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

Priority health packages in Afghanistan

In 2001, after the end of the first Taliban regime, the MoPH had the challenging task of rebuilding the health system including how best to address the key health challenges in the country; especially given that its population’s maternal mortality and child mortality rates represented the highest mortality rates in the world.16 In 2002/2003, the MoPH designed a unique package of health services that helped bring coherence among the health stakeholders in what was then a fragmented health system. Towards the end of 2003, the MoPH supported by its international partners, put in place the BPHS for the primary healthcare level throughout the country. This was followed in 2005 by the Essential Package of Health Services (EPHS) for hospitals up to provincial level.17

The MoPH and health economists included in the Expert Committee advising the MoPH estimated that US$235M were spent by government and donors on the BPHS and EPHS in 2018, equivalent to US$6.7 per capita. The BPHS accounted for 72% (US$172M) of total spending, whereas the EPHS accounted for around 28% (US$63M) of total spending.18 Maternal and child health accounted for around 45% of total BPHS spending. Combined, government and donor spending on the BPHS and EPHS averted an estimated 1.04M disability-adjusted life years (DALYs). Almost 60% (605 000) of DALYs averted by the BPHS and EPHS were related to maternal and child health interventions.19

In 2018, the MoPH decided that the BPHS and EPHS needed revising in light of the increase burden of disease since 2006 related to NCDs (+2.5% annually) and injuries (+4.4% annually), the international drive towards UHC.20 and the publication of DCP3.21 In August 2021 (see figure 1), the new priority package, the Integrated Package of Essential Health Services (IPEHS) was finalised.

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The various trade-offs

The difficult decisions made in Afghanistan when starting working on the IPEHS in 2018 were about responding both to the epidemiological transition and level of violence generated by armed conflict, while maintaining gains in maternal and child health, ensuring equitable access to interventions and providing financial protection—within a highly constrained government and donor budget envelope. Two key questions for the MoPH guided the priority setting process. First, in the current BPHS and EPHS, which interventions are no longer justified as a top priority and which additional health interventions are needed? Second, how to ensure the new package of health services is accessible to the most underprivileged that is, the poorest and the groups of populations living the furthest from primary healthcare facilities?

Priority setting in Afghanistan between 2028 and 2021 was about making trade-offs not only between different health interventions from different disease groups but also between health services, public health interventions and interventions tackling determinants of health. These decisions carried with them value judgements and efficiency (cost-effectiveness)-equity trade-offs. A priority setting process usually takes place in an environment where societal values are at stake and where tensions exist between different perspectives and interests.22 This process required legitimacy in order to gain any prospect of public and political acceptance. As a result, all decision was justified with rigorous documentation to make sure that every step in the process was cumulative from the previous one.23

In terms of governance, the MoPH, led by the Minister of Public Health, drove the revision process. In their role of overseeing this activity, the MoPH core team created and managed nine in-country Working Groups and ‘integrated expert opinion from members of the Ministry and the local stakeholder community including international organisations such as United Nations agencies. In Afghanistan, nine multistakeholder Working Groups were set up according to health domains (reproductive, maternal, child and adolescent health; mental health; surgery; cardiovascular health; infectious disease; surgery; cancer; palliative care; rehabilitation and inter-sectoral policy) to provide expertise in reviewing the shortfalls in the BPHS and EPHS. An advisory mechanism in the form of an international Expert Committee was put in place to maximise the use of data and evidence, ensure the adequacy of the methodology, encourage creativity in data analysis and provide accountability for use of the results by the Afghan government as well as by national and global stakeholders’.[24 Page 3]

A multi-criteria approach

MoPH adopted a multicriteria approach to enable them to have a fair, transparent and mutual process to set priorities.24 This approach was based on the following principles: (1) use of the latest global and national evidence on burden of disease and cost-effectiveness of interventions, (2) well-defined selection criteria agreed by all key stakeholders, (3) transparent and documented process of selecting interventions and (4) recognition that decisions made are reasonable, combining both analysis of evidence and expert discussions.

The selection criteria defined by the Expert Committee in May 2018 to guide decisions of MoPH and experts included the following: (1) effectiveness: What has been proven to work? (2) local feasibility: local resources exist to deliver? Are there staff in place? Are they trained? Is the intervention supported by existing infrastructure? (3) affordability: Are new drugs and equipment required? Is there a large setup cost?; and (iv) Equity: Will the intervention improve access to care? For whom?

The Expert Committee and MoPH also agreed on a set of priority conditions and risk factors to address the current burden of disease in Afghanistan. The priority conditions included reproductive, maternal, newborn and child health, injuries (conflict and road traffic accidents), mental health (substance use, suicide, posttraumatic stress disorder), cardiovascular diseases (heart attack, stroke), undifferentiated emergency presentation (difficulty breathing, shock, meningitis, diarrheal disease, lower respiratory diseases) and diabetes. The priority risk factors identified included undernutrition, over-nutrition, smoking, water sanitation and hygiene, air pollution and hypertension.

The MoPH designed a flexible process to examine in-depth the bigger picture that is internal and external to the setting of priorities by the institution to reflect the connection and relationship between the different parts of the health system, and in doing so:

1. MoPH research teams conducted an analysis of the health needs and the health system capacity.

2. An expert committee was established, chaired by the Minister of Public Health and composed of 12 national and international experts including from the DCP3 task force.

3. Nine local working groups were formed (one for each of the nine health volumes of DCP3),21 to create an initial draft of priority interventions based on field experience.

4. A number of opportunities created for a wide range of stakeholders to help decide the priorities through consultative workshops and meetings with NGOs, UN agencies, Donors and Presidential office.

5. Defined clear selection criteria for the setting of priority interventions and opportunities.

6. Costed the existing and new package of health services and the identification of relevant global cost-effective interventions.

7. Projections of the fiscal space between 2018 and 2030 conducted on different scenarios.

8. Enhancing advocacy and negotiation to mobilise domestic revenue.

9. Rigorously examined the short-term and long-term implications of the new package of health services and developing relevant implementation approaches and systems including a tailored monitoring and information system.

At the same time, MoPH determined which of the DCP3 early intersectoral policy interventions was addressed as a priority using standardised and transparent criteria. It also worked on minimising financial risks to people, especially the poor in Afghanistan.

The priority setting process was conducted within the available and projected fiscal space. According to the Ministry of Finance and the 2020 National Health Accounts, more than half (52%) of the national budget was funded by foreign aid, 44.8% by domestic revenue and 3.2% by loan.25 From the total budget, 5% was allocated to MoPH, of which about 79% was funded by donors covering the BPHS and EPHS. Through the MoPH’s budgetary prospect exercise, three possible realistic scenarios for budget expansion were developed in order to cover the potential expansion of services provided under the High Priority Programme for Afghanistan.26 Based on stable support from international donors, stable economic growth and a slight reduction in out of pocket expenditure, it was estimated that in a low variant projection, the per capita expenditure will increase by one per cent per year. In a medium variant projection, it was estimated that the total health spending per capita will increase by 5%, and in a high variant projection by 8%.26 Of course, these projections did not include the scenario that the Taliban would take over in August 2021.

The use of DCP3 data

The third edition of Disease Control Priorities published between 2015 and 2018 in nine volumes provides a review of evidence on cost-effective interventions to address the burden of disease in low and middle-income countries.21 It does so by drawing on systematic reviews of economic evaluations, epidemiological data and clinical effectiveness studies, and on the expertise and time of over 500 authors.27 While DCP3 data are generally considered thorough and to have been constituted in a transparent manner, considerable adaptation must be undertaken when applying it at the country level, especially in those countries, like Afghanistan, where contextually adapted evidence was especially needed given the complexity brought about by sectarian violence and armed conflict. National health officials are advised by DCP3 that its packages of interventions needed to be modified based on local priorities, and that country-specific analyses as to costs and impact should be carried out.

To inform each health system building block, team members consulted additional sources, including the most recently available national health information systems data and results from the28 Mental Health survey and other national surveys.29 To develop the list of interventions, working groups compared the DCP3 list of interventions with the existing BPHS and the EPHS. The MoPH decided that the revised package of health services would be unique from community level to provincial level—instead of two distinct packages. This involved prioritising the interventions in DCP3 and assigning them to the different categories of health system level, categorised by health facility type. Contextual knowledge and specialist assessment as to which interventions would be possible given government and partner support at each level were critical for this task.

DALY-driven rationale

DALYs are a measure of the burden of disease accounting for the number of years lost due to ill health, disability or early death. DALYs ‘measure the gap between a population’s health and a hypothetical ideal for health achievement’30 and are used in setting health research priorities, identifying disadvantaged groups and targeting health interventions. While estimates, projections and modelling that are based on mortality—how many deaths could be averted due to a health service being offered—are popular and compelling, unlike DALYs they do not capture morbidities such as chronic diseases, mental health, injuries and disabilities, that will have an impact on quality of life.

The Expert Committee took the decision to use DALYs through the Health Interventions Prioritisation tool (HIPtool),31 a health resource optimisation tool, using context-specific data on burden of disease and intervention cost-effectiveness to help stakeholders identify funding priorities and targets. The reference point of this expert committee consultation, the Essential Universal Health Coverage package published by DCP3, is based on evidence of cost-effectiveness, presenting data in the form of ‘cost per DALY averted’ (an incremental cost-effectiveness ratio, ICER).21 DALYs provided a single measure for which to compare interventions across the entire BPHS and EPHS packages. Given the amount of diseases and interventions considered, it is important to note that results might have been less clear to interpret if a variety of outputs were used.

Summary of analysis findings

In the first comprehensive list, 149 interventions were included for consideration. For the international expert committee meetings, HIPtool generated estimates of DALYs averted by: (1) existing spending, (2) additional spending projections based on fiscal space assessments, (3) scaling-up existing Reproductive, Maternal, Newborn and Child Health (RMNCH) interventions in the package and (4) optimised spending based on intervention cost-effectiveness and burden of disease. The HIPtool optimised spending scenario supported recommendations on the inclusion of emergency and trauma care as well as cost-effective mental health interventions in the IPEHS package.

The IPEHS was organised by seven platforms of the health system: (1) community health post; (2) mobile health teams (MHT); (3) subhealth centre (SHC); (4) basic health centre (BHC); (5) comprehensive health centre (CHC); (6) first referral hospital and (7) second referral hospital. In order to highlight the level of integration and continuum between the various levels of the health system, the interventions were defined by level based on the resources and skills available at the level with an explicit link with the previous or next level of referral (see Annex 1 for the full list of IPEHS interventions).

Nine domains were defined to help structure the interventions: (1) reproductive, maternal and newborn health; (2) child and adolescent health and development; (3) infectious diseases; (4) chronic NCDs; (v) mental, neurological and substance use disorders; (vi) emergency care; (vii) surgical interventions; (viii) palliative care and (ix) rehabilitation.

These nine domains were completed by 11 population-based interventions such as mass media campaign promoting healthy diet and physical exercise or preparedness strategy in case of infectious disease outbreak.

Finally, the IPEHS was composed of 15inter-sectoral interventions such as regulate transport, industrial, power and household generation emissions to reduce air pollution or ban smoking in public places.

Cost of IPEHS

Healthcare access, quality and outcomes vary widely across geographies in Afghanistan. Variations in the financing and provision of healthcare services along with population displacements, geographic remoteness, difficult terrain, sociocultural isolation and health awareness contribute to these differences. To address this, a number of provinces were carefully selected for inclusion in the cost analysis to achieve good geographic spread and sufficient representation from each region: Dikundi, Faryab, Takhar, Nangarhar, Paktya, Urzgan and Herat based on geographical representations from Central, North West, North East, East, South, South West, and West, respectively.

The BPHS cost analysis was carried out using the Cost Revenue Analysis Tool Plus (CORE Plus) for MHT, SHC, BHC, CHC and district hospital (DH) levels of the health system. Expenditure data were collected from NGOs from 534 health facilities in seven selected provinces in AFN currency, and it was converted to USD based on an exchange rate of 2020 at 78 AFN.18 The studied health facilities covered 21% of the total population in 2020. Provincial hospitals (PH) and higher levels of the health system, for the EPHS, were costed separately using hospital data.

The difference between the costs of BPHS and EPHS and IPEHS 2021 was also assessed to understand the costs of supplementary interventions under IPEHS 2021. The health facilities were categorised into two groups—primary healthcare services and secondary healthcare services, which included PH. The total additional cost of the supplementary interventions was estimated at US$39 141 581. The additional costs of IPEHS compared with BPHS at the primary healthcare level (Community level, Mobile Health Tesm, sub-Health Centre, BHC, CHC, DH) and compared with EPHS at secondary healthcare level (PH and above) were US$30 334 630 and US$8 808 951, respectively. In other words, primary healthcare accounted for 77.5% of the total required increase in IPEHS cost, whereas the cost of the additional secondary service share was 22.5% of the total cost. The overall average per capita cost of IPEHS was US$6.9.18