Package design process

The other papers in this collection describe the different processes followed by the six countries to design their packages.11–15 In this paper, we focus on steps that directly relate to the requirements that determine successful package design and increase the prospects of a successful rollout.

All countries required 1–3 years to design their packages (table 1). This is not surprising given the importance of ensuring that the guiding principles are adopted, effective partnerships are secured, baseline assessments are effectively conducted and processes for prioritisation and costing are sound and reliable. The time taken to develop the package also depends on local circumstances and capacity and varies considerably between countries. The Pakistan and Sudan packages were developed for the first time, while others were revisions and expansions of earlier versions that existed before the endorsement of the Sustainable Development Goals (SDG) target 3.8 in 2015. Baltussen et al review the experience of the six countries in prioritising essential health services.11 All countries used the DCP3 evidence to guide the prioritisation of essential health services, but two countries, Somalia and Sudan, used additional sources of evidence such as the WHO–UHC Compendium.17 Packages covered all DCP3 delivery platforms (community, health centre, first-level hospital, tertiary care and population-based interventions), but the Pakistani government decided early in the course of the package design to focus during the first 5 years of implementation on the district level system, which covers the first three platforms.

Conducting an analysis of the fiscal space and determining how the UHC services will be funded is a critical step at the onset. The decision on how the package is financed during the implementation phase varied between countries. Based on their national vision and strategic plan, policymakers in Pakistan decided on public financing of the 88 high-priority services of the district-level package. The other five countries adopted financing mechanisms that included other prepayment schemes, including health insurance schemes, combined with user fees and donor funding.

The cost of the package also varied (table 1). Gaudin et al reviews the costing process conducted in five of these countries.12 Afghanistan had the lowest per capita package cost in the first year of implementation (US$6.9), while Ethiopia had the highest (US$40). In some cases, the per capita cost during initial implementation was higher than the public health expenditure or even the current health expenditure. For the first year of implementation, this situation required either further prioritisation or consideration of different financing schemes for the different groups of interventions.

Because of the differences in the delivery platforms and in financing mechanisms, the number of health interventions varied considerably, from 88 in Pakistan to over 1000 in Ethiopia.

Securing political commitment

Political commitment to UHC and the resolve to improve access to essential health services is one of the key prerequisites to reaching SDG target 3.8; we analysed such commitment through four questions (online supplemental table S1). Since there is no reliable tool to accurately assess political commitment, these questions were considered as proxy indicators. All six countries endorsed UHC as a target in their national health strategies and the UHC package is part of the national SDG plans and monitoring schemes. However, the planning and finance sectors of the government have not been consistently engaged in most countries; despite participation in meetings and discussions, their engagement has not been sustained in some countries, particularly in the fiscal space assessment and the planning for increased funding. There was also no evidence of a concrete commitment by parliament.

Assessing health system and financing mechanisms

Assessment of health system performance and capacity, including financing, is a critical step at the onset, since its outcome has a major influence on package design, and how it will be financed and implemented. Table 2 presents the most recently reported information on selected health system indicators, particularly those focusing on the status of health services delivered, health financing and the health workforce.

The UHC service coverage index is below 50 in all countries (on a scale from 0 to 100, based on 16 tracer indicators of health service coverage), with a range between 25 in Somalia and 49.9 in Pakistan.

A major challenge in financing the EPHS is that the fiscal space for public expenditure on health is very limited in all countries and it is considerably lower than the initial cost required for implementing the package in some of these countries. The current per capita health expenditure ranged between US$33 in Ethiopia and US$66 in Afghanistan. Per capita public spending on health is as low as US$5 and US$6 in Afghanistan and Ethiopia, respectively. Government spending on health as a percentage of the current health expenditure ranges from less than 10% in Afghanistan to 53% in Zanzibar. Out-of-pocket expenditure as a share of current health expenditure is high in most countries, with the highest being in Afghanistan (79%). The incidence of catastrophic expenditure (household spending on health that exceeds 10% of total household budget) is lowest in Zanzibar and highest in Sudan.

Compared with the financial resources available in the six countries, the cost of the package illustrated in table 1 is higher than the government health expenditure in some of them. Table 2 presents the ratio of the package cost to the government health expenditure, which ranges between 0.7 and 6.7. The mismatch between the financial resources available for public spending and the estimated cost of the package represents a major challenge for the transition to implementation, even if part of the financing gap is covered by development partners and donors.

An equally important challenge of the transition to effective implementation is the health system capacity in LLMICs. Although all health system building blocks need to be assessed, the state of human resources is especially important since it often impedes access to health services and influences the prioritisation of interventions and the overall design of the essential package. Based on the SDG index threshold of doctors, nurses and midwives,18 the figures in table 2 indicate serious shortages in the healthcare workforce in the countries reviewed.

Engaging key stakeholders

A comprehensive stakeholder analysis was not conducted in some countries at the initial stage of package development (table 3).

As highlighted before, not all countries had meaningful engagement of the finance and planning sectors, and only one country engaged community and civil society representatives during the package design process (table 3). The private health sector, which currently delivers a major proportion of the high-priority health services,14 19 did not seem to be involved in four out of the six countries. A more elaborate review of the role of the private sector in package design and implementation is covered by Siddiqi et al.14 Of the multilateral partners, the WHO was involved in providing technical assistance in all countries and the United Nations International Children’s Emergency Fund (UNICEF) and the World Bank in most of them. However, the United Nations Development Programme (UNDP) did not seem to be significantly engaged in all six countries.

Developing and implementing a road map

Table 4 includes findings on the package development process and the various elements of the road map. At least two countries do not have a unit on priority setting, health economics or health technology assessment—such a unit is needed for designing, revising and monitoring the UHC package. Institutionalisation and capacity strengthening in these areas within the Ministry of Health varied between countries. The list of priority decision-making areas where training and capacity building is required covers priority setting, health technology assessment, equity analysis, costing, budget impact and health service delivery models.

Key challenges and lessons learned

The review highlights critical challenges at different stages of the EPHS development. Some of these challenges are directly related to the processes and methodologies used, including gaps in preparation and in readiness, while others are inherent in the capacity, resources and performance of the health system. These challenges were compounded by the timing of the exercise in some countries that coincided with the COVID-19 pandemic.

UHC is a political choice and priority.1 Only two countries reported some engagement of parliamentarians at some stage of the package development process, but there were no formal decisions or resolutions made on UHC or the EPHS. Similarly, although most countries reported some involvement of the finance and planning sectors in the package development process, the level and timing of engagement was not clear.

As mentioned before, assessing health systems building blocks and financing mechanisms is an essential component of package development. Scarcity of health resources requires trade-offs and tough choices. An extreme case is the situation in Afghanistan, where only about 8% of the current health expenditure is financed through the government budget and almost 80% comes from out-of-pocket expenditure. The countries reviewed have low levels of domestic government health expenditure (table 2), which are very far from the Abuja Declaration target of spending 15% of government budgets on health.20 As noted in the findings, funding the package should not only cover initial implementation. Population growth in some countries and the progressive increase in the coverage of interventions along the UHC timeline will result in rising costs that will far exceed the current expenditure and any forecasted economic growth. Therefore, between initial implementation and 2030 UHC targets, governments must plan for additional resources.

The experience in the six countries indicated that all of them must consider feasible options for increased health allocations, including re-prioritisation of the government budget. Irrespective of the level of fiscal constraints, the focus on public financing must be on high-priority, high-impact interventions.5 Overall, implementation is less likely if the country invests in a package development exercise without first assuring realistic and sustained finance prospects. Soucat et al in this series review the challenges, current experience and directions on package financing.13

Countries also have limited capacity because of serious gaps across health system building blocks. In such a situation, two difficult questions should be addressed by policymakers in countries aiming to achieve UHC.21 First, which health services should be considered for full population and full cost coverage? Second, how can health planners expand the size or power of pooled funds so that they can achieve UHC? Addressing these questions should be at the centre of the health system assessment that is conducted at the initial phase and in parallel with the prioritisation phase.

It is not possible to deliver effective services without the necessary human resources. Addressing these gaps through a carefully planned and realistic health workforce strategy will be a basic requirement for the transition from package design to implementation.22 Capacity building should start as soon as possible based on the health service delivery model required for package implementation.

Engaging key internal and external stakeholders is critical for national ownership of the process and its outcome. In this respect, we highlight the importance of civil society dialogue and engagement of community groups particularly in focusing on people’s perceptions of their priority health needs.23 Apart from Zanzibar, where this requirement has been partly acknowledged, none of the countries were engaged in serious interaction with people’s representatives. Thailand’s experiences in implementing UHC and forming the National Health Assembly for public participation is worth highlighting. The commitment to UHC became a collective community demand. As a result, despite an unstable political environment, repeated changes of governments and ministers of health and frequent elections, the commitment to achieve the required change and implement the package was maintained.24 In contrast, package implementation in Colombia, the Dominican Republic and Peru has faced significant challenges since national stakeholders and especially the beneficiaries were not involved in the package development.25

The role of external stakeholders is equally important. Experience indicates that technical and logistic support from WHO and UNICEF has been invaluable. However, as previously mentioned, it is important to note that UNDP, which coordinates the SDG monitoring initiatives, has not been significantly involved. In general, no strong coordination appears to have been established with the SDG monitoring part of the government.

Although all six countries reviewed in this paper illustrated an initial political commitment to the package (online supplemental table S1), sustainability of this commitment in countries with political instability is a major concern. Afghanistan, Somalia, Pakistan, Sudan and Ethiopia rank highly among almost 200 countries globally for likelihood of political instability and/or politically-motivated violence, including terrorism.26 After defining the package, Afghanistan faced a regime change, and Pakistan, Sudan and Somalia had changes in government. Such instability is commonly associated with economic constraints and limited fiscal space for health and social services.

Sustainability of EPHS implementation is more likely if economic realities are seriously considered during the package design and the technical expertise and skills are institutionalised.27 The dynamic of power and financing are important in package design and implementation because these often involve trade-offs and redistribution of resources between services and service providers. Good governance is therefore needed to ensure that setting EPHS follows equity and fairness principles, including stakeholders’ involvement, transparency and accountability, particularly in defining entitlements and identifying benefits. This is also why institutionalisation needs a strong leadership structure that meets legal, political, technical, human and financial requirements to govern the EPHS at the national or subnational level, depending on the authority structure of the country.28 Countries will be moving in the right direction if the governance structure is adopted or adapted to serve as a permanent UHC or national health reform and coordination unit. In this respect, capacity building is critical and sustainable skills are essential for priority setting, monitoring and evaluation and periodic revision of interventions.

Basic requirements for successful package design and transition to implementation

Many countries designed EPHS before setting UHC as a global commitment in 2015,25 29 30 but not all were implemented. Some packages were defined by countries in fragile situations and chronic crises, sometimes with the support and engagement of development agencies and donors, such as in Afghanistan,7 northern Syria,31 Somalia32 and Yemen.33 In some of these countries, the package aimed to identify a minimum set of essential services for emergency funding or for contracting with the private sector or non-governmental organisations to provide primary care services. While these reasons justify the need for the service package, the definition of the EPHS in the six countries has a broader objective and serves as a major milestone for the realisation of UHC. It is with this wider scope in mind that we reviewed the experience of six LLMICs in preparing for the development of the package and ensuring a robust process and a successful outcome. Based on the experience of these countries, we believe that the steps listed in box 1 are necessary for a successful design and transition to implementation of the EPHS.

We believe that all steps in this box are important in reinforcing the EPHS development process, particularly those that address gaps impeding implementation. As stated previously, there are key requirements that have to be considered in order to address the limitations in the package development process highlighted by the review. First, strong decisions on package rollout are more difficult to make in the absence of high-level government leadership and ownership, as well as active engagement of key stakeholders. Second, it is not realistic to expect improved access to essential interventions without a serious assessment of financing needs and health system constraints and related plans to secure the required resources and to address existing health system gaps. Third, experience shows that the private sector does not play a significant role in the design of UHC packages despite the fact that it currently provides a major proportion of primary healthcare services in the six countries reviewed. It is essential to consider measures to address key barriers related to governance, regulation, accountability and quality of services. The fourth requirement is that of institutionalisation. Priority setting, package design and monitoring of implementation are part of a dynamic process which requires building managerial and technical capacity in ministries of health and partner institutions in order to respond to policy changes and to monitor implementation. In this respect, we also believe that establishing and strengthening existing regional centres will make an important contribution to national efforts to institutionalise package design and implementation capacities in LLMICs.

In general, the analysis of the experience in the six countries demonstrates areas of strengths and weaknesses. We believe that a review of the contents of box 1 will support countries in identifying areas where reinforcement is needed during package design or revision.