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Simangolwa WM, Mbonigaba J, Govender K. Health technology assessment for sexual reproductive health and rights benefits package design in sub-Saharan Africa: A scoping review of evidence-informed deliberative processes. PLoS One 2024; 19:e0306042. [PMID: 38935794 DOI: 10.1371/journal.pone.0306042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/10/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Health technology assessment uses a multidisciplinary approach to support health benefits package design towards universal health coverage. The evidence-informed deliberative process framework has been used alongside Health technology assessment to enhance stakeholder participation and deliberations in health benefits package design. Applying the evidence-informed deliberative framework for Health assessment could support the morally diverse sexual reproductive health and rights (SRHR) benefits package design process. However, evidence on participation and deliberations for stakeholders in health technology assessment for SRHR benefits package design has not been curated in sub-Saharan Africa. This study synthesises literature to fill this gap. METHODS This scoping review applies the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews, and deductive analysis following the evidence-informed deliberative processes framework. The search strategy uses the Guttmacher-Lancet Commission-proposed comprehensive definition of SRHR and the World Health Organisation's universal health coverage compendium of SRHR interventions to generate search terms. Six databases and biographical hand searches were used to identify studies in Sub-Saharan Africa from 1994. RESULTS A total of 14 studies met the inclusion criteria. Evidence for yearly public budgets and explicit SRHR health technology assessment processes was not found. In 12 of the studies reviewed, new advisory committees were set up specifically for health technology assessment for SRHR priority-setting and benefits package design. In all decision-making processes reviewed, the committee member roles, participation and deliberations processes, and stakeholder veto powers were not clearly defined. Patients, the public, and producers of health technology were often excluded in the health technology assessment for the SRHR benefits package design. Most health technology assessment processes identified at least one decision-making criterion but failed to use this in their selection and appraisal stages for SRHR benefits design. The identification, selection, and scoping stages in health technology assessment for SRHR were non-existent in most studies. In 11 of the 14 processes of the included studies, stakeholders were dissatisfied with the health policy recommendation from the appraisal process in health technology assessment. Perceived benefits for evidence-informed deliberative processes included increased stakeholder engagement and fairness in decision-making. CONCLUSION To support the integration of diverse social values in health technology assessment for fairer SRHR benefits package design, evidence from this review suggests the need to institutionalise health technology assessment, establish prioritisation decision criteria, involve all relevant stakeholders, and standardise the process and assessment methodological approaches.
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Affiliation(s)
| | - Josue Mbonigaba
- College of Law and Management Sciences, University of KwaZulu Natal, Durban, South Africa
| | - Kaymarlin Govender
- Health Economics and HIV/AIDs Research Division, University of KwaZulu Natal, Durban, South Africa
- College of Law and Management Sciences, University of KwaZulu Natal, Durban, South Africa
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Alwan A, Jallah W, Baltussen R, Carballo M, Gonyon E, Gudumac I, Haghparast-Bidgoli H, Jacobs G, Abou Jaoude GJ, Kateh FN, Logan G, Skordis J. Designing an evidence-informed package of essential health services for Universal Health Coverage: lessons learnt and challenges to implementation in Liberia. BMJ Glob Health 2024; 9:e014904. [PMID: 38925666 PMCID: PMC11202745 DOI: 10.1136/bmjgh-2023-014904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/14/2024] [Indexed: 06/28/2024] Open
Abstract
Liberia developed an evidence-informed package of health services for Universal Health Coverage (UHC) based on the Disease Control Priorities 3 evidence. This paper describes the policy decisions, methods and processes adopted for prioritisation, key features of the package and lessons learnt, with special emphasis on feasibility of implementation. Package design was led by the Ministry of Health. Prioritisation of essential services was based on evidence on disease burden, cost-effectiveness, financial risk, equity, budget impact, and feasibility of implementation. Fiscal space analysis was used to assess package affordability and options for expanding the budget envelope. The final adopted package focuses on primary healthcare and comprises a core subpackage of 78 publicly financed interventions and a complementary subpackage of 50 interventions funded through cost-sharing. The estimated per capita cost to the government is US$12.28, averting around 1.2 million DALYs. Key lessons learnt are described: (1) priority setting is essential for designing affordable packages of essential services; (2) the most realistic and affordable option when domestic resources are critically limited is to focus on basic, high-impact primary health services; (3) Liberia and many other countries will continue to rely on donor funding to expand the range of essential services until more domestic resources become available; (4) national leadership and effective engagement of key stakeholders are critical for a successful package design; (5) effective implementation is less likely unless the package cost is affordable and the health system gaps are assessed and addressed. A framework of action was employed to assess the consistency with the prerequisites for an appropriate package design. Based on the framework, Liberia developed a transparent and affordable package for UHC, but the challenges to implementation require further action by the government.
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Affiliation(s)
- Ala Alwan
- Disease Control Priorities 3 (DCP3) Country Translation Project, London School of Hygiene & Tropical Medicine, London, UK
| | - Wilhemina Jallah
- Republic of Liberia Ministry of Health, Monrovia, Montserrado, Liberia
| | - Rob Baltussen
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - Manuel Carballo
- International Centre for Migration, Health and Development, Geneva, Switzerland
| | - Ernest Gonyon
- Republic of Liberia Ministry of Health, Monrovia, Montserrado, Liberia
| | - Ina Gudumac
- Disease Control Priorities 3 (DCP3) Country Translation Project, London School of Hygiene & Tropical Medicine, London, UK
| | | | - George Jacobs
- Republic of Liberia Ministry of Health, Monrovia, Montserrado, Liberia
| | | | - Francis Nah Kateh
- Republic of Liberia Ministry of Health, Monrovia, Montserrado, Liberia
| | - Gorbee Logan
- Republic of Liberia Ministry of Health, Monrovia, Montserrado, Liberia
| | - Jolene Skordis
- Institute for Global Health, University College London, London, UK
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Trabitzsch J, Marquardt M, Negash S, Belay W, Abebe Y, Seife E, Abdella K, Gizaw M, Getachew S, Addissie A, Kantelhardt EJ, Wondimagegnehu A. Understanding referral of patients with cancer in rural Ethiopia: a qualitative study. BMC Cancer 2024; 24:553. [PMID: 38698320 PMCID: PMC11067183 DOI: 10.1186/s12885-024-12294-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/19/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Cancer incidence is increasing in Ethiopia mainly due to increased life expectancy, while oncological capacities remain limited. Strong referral linkages between different levels of the healthcare system are key to provide timely access to cancer care. In this qualitative study, we assessed limitations and potential of cancer patient referral in the rural Southwest of Ethiopia. METHODS We held four focus group discussions (FGD) with health professionals at one primary and three secondary hospitals and conducted eight in-depth interviews (IDI) with the hospitals´ medical executives and local health bureau representatives. Data was analysed inductively using thematic analysis and emerging themes were categorized within the revised concept of access by Penchansky and Saurman. RESULTS The inevitable referral of patients with cancer in the rural Southwest of Ethiopia is characterized by the absence of clear communication protocols and the lack of formal referral linkages. The newly implemented hub-system has improved emergency referrals and could be expanded to non-emergency referrals, sensitive to the needs of advanced oncological care. Liaison officers can pave the way but need to be trained and equipped adequately. Referred patients struggle with inadequate transportation systems, the lack of accommodation close to specialized facilities as well as the inability to navigate at those sites due to language barriers, illiteracy, and stigmatization. Few Non-Governmental Organizations (NGOs) help but cannot compensate the limited governmental support. The shortage of medications at public hospitals leads to patients being directed to costly private pharmacies. In the light of those challenges, cancer remains to be perceived as a "death sentence" within the rural communities. CONCLUSIONS Standardized referral linkages and a multi-faceted support network throughout the cancer care continuum are necessary to make oncology care accessible to Ethiopia´s large rural population.
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Affiliation(s)
- Josephin Trabitzsch
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
| | - Morena Marquardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
| | - Sarah Negash
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
| | - Winini Belay
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Yonas Abebe
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
- Federal Ministry of Health, Addis Ababa, Ethiopia
| | - Edom Seife
- Department of Oncology, College of Health Science, Tikur Anbessa Specialized Hospital, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Muluken Gizaw
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sefonias Getachew
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Adamu Addissie
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eva Johanna Kantelhardt
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany.
- Department of Gynaecology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany.
| | - Abigiya Wondimagegnehu
- Global Health Working Group, Institute of Medical Epidemiology, Biometrics, and Informatics, Martin-Luther-University Halle-Wittenberg, Magdeburgerstraße 8, 06112, Halle (Saale), Germany
- Department of Preventive Medicine, School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
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Haile TG, Benova L, Mirkuzie AH, Asefa A. Effective coverage of curative child health services in Ethiopia: analysis of the Demographic and Health Survey and Service Provision Assessment survey. BMJ Open 2024; 14:e077856. [PMID: 38382958 PMCID: PMC10882307 DOI: 10.1136/bmjopen-2023-077856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Despite a remarkable decline, childhood morbidity and mortality in Ethiopia remain high and inequitable. Thus, we estimated the effective coverage of curative child health services in Ethiopia. DESIGN We conducted a cross-sectional analysis of data from the 2016 Ethiopia Demographic and Health Survey (DHS) and the 2014 Ethiopia Service Provision Assessment Plus (SPA+) survey. SETTING Nationally representative household and facility surveys. PARTICIPANTS AND OUTCOMES We included a sample of 2096 children under 5 years old (from DHS) who had symptoms of one or more common childhood illnesses (diarrhoea, fever and acute respiratory infection) and estimated the percentage of sick children who were taken to a health facility (crude coverage). To construct a quality index of child health services, we used the SPA+ survey, which was conducted in 1076 health facilities and included observations of care for 1980 sick children and surveys of 1908 mothers/caregivers and 5328 health providers. We applied the Donabedian quality of care framework to identify 58 quality parameters (structure, 31; process, 16; and outcome, 11) and used the weighted additive method to estimate the overall quality of care index. Finally, we multiplied the crude coverage by the quality of care index to estimate the effective coverage of curative child health services, nationally and by region. RESULTS Among the 2096 sick children, only 38.4% (95% CI: 36.5 to 40.4) of them were taken to a health facility. The overall quality of care was 54.4%, weighted from structure (30.0%), process (9.2%) and outcome (15.2%). The effective coverage of curative child health services was estimated at 20.9% (95%CI: 19.9 to 22.0) nationally, ranging from 16.9% in Somali to 34.6% in Dire Dawa regions. CONCLUSIONS System-wide interventions are required to address both demand-side and supply-side bottlenecks in the provision of child health services if child health-related targets are to be achieved in Ethiopia.
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Affiliation(s)
- Tsegaye Gebremedhin Haile
- Department of Health Systems and Policy, Institute of Public Health, University of Gondar, Gondar, Ethiopia
| | - Lenka Benova
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Anteneh Asefa
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
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Norheim OF, Watkins DA. The Role of HTA for Essential Health Benefit Package Design in Low or Middle-Income Countries. Health Syst Reform 2023; 9:2273051. [PMID: 37948391 DOI: 10.1080/23288604.2023.2273051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 10/16/2023] [Indexed: 11/12/2023] Open
Abstract
This Commentary explores the relationship between Health Technology Assessment (HTA) and Health Benefits Package (HBP) design to achieve Universal Health Coverage (UHC) in low- and middle-income countries. It emphasizes that while HTA evaluates individual healthcare interventions, HBP reform aims to create comprehensive service sets considering overall population health needs and available resources. Challenges in LMICs include limited local data and technical capacity, leading to reliance on cost-effectiveness estimates from other settings. We suggest a practical approach by combining HTA and HBP elements through a hybrid or compartmentalized method. This approach sets differentiated cost-effectiveness thresholds for specific healthcare platforms or programs (e.g., primary care or essential surgery), aligning priority-setting with organizational considerations, ethics, and implementation strategies. Strong institutions and academic support are vital for evidence-informed priority-setting processes. In summary, HTA can play a pivotal role in designing HBPs for UHC in LMICs, and a compartmentalized approach can enhance priority-setting while considering budget constraints and equity.
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Affiliation(s)
- Ole F Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, USA
| | - David A Watkins
- Bergen Centre for Ethics and Priority Setting (BCEPS), Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, USA
- Department of Global Health, University of Washington, Seattle, USA
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Alebachew A, Abdella E, Abera S, Dessie E, Mesele T, Mitiku W, Muñoz R, Opuni M, Teplitskaya L, Walker DG, Gilmartin C. Costs and resource needs for primary health care in Ethiopia: evidence to inform planning and budgeting for universal health coverage. Front Public Health 2023; 11:1242314. [PMID: 38174077 PMCID: PMC10762776 DOI: 10.3389/fpubh.2023.1242314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/15/2023] [Indexed: 01/05/2024] Open
Abstract
Introduction The Government of Ethiopia (GoE) has made significant progress in expanding access to primary health care (PHC) over the past 15 years. However, achieving national PHC targets for universal health coverage will require a significant increase in PHC financing. The purpose of this study was to generate cost evidence and provide recommendations to improve PHC efficiency. Methods We used the open access Primary Health Care Costing, Analysis, and Planning (PHC-CAP) Tool to estimate actual and normative recurrent PHC costs in nine Ethiopian regions. The findings on actual costs were based on primary data collected in 2018/19 from a sample of 20 health posts, 25 health centers, and eight primary hospitals. Three different extrapolation methods were used to estimate actual costs in the nine sampled regions. Normative costs were calculated based on standard treatment protocols (STPs), the population in need of the PHC services included in the Essential Health Services Package (EHSP) as per the targets outlined in the Health Sector Transformation Plan II (HSTP II), and the associated costs. PHC resource gaps were estimated by comparing actual cost estimates to normative costs. Results On average, the total cost of PHC in the sampled facilities was US$ 11,532 (range: US$ 934-40,746) in health posts, US$ 254,340 (range: US$ 68,860-832,647) in health centers, and US$ 634,354 (range: US$ 505,208-970,720) in primary hospitals. The average actual PHC cost per capita in the nine sampled regions was US$ 4.7, US$ 15.0, or US$ 20.2 depending on the estimation method used. When compared to the normative cost of US$ 38.5 per capita, all these estimates of actual PHC expenditures were significantly lower, indicating a shortfall in the funding required to deliver an expanded package of high-quality services to a larger population in line with GoE targets. Discussion The study findings underscore the need for increased mobilization of PHC resources and identify opportunities to improve the efficiency of PHC services to meet the GoE's PHC targets. The data from this study can be a critical input for ongoing PHC financing reforms undertaken by the GoE including transitioning woreda-level planning from input-based to program-based budgeting, revising community-based health insurance (CBHI) packages, reviewing exempted services, and implementing strategic purchasing approaches such as capitation and performance-based financing.
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Affiliation(s)
- Abebe Alebachew
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Engida Abdella
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | - Samuel Abera
- Strategic Affairs Executive Office, Ministry of Health, Addis Ababa, Ethiopia
| | - Ermias Dessie
- Strategic Affairs Executive Office, Ministry of Health, Addis Ababa, Ethiopia
| | - Tesfaye Mesele
- Strategic Affairs Executive Office, Ministry of Health, Addis Ababa, Ethiopia
| | - Workie Mitiku
- Breakthrough International Consultancy, Addis Ababa, Ethiopia
| | | | | | | | | | - Colin Gilmartin
- Management Sciences for Health, Arlington, VA, United States
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Dale E, Peacocke EF, Movik E, Voorhoeve A, Ottersen T, Kurowski C, Evans DB, Norheim OF, Gopinathan U. Criteria for the procedural fairness of health financing decisions: a scoping review. Health Policy Plan 2023; 38:i13-i35. [PMID: 37963078 PMCID: PMC10645052 DOI: 10.1093/heapol/czad066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 06/19/2023] [Accepted: 08/02/2023] [Indexed: 11/16/2023] Open
Abstract
Due to constraints on institutional capacity and financial resources, the road to universal health coverage (UHC) involves difficult policy choices. To assist with these choices, scholars and policy makers have done extensive work on criteria to assess the substantive fairness of health financing policies: their impact on the distribution of rights, duties, benefits and burdens on the path towards UHC. However, less attention has been paid to the procedural fairness of health financing decisions. The Accountability for Reasonableness Framework (A4R), which is widely applied to assess procedural fairness, has primarily been used in priority-setting for purchasing decisions, with revenue mobilization and pooling receiving limited attention. Furthermore, the sufficiency of the A4R framework's four criteria (publicity, relevance, revisions and appeals, and enforcement) has been questioned. Moreover, research in political theory and public administration (including deliberative democracy), public finance, environmental management, psychology, and health financing has examined the key features of procedural fairness, but these insights have not been synthesized into a comprehensive set of criteria for fair decision-making processes in health financing. A systematic study of how these criteria have been applied in decision-making situations related to health financing and in other areas is also lacking. This paper addresses these gaps through a scoping review. It argues that the literature across many disciplines can be synthesized into 10 core criteria with common philosophical foundations. These go beyond A4R and encompass equality, impartiality, consistency over time, reason-giving, transparency, accuracy of information, participation, inclusiveness, revisability and enforcement. These criteria can be used to evaluate and guide decision-making processes for financing UHC across different country income levels and health financing arrangements. The review also presents examples of how these criteria have been applied to decisions in health financing and other sectors.
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Affiliation(s)
- Elina Dale
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | | | - Espen Movik
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Alex Voorhoeve
- Philosophy, Logic and Scientific Method, London School of Economics and Political Science (LSE), Houghton Street, London WC2A 2AE, UK
| | - Trygve Ottersen
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
| | - Christoph Kurowski
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - David B Evans
- Health, Nutrition and Population, World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting (BCEPS), University of Bergen, Årstadveien 21, Bergen 5018, Norway
| | - Unni Gopinathan
- Norwegian Institute of Public Health, Sandakerveien 24C, Oslo 0473, Norway
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Baltussen R, Surgey G, Vassall A, Norheim OF, Chalkidou K, Siddiqi S, Nouhi M, Youngkong S, Jansen M, Bijlmakers L, Oortwijn W. The use of cost-effectiveness analysis for health benefit package design - should countries follow a sectoral, incremental or hybrid approach? COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:75. [PMID: 37814257 PMCID: PMC10563323 DOI: 10.1186/s12962-023-00484-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND Countries around the world are increasingly rethinking the design of their health benefit package to achieve universal health coverage. Countries can periodically revise their packages on the basis of sectoral cost-effectiveness analyses, i.e. by evaluating a broad set of services against a 'doing nothing' scenario using a budget constraint. Alternatively, they can use incremental cost-effectiveness analyses, i.e. to evaluate specific services against current practice using a threshold. In addition, countries may employ hybrid approaches which combines elements of sectoral and incremental cost-effectiveness analysis - a country may e.g. not evaluate the comprehensive set of all services but rather relatively small sets of services targeting a certain condition. However, there is little practical guidance for countries as to which kind of approach they should follow. METHODS The present study was based on expert consultation. We refined the typology of approaches of cost-effectiveness analysis for benefit package design, identified factors that should be considered in the choice of approach, and developed recommendations. We reached consensus among experts over the course of several review rounds. RESULTS Sectoral cost-effectiveness analysis is especially suited in contexts with large allocative inefficiencies in current service provision and can, in theory, realize large efficiency gains. However, it may be challenging to implement a comprehensive redesign of the package in practice. Incremental cost-effectiveness analysis is especially relevant in contexts where specific new services may impact the sustainability of the health system. It may potentially support efficiency improvement, but its focus has typically been on new services while existing inefficiencies remain unchallenged. The use of hybrid approach may be a way forward to address the strengths and weaknesses of sectoral and incremental analysis areas. Such analysis may be especially useful to target disease areas with suspected high inefficiencies in service provision, and would then make good use of the available research capacity and be politically rewarding. However, disease-specific analyses bear the risk of not addressing resource allocation inefficiencies across disease areas. CONCLUSIONS Countries should carefully select their approach of cost-effectiveness analyses for benefit package design, based on their decision-making context.
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Affiliation(s)
- Rob Baltussen
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands.
| | - Gavin Surgey
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Mojtaba Nouhi
- Ministry of Health and Medical Education, Tehran, Iran
- Tehran University of Medical Sciences, Tehran, Iran
| | | | - Maarten Jansen
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Leon Bijlmakers
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
| | - Wija Oortwijn
- Radboud University Medical Center, P.O. Box 9101, Nijmegen, 6500 HB, The Netherlands
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Dai X, Jiang Y, Li Y, Wang X, Wang R, Zhang Y. Evaluation of community basic public health service effect in a city in Inner Mongolia Autonomous Region--based on entropy weight TOPSIS method and RSR fuzzy set. Arch Public Health 2023; 81:149. [PMID: 37592329 PMCID: PMC10433667 DOI: 10.1186/s13690-023-01151-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 07/10/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND By analyzing 23 evaluation indicators included in 14 national basic public health service programs in a region of Hohhot City, Inner Mongolia Autonomous Region, China, the performance of basic public health services in the region in 2021 were analyzed to clarify the implementation and conduct of relevant programs. We also use this study as a basis to radiate the work of municipal basic public health services centered on the region and the outstanding problems reflected and to provide theoretical contents and suggestions that can be referred to for the same regions in central and western China as well as worldwide. METHODS Using the TOPSIS method as the basis for the data analysis method, the evaluation indexes are ranked in terms of their proximity to the idealized target, and combined with the entropy value method, Technique for order preference by similarity to an ideal solution (TOPSIS) and rank-sum ratio (RSR) were used to rank 14 basic health care providers by grade. A comprehensive evaluation of the performance of basic public health services in a region of Hohhot City, Inner Mongolia Autonomous Region in 2021 was conducted through a joint model of entropy -weighted TOPSIS and RSR, making full use of the characteristics and advantages of the fuzzy joint, and conducting a comprehensive analysis from the perspective of the ratio weight and the method of graded calculation, making the study more distinguishable and measureable. RESULTS In this study, for the regional basic public health services, a total of 23 evaluation indicators of basic public health service projects were included, among which the top three indicators with the weight of the entropy value method indicators were found to include the rate of Chinese medicine health management for the elderly, the rate of health management for the elderly, and the BCG vaccination rate after the analysis of the weight of the indicators; After the entropy-weighted TOPSIS evaluation showed that the Ci values of the regions were found to be between 0.378 and 0.715 through the calculation of the positive and negative ideal values of each indicator; RSR staging method evaluation showed that three community health centers (X2, X10, X12) had excellent evaluations of basic public health services; The number of evaluations as poor and moderate are 2 (X3, X9) and 9 (X1, X4, X5, X6, X7, X8, X11, X13, X14), respectively; Finally, the results of the entropy-weighted TOPSIS method and the fuzzy joint model of RSR staging method are basically consistent with the overall trend of the above two methods, and the reliability and credibility of the research results are high. CONCLUSION The entropy-weighted TOPSIS and RSR joint model can evaluate the effectiveness of basic public health services in a more comprehensive and holistic way. The results of the RSR staging results and the related weight ratio analysis show that the basic public health service programs in Hohhot, Inner Mongolia Autonomous Region are relatively balanced, but there are some differences; The same genus of elderly Chinese medicine health management rate, health management rate of the elderly, BCG vaccination rate several indicators accounted for a higher weight, its correlation with the key population-related items is high, suggesting that the future key population health service items should be focused on, and future research should be suggested from two key research.
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Affiliation(s)
- Xin Dai
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China
| | - Yiru Jiang
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China
| | - YingYing Li
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China
| | - XiaoXue Wang
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China
| | - Rongrong Wang
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China
| | - Yuanyuan Zhang
- School of Public Health, Dalian Medical University, Dalian, Liaoning Province, China.
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10
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Assebe LF, Norheim O. Distributional impact of infectious disease interventions in the Ethiopian Essential Health Service Package: a modelling study. BMJ Open 2023; 13:e067658. [PMID: 37460265 DOI: 10.1136/bmjopen-2022-067658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES Reducing inequalities in health and financial risk are key goals on the path toward universal health coverage, particularly in low-income and middle-income countries. The design of the health benefit package creates an opportunity to select interventions through established criteria. The aim of this study is to examine the health equity and financial protection impact of selected interventions, along with their costs, at the national level in Ethiopia. DESIGN Distributional cost-effectiveness analysis. POPULATION The eligible population for all selected interventions is assumed to be 10 million. DATA SOURCES Data on disease prevalence and population size were gathered from the Global Burden of Disease database, and average health benefits and program costs are sourced from the Ethiopian Essential Health Service Package (EHSP) database, national surveys and other publicly available sources. INTERVENTION A total of 30 interventions were selected from the latest EHSP revision and analysed over a 1-year period. OUTCOME MEASURES Health benefits, social welfare indices and financial protection metrics across income quintiles were reported. RESULTS We found 23 interventions that improve population health and reduce health inequality and four interventions reduce both population health and health inequality. Additionally, three interventions improve population health while increasing health inequality. Overall, the EHSP interventions provide a 0.021 improvement in health-adjusted life expectancy (HALE) per person, with a positive distributional equity impact: 0.029 (26.9%) HALE gained in the poorest and 0.015 (14.0%) in the richest quintile. Similarly, a total of 1 79 475 cases of catastrophic health expenditure were averted, including 82 100 (46.0%) cases in the poorest and 17 900 (10.0%) in the richest quintile. CONCLUSION Increasing access to the EHSP improves health equity and financial protection. Improved access to selected EHSP interventions also has the potential to provide greater benefits to the poorest and thereby improve social welfare.
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Affiliation(s)
- Lelisa Fekadu Assebe
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, Massachusetts, USA
| | - Ole Norheim
- Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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11
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Reynolds T, Wilkinson T, Bertram MY, Jowett M, Baltussen R, Mataria A, Feroz F, Jama M. Building implementable packages for universal health coverage. BMJ Glob Health 2023; 8:e010807. [PMID: 37197791 PMCID: PMC10201243 DOI: 10.1136/bmjgh-2022-010807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/08/2023] [Indexed: 05/19/2023] Open
Abstract
Since no country or health system can provide every possible health service to everyone who might benefit, the prioritisation of a defined subset of services for universal availability is intrinsic to universal health coverage (UHC). Creating a package of priority services for UHC, however, does not in itself benefit a population-packages have impact only through implementation. There are inherent tensions between the way services are formulated to facilitate criteria-driven prioritisation and the formulations that facilitate implementation, and service delivery considerations are rarely well incorporated into package development. Countries face substantial challenges bridging from a list of services in a package to the elements needed to get services to people. The failure to incorporate delivery considerations already at the prioritisation and design stage can result in packages that undermine the goals that countries have for service delivery. Based on a range of country experiences, we discuss specific choices about package structure and content and summarise some ideas on how to build more implementable packages of services for UHC, arguing that well-designed packages can support countries to bridge effectively from intent to implementation.
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Affiliation(s)
- Teri Reynolds
- Department of Integrated Health Services, World Health Organization, Geneva, Switzerland
| | | | - Melanie Y Bertram
- Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Matthew Jowett
- Health Financing and Governance, World Health Organization, Geneva, Switzerland
| | - Rob Baltussen
- Department for Health Evidence, Radboudumc, Nijmegen, The Netherlands
| | - Awad Mataria
- Department of Universal Health Coverage/Health Systems, World Health Organisation Regional Office for the Eastern Mediterranean, Cairo, Egypt
| | - Ferozuddin Feroz
- Islamic Republic of Afghanistan Ministry of Public Health, Kabul, Afghanistan
| | - Mohamed Jama
- Federal Government of Somalia, Mogadishu, Somalia
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12
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Foster N, Tadesse AW, McQuaid CF, Gosce L, Abdurhman T, Assefa D, Bedru A, Houben RMGJ, van Kalmthout K, Letta T, Mohammed Z, van Rest J, Umeta DG, Weldemichael GT, Yazew H, Jerene D, Quaife M, Fielding KL. Evaluating the equity impact and cost-effectiveness of digital adherence technologies with differentiated care to support tuberculosis treatment adherence in Ethiopia: protocol and analysis plan for the health economics component of a cluster randomised trial. Trials 2023; 24:292. [PMID: 37095533 PMCID: PMC10123464 DOI: 10.1186/s13063-023-07289-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/03/2023] [Indexed: 04/26/2023] Open
Abstract
BACKGROUND Tuberculosis remains a leading infectious cause of death in resource-limited settings. Effective treatment is the cornerstone of tuberculosis control, reducing mortality, recurrence and transmission. Supporting treatment adherence through facility-based observations of medication taking can be costly to providers and patients. Digital adherence technologies (DATs) may facilitate treatment monitoring and differentiated care. The ASCENT-Ethiopia study is a three-arm cluster randomised trial assessing two DATs with differentiated care for supporting tuberculosis treatment adherence in Ethiopia. This study is part of the ASCENT consortium, assessing DATs in South Africa, the Philippines, Ukraine, Tanzania and Ethiopia. The aim of this study is to determine the costs, cost-effectiveness and equity impact of implementing DATs in Ethiopia. METHODS AND DESIGN A total of 78 health facilities have been randomised (1:1:1) into one of two intervention arms or a standard-of-care arm. Approximately 50 participants from each health facility will be enrolled on the trial. Participants in facilities randomised to the intervention arms are offered a DAT linked to the ASCENT adherence platform for daily adherence monitoring and differentiated response for those who have missed doses. Participants at standard-of-care facilities receive routine care. Treatment outcomes and resource utilisation will be measured for each participant. The primary effectiveness outcome is a composite index of unfavourable end-of-treatment outcomes (lost to follow-up, death or treatment failure) or treatment recurrence within 6 months of end-of-treatment. For the cost-effectiveness analysis, end-of-treatment outcomes will be used to estimate disability-adjusted life years (DALYs) averted. Provider and patient cost data will be collected from a subsample of 5 health facilities per study arm, 10 participants per facility (n = 150). We will conduct a societal cost-effectiveness analysis using Bayesian hierarchical models that account for the individual-level correlation between costs and outcomes as well as intra-cluster correlation. An equity impact analysis will be conducted to summarise equity efficiency trade-offs. DISCUSSION Trial enrolment is ongoing. This paper follows the published trial protocol and describes the protocol and analysis plan for the health economics work package of the ASCENT-Ethiopia trial. This analysis will generate economic evidence to inform the implementation of DATs in Ethiopia and globally. TRIAL REGISTRATION Pan African Clinical Trial Registry (PACTR) PACTR202008776694999. Registered on 11 August 2020, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=12241 .
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Affiliation(s)
- Nicola Foster
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.
| | - Amare W Tadesse
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher Finn McQuaid
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Lara Gosce
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Ahmed Bedru
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Rein M G J Houben
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Taye Letta
- National Tuberculosis Control Program, Ethiopian Ministry of Health, Addis Ababa, Ethiopia
| | | | - Job van Rest
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | | | | | - Hiwot Yazew
- KNCV Tuberculosis Foundation, Addis Ababa, Ethiopia
| | - Degu Jerene
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Matthew Quaife
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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13
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Balcha BA, Endeshaw M, Mebratie AD. Household satisfaction with a pilot community-based health insurance scheme and associated factors in Addis Ababa. J Public Health Res 2023; 12:22799036231163382. [PMID: 37065469 PMCID: PMC10102943 DOI: 10.1177/22799036231163382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 02/24/2023] [Indexed: 04/18/2023] Open
Abstract
Background Many countries introduce CBHI as their healthcare financing system to ensure healthcare access. Understanding the level of satisfaction and factors associated with it is essential to ensure the sustainability of the program. Therefore, this study aimed to assess household satisfaction with a CBHI scheme and its associated factors in Addis Ababa. Design and methods Institutional-based cross-sectional study was conducted in the 10 health centers found in the 10 sub-cities of Addis Ababa. Both quantitative and qualitative methods were used. Logistic regression analysis was carried out to identify its associated factors and thematic analysis was used for qualitative data. Finally, variables with a p-value of <0.05 have been considered statistically significant. Results In this study, the overall satisfaction level of households with CBHI was 46.3%. Satisfaction was associated with valid CBHI management regulations (AOR = 1.96, 95% CI: 1.12, 3.46), participants who received the right drug (AOR = 1.77, 95% CI: 1.08, 2.93), households who got immediate care (AOR = 4.95, 95% CI: 2.72, 8.98), those who agreed with the adequacy of medical equipment (AOR = 1.65, 95% CI: 1.02, 2.69), and households who agreed with qualification of health personnel (AOR = 1.89, 95% CI: 1.12, 3.20) were more satisfied with the scheme than their counterparts. The challenges mentioned by the discussants were the shortage of drugs, poor attitude of health professionals, absence of kenema pharmacy, lack of laboratory services, lack of awareness about the CBHI scheme, and tight payment schedule. Conclusions the satisfaction level of households was low. To achieve a better result, the concerned bodies should work to improve the availability of medication, and medical equipment and improve the attitude of healthcare workers.
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Affiliation(s)
| | - Mulualem Endeshaw
- Department Chair of Masters of Public
health at Rift Valley University, Addis Ababa, Ethiopia
- Mulualem Endeshaw, Department Chair of
Masters of Public Health at Rift Valley University, Lancha Campus, Addis Ababa,
PO BOX 7466, Ethiopia.
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Mangoya D, Barham L, Moyo E, Moyo P, Dzinamarira T. The Use of Economic Evaluation Tools in Essential Health Benefits Package Selection for Universal Health Coverage. Value Health Reg Issues 2023; 36:1-9. [PMID: 36934592 DOI: 10.1016/j.vhri.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVES The sustainable development goals launched in 2015 are a follow-up commitment to the successful Millennium Development Goals. Goal number 3 of ensuring "good health and well-being" is a target to ensure universal health coverage. Universal health coverage means the provision of quality services that meet the needs of populations without risking financial impoverishment in the process. The guaranteed minimum health services in every health system constitute the health benefits package (HBP), which should be explicit and be composed of services that represent the best value for money and guarantee the best return on investment. The objective of this study was to review the application of cost-effectiveness analysis (CEA) and budget impact analysis in the development of HBP in low-to-middle income countries across the world. METHODOLOGY A literature review using a systematic approach was used. A search of PubMed, Google Scholar, World Health Organization, and World Bank databases was made for articles outlining the development of HBP in low- and middle-income countries, and a narrative synthesis was used for analysis. RESULTS Results from processes in Armenia, Ethiopia, Kyrgyz Republic, Lebanon, and Malawi showed CEA and budget impact analysis as 2 criteria used in HBP development in a limited number of countries with either no reference to the two or no reporting from the others. Local CEA estimates and cost data limitations were the biggest challenges to efforts to use robust methods. CONCLUSION Sustained efforts are needed to understand and address the challenges to the use of economic evaluation in the development of HBPs.
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Affiliation(s)
| | - Leela Barham
- Faculty of Life Science and Education, Learna, Cardiff, Wales, UK
| | - Enos Moyo
- Medical Centre Oshakati, Oshakati, Namibia.
| | | | - Tafadzwa Dzinamarira
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
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15
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Danforth K, Ahmad AM, Blanchet K, Khalid M, Means AR, Memirie ST, Alwan A, Watkins D. Monitoring and evaluating the implementation of essential packages of health services. BMJ Glob Health 2023; 8:bmjgh-2022-010726. [PMID: 36977532 PMCID: PMC10069525 DOI: 10.1136/bmjgh-2022-010726] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 03/09/2023] [Indexed: 03/30/2023] Open
Abstract
Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the ‘what’ and ‘for whom’ of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.
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Affiliation(s)
- Kristen Danforth
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Ahsan Maqbool Ahmad
- Center for Global Public Health, Islamabad, Pakistan
- Department of Community Health Sciences, Institute for Global Public Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Karl Blanchet
- Faculty of Medicine, Geneva Centre of Humanitarian Studies, University of Geneva, Geneve, Switzerland
| | - Muhammad Khalid
- Health Planning Systems Strengthening and Information Analysis Unit (HPSIU), Ministry of National Health Services Regulations and Coordination, Islamabad, Pakistan
| | - Arianna Rubin Means
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Solomon Tessema Memirie
- College of Health Sciences, Addis Center for Ethics and Priority Setting, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ala Alwan
- DCP3 Country Translation Project, London School of Hygiene & Tropical Medicine, London, UK
| | - David Watkins
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
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16
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Alwan A, Majdzadeh R, Yamey G, Blanchet K, Hailu A, Jama M, Johansson KA, Musa MYA, Mwalim O, Norheim OF, Safi N, Siddiqi S, Zaidi R. Country readiness and prerequisites for successful design and transition to implementation of essential packages of health services: experience from six countries. BMJ Glob Health 2023; 8:bmjgh-2022-010720. [PMID: 36657808 PMCID: PMC9853149 DOI: 10.1136/bmjgh-2022-010720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/10/2022] [Indexed: 01/20/2023] Open
Abstract
This paper reviews the experience of six low-income and lower middle-income countries in setting their own essential packages of health services (EPHS), with the purpose of identifying the key requirements for the successful design and transition to implementation of the packages in the context of accelerating progress towards universal health coverage (UHC). The analysis is based on input from three meetings of a knowledge network established by the Disease Control Priorities 3 Country Translation Project and working groups, supplemented by a survey of participating countries.All countries endorsed the Sustainable Development Goals target 3.8 on UHC for achievement by 2030. The assessment of country experiences found that health system strengthening and mobilising and sustaining health financing are major challenges. EPHS implementation is more likely when health system gaps are addressed and when there are realistic and sustainable financing prospects. However, health system assessments were inadequate and the government planning and finance sectors were not consistently engaged in setting the EPHS in most of the countries studied. There was also a need for greater engagement with community and civil society representatives, academia and the private sector in package design. Leadership and reinforcement of technical and managerial capacity are critical in the transition from EPHS design to sustained implementation, as are strong human resources and country ownership of the process. Political commitment beyond the health sector is key, particularly commitment from parliamentarians and policymakers in the planning and finance sectors. National ownership, institutionalisation of technical and managerial capacity and reinforcing human resources are critical for success.The review concludes that four prerequisites are crucial for a successful EPHS: (1) sustained high-level commitment, (2) sustainable financing, (3) health system readiness, and (4) institutionalisation.
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Affiliation(s)
- Ala Alwan
- DCP3 Country Translation Project, London School of Hygiene & Tropical Medicine, London, UK
| | - Reza Majdzadeh
- School of Health and Social Care, University of Essex, Colchester, Essex, UK
| | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Karl Blanchet
- Geneva Centre of Humanitarian Studies, University of Geneva, Geneva, Switzerland
| | - Alemayehu Hailu
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway,Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Mohamed Jama
- Ministry of Health, Federal Government of Somalia, Mogadishu, Somalia
| | - Kjell Arne Johansson
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Omar Mwalim
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole Frithjof Norheim
- Bergen Center for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | | | - Sameen Siddiqi
- Department of Community Health Sciences, Aga Khan University Medical College Pakistan, Karachi, Sindh, Pakistan
| | - Raza Zaidi
- Pakistan Ministry of National Health Services, Regulations, and Coordination, Islamabad, Pakistan
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17
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Vellekoop H, Odame E, Ochalek J. Supporting a review of the benefits package of the National Health Insurance Scheme in Ghana. Cost Eff Resour Alloc 2022; 20:32. [PMID: 35842698 PMCID: PMC9287965 DOI: 10.1186/s12962-022-00365-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 06/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although Ghana is lauded for its National Health Insurance Scheme (NHIS), concerns exist about the scheme's functioning and sustainability. An often-cited issue-contributing to the scheme's decreasing membership, long-standing financial deficit, and frequent out-of-pocket payments among members-is the large benefits package (BP). While, on paper, the BP covers over 95% of the conditions occurring in Ghana, its design was not informed by any budget analysis, nor any systematic prioritization of interventions. This paper aims to provide evidence-based input into ongoing discussions regarding a review of the NHIS benefits package. METHODS An existing analytic framework is used to calculate net health benefit (NHB) for a range of interventions in order to assess their cost-effectiveness and enable the prioritization of 'best buys'. The framework is expanded upon by incorporating concerns for financial protection, and practical feasibility, as well as the political economy challenges of disinvesting in currently funded activities. Five different options for the benefits package, each based on policy discourse in Ghana's health sector, are presented and evaluated. RESULTS Implementing all interventions for which data was available to 100% of the population in need was estimated to cost GH₵4323 million (US$994 million), while the available NHIS budget was only GH₵970 million (US$223 million). Options for the benefits package that focussed on cost-effectiveness and primary care provision achieved the best health outcomes, while options reflecting the status quo and allowing for co-payments included a higher number of healthcare interventions. Apart from the package option focussing on primary care, all packages were faced with physician shortages. CONCLUSIONS Current funding to the NHIS is insufficient to provide the historical benefits package, which promises to cover over 95% of disease conditions occurring in Ghana, to the total population. Shifting the NHIS focus from intervention coverage to population coverage is likely to lead to better health outcomes. A primary care package may be most feasible in the short-term, though additional physicians should be trained to provide higher-level care that is highly cost-effective, such as emergency neonatal care.
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Affiliation(s)
- Heleen Vellekoop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands. .,Ministry of Health, Accra, Ghana.
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Lange IL, Feroz F, Naeem AJ, Saeedzai SA, Arifi F, Singh N, Blanchet K. The development of Afghanistan's Integrated Package of Essential Health Services: Evidence, expertise and ethics in a priority setting process. Soc Sci Med 2022; 305:115010. [PMID: 35597187 DOI: 10.1016/j.socscimed.2022.115010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 03/08/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
Health systems in fragile states need to respond to shifting demographics, burden of disease and socio-economic circumstances in the revision of their health service packages. This entails making difficult decisions about what is and is not included therein, especially in resource-constrained settings offering or striving for universal health coverage. In this paper we turn the lens on the 2017-2021 development of Afghanistan's Integrated Package of Essential Health Services (IPEHS) to analyse the dynamics of the priority setting process and the role and value of evidence. Using participant observation of meetings and interviews with 25 expert participants, we conducted a qualitative study of the consultation process aimed at examining the characteristics of its technical, socio-cultural and organisational aspects, in particular data use and expert input, and how they influenced how evidence was discussed, taken up, and used (or not used) in the process. Our analysis proposes that the particular dynamics shaped by the context, information landscape and expert input shaped and operationalized knowledge sharing and its application in such a way to constitute a sort of "vernacular evidence". Our findings underline the importance of paying attention to the constellation of the priority setting processes in order to contribute to an ethical allocation of resources, particularly in contexts of resource scarcity and humanitarian need.
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Affiliation(s)
- Isabelle L Lange
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.
| | | | | | | | | | - Neha Singh
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK.
| | - Karl Blanchet
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK; Geneva Centre of Humanitarian Studies, University of Geneva, Switzerland.
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Quality disparity in terms of clients’ satisfaction with selected exempted health care services provided in Ethiopia: meta-analysis. HEALTH POLICY OPEN 2022. [DOI: 10.1016/j.hpopen.2022.100068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Erku D, Mersha AG, Ali EE, Gebretekle GB, Wubshet BL, Kassie GM, Mulugeta A, Mekonnen AB, Eshetie TC, Scuffham P. A Systematic Review of Scope and Quality of Health Economic Evaluations Conducted in Ethiopia. Health Policy Plan 2022; 37:514-522. [PMID: 35266523 PMCID: PMC9128743 DOI: 10.1093/heapol/czac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 12/16/2021] [Accepted: 02/20/2022] [Indexed: 11/13/2022] Open
Abstract
There has been an increased interest in health technology assessment and economic evaluations for health policy in Ethiopia over the last few years. In this systematic review, we examined the scope and quality of healthcare economic evaluation studies in Ethiopia. We searched seven electronic databases (PubMed/MEDLINE, EMBASE, PsycINFO, CINHAL, Econlit, York CRD databases and CEA Tufts) from inception to May 2021 to identify published full health economic evaluations of a health-related intervention or programme in Ethiopia. This was supplemented with forward and backward citation searches of included articles, manual search of key government websites, the Disease Control Priorities-Ethiopia project and WHO-CHOICE programme. The quality of reporting of economic evaluations was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. The extracted data were grouped into subcategories based on the subject of the economic evaluation, organized into tables and reported narratively. This review identified 34 full economic evaluations conducted between 2009 and 2021. Around 14 (41%) of studies focussed on health service delivery, 8 (24%) on pharmaceuticals, vaccines and devices, and 4 (12%) on public-health programmes. The interventions were mostly preventive in nature and focussed on communicable diseases (n = 19; 56%) and maternal and child health (n = 6; 18%). Cost-effectiveness ratios varied widely from cost-saving to more than US $37 313 per life saved depending on the setting, perspectives, types of interventions and disease conditions. While the overall quality of included studies was judged as moderate (meeting 69% of CHEERS checklist), only four out of 27 cost-effectiveness studies characterized heterogeneity. There is a need for building local technical capacity to enhance the design, conduct and reporting of health economic evaluations in Ethiopia.
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Affiliation(s)
- Daniel Erku
- Centre for Applied Health Economics, Griffith University, Nathan, QLD
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD
- Addis Consortium for Health Economics and Outcomes Research (AnCHOR)
| | - Amanual G Mersha
- School of Medicine and Public Health, The University of Newcastle, Newcastle, Australia
| | - Eskindir Eshetu Ali
- Department of Pharmaceutics and Social Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University
| | - Gebremedhin B Gebretekle
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Befikadu L Wubshet
- Health Services Research Centre Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Gizat Molla Kassie
- University of South Australia: Clinical & Health Sciences, Quality Use of Medicines and Pharmacy Research Centre
| | - Anwar Mulugeta
- Australian Centre for Precision Health, Unit of Clinical and Health Sciences, University of South Australia, Adelaide, Australia, SA 5000, Australia
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa 1000, Ethiopia
- South Australian Health and Medical Research Institute, Adelaide, SA 5000, Australia
| | - Alemayehu B Mekonnen
- Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, VIC, Australia
| | - Tesfahun C Eshetie
- Plein Center for Geriatric Pharmacy Research, Education and Outreach, School of Pharmacy, University of Washington, Seattle, WA, USA
| | - Paul Scuffham
- Centre for Applied Health Economics, Griffith University, Nathan, QLD
- Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD
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21
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Shekh Mohamed I, Hepburn JS, Ekman B, Sundewall J. Inclusion of Essential Universal Health Coverage Services in Essential Packages of Health Services: A Review of 45 Low- and Lower- Middle Income Countries. Health Syst Reform 2022; 8:e2006587. [DOI: 10.1080/23288604.2021.2006587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Idil Shekh Mohamed
- Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
- Swedish Institute for Global Health Transformation (SIGHT), Stockholm, Sweden
| | | | - Björn Ekman
- Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
| | - Jesper Sundewall
- Division of Social Medicine and Global Health, Lund University, Malmö, Sweden
- Health Economics and HIV and AIDS Research Division (HEARD), University of KwaZulu-Natal, Durban, South Africa
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22
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Burrowes S, Holcombe SJ, Leshargie CT, Hernandez A, Ho A, Galivan M, Youb F, Mahmoud E. Perceptions of cervical cancer care among Ethiopian women and their providers: a qualitative study. Reprod Health 2022; 19:2. [PMID: 34983586 PMCID: PMC8725313 DOI: 10.1186/s12978-021-01316-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 12/04/2021] [Indexed: 01/26/2023] Open
Abstract
Background Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. As the government rolls out the country’s first national cancer control strategy, information on patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment is critical. Methods This qualitative study aimed to assess the availability of cervical cancer care; explore care barriers and sources of delay; and describe women’s and providers’ perceptions and experiences of care. We analyzed data from 45 informants collected at 16 health centers, district hospitals and referral hospitals in East Gojjam Zone and a support center in Addis Ababa. Thirty providers and ten women receiving care were interviewed, and five women in treatment or post-treatment participated in a focus group discussion. Deductive and inductive codes were used to thematically analyze data. Results Providers lacked equipment and space to screen and treat patients and only 16% had received in-service cervical cancer training. Consequently, few facilities provided screening or preventative treatment. Patients reported low perceptions of risk, high stigma, a lack of knowledge about cervical cancer, and delayed care initiation. All but one patient sought care only when she became symptomatic, and, pre-diagnosis, only half of the patients knew about cervical cancer. Even among those aware of cervical cancer, many assumed they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay experienced by half of the patients. Once diagnosed, women faced multiple-month waits for referrals, and, once in treatment, broken equipment and shortages of hospital beds resulted in additional delays. Barriers to therapeutic treatment included a lack of housing and travel funds. Patient-provider communication of cancer diagnosis was often lacking. Conclusions In-service provider training should be intensified and should include discussions of cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities are also a priority. Expanded cervical cancer health education should focus on stigma reduction and emphasize a broad, wide-spread risk of cervical cancer. Cervical cancer is the second most commonly diagnosed cancer among Ethiopian women, killing an estimated 4700 women each year. This study aimed to assess patient and provider experiences in receiving and providing cervical cancer screening, diagnosis, and treatment. We interviewed 30 midlevel providers and ten women receiving care and held a focus group discussion with five women who were receiving treatment or who had recently completed treatment. Patients reported bottlenecks and delays at each stage of care. Low perception of risk, high stigma, and a lack of knowledge about cervical cancer among both providers and patients, were significant sources of delay in initiating care. Few patients had been aware of cervical cancer before they were diagnosed and of those who were aware, many assumed that they were not at risk because they were not sexually active. Misdiagnosis was another common source of delay. Once diagnosed correctly, women faced multiple-month delays after referrals, and, once in treatment, broken equipment and a shortage of hospital beds resulted in additional delays. The most frequently mentioned barriers to care were a lack of housing and travel funds while receiving treatment in the capital. Patient-provider communication of cancer diagnosis was often poor. Our findings suggest the need to intensify in-service training for providers, focusing initially on alerting them to cervical cancer symptoms. Better distribution of screening and diagnostic supplies to lower-level facilities and better maintenance of treatment equipment at tertiary facilities should also be a priority.
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Affiliation(s)
| | - Sarah Jane Holcombe
- Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | | | - Anthony Ho
- Touro University California, Vallejo, CA, USA
| | | | - Fatuma Youb
- Touro University California, Vallejo, CA, USA
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23
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Koon AD, Wright J, Ageze L, Charles J, Holtz J. Aligning priorities in Ethiopian health finance: How do the essential health services package and health benefit plans compare? Int J Health Plann Manage 2021; 37:417-428. [PMID: 34636078 DOI: 10.1002/hpm.3349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 08/19/2021] [Accepted: 10/01/2021] [Indexed: 11/09/2022] Open
Abstract
Priority setting is a key function of health systems in low- and middle-income countries that seek to achieve universal health coverage. Essential health services packages (EHSPs) and health benefit plans are two types of instruments used in setting health care priorities. Both instruments exist in Ethiopia, but little is known about how they are aligned. To gain insights into the evolution, purpose, policy objectives, and governance of the EHSP, community-based health insurance (CBHI), and social health insurance (SHI) in Ethiopia, we conducted a case study. This included a desk review of relevant documents as well as qualitative analysis of key informant interviews conducted with 15 leading health finance experts in Addis Ababa. Interviewees understood the EHSP to be a key priority-setting instrument in the country by coordinating the activities of health system stakeholders, and guaranteeing the right of citizens to a basic level of care. Community-based health insurance and SHI were described as mechanisms for the government to expand health coverage and provide financial protection. Interviewees acknowledged that Ethiopia had drawn on the experience of other countries when designing health benefit plans, but contrasted Ethiopia's experience with that of other countries. We found that in Ethiopia, the EHSP, CBHI, and SHI are not explicitly aligned. We propose that EHSPs play an important role in early stages of health systems development. However, as governments develop health benefit plans with expansive packages of services, the importance of EHSPs becomes less clear.
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Affiliation(s)
- Adam D Koon
- Department of International Health, Johns Hopkins University, Baltimore, Maryland, USA.,Health Finance and Governance Project, Abt Associates Inc., Rockville, Maryland, USA
| | - Jenna Wright
- RTI International, Washington, District of Columbia, USA
| | - Leulseged Ageze
- USAID Health Financing Improvement Program, Abt Associates Inc., Addis Ababa, Ethiopia
| | - Jodi Charles
- Office of Health Systems, United States Agency for International Development, Washington, District of Columbia, USA
| | - Jeanna Holtz
- Health Finance and Governance Project, Abt Associates Inc., Rockville, Maryland, USA
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24
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Hailu A, Eregata GT, Yigezu A, Bertram MY, Johansson KA, Norheim OF. Contextualization of cost-effectiveness evidence from literature for 382 health interventions for the Ethiopian essential health services package revision. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:58. [PMID: 34521437 PMCID: PMC8442298 DOI: 10.1186/s12962-021-00312-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 08/23/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cost-effectiveness of interventions was a criterion decided to guide priority setting in the latest revision of Ethiopia's essential health services package (EHSP) in 2019. However, conducting an economic evaluation study for a broad set of health interventions simultaneously is challenging in terms of cost, timeliness, input data demanded, and analytic competency. Therefore, this study aimed to synthesize and contextualize cost-effectiveness evidence for the Ethiopian EHSP interventions from the literature. METHODS The evidence synthesis was conducted in five key steps: search, screen, evaluate, extract, and contextualize. We searched MEDLINE and EMBASE research databases for peer-reviewed published articles to identify average cost-effectiveness ratios (ACERs). Only studies reporting cost per disability-adjusted life year (DALY), quality-adjusted life year (QALY), or life years gained (LYG) were included. All the articles were evaluated using the Drummond checklist for quality, and those with a score of at least 7 out of 10 were included. Information on cost, effectiveness, and ACER was extracted. All the ACERs were converted into 2019 US dollars using appropriate exchange rates and the GDP deflator. RESULTS In this study, we synthesized ACERs for 382 interventions from seven major program areas, ranging from US$3 per DALY averted (for the provision of hepatitis B vaccination at birth) to US$242,880 per DALY averted (for late-stage liver cancer treatment). Overall, 56% of the interventions have an ACER of less than US$1000 per DALY, and 80% of the interventions have an ACER of less than US$10,000 per DALY. CONCLUSION We conclude that it is possible to identify relevant economic evaluations using evidence from the literature, even if transferability remains a challenge. The present study identified several cost-effective candidate interventions that could, if scaled up, substantially reduce Ethiopia's disease burden.
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Affiliation(s)
- Alemayehu Hailu
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
- Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.
| | - Getachew Teshome Eregata
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Amanuel Yigezu
- Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Melanie Y Bertram
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland
| | - Kjell Arne Johansson
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole F Norheim
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, USA
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25
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Regan L, Wilson D, Chalkidou K, Chi YL. The journey to UHC: how well are vertical programmes integrated in the health benefits package? A scoping review. BMJ Glob Health 2021; 6:bmjgh-2021-005842. [PMID: 34344664 PMCID: PMC8336212 DOI: 10.1136/bmjgh-2021-005842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/07/2021] [Indexed: 11/11/2022] Open
Abstract
Background Countries are recommended to progressively work towards universal health coverage (UHC), and to make explicit choices regarding the expansion of priority services. However, there is little guidance on how to manage the inclusion of vertical programmes, funded by external partners, in health benefits packages (HBP) in low and middle-income countries (LMICs). Objective We conducted a scoping review to map the inclusion of six vertical programmes (HIV, tuberculosis, malaria, maternal and child health, contraceptives, immunisation) in 26 LMICs. Methods We identified 26 LMICs with an HBP that was not aspirational (eg, with evidence of implementation or funding). For each HBP, we collected information on the corresponding UHC scheme, health financing at the time of establishment, revisions since inception and entitlements. For each vertical programme, we developed a list of tracer interventions based on the Disease Control Priorities 3 and the 100 Core Health Indicators List. We then used this list of tracer interventions to map the coverage of the six vertical programmes. Results The review shows that there is no common starting point for countries embarking into UHC. Some HBPs were almost three decades old. Whole package revisions are rare. The inclusion of vertical programme does not follow a given pattern based on health financing indicators or country’s income group. Maternal child health services are the most often included and family planning the least. Six countries in our sample covered all vertical programmes, while one covered only one of six. Conclusions This review has shown that there has been a long history of countries facing this question and we have provided the first mapping of inclusion of vertical programmes in UHC. The results of the mapping can inform decisions in countries embarking in UHC.
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Affiliation(s)
- Lydia Regan
- Global Health, Center for Global Development, London, UK
| | - David Wilson
- Decision Sciences, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Kalipso Chalkidou
- The Global Fund to Fight AIDS, Tuberculosis and Malaria, Grand-Saconnex, Switzerland
| | - Y-Ling Chi
- Global Health, Center for Global Development, London, UK
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26
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Hailu A, Eregata GT, Stenberg K, Norheim OF. Is Universal Health Coverage Affordable? Estimated Costs and Fiscal Space Analysis for the Ethiopian Essential Health Services Package. Health Syst Reform 2021; 7:e1870061. [PMID: 33739233 DOI: 10.1080/23288604.2020.1870061] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50-70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10-17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap.
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Affiliation(s)
- Alemayehu Hailu
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Getachew Teshome Eregata
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Ministry of Health of Ethiopia, Addis Ababa, Ethiopia
| | - Karin Stenberg
- Department of Health Systems Governance and Financing, World Health Organization, Geneva, Switzerland.,Swiss Tropical and Public Health Institute, University of Basel, Basel, Switzerland
| | - Ole Frithjof Norheim
- Bergen Centre for Ethics and Priority Setting, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Harvard T.H.Chan School of Public Health, Harvard University, Boston, USA
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27
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Verguet S, Hailu A, Eregata GT, Memirie ST, Johansson KA, Norheim OF. Toward universal health coverage in the post-COVID-19 era. Nat Med 2021; 27:380-387. [PMID: 33723458 DOI: 10.1038/s41591-021-01268-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 01/27/2021] [Indexed: 01/29/2023]
Abstract
All countries worldwide have signed up to the United Nations Sustainable Development Goals and have committed to the objective of achieving 'universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all'. During the COVID-19 pandemic and beyond, advancement toward universal health coverage (UHC) will become more difficult for many countries, demonstrating that locally led priority setting is urgently needed to provide health services with appropriate financial protection to all. Because resources are limited and no national constituency can provide an unlimited number of services to their whole population in a sustainable manner, rationing and setting priorities for the selection of interventions to be included in a defined package of services is critical. In this Perspective, we discuss how packages of essential health services can be developed in resource-constrained settings, and detail how experts and the public can decide on principles and criteria, use a comprehensive array of analytical methods and choose which services to be provided free of charge. We illustrate these main steps while drawing on a recently conducted exercise of revising the national essential health services package in Ethiopia, which we compare with examples from other countries that have defined their essential benefits packages. This Perspective also provides recommendations for other low- and middle-income countries on their pathway to UHC.
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Affiliation(s)
- Stéphane Verguet
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA
| | - Alemayehu Hailu
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Getachew Teshome Eregata
- Federal Ministry of Health of Ethiopia, Addis Ababa, Ethiopia.,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Solomon Tessema Memirie
- Department of Pediatrics and Child Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Kjell Arne Johansson
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ole Frithjof Norheim
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, USA. .,Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.
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