The Use of Evidence to Design an Essential Package of Health Services in Pakistan: A Review and Analysis of Prioritisation Decisions at Different Stages of the Appraisal Process

Torres-Rueda, Sergio; Vassall, Anna; Zaidi, Raza; Kitson, Nichola; Khalid, Muhammad; Zulfiqar, Wahaj; Jansen, Maarten; Raza, Wajeeha; Huda, Maryam; Sandmann, Frank; Baltussen, Rob; Siddiqi, Sameen; Alwan, Ala

doi:10.34172/ijhpm.2024.8043

The Use of Evidence to Design an Essential Package of Health Services in Pakistan: A Review and Analysis of Prioritisation Decisions at Different Stages of the Appraisal Process

Document Type : Original Article

Authors

Sergio Torres-Rueda ¹

Anna Vassall ¹

Raza Zaidi ²

Nichola Kitson ¹

Muhammad Khalid ²

Wahaj Zulfiqar ²

Maarten Jansen ³

Wajeeha Raza ⁴

Maryam Huda ⁵

Frank Sandmann ⁶

Rob Baltussen ³

Sameen Siddiqi ⁵

Ala Alwan ⁷

¹ Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK

² Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan

³ Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands

⁴ Centre for Health Economics, University of York, York, UK

⁵ Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

⁶ Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK

⁷ DCP3 Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK

10.34172/ijhpm.2024.8043

Abstract

Background
Pakistan embarked on a process of designing an essential package of health services (EPHS) as a pathway towards universal health coverage (UHC). The EPHS design followed an evidence-informed deliberative process; evidence on 170 interventions was introduced along multiple stages of appraisal engaging different stakeholders tasked with prioritising interventions for inclusion. We report on the composition of the package at different stages, analyse trends of prioritised and deprioritised interventions and reflect on the trade-offs made.

Methods
Quantitative evidence on cost-effectiveness, budget impact, and avoidable burden of disease was presented to stakeholders in stages. We recorded which interventions were prioritised and deprioritised at each stage and carried out three analyses: (1) a review of total number of interventions prioritised at each stage, along with associated costs per capita and disability-adjusted life years (DALYs) averted, to understand changes in affordability and efficiency in the package, (2) an analysis of interventions broken down by decision criteria and intervention characteristics to analyse prioritisation trends across different stages, and (3) a description of the trajectory of interventions broken down by current coverage and cost-effectiveness.

Results
Value for money generally increased throughout the process, although not uniformly. Stakeholders largely prioritised interventions with low budget impact and those preventing a high burden of disease. Highly cost-effective interventions were also prioritised, but less consistently throughout the stages of the process. Interventions with high current coverage were overwhelmingly prioritised for inclusion.

Conclusion
Evidence-informed deliberative processes can produce actionable and affordable health benefit packages. While cost-effective interventions are generally preferred, other factors play a role and limit efficiency.

Keywords

Health Benefit Packages

Essential Packages of Health Services

Pakistan

Priority Setting

Cost-Effectiveness

Decision Criteria

World Health Organization (WHO). Principles of Health Benefit Packages. Geneva: WHO; 2021.
Glassman A, Chalkidou K. Priority-Setting in Health: Building Institutions for Smarter Public Spending. Washington, DC: Center for Global Development; 2012.
World Bank. Universal Health Coverage Study Series (UNICO). World Bank; 2017.
Eregata GT, Hailu A, Geletu ZA, et al. Revision of the Ethiopian essential health service package: an explication of the process and methods used. Health Syst Reform. 2020;6(1):e1829313. doi:1080/23288604.2020.1829313
Islamic Republic of Afghanistan Ministry of Public Health. Integrated Package of Essential Health Services. 2019.
World Health Organization (WHO). Health Technology Assessment and Health Benefit Package Survey 2020/2021. WHO; 2021.
Hayati R, Bastani P, Kabir MJ, Kavosi Z, Sobhani G. Scoping literature review on the basic health benefit package and its determinant criteria. Global Health. 2018;14(1):26. doi:1186/s12992-018-0345-x
Mohamadi E, Olyaeemanesh A, Rashidian A, Hassanzadeh A, Razavi M, Rahimi Foroushani A. Stakeholders analysis of health insurance benefit package policy in Iran. Health Scope. 2018;7(2):e63165. doi:5812/jhealthscope.63165
Glassman A, Giedion U, Sakuma Y, Smith PC. Defining a health benefits package: what are the necessary processes? Health Syst Reform. 2016;2(1):39-50. doi:1080/23288604.2016.1124171
Dakin H, Devlin N, Feng Y, Rice N, O'Neill P, Parkin D. The influence of cost-effectiveness and other factors on nice decisions. Health Econ. 2015;24(10):1256-1271. doi:1002/hec.3086
Dakin HA, Devlin NJ, Odeyemi IA. "Yes", "No" or "Yes, but"? Multinomial modelling of NICE decision-making. Health Policy. 2006;77(3):352-367. doi:1016/j.healthpol.2005.08.008
Svensson M, Nilsson FOL, Arnberg K. Reimbursement decisions for pharmaceuticals in Sweden: the impact of disease severity and cost effectiveness. Pharmacoeconomics. 2015;33(11):1229-1236. doi:1007/s40273-015-0307-6
Karikios DJ, Chim L, Martin A, et al. Is it all about price? Why requests for government subsidy of anticancer drugs were rejected in Australia. Intern Med J. 2017;47(4):400-407. doi:1111/imj.13350
Chen G, Peirce V, Marsh W. Evaluation of the national institute for health and care excellence diagnostics assessment program decisions: incremental cost-effectiveness ratio thresholds and decision-modifying factors. Value Health. 2020;23(10):1300-1306. doi:1016/j.jval.2020.04.1835
Trenaman L, Pearson SD, Hoch JS. How are incremental cost-effectiveness, contextual considerations, and other benefits viewed in health technology assessment recommendations in the United States? Value Health. 2020;23(5):576-584. doi:1016/j.jval.2020.01.011
Devlin N, Parkin D. Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis. Health Econ. 2004;13(5):437-452. doi:1002/hec.864
Cerri KH, Knapp M, Fernández JL. Decision making by NICE: examining the influences of evidence, process and context. Health Econ Policy Law. 2014;9(2):119-141. doi:1017/s1744133113000030
Harris AH, Hill SR, Chin G, Li JJ, Walkom E. The role of value for money in public insurance coverage decisions for drugs in Australia: a retrospective analysis 1994-2004. Med Decis Making. 2008;28(5):713-722. doi:1177/0272989x08315247
Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices. Aust New Zealand Health Policy. 2007;4:23. doi:1186/1743-8462-4-23
Lim BP, Heng BH, Tai HY, Tham L, Chua HC. Health technology disinvestment in Singapore. Ann Acad Med Singap. 2018;47(8):338-344.
Mayer J, Nachtnebel A. Disinvesting from ineffective technologies: lessons learned from current programs. Int J Technol Assess Health Care. 2015;31(6):355-362. doi:1017/s0266462315000641
Polisena J, Trunk G, Gutierrez-Ibarluzea I, Joppi R. Disinvestment activities and candidates in the health technology assessment community: an online survey. Int J Technol Assess Health Care. 2019;35(3):189-194. doi:1017/s0266462319000229
Elshaug AG, Hiller JE, Moss JR. Exploring policy-makers' perspectives on disinvestment from ineffective healthcare practices. Int J Technol Assess Health Care. 2008;24(1):1-9. doi:1017/s0266462307080014
Rooshenas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL. "I won't call it rationing...": an ethnographic study of healthcare disinvestment in theory and practice. Soc Sci Med. 2015;128:273-281. doi:1016/j.socscimed.2015.01.020
Mitchell D, O'Brien L, Bardoel A, Haines T. Understanding health professional responses to service disinvestment: a qualitative study. Int J Health Policy Manag. 2019;8(7):403-411. doi:15171/ijhpm.2019.20
Leech AA, Kim DD, Cohen JT, Neumann PJ. Are low and middle-income countries prioritising high-value healthcare interventions? BMJ Glob Health. 2020;5(2):e001850. doi:1136/bmjgh-2019-001850
World Bank. Open Data. 2020.
Zaidi SA, Bigdeli M, Langlois EV, et al. Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan. BMJ Glob Health. 2019;4(1):e001013. doi:1136/bmjgh-2018-001013
Institute for Health Metrics and Evaluation (IHME). Global Burden of Disease Compare. IHME; 2022.
World Health Organization (WHO). Global Health Expenditure Database. WHO; 2022.
Watkins DA, Jamison DT, Mills T, et al. Universal health coverage and essential packages of care. In: Jamison DT, Gelband H, Horton S, et al, eds. Disease Control Priorities: Improving Health and Reducing Poverty. 3rd ed. Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2017.
Alwan A, Siddiqi S, Safi M, et al. Addressing the UHC challenge using the Disease Control Priorities 3 approach: lessons learned and an overview of the Pakistan experience. Int J Health Policy Manag. 2023;12:8003. doi:34172/ijhpm.2023.8003
Baltussen R, Jansen M, Akhtar SS, et al. The use of evidence-informed deliberative processes for designing the essential package of health services in Pakistan. Int J Health Policy Manag. 2023;12:8004. doi:34172/ijhpm.2023.8004
Raza W, Zulfiqar W, Shah MM, et al. Costing interventions for developing an essential package of health services: application of a rapid method and results from Pakistan. Int J Health Policy Manag. 2024;13:8006. doi:34172/ijhpm.2023.8006
Huda M, Kitson N, Saadi N, et al. Assessing global evidence on cost-effectiveness to inform development of Pakistan’s essential package of health services. Int J Health Policy Manag. 2024;13:8005. doi:34172/ ijhpm.2023.8005
Baltussen R, Marsh K, Thokala P, et al. Multicriteria decision analysis to support health technology assessment agencies: benefits, limitations, and the way forward. Value Health. 2019;22(11):1283-1288. doi:1016/j.jval.2019.06.014
Government of Pakistan, Ministry of National Health Services Regulations & Coordination. Interventions’ Description of Essential Package of Health Services/UHC Benefit Package of Pakistan. WHO, DCP3; 2020.
Baltussen R, Mwalim O, Blanchet K, et al. Decision-making processes for essential packages of health services: experience from six countries. BMJ Glob Health. 2023;8(Suppl 1):e010704. doi:1136/bmjgh-2022-010704
Nouhi M, Baltussen R, Razavi SS, et al. The use of evidence-informed deliberative processes for health insurance benefit package revision in Iran. Int J Health Policy Manag. 2022;11(11):2719-2726. doi:34172/ijhpm.2022.6485
Health Intervention Prioritization Working Group, Health Intervention Prioritization Tool. 2019.
McKie J, Richardson J. The rule of rescue. Soc Sci Med. 2003;56(12):2407-2419. doi:1016/s0277-9536(02)00244-7
Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med. 2012;75(12):2386-2393. doi:1016/j.socscimed.2012.09.014
Skedgel C, Wranik D, Hu M. The relative importance of clinical, economic, patient values and feasibility criteria in cancer drug reimbursement in Canada: a revealed preferences analysis of recommendations of the pan-Canadian Oncology Drug Review 2011-2017. Pharmacoeconomics. 2018;36(4):467-475. doi:1007/s40273-018-0610-0
Garpenby P, Nedlund AC. Political strategies in difficult times - The "backstage" experience of Swedish politicians on formal priority setting in healthcare. Soc Sci Med. 2016;163:63-70. doi:1016/j.socscimed.2016.06.046
Aman A, Gashumba D, Magaziner I, Nordström A. Financing universal health coverage: four steps to go from aspiration to action. Lancet. 2019;394(10202):902-903. doi:1016/s0140-6736(19)32095-1
Government of Pakistan, Ministry of National Health Services Regulation & Coordination. Review of Essential Health Services in Pakistan Based on Disease Control Priorities-3. WHO, DCP3; 2019.