Costing Interventions for Developing an Essential Package of Health Services: Application of a Rapid Method and Results From Pakistan.

BACKGROUND: The Federal Ministry of National Health Services, Regulations and Coordination (MNHSR&C) in Pakistan has committed to progress towards universal health coverage (UHC) by 2030 by providing an Essential Package of Health Services (EPHS). Starting in 2019, the Disease Control Priorities 3rd edition (DCP3) evidence framework was used to guide the development of Pakistan's EPHS. In this paper, we describe the methods and results of a rapid costing approach used to inform the EPHS design process. METHODS: A total of 167 unit costs were calculated through a context-specific, normative, ingredients-based, and bottom-up economic costing approach. Costs were constructed by determining resource use from descriptions provided by MNHSR&C and validated by technical experts. Price data from publicly available sources were used. Deterministic univariate sensitivity analyses were carried out. RESULTS: Unit costs ranged from 2019 US$ 0.27 to 2019 US$ 1478. Interventions in the cancer package of services had the highest average cost (2019 US$ 837) while interventions in the environmental package of services had the lowest (2019 US$ 0.68). Cost drivers varied by platform; the two largest drivers were drug regimens and surgery-related costs. Sensitivity analyses suggest our results are not sensitive to changes in staff salary but are sensitive to changes in medicine pricing. CONCLUSION: We estimated a large number of context-specific unit costs, over a six-month period, demonstrating a rapid costing method suitable for EPHS design.

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

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.

Assessing Global Evidence on Cost-Effectiveness to Inform Development of Pakistan's Essential Package of Health Services.

BACKGROUND: Countries designing a health benefit package (HBP) to support progress towards universal health coverage (UHC) require robust cost-effectiveness evidence. This paper reports on Pakistan's approach to assessing the applicability of global cost-effectiveness evidence to country context as part of a HBP design process. METHODS: A seven-step process was developed and implemented with Disease Control Priority 3 (DCP3) project partners to assess the applicability of global incremental cost-effectiveness ratios (ICERs) to Pakistan. First, the scope of the interventions to be assessed was defined and an independent, interdisciplinary team was formed. Second, the team familiarized itself with intervention descriptions. Third, the team identified studies from the Tufts Medical School Global Health Cost-Effectiveness Analysis (GH-CEA) registry. Fourth, the team applied specific knock-out criteria to match identified studies to local intervention descriptions. Matches were then cross-checked across reviewers and further selection was made where there were multiple ICER matches. Sixth, a quality scoring system was applied to ICER values. Finally, a database was created containing all the ICER results with a justification for each decision, which was made available to decision-makers during HBP deliberation. RESULTS: We found that less than 50% of the interventions in DCP3 could be supported with evidence of cost-effectiveness applicable to the country context. Out of 78 ICERs identified as applicable to Pakistan from the Tufts GH-CEA registry, only 20 ICERs were exact matches of the DCP3 Pakistan intervention descriptions and 58 were partial matches. CONCLUSION: This paper presents the first attempt globally to use the main public GH-CEA database to estimate cost-effectiveness in the context of HBPs at a country level. This approach is a useful learning for all countries trying to develop essential packages informed by the global database on ICERs, and it will support the design of future evidence and further development of methods.

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

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. CONCLUSION: 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.

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.

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.

Pakistan's Progress on Universal Health Coverage: Lessons Learned in Priority Setting and Challenges Ahead in Reinforcing Primary Healthcare.

Pakistan developed an essential package of health services at the primary healthcare (PHC) level as a key component of health reforms aiming to achieve universal health coverage (UHC). This supplement describes the methods and processes adopted for evidence-informed prioritization of services, policy decisions adopted, and the lessons learned in package design as well as in the transition to effective rollout. The papers conclude that evidence-informed deliberative processes can be effectively applied to design affordable packages of services that represent good value for money and address a major part of the disease burden. Transition to implementation requires a comprehensive assessment of health system gaps, strong engagement of the planning and financing sectors, serious involvement of key national stakeholders and the private health sector, capacity building, and institutionalization of technical and managerial skills. Pakistan's experience highlights the need for updating the evidence and model packages of the Disease Control Priorities 3 (DCP3) initiative and reinforcing international collaboration to support technical guidance to countries in priority setting and UHC reforms.

Designing an evidence-informed package of essential health services for Universal Health Coverage: lessons learnt and challenges to implementation in Liberia.

Liberia developed an evidence-informed package of health services for Universal Health Coverage (UHC) based on the Disease Control Priorities 3 evidence. This paper describes the policy decisions, methods and processes adopted for prioritisation, key features of the package and lessons learnt, with special emphasis on feasibility of implementation. Package design was led by the Ministry of Health. Prioritisation of essential services was based on evidence on disease burden, cost-effectiveness, financial risk, equity, budget impact, and feasibility of implementation. Fiscal space analysis was used to assess package affordability and options for expanding the budget envelope. The final adopted package focuses on primary healthcare and comprises a core subpackage of 78 publicly financed interventions and a complementary subpackage of 50 interventions funded through cost-sharing. The estimated per capita cost to the government is US$12.28, averting around 1.2 million DALYs. Key lessons learnt are described: (1) priority setting is essential for designing affordable packages of essential services; (2) the most realistic and affordable option when domestic resources are critically limited is to focus on basic, high-impact primary health services; (3) Liberia and many other countries will continue to rely on donor funding to expand the range of essential services until more domestic resources become available; (4) national leadership and effective engagement of key stakeholders are critical for a successful package design; (5) effective implementation is less likely unless the package cost is affordable and the health system gaps are assessed and addressed. A framework of action was employed to assess the consistency with the prerequisites for an appropriate package design. Based on the framework, Liberia developed a transparent and affordable package for UHC, but the challenges to implementation require further action by the government.

Lessons from the development process of the Afghanistan integrated package of essential health services.

In 2017, in the middle of the armed conflict with the Taliban, the Ministry of Public Health decided that the Afghan health system needed a well-defined priority package of health services taking into account the increasing burden of non-communicable diseases and injuries and benefiting from the latest evidence published by DCP3. This leads to a 2-year process involving data analysis, modelling and national consultations, which produce this Integrated Package of Essential health Services (IPEHS). The IPEHS was finalised just before the takeover by the Taliban and could not be implemented. The Afghanistan experience has highlighted the need to address not only the content of a more comprehensive benefit package, but also its implementation and financing. The IPEHS could be used as a basis to help professionals and the new authorities to define their priorities.

Evaluation of Cholesterol Thickness of Blood Vessels Using Photoacoustic Technology.

One of the primary indicators of plaque vulnerability is the lipid composition of atherosclerotic plaques. Therefore, the medical industry requires a method to evaluate necrotic nuclei in atherosclerosis imaging with sensitivity. In this regard, photoacoustic imaging is a plaque detection method that provides chemical information on lipids and cholesterol thickness in the arterial walls of the patient. This aspect aims to increase the low-frequency axial resolution by developing a new photoacoustic-based system. A photoacoustic system has been developed to detect the cholesterol thickness of the blood vessels to observe the progression of plaque in the heart's blood vessels. The application of the coherent photoacoustic discontinuous correlation tomography technique, which is based on a novel signal processing, significantly increased the cholesterol oleate's sensitivity to plaque necrosis. By enhancing the quality of thickness detection, the system for measuring the thickness of cholesterol in blood vessels has been reduced to approximately 23 microns. The results show that the phase spectrum peaked at 100 Hz at 58.66 degrees, and at 400 Hz, the phase spectrum was 46.37 degrees. The minimum amplitude is 1.95 at 100 Hz and 17.67 at 400 Hz. In conclusion, it can be stated that photoacoustic imaging as a method based on new technologies is of great importance in medical research, which is based on the use of nonionizing radiation to perform diagnostic processes and measure different types of body tissues.

Monitoring and evaluating the implementation of essential packages of health services.

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the 'what' and 'for whom' of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.

Bentall procedure as a lifesaving surgery: A single center experience.

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve issues. The present study aimed to evaluate the outcomes of 18 patients treated with the Bentall procedure in a single center. The present study was a single-center retrospective case series conducted over a period of 3 years. The patients had either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction. The Bentall procedure was performed via standard median sternotomy. St. Jude Medical composite grafts with a valve were applied in all cases. A total number of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. The age of the participants ranged from 27-60 years. The ratio of males to females was 16:2 (males, 88.8%). The symptoms developed 3-4 days prior to hospital admission. Chest pain was the most common presenting symptom (n=10, 55.5%). Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. Early post-operative complications occurred in 5 patients (27.7%). On the whole, as demonstrated herein, the modifications of the Bentall procedure have a notable impact on decreasing the overall mortality rates. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Effect of ginger (Zingiber officinale) intake on human serum lipid profile: Systematic review and meta-analysis.

Dyslipidemia is associated with an increased risk of cardiovascular events. Effect of ginger supplementation on lipid profile in humans remains controversial particularly in diabetic patients. A systematic search was performed covering PubMed, Medline, and Scopus, Web of Science (ISI), and Google scholar from January 2010 to January 2022. Inclusion criteria were randomized controlled clinical trials (RCT) study design, at least one of lipid profile components triglyceride (TG), total cholesterol (TC), low-density lipoprotein (LDL-C), and high-density lipoprotein (HDL-C) measured before and after ginger consumption. For quantitative data synthesis, a random-effects model was applied. Pooled data showed that ginger intake reduced TC (SMD -0.44; 95% CI: -0.86, -0.02; p = 0.025) and TG (SMD -0.61; 95% CI: -1.14, -0.08; p = 0.024) levels significantly, but it has no significant effect on improving HDL-C (SMD 0.40; 95% CI: -0.01, 0.80; p = 0.057) and LDL-C (SMD -0.34; 95% CI: -0.81, 0.13; p = 0.153). Ginger supplementation decreased TG in obese and diabetic subjects more efficiently. In terms of ginger dose, the result of meta-regression found to be significant only for TC, so that increasing daily doses of ginger reduces TC levels by (ß: -0.67; 95% CI: -1.28, -0.07; p = 0.028). Therefore, ginger could be considered as an effective lipid lowering nutraceuticals.

Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences.

As countries progress towards universal health coverage (UHC), they frequently develop explicit packages of health services compatible with UHC goals. As part of the Disease Control Initiative 3 Country Translation project, a systematic survey instrument was developed and used to review the experience of five low-income and lower-middle-income countries-Afghanistan, Ethiopia, Pakistan, Somalia and Sudan-in estimating the cost of their proposed packages. The paper highlights the main results of the survey, providing information about how costing exercises were conducted and used and what country teams perceived to be the main challenges. Key messages are identified to facilitate similar exercises and improve their usefulness. Critical challenges to be addressed include inconsistent application of costing methods, measurement errors and data reliability issues, the lack of adequate capacity building, and the lack of integration between costing and budgeting. The paper formulates four recommendations to address these challenges: (1) developing more systematic guidance and standard ways to implement costing methodologies, particularly regarding the treatment of health systems-related common costs, (2) acknowledging ranges of uncertainty of costing results and integrating sensitivity analysis, (3) building long-term capacity at the local level and institutionalising the costing process in order to improve both reliability and policy relevance, and (4) closely linking costing exercises to public budgeting.

Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries.

This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.

The role of the private sector in delivering essential packages of health services: lessons from country experiences.

Many countries are adopting essential packages of health services (EPHS) to implement universal health coverage (UHC), which are mostly financed and delivered by the public sector, while the potential role of the private health sector (PHS) remains untapped. Currently, many low-income and lower middle-income countries (LLMICs) have devised EPHS; however, guidance on translating these packages into quality, accessible and affordable services is limited. This paper explores the role of PHS in achieving UHC, identifies key concerns and presents the experience of the Diseases Control Priorities 3 Country Translation project in Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar. There are key challenges to engagement of the PHS, which include the complexity and heterogeneity of private providers, their operation in isolation of the health system, limitations of population coverage and equity when left to PHS's own choices, and higher overall cost of care for privately delivered services. Irrespective of the strategies employed to involve the PHS in delivering EPHS, it is necessary to identify private providers in terms of their characteristics and contribution, and their response to regulatory tools and incentives. Strategies for regulating private providers include better statutory control to prevent unlicensed practice, self-regulation by professional bodies to maintain standards of practice and accreditation of large private hospitals and chains. Potentially, purchasing delivery of essential services by engaging private providers can be an effective 'regulatory approach' to modify provider behaviour. Despite existing experience, more research is needed to better explore and operationalise the role of PHS in implementing EPHS in LLMICs.

Protecting essential health services in low-income and middle-income countries and humanitarian settings while responding to the COVID-19 pandemic.

In health outcomes terms, the poorest countries stand to lose the most from these disruptions. In this paper, we make the case for a rational approach to public sector health spending and decision making during and in the early recovery phase of the COVID-19 pandemic. Based on ethics and equity principles, it is crucial to ensure that patients not infected by COVID-19 continue to get access to healthcare and that the services they need continue to be resourced. We present a list of 120 essential non-COVID-19 health interventions that were adapted from the model health benefit packages developed by the Disease Control Priorities project.

Global Health in the Age of COVID-19: Responsive Health Systems Through a Right to Health Fund.

We propose that a Right to Health Capacity Fund (R2HCF) be created as a central institution of a reimagined global health architecture developed in the aftermath of the COVID-19 pandemic. Such a fund would help ensure the strong health systems required to prevent disease outbreaks from becoming devastating global pandemics, while ensuring genuinely universal health coverage that would encompass even the most marginalized populations. The R2HCF's mission would be to promote inclusive participation, equality, and accountability for advancing the right to health. The fund would focus its resources on civil society organizations, supporting their advocacy and strengthening mechanisms for accountability and participation. We propose an initial annual target of US$500 million for the fund, adjusted based on needs assessments. Such a financing level would be both achievable and transformative, given the limited right to health funding presently and the demonstrated potential of right to health initiatives to strengthen health systems and meet the health needs of marginalized populations-and enable these populations to be treated with dignity. We call for a civil society-led multi-stakeholder process to further conceptualize, and then launch, an R2HCF, helping create a world where, whether during a health emergency or in ordinary times, no one is left behind.