Introduction
Although countries pledged to achieve universal health coverage (UHC) by 2030,1 the current pace of progress indicates that more than one-third of the world’s population will not have access to essential health services by this target date.2 The situation is compounded by the adverse effects of the COVID-19 pandemic on health systems worldwide and the resulting disruptions in access to quality health services. Since countries must re-double their efforts in improving such access, there is growing demand from governments of low-income and lower middle-income countries (LLMICs) for technical assistance in health system strengthening and UHC.3
The third edition of the Disease Control Priorities series (DCP3)4 5 provides an up-to-date review of cost-effectiveness of health interventions through a systematic appraisal of evidence, new economic analysis and expert judgement of a wide range of health services. The goal is to influence resource allocation decisions at country level to achieve the highest impact of health interventions provided by LLMICs.
Two model essential packages of health services (EPHS)—also called health benefits packages—were developed to serve as a guide and starting point for the development or revision of EPHS. The first is the essential UHC (EUHC) package, which includes 218 interventions designed for lower middle-income countries. The second is the high priority package, a subset of the EUHC, that includes 108 interventions, proposed as a model for low-income countries. The criteria adopted for selecting health services are evidence of impact, cost-effectiveness, financial risk protection, equity and feasibility of implementation.4 The DCP3 approach recommends that the package is financed publicly and is implemented to achieve UHC in a stepwise manner through a progressive universalism approach.5 In this approach, the package is initially designed to provide highly cost-effective health services, particularly for diseases that disproportionately affect the poor. As health resources grow, coverage will increase and include a wider range of interventions.6 By publicly financing the highest priority health services, the DCP3 approach covers the three key dimensions of UHC: providing unimpeded access to all population groups, expanding the range of essential services and reducing financial risk.
Since their launch in December 2017, the DCP3 evidence and packages have been used by several countries to design or revise their national EPHS.7–10 The experience of six LLMICs has recently been reviewed by a knowledge network of professionals engaged in DCP3-related country work to extract lessons learnt and update evidence and good practice. The review covered seven key areas in the process of designing an EPHS: requirements for successful EPHS design (current paper), decision-making processes,11 estimating costs,12 financing,13 building implementable packages, role of the private sector14 and monitoring and evaluation.15 The seven papers in this collection cover the key findings of the review. Because there is limited value in investing in the development of an EPHS if the process does not lead to high-level government endorsement, this first paper specifically assesses the requirements for an appropriate design of UHC packages. Since the ultimate goal is to improve healthcare, the paper also aims to identify the essential elements needed for the transition from package design to implementation and improved access to services that are essential for accelerating progress to UHC.
We conducted an initial review of the experiences of Afghanistan, Ethiopia, Pakistan, Somalia, Sudan and Zanzibar–Tanzania in setting their own EPHS by establishing a knowledge network of professionals working in priority setting and UHC-related policies. The World Bank classifies Pakistan and Zanzibar–Tanzania as lower middle-income countries, and the remaining four as low-income countries.16 Key representatives from each of the six countries presented their experiences during the first DCP3 country review meeting in Geneva on 27–28 September 2021, organised by the DCP3 Country Translation Project at the London School of Hygiene & Tropical Medicine. It was attended by a network of 60 experts and professionals engaged in DCP3-related work. The team collectively decided to conduct a survey to fill in gaps and standardise data from all six countries and to stimulate group discussions. A group consisting of the authors of this paper updated and presented the review to the network during the second and third DCP3 country review meetings held on 6 December 2021 and 31 March 2022, respectively. The current analysis is based on the discussions in these meetings and the group work in between meetings. Online supplemental box S1 summarises the review meeting, the survey and the development of the framework for this paper.
An outline of requirements for country readiness and prerequisites for successful design of essential packages of health services and transition to implementation
Securing political commitment
Ensuring sustained political commitment for universal health coverage (UHC).
Commitment and a clear government position, including that of financing and planning sectors.
Commitment at the level of the parliament.
Commitment at the subnational level, particularly in decentralised systems.
Demonstrated commitment to fund the package and to finance the UHC road map.
Engaging key stakeholders
Conducting stakeholder analysis of key national players, including the private sector, academic and public health institutions, community representatives and external partners.
Engaging the planning and finance government sectors and the National Bureau of Statistics as early as possible.
Building national consensus and conducting societal dialogue on health services.
Assessing health system and financing mechanisms
Conducting an in-depth assessment of the health system, including governance structure, infrastructure, delivery arrangements, health workforce, information system.
Mapping of health services currently provided, based on the DCP3 model packages, UHC Compendium or previously existing packages.
Assessing fiscal space, existing health financing mechanisms and sustainability of health financing; deciding on the level of public funds provided to finance the package.
Developing and implementing a road map
Agreeing on principles, especially transparency, impartiality and inclusiveness.
Defining a governance structure to design the EPHS and sustain implementation and revision.
Ensuring prioritisation and package costing are data-driven and evidence-informed.
Agreeing on the steps, decision criteria and processes for prioritising and costing interventions.
Defining the scope of the EPHS, including health delivery platforms with special focus on primary healthcare.
Developing an action plan, including roles, mandates, required skills and resources, including capacity building in priority setting and UHC package design.
Securing a successful transition to sustainable implementation
Ensuring affordable and sustainable financing of high-priority health services along the UHC timeline.
Addressing health system gaps and reinforcing health service delivery, including the role of the private health sector.
Addressing the risk of instability in fragile and politically unstable contexts and proposing risk mitigation measures with stakeholders.