allocation of resources, since health planners, clinicians and politicians may have conflicts of interest and differing priorities inconflicts of interest and differing priorities in determining which services to provide

l f l l l• Tool for political mileage

• Own incentives may not closely match withOwn incentives may not closely match with those of society as a whole (Wong & Bitrán 1999).

23

WHAT IS EXPLICIT BP?WHAT IS EXPLICIT BP?

• Identifying and using standard specific criteria(s) to d f h h h ldidentify services which should receive priority

– the identification of community needs and preferences

– the criteria of cost effectiveness and/or efficiency

– criteria that a health problem involves a large number of– criteria that a health problem involves a large number of people, services are available and effective, and quantified targets can be setg

• A positive list of included interventions or a negative list of excluded interventionsof excluded interventions

• When governments decide to purchase health care from private or public providers, BPs must necessarily be explicit 24

Explicit ‐ ProsExplicit ‐ ProsWaste fewer resources,

MoreFinancial protection and

beneficiary ti f ti

More technical efficiency

Greater accountability

satisfaction

Better legitimacyCitizen

empowerment -right to demand

of rationing decisions, fair,

democratic

What can li it BP

Get more health explicit BPs

potentially achieve?

health for your money,

Value for money

More equity

25

achieve?y

(Bitran& Giedion, 2009)

EXPLICIT ‐ ProsEXPLICIT ‐ Pros

In Chile:

• Quality: Each health problem has a specific protocol developed in a process of reviewing p p p gclinical guidelines and adjusting to available human and technical resources – designed tohuman and technical resources  designed to be as high quality as is realistic in Chilean conditions.conditions.

• Timeliness: Protocols have maximum times for diagnosis treatment and follow up Iffor diagnosis, treatment and follow‐up. If provider fails to meet the timing, it is required to pay an alternative providerto pay an alternative provider.

(Bossert 2009) 26

EXPLICIT ‐ ProsEXPLICIT ‐ Pros

In Italy a clear definition of the benefits providedIn Italy, a clear definition of the benefits provided by the statutory system maybe beneficial for several reasonsseveral reasons: 

1. it can contribute to a better allocation of resources, (allocative efficiency)

2 helps reassure beneficiaries about their rights2. helps reassure beneficiaries about their rights and responsibilities, and

3. facilitate the development of supplementary insurance 

(Del Vecchio M 1997 & Torbica& Fattore 2005)27

EXPLICIT – ConsEXPLICIT – Cons• May result in more resources being allocated to the health care budget      (Ham & Coulter 2001)g ( )

– What is the unmet need, what further investments are needed, actual availability of services (addressing equity of access)

• Likely to focus conflict and dissatisfaction,  politically destabilizing.  (Mechanic 1995).  In the USA, ‘attempts to ration health care explicitly are ‘political dynamite’ ( & l )health care explicitly are  political dynamite  (Ham & Coulter 2001)

• Explicit priority setting is a continuing process which is not amenable to ‘once and for all’ solutions Have put in placeamenable to  once and for all  solutions. Have put in place mechanisms to ensure that the issues involved are kept under CONTINUOUS REVIEW (Ham 1997)

• Criteria approach ‐may be difficult for the population to agree on what criteria to use, difficulties in measurement (Wong & Bitrán 1999)(Wong & Bitrán 1999).

28

EXPLICIT ‐ ConsEXPLICIT ‐ Cons• New Policy Instruments and Technical solution

– Clarity about objectives outcomesClarity about objectives, outcomes– Good information/ data/ health technology assessment– Evidence base– Ability and methodology to measure performance

• Capacity and Knowledge of policy maker and other p y g p ystakeholders

• Effective “vehicles” for BP implementationEffective  vehicles  for BP implementation – Clinical or quality assurance protocols, including for referrals.– Contracting providers to provide the essential package.– The regulation and accreditation of individual facilities.– Supervision.A i i i t t t th d f th BP i f t t– Assigning inputs to meet the needs of the BP – infrastructure plans, essential equipment lists etc.

29(Ham & Coulter, 2001)

Malaysia – Implicit to Explicit BPMalaysia – Implicit to Explicit BP

• Criteria – Disease burden, waiting times to tx

• Methodology – representation, voice, data, source

Fi i h b h• Financing – who bears the cost

• Understanding – services to be provided and notg p

• Criteria to document what is provided now

B d C i V S ifi S i /P d /P d– Broad Categories Vs Specific Service/Product/Procedure

– Technology (Minimum threshold), CPG, Clinical pathway

– Indications, Population , Provider, Referral threshold

– Current waiting times (assessment of unmet need)Current waiting times (assessment of unmet need)

– Cost and cost effectiveness, source of funding, co‐pay30

EXPLICIT – ConsEXPLICIT – Cons

• Potential for distress for frontline providers ote t a o d st ess o o t e p o de scaused through rationing openly 

Wh th li it i l th b t• Whether explicitness is always the best approach at the consultation level??

• Professionals need further training and support to deal with the stressful nature of makingto deal with the stressful nature of making rationing decisions openly.  (Smith, Coast & Donovan, 2010)

l h l• Implementing an BP is not just a technicalexercise – political and institutional processes need to be engaged

31

ConclusionConclusion

• Many comparison of merits and difficulties with implicit and explicit benefit packages.p p p g

• Moot point with purchaser provider split

R l h i i h b• Recently, the issue now is how best to develop a more explicit BP

• Globally, a mixture of implicit and explicit BP –how to strike the balancehow to strike the balance.

32

ReferencesReferences• Del Vecchio M (1997) Guaranteed entitlement to health care: an Italian point of view. In: Lenaghan

J (ed) Hard choices in health care. BMJ Books:London

• Ham, C. Coulter, A. 2001. Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices Journal of Health Services Research & Policy Vol 6 No 3 2001: 163–169health care choices. Journal of Health Services Research & Policy Vol 6 No 3, 2001: 163 169

• Wong, H. Bitrán, R. 1999. Designing A Benefits Package. World Bank Institute.

• Hunter, D.J.  1995. Rationing health care: the political perspective. Br Med Bull (1995) 51 (4): 876‐884.

h l h l h h f l• Mechanic, D. 1995. Dilemmas in rationing health care services: the case for implicit rationing. BMJ 1995:310:1655‐9

• Torbica, A. Fattore, G. 2005. The “Essential Levels of Care” in Italy: when being explicit serves the devolution of powers. Eur J Health Econom 2005 ∙ [Suppl 1] 6:46–52

• Guerrero, R. Ornelas, H. A. Knaul, F. M. 2010. The world health report. Health system financing. Technical Brief Series ‐ Brief No 13. Breadth and depth of benefit packages: lessons from Latin America. World Health Organization.

• Smith, A. O. Coast, J. Donovan, J. 2010. The desirability of being open about health care rationing d i i fi di f lit ti t d f ti t d li i l f i l J l f H lthdecisions: findings from a qualitative study of patients and clinical professionals. Journal of Health Services Research & Policy Vol 15 No 1, 2010: 14–20

• Sabik, L. M. Lie, K. R. 2008. Priority setting in health care: Lessons from the experiences of eight countries. International Journal for Equity in Health 2008, 7:4

• Alexander GC Werner RM Ubel PA: The Costs of Denying Scarcity Archives of Internal Medicine• Alexander GC, Werner RM, Ubel PA: The Costs of Denying Scarcity. Archives of Internal Medicine 2004, 164:593‐596.

• Fleck LM: Rationing: Don't Give Up. Hastings Center Report 2002, 32:35‐36.• Fleck LM: Just Caring: Health Reform and Health Care Rationing. Journal of Medicine and 

Philosophy 1994 19:435‐443Philosophy 1994, 19:435 443.• Ham, C. 1997. Priority setting in health care: learning from international experience. Health Policy 

42 (1997) 49–6633

Th kThank youy

34