USAID Health Finance and Governance Activity Essential Health Underwriting (EHU) Pilot Concept Note

A sustainable healthcare system is one in which both costs and utilization of services are evaluated and managed to minimize net expenses, allowing for expanded benefits, more treatment options, and increased population coverage. However, in Jordan, it is difficult to study healthcare service patterns due to fragmented and weak health claims data availability, particularly in the public sector. The public sector's claims data are often submitted in summary format and on paper, rather than electronically, and lack standard coding classification systems. This makes it challenging to accurately compare utilization patterns across public and private providers. The absence of standard diagnosis and procedure codes at a country level further complicates the issue, making it difficult to manage provider patterns and study healthcare risks. Jordan faces significant lifestyle risks, including increasing rates of being overweight or obese and high smoking rates, which contribute to rising NCD incidence and medical costs. The lack of data makes it difficult to measure the current cost of NCDs within the Civil Health Insurance Program (CHIP) population and identify comorbidities. Historical claims data are less effective in identifying future healthcare risks, as they do not capture predictive data such as family history and lifestyle factors. Three gaps exist in the current healthcare system: (1) the absence of risk profile information, including claims history and lifestyle risks in the CHIP population; (2) unknown barriers to change, including low health literacy levels, specific medical access obstacles, and barriers to screening; and (3) unknown financial value of managing NCDs through programs aimed at positively impacting medical costs and patient outcomes. The EHU Pilot Concept aims to address these gaps by expanding the concept of medical underwriting, a self-reported health risk assessment tool used in the private sector, to collect data on health and lifestyle risks, emotional wellbeing, access to the public healthcare system, health literacy levels, barriers to preventive care, and estimates of healthcare utilization. This will enable analysis of current and future healthcare risks and costs, allowing for targeted risk management programs to be introduced to manage both current and future risk populations. The pilot will be conducted in three catchment areas, including the north, south, and central regions, with CHIP policyholders in HIA and health insurance departments participating voluntarily. The Essential Health Underwriting (EHU) Pilot Questionnaire will collect individual information regarding demographics, lifestyles, attitudes, and opinions, and medical factors, with each respondent scored based on various aspects, including individual chronic diseases, emotional wellbeing, and access to healthcare. The questionnaire was developed and reviewed with the Ministry of Health (MOH) via workshops, and tested in two local populations to ensure sensitivity, privacy, and reliability of answers. Initial results demonstrated high interest in the concept, with over 99.9% of test respondents indicating a willingness to share ideas and receive further health advice. The results also highlighted high rates of future comorbid conditions, poor access to primary care, and low health literacy levels, which are major contributors to NCD incidence and medical costs. The EHU Pilot Concept has the potential to reduce the data gap and incidence of NCDs in Jordan by providing a comprehensive understanding of healthcare risks and costs, enabling targeted risk management programs to be introduced, and improving health outcomes and quality of life for CHIP beneficiaries.