# Health Benefit Package Revision Is an Art as Much as a Science – Lessons Learned on the Organization of the Appraisal Phase

## TL;DR

This paper discusses the challenges of revising health benefit packages in low- and middle-income countries, emphasizing the balance between science and practical decision-making.

## Contribution

The paper introduces four key themes for organizing appraisal processes in HBP revisions, highlighting the need for cross-country learning and detailed documentation.

## Key findings

- Appraisal processes in HBP revisions involve complex decision-making structures and trade-offs.
- Use of cost-effectiveness evidence and budget thresholds is a central challenge in multiple countries.
- Cross-country learning is essential to address appraisal challenges pragmatically.

## Abstract

Many low- and middle-income countries are designing or revising their health benefit packages (HBPs), with appraisal—prioritizing services for reimbursement—being a critical phase. This occurs in a complex landscape of multiple criteria, multiple stakeholders, limited evidence, budget constraints, and tight timelines, varying across countries. Existing guidance documents do not fully address these complexities, requiring analysts to balance methodological rigor with practical constraints. This editorial highlights four key themes in organizing appraisal: decision-making structures, trade-offs between criteria, final recommendations, and the use of cost-effectiveness evidence, thresholds, and budgets. These emerged as central challenges in HBP revisions in Iran, Kyrgyzstan, Liberia, Pakistan, and Rwanda. We emphasize cross-country learning to address these challenges pragmatically, recognizing that high-quality, legitimate appraisal is as much an art as a science. More detailed documentation of appraisal processes is needed to refine HBP revision guidelines and strengthen priority-setting in health systems.