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Health Benefits Packages (HBPs) can be a strategic tool to advance Universal Health Coverage. But their impact depends not only on the services included, but also on whether people effectively receive those services with adequate quality and financial protection. It also depends on the factors behind implementation gaps. While there is no shortage of guidance for using evidence-informed priority-setting approaches, less attention has been paid to monitoring whether, how, and why HBPs deliver (or not) in the real world. This gap matters, particularly in the context of stagnating progress towards Universal Health Coverage, because it leaves policymakers in the dark: Are HBPs delivering on the promise made to the population? If not, why, and what corrective action can be taken?
Today, we launch two papers that aim to bridge this gap: a conceptual framework for HBP monitoring (HBPM) and an HBPM maturity assessment tool (HBPM MAT), which includes two case studies in Argentina and Chile that demonstrate its application and potential.
The fundamentals of a strong monitoring system for HBPs
Our proposed conceptual framework is anchored in eight foundational principles that define what must be in place for HBPM to work effectively (Table 1). The principles set out what HBPM should focus on, how monitoring indicators should be selected, and how monitoring should be organized to support decision-making on HBP updating and implementation. We don’t expect these principles to be fully met—either collectively or individually—in most settings, but they offer a coherent vision toward which HBPM systems can progressively evolve.
Table 1. Eight foundational principles for HBPM
| Principle | Description |
|---|---|
Principle 1 Clearly and explicitly defined HBP | Monitoring depends on clearly defined HBP goals and on a well-defined and explicit package—what’s covered with what quality, for whom, where services are available, and under what conditions of financial protection—enabling monitoring of actual access. |
Principle 2 Clinical Practice Guidelines as a foundation for HBP content and monitoring | Clinical guidelines and care pathways provide the technical foundation for structuring and operationalizing HBPs. Aligning the services included in the HBP with recommendations in evidence-based clinical practice guidelines enables consistent implementation of appropriate clinical care and creates a reference point for systematic monitoring of service coverage and quality across the continuum of care. |
Principle 3 Linking monitoring to the HBP updating cycle and related decision space | For HBPM to be effective, it must generate evidence that aligns not just with what is measurable, but with what is actionable within the HBP updating cycle. Monitoring should feed directly into decisions across the design, implementation and updating of HBP. |
Principle 4 Focus of monitoring domains: HBP Goals and Direct Enablers | Monitoring should concentrate on HBP-specific goals as well as on the direct enablers being addressed during the HBP updating cycle. While goals capture the intended outcomes of the package, focusing on direct enablers ensures attention to the operational factors that truly drive HBP’s performance. Together, these two domains provide a complementary perspective that links strategic objectives with the conditions required for their achievement. |
Principle 5 Strategic and targeted indicator selection | Within each priority domain, monitoring should focus on tracer indicators that are most valuable for decision-making related to updating the HBP, avoiding unnecessary measures and ensuring each indicator has a clear policy purpose. |
Principle 6 Feasible and phased monitoring | Monitoring should start with a scope that is feasible and realistically manageable with existing capacity and scale up progressively as systems mature. This principle of graduality applies across all three pillars of HBPM—indicators, health information systems, and institutional arrangements—ensuring that early efforts remain manageable while creating space for adaptive learning and sustainable scale-up. |
Principle 7 HBPM aligned with national health information systems strategy (HIS) | HBP monitoring should strengthen, not bypass, national data governance and HIS policies, ensuring sustainability and avoiding parallel systems, including standards for data quality, interoperability and progressive digitalization to enable real-time, scalable monitoring. |
Principle 8 Institutionalization and multi- level governance of HBPM | Effective HBPM requires robust institutionalization embedded in national frameworks, with clear mandates, sustainable financing, capacity-building, and accountability mechanisms across all levels. A solid institutional backbone - anchored in a clear vision, legal frameworks, and managerial capacity - ensures coherence and long-term, while integration into multi-level governance arrangements guarantees responsiveness to subnational implementation and feedback. |
Source: The authors.
The principles state that a clear and explicitly defined HBP with content based on clinical practice guidelines is an important foundation for effective HBPM. HBPM is relevant only when its data is linked to decisions in the HBP updating cycle. A strategic and targeted indicator selection to track both progress on HBP goals and barriers in implementation should be adopted in a feasible and phased manner as capacity evolves. HBPM is sustainable only when it’s aligned with the national HIS strategy of the country and embedded within an institutionalized and multi- level governance mechanism.
These principles inform the three pillars of the HBPM framework:
- Indicators. HBPM indicators monitor HBP performance and support decision-making throughout the HBP updating cycle. Their selection should be guided by targeted questions addressing both health system goals and the direct enablers that influence implementation. They should also be defined in a SMART way and be phased operationally, and their data collection should align with existing HIS.
- Institutions. The institutional framework for HBPM refers to the rules, functions, and organizational arrangements developed to monitor an HBP. Such a framework provides an institutional platform that enables monitoring to be feasible and sustainable throughout the HBP updating cycle. A fit-for-purpose frameworks combines multiple elements such as political support, a sound legal and procedural framework, technical and managerial capacity, financial resources and dissemination mechanisms.
- Health information systems (HIS). In the context of HBPM, HIS generate the information needed to assess whether the HBP is achieving its intended results, identify implementation problems, and inform timely decisions on HBP management. HBPM should be built, whenever possible, on information that the health system already generates routinely so that that HBPM becomes part of a coherent health information ecosystem rather than a parallel initiative.
The conceptual framework paper provides more details and examples on how the three pillars can be operationalized in practice.
A practical tool to assess and strengthen HBP monitoring capacity
Building on the conceptual framework, the HBPM maturity assessment tool (HBPM MAT) provides a structured framework for assessing capacity to monitor HBPs. It is intended to support countries in identifying gaps and priorities for strengthening their HBPM systems.
The HBPM MAT comprises 13 maturity statements distributed across four domains: the three pillars (indicators, institutions, and information systems) and a general prerequisites domain (Table 2). Each maturity statement is broken down into key attributes, defined through concrete and observable characteristics which are assessed using a checklist. The pattern of answers from the checklist is then used to classify HBPM systems into one of three maturity levels: Emerging, Established or Advanced. The working paper offers extensive guidance on how to operationalize the assessment, including definitions, templates and examples.
Table 2. The 13 maturity statements of the HBPM MAT
| Maturity domain | Maturity statement |
|---|---|
| Prerequisites | 1. Health benefits are defined clearly, in sufficient detail to be operational, verifiable, and enforceable. |
| 2. A formally endorsed HBPM framework is in place, with clear and measurable monitoring goals that are aligned with HBP objectives and updating cycle. | |
| Indicators | 3. HBPM indicators reflect the HBP goals or intended outcomes of the health benefits package as well as the direct enablers that are operational factors driving achievement of these goals. |
| 4. HBPM indicators are linked to the HBP decision cycle. | |
| 5. Clinical guidance documents are explicitly linked to the definition and periodic update of HBPM indicators to ensure evidence-based monitoring. | |
| 6. HBPM indicators’ definitions are formulated in a SMART way, standardized and harmonized with the national health information system. | |
| Institutions | 7. Roles and responsibilities for key HBPM functions are covered by legislation and procedures, are clear, complete, consistent, enforceable and sustainable. |
| 8. HBPM results inform HBP updates. | |
| 9. Managerial, technical, and financial resources are backing HBPM. | |
| 10. HBPM results are communicated to multiple audiences and government levels. | |
| Health information systems | 11. HBPM aligned with national HIS norms, using standardized codes and classifications to ensure data comparability, efficiency, and sustainability. |
| 12.HIS supports a strong data use culture by sharing raw and analysed HBPM data accessible across all levels, and by providing dashboards and feedback loops to drive regular reviews and HBP-related decisions within the HBP updating cycle. | |
| 13. The HIS is primarily funded by domestic financing to ensure sustainability and national ownership, with strong privacy and ethical safeguards that protect data, reinforce trust, and uphold accountability. |
Source: The authors.
We also conducted two HBPM MAT case studies: the Sumar Program (Programa Sumar) in Argentina, a longstanding results-based financing program; and for the Explicit Health Guarantees (Garantías Explícitas en Salud, GES) package in Chile. For Programa Sumar, we identified many strong monitoring practices, with some not yet fully institutionalized through standardized procedures, public-facing mechanisms, or routine governance processes. In this context, the tool can help countries move from having adequate monitoring systems in place to ensuring they actively drive system learning and performance improvement. For GES in Chile, we found that the Health Superintendence has been effective in monitoring the GES, but we also identified differences in monitoring the same HBP between public and private providers. Decision-makers may want to consider whether these differences are purposeful and warranted. These case studies show that the HBPM MAT tool serves its purpose of identifying strengths and areas of improvement, and can offer valuable and actionable insights for both program-focused and nationwide HBPs.
How to use the HBPM tools for better decisions
The HBPM conceptual framework and accompanying HBPM MAT aim to understand capacity for monitoring HBP implementation and to initiate structured, coherent and relevant policy dialogue and action. Together they provide a comprehensive, evidence-driven, concrete foundation that countries can use for thinking about and acting on HBPM. Ultimately, HBPM translates broad Universal Health Coverage ambitions into actionable, country-specific questions: what is guaranteed, whether people receive those services, and what enables or constrains implementation.
We encourage governments, global and national technical partners, and the health priority-setting community to engage critically with the papers; support and document further applications; and integrate their use into decision-making processes for HBP implementation, monitoring and updating.
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CGD's publications reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions. You may use and disseminate CGD's publications under these conditions.
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