Package design process
The process of developing the UHC EPHS was initiated in January 2022 as part of a collaboration between the MoH and the DCP3 Country Translation Project. Package design was led by the ministry, with technical guidance and support from DCP3 experts. The process built on the experience of other countries where the DCP3 evidence had been used as a guide.13–16
Timeline and key steps
A work plan was developed jointly with the MoH’s Planning Department and endorsed by the Minister of Health. The plan involved:
Conducting an inception workshop to build consensus, mobilise key stakeholders and agree on an operational plan and timeline.
Establishing a governance structure and a secretariat within the MoH, headed by the assistant minister of Health for Policy and Planning.
Assessing the financial mechanisms for health.
Mapping existing health services and selecting services for prioritisation.
Implementing an evidence-informed prioritisation process to identify and cost essential health services.
Developing implementation scenarios.
Reviewing the entire process and reaching consensus on the most appropriate scenario for adoption.
Figure 1 shows the key steps and timeline adopted by the MoH and partners during the inception workshop.
Figure 1Timeline and steps followed in developing the Liberia Universal Health Coverage Essential Package of Health Services. HIPTool, Health Intervention Prioritisation Tool; TWG, technical working group.
Establishing a governance structure
Decision-making forums were built on existing structures and included:
Five technical working groups (TWGs) on reproductive, maternal, newborn, child and adolescent health (RMNCAH), communicable diseases, NCDs, health system and emergency preparedness and response.
The health coordinating committee (HCC), chaired by the Chief Medical Officer.
The health sector coordinating committee (HSCC), chaired by the Minister of Health and involving key government officials and critical development partners.
Representatives of multilateral agencies, development partners and key non-governmental organisations (NGOs) were actively involved in all technical meetings (figure 2).
Figure 2Governance structure for package design. DCP3, Disease Control Priorities 3; EPHS, Essential Package of Health Services; UHC, Universal Health Coverage.
Assessing financing mechanisms
A fiscal space analysis was conducted to assess current financing mechanisms and potential for fiscal expansion. The data used for this analysis were drawn from the International Monetary Fund 2021 World Economic Outlook Database,17 the MoH and the Ministry of Finance and Development Planning (MFDP). The available fiscal space estimated for the UHC EPHS was based on the total budget available from public sources, defined as the sum of government and donor budgets allocated to health.
In 2021, the government allocated 14% of its budget to health, equivalent to US$16 per capita. This is close to the Abuja Declaration’s recommendation of allocating 15% of national budgets to the health sector.18 However, domestic general government health expenditure accounted for only 48% of the total publicly available health budget, with the remaining 52% coming from donor funding. Further exacerbating resource constraints, challenges in public financial management (PFM) contributed to an average budget execution rate of 84%, resulting in a loss of approximately US$2–US$3 of potential per capita spending per year.
In the next 5 years, the government health budget is projected to increase from US$16 per capita in 2021 to US$21 in 2026 (figure 3). However, the projected increase in government spending is insufficient to replace the expected decrease in donor funding over that period from US$17 per capita in 2021 to US$5 in 2026. Total spending on health from public sources is therefore projected to decrease from US$33 per capita in 2021 to around US$ 27 in 2026. Based on this analysis and the government’s UHC vision, the MoH planned a funding level of US$12–US$14 per capita for the publicly funded UHC package. This estimate is based on the fact that other priorities apart from package financing require funding from the government part of the fiscal space.
Figure 3Projected per capita government and donor health funding.
Mapping existing health services and selecting services for prioritisation
Mapping of existing health services was conducted by the TWGs. The exercise aimed at addressing two questions, namely: (1) what DCP3 Essential UHC (EUHC) package interventions are relevant to Liberia’s healthcare needs and should be included in the prioritisation process? and (2) what is the estimated population coverage for the DCP3 interventions that are already provided by the health system?
Existing services were analysed against the interventions proposed by the DCP3 EUHC model package.19 Online supplemental table S1 shows the results of the mapping exercise. Around one-third of the 218 EUHC interventions were not provided in Liberia. Out of the remaining 151 interventions provided, it was estimated that only 25% are accessible at the required coverage level (76%–100%), while 52% were available at low coverage (1%–50%) and 23% at medium coverage (51%–75%)).
Based on the mapping exercise, the TWGs deemed 200 DCP3 interventions relevant to the Liberian context. An additional 40 services, distinct from the DCP3 interventions, were recommended by an EPHS review group in the MoH for inclusion in the prioritisation list. This addition resulted in 240 interventions shortlisted for TWG deliberations and priority setting. Many of the DCP3 interventions were adjusted to align with the country context, which resulted in modification of some interventions’ contents and/or level of care.
Prioritising interventions
Selection of key decision criteria followed three steps. First, national policy documents were reviewed to identify key social values. Second, the DCP3 Secretariat operationalised these values in eight decision criteria, namely disease burden, effectiveness, cost-effectiveness, quality of evidence, financial risk, budget impact, feasibility, and servicing vulnerable populations. Third, a survey was conducted during a workshop with TWGs and stakeholders to define the identified criteria and rank them according to their perceived importance for Liberia.
To provide TWGs with sufficient information about the 240 shortlisted interventions, data were collated on the first six decision criteria using local, regional and global secondary sources.20 Information on the two remaining decision criteria—‘feasibility’ and ‘servicing vulnerable populations’—was gathered during the TWG deliberation process, described below. The Health Intervention Prioritisation Tool21 was used to collate and contextualise global evidence on intervention cost, cost-effectiveness, financial risk protection and estimate impact on burden of disease. This information was validated with the MoH and reported to the TWGs before a prioritisation workshop using colour-coded evidence sheets for each of the 240 interventions. An example of the evidence sheets, including definitions of decision criteria, is provided in online supplemental figure S1 and table S2.
The TWGs ranked the 240 interventions as high, medium or low priority using the framework of evidence-informed deliberative processes.22 This step ensured that the selection of services was objective, grounded in scientific evidence, and based on the agreed-upon decision criteria and evidence. At the initial stage, prioritisation was done without strict consideration for the available fiscal space for health. Out of 240 interventions, 132 were considered ‘high priority’. When costed, these high-priority interventions exceeded the available fiscal space for public expenditure on health. A second round of prioritisation was thus required to recommend a package that could be funded with government’s resource envelope of US$12–US$14 per capita. The 132 interventions were further refined, resulting in a final list of 128 highest-priority interventions.
Developing package scenarios and final deliberations
Four scenarios were developed. Scenario development involved an analysis of the evidence collected for each prioritised intervention, the votes of TWGs during the prioritisation process and the extent of partner/donor funding. Funding for interventions currently receiving partial or full donor support was assumed to continue for the next 5 years. These included four fully sponsored interventions on child immunisation and prevention of mother-to-child transmission of HIV at a total cost of US$ 4.35 per capita, and 78 partially funded interventions. For partially funded interventions, the assumption was that donors contribute 30% of the cost of each partially funded intervention.
Furthermore, scenario development considered the fiscal space realities, ongoing discussions with development partners in Liberia on cost-sharing options for selected interventions, and the potential introduction of a cost-sharing programme for specific service categories. A provisional cost-sharing level of 50% was initially proposed, subject to subsequent review and further consultation. The share covered by patients is currently being considered by the government during the final stages of the development of the cost-sharing programme. Figure 4 shows the distribution of interventions across the four scenarios.
Figure 4Distribution of interventions, per capita cost to the government, and DALYs averted of core and complementary subpackages in the four scenarios. DALYs, disability-adjusted life years.
Scenario 1 proposed an aspirational package, which included all high-priority interventions across six platforms, fully financed by the government. Since the cost of the package exceeds existing government spending, it could serve as a basis for advocacy and resource mobilisation or be implemented progressively as additional health resources become available.
In Scenario 2, the aim was to go through a second phase to identify the highest priority interventions that should be fully covered by government and donor funding and establish a complementary package funded through a cost-sharing programme to cover the remaining priority interventions. This scenario therefore presented a core subpackage of 101 government-funded interventions delivered through all 6 platforms and a complementary package of 27 cost-shared interventions delivered through the clinic, health centre, district and tertiary hospitals. Like Scenario 1, it also surpassed available government health spending.
Scenarios 3 and 4, in contrast, aligned with the government’s current level of health spending. Scenario 3 focused on an expanded PHC package, with core interventions provided free at point of use at population, community, clinic and health centre levels and complementary interventions provided through cost-sharing at the district, county and tertiary hospitals. Scenario 4 focused on Liberia’s definition of PHC, with core interventions provided at population, community and clinic levels. In the core subpackage, the clinic platform has the highest number of interventions, costs and DALYs averted, particularly in scenarios 3 and 4, while most of the interventions in the complementary subpackages are in the district and county hospital level and they are responsible for most of the cost.
The government’s decision on the contents of the final package was made following an in-depth analysis during a ministerial retreat organised to review the proposed scenarios. A strategic consensus was reached by the MoH leadership to use the available public funding by focusing on essential PHC services. The package included under scenario 4 was adopted during the ministerial retreat in August 2023 and subsequently endorsed by the HSCC. The selected highest-impact interventions ensure that the greatest possible health benefits are achieved within Liberia’s budget constraints.