Benefit design refers to decisions about those health services and goods to be funded, either fully or partially, from public revenues. Benefit design also involves decisions about the conditions which must be met to access publicly funded benefits. Overall, policy decisions should be guided by health system goals in other words to maximize progress towards universal health coverage (UHC). This means making decisions which reduce unmet needs and improve financial protection, to the greatest extent possible given fiscal constraints.

Decisions about what to fund inevitably face trade-offs, which can be addressed through a structured process to consider evidence and involves stakeholders. Conditions of access can use price, time, the level of the health system and various other criteria. When aligned with other health system functions, benefit design is a powerful instrument through which policy makers can steer the health system towards UHC.

Decisions about which services to include in a benefit package are also decisions about which services to exclude. It clearly defines which services are funded publicly, either fully or partially, and those services that are not funded. All countries, whether higher or lower income, set limits on entitlements; this is called rationing, and decisions about how access to benefits are rationed or prioritized, influences a country’s progress towards UHC.

All public and private healthcare systems ration patient access to health care. The private sector rations access by using market prices, with demand driven by a person's ability and willingness to pay as a result. Public systems ration care primarily on the basis of patient needs, for example by ensuring funding for priority cost-effective treatments, and through the use of waiting lists. Patients may also be asked to make a co-payment.

A number of countries have made changes to the entitlements defined in their benefit packages in order to make progress towards UHC. In Chile, for example, the publicly funded AUGE programme (Universal Access with Explicit Guarantees) includes four guarantees for a number of high-mortality conditions.

Aligning benefit decisions with health financing functions: To make progress towards UHC declared benefit entitlements must translate into effective coverage for the population. Where there is significant mismatch between what is promised and what is delivered, rationing will start to occur implicitly, for example through increased unofficial payments, or poor quality of care due to a lack of medicines. Ensuring adequate revenues, minimal fragmentation in pooling arrangements, and effective purchasing mechanisms are all critical to ensure effective coverage.

Trade-offs frequently arise in decisions on benefit design. Is the priority to provide cost-effective services to those living in relatively well-served urban areas, or less cost-effective services in underserved remote areas? Equity considerations in some cases may take priority over efficiency considerations.

Between 2012-2014 WHO convened a Consultative Group to look at questions of how best to address fairness and equity in benefit package decisions, as countries move towards UHC. The group proposed a three-stage approach:

• Categorize services into priority classes. Relevant criteria include services which are most cost-effective, those which benefit the poorest, and those which offer financial protection to the patient. Each country will do this differently reflecting the local situation and societal preferences.
• Expand coverage for high-priority services (as defined by the country) to everyone. This includes eliminating patient co-payments while increasing mandatory, progressive pre-payments and greater pooling of funds.
• Ensure that disadvantaged groups are not left behind in terms of accessing entitlements. For example, low-income groups and rural populations often face barriers to accessing healthcare beyond patient co-payments.