The need to protect essential health services

Governments in low-income and middle-income countries and relief agencies need to make clear decisions to not only mitigate the impact of the COVID-19 pandemic but also deliver essential routine services to their populations. This is a clear message from WHO in their operational guidance for maintaining essential health services during an outbreak.4 While each country will need to define essential services according to their epidemiological profile, health system capacity and available resources, we believe that guidance on the type of essential services required by low-income and lower-middle-income countries is a valuable contribution to inform urgent decision making during health crises.

Since March 2020, routine immunisation services have been disrupted on a global scale putting millions of children at risk of diseases like diphtheria, measles and polio. According to data collected by the WHO, UNICEF, Gavi and the Sabin Institute is likely to affect around 80 million children under 1 year worldwide. Some countries have reported the emergence of new outbreaks of cholera, measles and Ebola, health personnel being absent from facilities because of quarantine, lack of personal protective equipment or fear, and that patients are not seeking care because of perceived risk of infectious spread and the consequences of lockdown (eg, travel restrictions, closure of markets, decrease in income).5 An important concern is that decline in supply and demand for non-COVID-19 essential routine health services may exacerbate the general health situation and lead to excess mortality beyond what is directly attributed to the pandemic. Studies indicated that excess mortality superseded Ebola deaths during the 2014–2015 outbreak in West-Africa.6 7

The selected 120 essential health interventions that should be unconditionally protected and delivered despite the disruptions caused by COVID-19 were extracted from the highest priority package (HPP) for universal health coverage (UHC) developed by the DCP project. The HPP list of interventions was used as a starting point for discussions and adaptation together with national policy-makers in Afghanistan,8 Ethiopia, Pakistan and Zanzibar. All invited policy-makers in each of these countries had past experience with translating the evidence from the original list of HPP interventions into national health benefit packages, providing an important source of information from diverse contexts. Given substantial resource scarcity, we present a modified highest priority model list of essential services that are urgent for patients and provide the greatest health impact given resource scarcity. Subject to local disease burden and circumstances, access to these services should be protected for all residents irrespective of income, refugee or migrant status, gender and place of residence.

In countries where the response to the COVID-19 pandemic leads to substantial limitations of resources, the scarcity of health services will affect healthcare seeking behaviour and all patients’ health, including those with life-threatening conditions requiring prompt medical attention. Fair allocation of resources that prioritises the value of maximising benefits applies across all patients who need healthcare. There should be no difference in allocating scarce resources between patients with COVID-19 and those with other equally serious medical conditions.

Objectives of the prioritisation process

Service providers and decision-makers are now amidst processes aiming to identify which essential services to protect, identify areas where resources can be reallocated to the COVID-19 response, mitigate the effect of the COVID-19 pandemic on the effectiveness of routine services, and restore trust of the public vis-à-vis health services.

Beyond the specific response to the COVID-19 pandemic, decisions need to be made about allocation of the limited resources between continuation of routine services, adjustment of routine services and postponement of non-essential services. Decisions will also need to be made on shifting the platform of delivery of some interventions based on health system capacity (eg, shifting some interventions from community to health centre considering the level of workload of community health workers in contract tracing).

Criteria and process for selecting interventions

These further prioritisation decisions need to be made based on evidence and transparent selection criteria on fair priority setting widely accepted by policy-makers, practitioners and academics, such as impact on mortality and morbidity, urgency (ie, impact on patient health of delaying services), cost-effectiveness, protection of politically sensitive interventions, financial risk protection and public acceptability. The members of the global and country DCP teams, coauthors of this paper were consulted through group meetings and online tools to comment on the essential list of health services.

Standard principles for selection are based on humanitarian and UHC principles9–11:

• Treating people equally (non-discrimination).

• Maximising the benefits produced by scarce resources (saving the most individual lives or saving the most life-years by giving priority to patients likely to survive longest after treatment).

• Giving priority to the worst off (in terms of poverty or in terms of health: the sickest or those who will have lived the shortest lives if they die untreated).

These principles can be combined with other goals and principles relevant for governments and agencies (eg, the humanitarian principles of humanity, impartiality and neutrality).

Our recommendations first emerged from the 115 HPP interventions proposed by DCP3 in 2018.12 Originally, interventions in HPP were identified after wide consultations considering evidence on burden of disease, implementation feasibility, and value for money.3 Value for money includes considerations of cost-effectiveness, priority to the worst off and financial risk protection. We modified the original HPP and added three considerations of particular relevance under the present circumstances:

1. Context-specific relevance (revisions made by national policy makers in Afghanistan, Ethiopia, Pakistan and Zanzibar).

2. Urgency (for patient) (high-impact interventions for which delays would substantially increase mortality and morbidity).

3. Non-urgency (important services where delayed provision (3–6 months) would not affect the health impact).

The original HPP list was informed by wide consultations and actual data and analysis. However, this revised list was informed by extensive deliberations on how contextual factors and urgency (1–3 above) could justify inclusion or exclusion, or revision of delivery platform, of each HPP intervention. Country DCP teams from Afghanistan, Ethiopia, Pakistan and Zanzibar were included in this COVID-19 revision of the HPP because all of these countries have experience with using the DCP3 framework and the HPP in detailed revisions of national essential healthcare packages. Even though they represent diverse settings, all low-income and middle-income settings are not represented here. Implementation of the revised HPP list therefore needs to be adapted to context and resources available.

Scope of the priority list of essential services

The priority list of 120 essential services is mainly designed for low-income and middle-income countries and humanitarian settings. For countries not hard hit by COVID-19, the full range of HPP health services is still relevant, even if not fully implemented in every country for reasons of resource constraints.

Table 1 provides the proposed list of essential services within each programme area. Only a few interventions from the original HPP list were not included in the current revised list. The five interventions that should be postponed during the time of COVID-19 are: (1) Mass media messages concerning healthy eating or physical activity; (2) Management of osteomyelitis, including surgical debridement for refractory cases; (3) Cataract extraction and insertion of intraocular lens; (4) Elective surgical repair of common orthopaedic injuries (eg, meniscal and ligamentous tears) in individuals with severe functional limitation and (5) Repair of cleft lip and cleft palate.

We have conducted a minor revision of the original HPP because most of the HPP interventions have high levels of urgency. An immediate interruption of these services, due to COVID-19 disinvestments, may have serious negative impact on individual patients and population health. Immediate interruption of any of the, for example, emergency care interventions, obstetric or neonatal interventions, surgery interventions or mental healthcare interventions will most likely worsen the prognosis for all patients currently receiving this type of care (or patients that would receive this type of care if there were no COVID-19 pandemic). Therefore, and since all the original HPP interventions are best buys to begin with, it is hard to justify a substantial reduction in number of interventions to protect from disinvestments.

In order to protect patients and community health workers, and considering the additional workload of community health workers busy in COVID-19 contact tracing and surveillance, several HPP interventions were shifted from community to health centre level: Postgender-based violence care, including counselling, provision of emergency contraception, and rape-response referral (medical and judicial); iron and folic acid supplementation to pregnant women and adolescent girls; provision of food or caloric supplementation to pregnant women in food insecure households; identify and refer patients with high risk, including pregnant women, young children and those with underlying medical conditions. COVID-19 presents an opportunity to introduce digital tools in delivery of healthcare. Tools like telemedicine, mobile consultations or digital consultations may serve as useful supplements to existing delivery platforms, as documented on the COVID-19 humanitarian platform.13 Digital or mobile consultations still need to be anchored within existing delivery platforms at the community, health centre or hospital level.

Coverage of the remaining essential services should be, at least, unchanged during the COVID-19 pandemic and still provided to patients irrespective of income, refugee or migrant status, gender and place of residence. These services must still be subsidised by domestic and external funding as much as possible. The promotive, preventive, curative and rehabilitative interventions included in the priority package are considered the minimum that people can expect to receive through the various healthcare delivery mechanisms and facilities available at various levels of the health system (community, health centre and hospital levels (first level and referral hospitals)). Countries where these interventions are either not available or have low coverage should strive to deliver them, and in countries where they are already implemented, they should be maintained and protected during times of pandemics. The public should be informed, through public media campaigns, that these services will be offered in a safe manner, if necessary, in designated locations, free of charge and with acceptable quality.

Process and implementation

We propose that governments and agencies that are in the process of defining which essential services should be protected under the COVID-19 crisis use our model list as input for further deliberation with key stakeholders, citizens, funders, local and national decision-makers. Local context may allow for a larger set of services to be provided. International organisations may also adapt the list through a broader, more representative process. We expect that the COVID-19 pandemic will affect the share of domestic resources invested in total health expenditure, considering that economic growth is the main driver for domestic resources for health. This list of priority essential interventions may also become an important source of guidance for the post-COVID-19 period.