International Journal of Health Policy and Management

International Journal of Health Policy and Management

The Use of Evidence-Informed Deliberative Processes for Designing the Essential Package of Health Services in Pakistan

Document Type : Original Article

Authors
Rob Baltussen 1
Maarten Jansen 1
Syeda Shehirbano Akhtar 2
Leon Bijlmakers 1
Sergio Torres-Rueda 3
Muhammad Khalid 4
Wajeeha Raza 5
Maryam Huda 6
Gavin Surgey 1
Wahaj Zulfiqar 4
Anna Vassall 3
Raza Zaidi 4
Sameen Siddiqi 6
Ala Alwan 7
1 Department of Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
2 Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
3 Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
4 Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
5 Centre for Health Economics, University of York, York, UK
6 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
7 DCP3 Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK
10.34172/ijhpm.2023.8004
Abstract
Background 
The Disease Control Priorities 3 (DCP3) project provides long-term support to Pakistan in the development and implementation of its universal health coverage essential package of health services (UHC-EPHS). This paper reports on the priority setting process used in the design of the EPHS during the period 2019-2020, employing the framework of evidence-informed deliberative processes (EDPs), a tool for priority setting with the explicit aim of optimising the legitimacy of decision-making in the development of health benefit packages.

Methods 
We planned the six steps of the framework during two workshops in the Netherlands with participants from all DCP3 Pakistan partners (October 2019 and February 2020), who implemented these at the country level in Pakistan in 2019 and 2020. Following implementation, we conducted a semi-structured online survey to collect the views of participants in the UHC benefit package design about the prioritisation process.

Results 
The key steps in the EDP framework were the installation of advisory committees (involving more than 150 members in several Technical Working Groups [TWGs] and a National Advisory Committee [NAC]), definition of decision criteria (effectiveness, cost-effectiveness, avoidable burden of disease, equity, financial risk protection, budget impact, socio-economic impact and feasibility), selection of interventions for evaluation (a total of 170), and assessment and appraisal (across the three dimensions of the UHC cube) of these interventions. Survey respondents were generally
positive across several aspects of the priority setting process.

Conclusion 
Despite several challenges, including a partial disruption because of the COVID-19 pandemic, implementation of the priority setting process may have improved the legitimacy of decision-making by involving stakeholders through participation with deliberation, and being evidence-informed and transparent. Important lessons were learned that can be beneficial for other countries designing their own health benefit package such as on the options and limitations of broad stakeholder involvement.
Keywords
Pakistan
Universal Health Coverage
Benefit Package
Priority Setting
Evidence-Informed Deliberative Process 
  1. United Nations. Sustainable Development Goals. Goal 3: Ensure Healthy Lives and Promote Well-Being for All at All Ages. 2016. http://www.un.org/sustainabledevelopment/health/.
  2. Government of Pakistan. National Initative for Sustainable Development Goals. https://www.sdgpakistan.pk/.
  3. Planning Commission Ministry of Planning, Development & Reform. Pakistan 2025: One Nation - One Vision. Islamabad. https://www.pc.gov.pk/uploads/vision2025/Pakistan-Vision-2025.pdf.
  4. Disease Control Priorities Project, Third Edition. University of Washington. http://dcp-3.org/.
  5. Jamison DT, Alwan A, Mock CN, et al. Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition. Lancet. 2018;391(10125):1108-1120. doi:1016/s0140-6736(17)32906-9
  6. Daniels N. Accountability for reasonableness. BMJ. 2000;321(7272):1300-1301. doi:1136/bmj.321.7272.1300
  7. World Health Organization (WHO). WHO Consultative Group on Equity and Universal Health Coverage. Making Fair Choices on the Path to UHC. Geneva: WHO; 2016.
  8. Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP. Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med. 2003;57(2):239-251. doi:1016/s0277-9536(02)00343-x
  9. Safaei J. Deliberative democracy in health care: current challenges and future prospects. J Healthc Leadersh. 2015;7:123-136. doi:2147/jhl.s70021
  10. Bond K, Stiffell R, Ollendorf DA. Principles for deliberative processes in health technology assessment. Int J Technol Assess Health Care. 2020:1-8. doi:1017/s0266462320000550
  11. Oortwijn W, Husereau D, Abelson J, et al. Designing and implementing deliberative processes for health technology assessment: a good practices report of a joint HTAi/ISPOR task force. Value Health. 2022;25(6):869-886. doi:1016/j.jval.2022.03.018
  12. Baltussen R, Jansen MPM, Bijlmakers L, et al. Value assessment frameworks for HTA agencies: the organization of evidence-informed deliberative processes. Value Health. 2017;20(2):256-260. doi:1016/j.jval.2016.11.019
  13. Baltussen R, Jansen MP, Bijlmakers L, Tromp N, Yamin AE, Norheim OF. Progressive realisation of universal health coverage: what are the required processes and evidence? BMJ Glob Health. 2017;2(3):e000342. doi:1136/bmjgh-2017-000342
  14. Oortwijn W, Jansen M, Baltussen R. Evidence-Informed Deliberative Process: A Practical Guide for HTA Bodies for Legitimate Benefit Package Design. Nijmegen: Radboud University Medical Center; 2021. https://www.radboudumc.nl/global-health-priorities.
  15. Oortwijn W, Jansen M, Baltussen R. Evidence-informed deliberative processes for health benefit package design - part II: a practical guide. Int J Health Policy Manag. 2022;11(10):2327-2336. doi:34172/ijhpm.2021.159
  16. Terwindt F, Rajan D, Soucat A. Priority-setting for national health policies, strategies and plans. In: Strategizing National Health in the 21st Century: A Handbook. Geneva: World Health Organization; 2016.
  17. Glassman A, Giedion U, Smith PC. What's In, What's Out: Designing Benefits for Universal Health Coverage. Washington, DC: Brookings Institution Press, Center for Global Development; 2017.
  18. International Decision Support Initiative (iDSI). The HTA Toolkit. 2018. http://www.idsihealth.org/HTATOOLKIT/.
  19. Castro H, Suharlim C, Kumar R. Moving LMICs Toward Self-Reliance: A Roadmap for Systematic Priority Setting for Resource Allocation. https://msh.org/resources/a-roadmap-for-systematic-priority-setting-and-health-technology-assessment-hta-a-practical/.
  20. 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. 2023; Forthcoming
  21. 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. BMJ Glob Health. 2023; Forthcoming
  22. 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. 2023; Forthcoming
  23. Alwan A, Siddiqi S, Safi M, et al. Addressing the UHC challenge using the Disease Control Priorities-3 approach: learning from the Pakistan experience. Int J Health Policy Manag. 2023; Forthcoming.
  24. Ministry of National Health Services, Regulations and Coordination. Review of Essential Health Services in Pakistan Based on Disease Control Priorities-3. April 2019. http://www.nhsrc.gov.pk/.
  25. 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

  • Received Date 03 March 2023
  • Revised Date 30 August 2023
  • Accepted Date 07 October 2023
  • First Published Date 09 October 2023
  • Published Date 01 December 2024