Addressing the UHC Challenge Using the Disease Control Priorities 3 Approach: Lessons Learned and an Overview of the Pakistan Experience

Document Type : Original Article

Authors

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

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

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

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

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

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

Abstract

Background 
Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned.

Methods 
EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes.

Results 
The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP.

Conclusions 
Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.

Keywords

References

  1. World Health Organisation and the International Bank for Reconstruction and Development. Tracking Universal Health Coverage: 2017 Global Monitoring Report. Geneva: World Health Organization and The World Bank; 2017. https://documents1.worldbank.org/curated/en/640121513095868125/pdf/122029-WP-REVISED-PUBLIC.pdf. Accessed January 9, 2022
  2. World Health Organisation and the International Bank for Reconstruction and Development. Tracking Universal Health Coverage: 2021 Global Monitoring Report. Geneva: World Health Organization and The World Bank; 2021. https://cdn.who.int/media/docs/default-source/world-health-data-platform/events/tracking-universal-health-coverage-2021-global-monitoring-report_uhc-day.pdf?sfvrsn=fd5c65c6_5&download=true. Accessed January 9, 2022
  3. SDG indicators. United Nations Department of Economic and Social Affairs website. https://unstats.un.org/sdgs/metadata/?Text=&Goal=3&Target=3.8. Accessed November 18, 2022
  4. The UN High-Level Meeting (UN HLM) on Universal Health Coverage, 23 September 2019, New York. UHC2030 website. https://www.uhc2030.org/un-hlm-2019/. Accessed November 18, 2022
  5. World Bank. World Development Report 1993: Investing in Health. New York: Oxford University Press; 1993. https://openknowledge.worldbank.org/handle/10986/5976. Accessed November 18, 2022
  6. Jamison DT, Breman JG, Measham AR, et al. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank and Oxford University Press; 2006
  7. Volumes. Disease Control Priorities 3 (DCP3) website. https://dcp-3.org/volumes. Accessed January 9, 2022.
  8. Watkins D, Jamison DT, Mills A, 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. Volume 9. 3rd Edition. Washington, DC: World Bank; 2017.
  9. Annex 3C Essential Universal Health Coverage: Interventions and

Platforms. Disease Control Priorities 3 (DCP3) website. http://dcp-3.org/sites/default/files/chapters/Annex%203C_Interventions%20in%20EUHC.pdf. Accessed November 18, 2022.

  1. Population, total – Pakistan (2020). World Bank website. https://data.worldbank.org/indicator/SP.POP.TOTL?locations=PK. Accessed January 9, 2022.
  2. 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: 10.1136/bmjgh-2018-001013.
  3. Pakistan Bureau of Statistics. National Health Accounts 2017-18. Islamabad; 2018. https://www.pbs.gov.pk/sites/default/files/national_accounts/national_health_accounts/national_health_accounts_2017_18.pdf. Accessed January 9, 2022
  4. Baltussen R, Jansen M, Akhtar S, et al. The use of evidence-informed deliberative processes for designing the essential package of health services in Pakistan. Int J Health Policy Manag [under submission]
  5. 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 [under submission]
  6. 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 [under submission]
  7. Torres-Rueda S, Vassall A, Zaidi R, et al. 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. Int J Health Policy Manag [under submission]
  8. Alwan A, Yamey G, Soucat A. Essential packages of health services in low-income and lower-middle-income countries: what have we learnt? BMJ Glob Heal. 2023;8(Suppl 1):e010724. doi:10.1136/bmjgh-2022-010724
  9. Alwan A, Majdzadeh R, Yamey G, et al. Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries. BMJ Glob Heal. 2023;8(Suppl 1):e010720. doi:10.1136/bmjgh-2022-010720
  10. Baltussen R, Mwalim O, Blanchet K, et al. Decision-making processes for essential packages of health services: experience from six countries. BMJ Glob Heal. 2023;8(Suppl 1):e010704. doi:10.1136/bmjgh-2022-010704
  11. Gaudin S, Raza W, Skordis J, Soucat A, Stenberg K, Alwan A. Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences. BMJ Glob Heal. 2023;8(Suppl 1):e010735. doi:10.1136/bmjgh-2022-010735
  12. Soucat A, Tandon A, Pier EG. From Universal Health Coverage services packages to budget appropriation: the long journey to implementation. BMJ Glob Heal. 2023;8(Suppl 1):e010755. doi:10.1136/bmjgh-2022-010755
  13. Reynolds T, Wilkinson T, Bertram MY, et al. Building implementable packages for universal health coverage. BMJ Glob Heal. 2023;8(Suppl 1):e010807. doi:10.1136/bmjgh-2022-010807
  14. Siddiqi S, Aftab W, Raman AV, Soucat A, Alwan A. The role of the private sector in delivering essential packages of health services: lessons from country experiences. BMJ Glob Heal. 2023;8(Suppl 1):e010742. doi:10.1136/bmjgh-2022-010742
  15. Danforth K, Ahmad AM, Blanchet K, et al. Monitoring and evaluating the implementation of essential packages of health services. BMJ Glob Heal. 2023;8(Suppl 1):e010726. doi:10.1136/bmjgh-2022-010726
  16. Institute for Health Metrics and Evaluation. Global Burden of Disease Study 2019 Data Resources. https://ghdx.healthdata.org/gbd-2019. Accessed June 15, 2022
  17. Center for the Evaluation of Value and Risk in Health. GH CEA Registry. http://ghcearegistry.org/ghcearegistry/. Accessed June 15, 2022
  18. Vassall A, Sweeney S, Kahn JG, et al. Reference Case for Estimating the Costs of Global Health Services and Interventions. Global Health Cost Consortium; 2017
  19. Ministry of National Health Services, Regulations, and Coordination, Disease Control Priorities 3 (DCP3), World Health Organization. Interventions’ description of Essential Package of Health Services/ UHC Benefit Package of Pakistan. Islamabad: MoNHSR&C; 2020. http://dcp-3.org/resources/interventions-description-essential-package-health-services-uhc-benefit-package-pakistan-0. Accessed January 25, 2023
  20. Health Interventions Prioritization Tool. http://hiptool.org/. Accessed January 9, 2022
  21. Institute for Health Metrics and Evaluation (IHME). Pakistan profile. Seattle, WA: IHME, University of Washington, 2021. Available from https://www.healthdata.org/pakistan. Accessed February 11, 2023
  22. Ministry of National Health Services, Regulations and Coordination. Towards Universal Health Coverage through primary health care: Pakistan investment case for 2021-2026. Islamabad: MNHSR&C; 2021.
  23. Ministry of Health. The Essential Package of Hospital Services for Afghanistan. 2005. http://www.ahds.org/documents/EPHS%202005%20FINAL.pdf. Accessed November 18, 2022.
  24. Wright J. Essential Package of Health Services Country Snapshot: Kenya. Health Finance & Governance Project. Bethesda, MD: USAID & GFG; 2015. https://www.hfgproject.org/essential-package-of-health-services-country-snapshot-kenya/. Accessed November 18, 2022.
  25. Ministry of Health & Social Welfare. Essential Package of Health Services. Secondary & Tertiary Care: The District, County & National Health Systems. Monrovia, Liberia: MHSW; 2011. https://www.medbox.org/document/essential-package-of-health-services-ephs-secondary-tertiary-care-the-district-county-national-health-systems-liberia#GO. Accessed September 28, 2022.
  26. Lange IL, Feroz F, Naeem AJ, et al. The Development of Afghanistan's Integrated Package of Essential Health Services: Evidence, Expertise and Ethics in a Priority Setting Process. Soc Sci Med. 2022;305:115010. doi:10.1016/j.socscimed.2022.115010
  27. Ministry of Health and Human Services. Essential Package of Health Services (EPHS) Somalia, 2020. Mogadishu: Ministry of Health and Human Services; 2020. https://moh.gov.so/en/wp-content/uploads/2021/10/Somalia_EPHS_Executive_Action_Doc_web.pdf. Accessed November 18, 2022
  28. Ministry of Health Ethiopia. Essential Health Services Package of Ethiopia 2019. Addis Ababa: Ministry of Health; 2019. https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/documents/files/essential_health_services_package_of_ethiopia_2019.pdf. Accessed November 18, 2022
  29. Ministry of Health of Liberia, Disease Control Priorities 3 (DCP3), LSHTM, et al. Report on Developing the Liberia Universal Health Coverage Essential Package of Health Services. 2022. https://dcp-3.org/resources/report-developing-liberia-universal-health-coverage-essential-package-health-services. Accessed November 18, 2022.
  30. Ministry of National Health Services, Regulations & Coordination, Disease Control Priorities 3 (DCP3), World Health Organization. Essential Package of Health Services with localized evidence. Islamabad: HPSIU 2020. https://dcp-3.org/resources/universal-health-coverage-benefit-package-pakistan-essential-package-health-services. Accessed November 18, 2022.
  31. Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382(9908):1898-955. doi: 10.1016/S0140-6736(13)62105-4.
  32. Eregata GT, Hailu A, Stenberg K, et al. Generalised cost-effectiveness analysis of 159 health interventions for the Ethiopian essential health service package. Cost Eff Resour Alloc. 2021;19(1):2. doi: 10.1186/s12962-020-00255-3.
  33. Hailu A, Eregata GT, Yigezu A, et al. Contextualization of cost-effectiveness evidence from literature for 382 health interventions for the Ethiopian essential health services package revision. Cost Eff Resour Alloc. 2021;19(1):58. doi: 10.1186/s12962-021-00312-5.
  34. Zaidi S, Riaz A, Thaver A, et al. Role and contribution of private sector in moving towards universal health coverage in the Eastern Mediterranean region. Aga Khan University; 2012. https://ecommons.aku.edu/pakistan_fhs_mc_chs_chs/193/. Accessed August 29, 2022
  35. Siddiqi S, Aftab W, Raman AV, et al. The role of private sector in delivering essential packages of health services: lessons from country experiences. BMJ Glob Health. 2023; 8(Suppl 1): e010742. 2022. doi: 10.1136/bmjgh-2022-010742.
  36. Rajan D, Mathurapote N, Putthasri W, et al. Institutionalising participatory health governance: lessons from nine years of the National Health Assembly model in Thailand. BMJ Glob Health. 2019;4(Suppl 7):e001769. doi: 10.1136/bmjgh-2019-001769.
  37. Ben Mesmia H, Chtioui R, Ben Rejeb M. The Tunisian societal dialogue for health reform (a qualitative study). European Journal of Public Health. 2020;30(Supplement 5). doi: 10.1093/eurpub/ckaa166.1393
International Journal of Health Policy and Management

Articles in Press, Accepted Manuscript
Available Online from 08 October 2023

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History

  • Receive Date: 03 March 2023
  • Revise Date: 19 September 2023
  • Accept Date: 07 October 2023
  • First Publish Date: 08 October 2023

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