Decision-making processes for essential packages of health services: experience from six countries

Many countries around the world strive for universal health coverage, and an essential packages of health services (EPHS) is a central policy instrument for countries to achieve this. It defines the coverage of services that are made available, as well as the proportion of the costs that are covered from different financial schemes and who can receive these services. This paper reports on the development of an analytical framework on the decision-making process of EPHS revision, and the review of practices of six countries (Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar-Tanzania).The analytical framework distinguishes the practical organisation, fairness and institutionalisation of decision-making processes. The review shows that countries: (1) largely follow a similar practical stepwise process but differ in their implementation of some steps, such as the choice of decision criteria; (2) promote fairness in their EPHS process by involving a range of stakeholders, which in the case of Zanzibar included patients and community members; (3) are transparent in terms of at least some of the steps of their decision-making process and (4) in terms of institutionalisation, express a high degree of political will for ongoing EPHS revision with almost all countries having a designated governing institute for EPHS revision.We advise countries to organise meaningful stakeholder involvement and foster the transparency of the decision-making process, as these are key to fairness in decision-making. We also recommend countries to take steps towards the institutionalisation of their EPHS revision process.

Contextualization of cost-effectiveness evidence from literature for 382 health interventions for the Ethiopian essential health services package revision

BACKGROUND

Cost-effectiveness of interventions was a criterion decided to guide priority setting in the latest revision of Ethiopia's essential health services package (EHSP) in 2019. However, conducting an economic evaluation study for a broad set of health interventions simultaneously is challenging in terms of cost, timeliness, input data demanded, and analytic competency. Therefore, this study aimed to synthesize and contextualize cost-effectiveness evidence for the Ethiopian EHSP interventions from the literature.

METHODS

The evidence synthesis was conducted in five key steps: search, screen, evaluate, extract, and contextualize. We searched MEDLINE and EMBASE research databases for peer-reviewed published articles to identify average cost-effectiveness ratios (ACERs). Only studies reporting cost per disability-adjusted life year (DALY), quality-adjusted life year (QALY), or life years gained (LYG) were included. All the articles were evaluated using the Drummond checklist for quality, and those with a score of at least 7 out of 10 were included. Information on cost, effectiveness, and ACER was extracted. All the ACERs were converted into 2019 US dollars using appropriate exchange rates and the GDP deflator.

RESULTS

In this study, we synthesized ACERs for 382 interventions from seven major program areas, ranging from US$3 per DALY averted (for the provision of hepatitis B vaccination at birth) to US$242,880 per DALY averted (for late-stage liver cancer treatment). Overall, 56% of the interventions have an ACER of less than US$1000 per DALY, and 80% of the interventions have an ACER of less than US$10,000 per DALY.

CONCLUSION

We conclude that it is possible to identify relevant economic evaluations using evidence from the literature, even if transferability remains a challenge. The present study identified several cost-effective candidate interventions that could, if scaled up, substantially reduce Ethiopia's disease burden.

Is Universal Health Coverage Affordable? Estimated Costs and Fiscal Space Analysis for the Ethiopian Essential Health Services Package

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50-70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10-17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap.

Toward universal health coverage in the post-COVID-19 era

All countries worldwide have signed up to the United Nations Sustainable Development Goals and have committed to the objective of achieving 'universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all'. During the COVID-19 pandemic and beyond, advancement toward universal health coverage (UHC) will become more difficult for many countries, demonstrating that locally led priority setting is urgently needed to provide health services with appropriate financial protection to all. Because resources are limited and no national constituency can provide an unlimited number of services to their whole population in a sustainable manner, rationing and setting priorities for the selection of interventions to be included in a defined package of services is critical. In this Perspective, we discuss how packages of essential health services can be developed in resource-constrained settings, and detail how experts and the public can decide on principles and criteria, use a comprehensive array of analytical methods and choose which services to be provided free of charge. We illustrate these main steps while drawing on a recently conducted exercise of revising the national essential health services package in Ethiopia, which we compare with examples from other countries that have defined their essential benefits packages. This Perspective also provides recommendations for other low- and middle-income countries on their pathway to UHC.

Generalised cost-effectiveness analysis of 159 health interventions for the Ethiopian essential health service package

BACKGROUND

Cost effectiveness was a criterion used to revise Ethiopia's essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average cost-effectiveness ratios (ACERs) of 159 health interventions used in the revision of Ethiopia's EHSP.

METHODS

In this study, we estimate ACERs for 77 interventions on reproductive maternal neonatal and child health (RMNCH), infectious diseases and water sanitation and hygiene as well as for 82 interventions on non-communicable diseases. We used the standardised World Health Organization (WHO) CHOosing Interventions that are cost effective methodology (CHOICE) for generalised cost-effectiveness analysis. The health benefits of interventions were determined using a population state-transition model, which simulates the Ethiopian population, accounting for births, deaths and disease epidemiology. Healthy life years (HLYs) gained was employed as a measure of health benefits. We estimated the economic costs of interventions from the health system perspective, including programme overhead and training costs. We used the Spectrum generalised cost-effectiveness analysis tool for data analysis. We did not explicitly apply cost-effectiveness thresholds, but we used US$100 and $1000 as references to summarise and present the ACER results.

RESULTS

We found ACERs ranging from less than US$1 per HLY gained (for family planning) to about US$48,000 per HLY gained (for treatment of stage 4 colorectal cancer). In general, 75% of the interventions evaluated had ACERs of less than US$1000 per HLY gained. The vast majority (95%) of RMNCH and infectious disease interventions had an ACER of less than US$1000 per HLY while almost half (44%) of non-communicable disease interventions had an ACER greater than US$1000 per HLY.

CONCLUSION

The present study shows that several potential cost-effective interventions are available that could substantially reduce Ethiopia's disease burden if scaled up. The use of the World Health Organization's generalised cost-effectiveness analysis tool allowed us to rapidly calculate country-specific cost-effectiveness analysis values for 159 health interventions under consideration for Ethiopia's EHSP.

Measuring progress towards universal health coverage: national and subnational analysis in Ethiopia

Introduction

Aiming for universal health coverage (UHC) as a country-level goal requires that progress is measured and tracked over time. However, few national and subnational studies monitor UHC in low-income countries and there is none for Ethiopia. This study aimed to estimate the 2015 national and subnational UHC service coverage status for Ethiopia.

Methods

The UHC service coverage index was constructed from the geometric means of component indicators: first, within each of four major categories and then across all components to obtain the final summary index. Also, we estimated the subnational level UHC service coverage. We used a variety of surveys data and routinely collected administrative data.

Results

Nationally, the overall Ethiopian UHC service coverage for the year 2015 was 34.3%, ranging from 52.2% in the Addis Ababa city administration to 10% in the Afar region. The coverage for non-communicable diseases, reproductive, maternal, neonatal and child health and infectious diseases were 35%, 37.5% and 52.8%, respectively. The national UHC service capacity and access coverage was only 20% with large variations across regions, ranging from 3.7% in the Somali region to 41.1% in the Harari region.

Conclusion

The 2015 overall UHC service coverage for Ethiopia was low compared with most of the other countries in the region. Also, there was a substantial variation among regions. Therefore, Ethiopia should rapidly scale up promotive, preventive and curative health services through increasing investment in primary healthcare if Ethiopia aims to reach the UHC service coverage goals. Also, policymakers at the regional and federal levels should take corrective measures to narrow the gap across regions, such as redistribution of the health workforce, increase resources allocated to health and provide focused technical and financial support to low-performing regions.