Objective The health systems costs of COVID-19 are high in many countries, including Pakistan. Without increases in fiscal space, COVID-19 interventions are likely to displace other activities within the health system. We reflect on the inclusion of COVID-19 interventions in Pakistan’s Essential Package of Health Services (EPHS) and, from a financial optimisation perspective, propose which interventions should be displaced to ensure the highest possible overall health utility within budgetary constraints.
Methods We estimated the costs of all 88 interventions currently included in the EPHS and collected published data on their cost-effectiveness. We also estimated total costs and cost-effectiveness of COVID-19 vaccination in Pakistan. We ranked all EPHS interventions and COVID-19 vaccination by cost-effectiveness, determining which interventions are comparatively least cost-effective and, in the absence of additional funding, no longer affordable.
Results The EPHS assumes a spending per capita of US$12.96, averting 40.36 million disability-adjusted life years (DALYs). From a financial optimisation perspective, and assuming no additional funds, the introduction of a COVID-19 vaccine (US$3 per dose) should displace 8 interventions out of the EPHS, making the EPHS more cost-effective by averting 40.62 million DALYs. A US$6 dose should displace a further intervention and avert 40.56 million DALYs. A US$10 dose would partially fall out of the package, displacing four additional interventions. If health spending per capita decreased to US$8, a US$3 dose would still be affordable, but not US$6 or US$10 doses.
Discussion Cost-effectiveness is only one criterion considered when deciding which interventions are included in (or removed from) a health benefits package. While displacing certain interventions to create fiscal space for the COVID-19 vaccine may lead to a financially optimal scenario, doing so may be politically unfeasible or socially undesirable. We highlight the difficult trade-offs that health systems face in the era of COVID-19.
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