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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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Alwan A, Siddiqi S, Safi M, Zaidi R, Khalid M, Baltussen R, Gudumac I, Huda M, Jansen M, Raza W, Torres-Rueda S, Zulfiqar W, Vassall A. Addressing the UHC Challenge Using the Disease Control Priorities 3 Approach: Lessons Learned and an Overview of the Pakistan Experience. Int J Health Policy Manag 2023; 13:8003. [PMID: 39099517 DOI: 10.34172/ijhpm.2023.8003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 10/07/2023] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Pakistan developed its first national Essential Package of Health Services (EPHS) as a key step towards accelerating progress in achieving Universal Health Coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned. METHODS EPHS design was led by the Ministry of National Health Services, Regulations & Coordination. The methods adopted were technically guided by the Disease Control Priorities 3 Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes. RESULTS The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$29.7. The EPHS also includes an additional set of 12 population-based interventions at US$0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP. CONCLUSION Key ingredients for a successful EPHS design requires a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030.
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Affiliation(s)
- Ala Alwan
- DCP3 Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK
| | - Sameen Siddiqi
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Malik Safi
- Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Raza Zaidi
- Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Muhammad Khalid
- Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Rob Baltussen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ina Gudumac
- DCP3 Country Translation Project, London School of Hygiene and Tropical Medicine, London, UK
| | - Maryam Huda
- Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
| | - Maarten Jansen
- Department of Health Evidence, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wajeeha Raza
- Centre for Health Economics, University of York, York, UK
| | - Sergio Torres-Rueda
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Wahaj Zulfiqar
- Ministry of National Health Services, Regulations and Coordination, Islamabad, Pakistan
| | - Anna Vassall
- Department of Global Health & Development, London School of Hygiene and Tropical Medicine, London, UK
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Mohamedsharif A, Elfeaki M, Bushra R, Gemperli A. Effectiveness of hospital-to-home transitional care interventions and consultation for implementation in Sudan: a scoping review of systematic reviews. FRONTIERS IN HEALTH SERVICES 2023; 3:1288575. [PMID: 38162192 PMCID: PMC10755884 DOI: 10.3389/frhs.2023.1288575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/27/2023] [Indexed: 01/03/2024]
Abstract
Background Hospital discharge is often associated with a lack of continuity resulting in fragmented care, particularly in low-income countries. As there is limited information about interventions in these countries and no study evaluating the effectiveness of hospital discharge interventions, we conducted a scoping review to identify effective hospital-to-home transitional care interventions and explore their applicability in a low-income country (Sudan). Methods Our scoping review of systematic reviews and meta-analyses classed interventions as effective, ineffective, undesirable, or uncertain, based on the quality of their evidence and their estimated effects on the following outcomes: readmission rates, mortality, costs, quality of life, and adverse outcomes) and certainty of evidence. Our authors from Sudan used the SUPPORT summary tool to determine if three effective interventions could be implemented in Sudan. Results Out of 3,276 articles that were identified, and 72 articles were reviewed, 10 articles has been included in the review. Seven interventions were classified as effective, one as ineffective, and none with undesirable effects. Eight interventions were classified as having an uncertain effect. The effective interventions were composed of home visits, information and communication technology (ICT), case manager models, multidisciplinary teams, and self-management support. Conclusions The finding of this study suggested that a combining two to four interventions can improve enhance hospital-to-home transitional care. Effective interventions are composed of home visits, ICT, case manager models, multidisciplinary teams, and self-management support. The implementation of these interventions in Sudan was found to be undermined by contextual factors such as inadequate human resources, telecommunication instability, and inequality in accessibility. These interventions could be tailored based on an in-depth understanding of the contextual factors in low-income countries that influence implementation. Systematic Review Registration https://osf.io/9eqvr/, doi: 10.17605/OSF.IO/9EQVR.
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Affiliation(s)
- Asma Mohamedsharif
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Mohammed Elfeaki
- Directorate of Quality, Development and Accreditation, Federal Ministry of Health, Khartoum, Sudan
| | - Rayan Bushra
- Department of General Medicine, Ibrahim Malik Teaching Hospital, Khartoum, Sudan
| | - Armin Gemperli
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
- Center of Primary and Community Care, University of Lucerne, Lucerne, Switzerland
- Swiss Paraplegic Research, Nottwil, Switzerland
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Alba S, Jacobs E, Kleipool E, Salehi A, Naeem A, Arab SR, Van Gurp M, Hamid N, Manalai P, Saeedzai SA, Safi S, Paiman F, Siddiqi AM, Gerretsen B, Gari S, Sondorp E. Third party monitoring for health in Afghanistan: the good, the bad and the ugly. BMJ Glob Health 2023; 8:e013470. [PMID: 38084481 PMCID: PMC10711846 DOI: 10.1136/bmjgh-2023-013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/01/2023] [Indexed: 12/18/2023] Open
Abstract
Third party monitoring (TPM) is used in development programming to assess deliverables in a contract relationship between purchasers (donors or government) and providers (non-governmental organisations or non-state entities). In this paper, we draw from our experience as public health professionals involved in implementing and monitoring the Basic Package of Health Services (BPHS) and the Essential Package of Hospital Services (EPHS) as part of the SEHAT and Sehatmandi programs in Afghanistan between 2013 and 2021. We analyse our own TPM experience through the lens of the three parties involved: the Ministry of Public Health; the service providers implementing the BPHS/EPHS; and the TPM agency responsible for monitoring the implementation. Despite the highly challenging and fragile context, our findings suggest that the consistent investments and strategic vision of donor programmes in Afghanistan over the past decades have led to a functioning and robust system to monitor the BPHS/EPHS implementation in Afghanistan. To maximise the efficiency, effectiveness and impact of this system, it is important to promote local ownership and use of the data, to balance the need for comprehensive information with the risk of jamming processes, and to address political economy dynamics in pay-for-performance schemes. Our findings are likely to be emblematic of TPM issues in other sectors and other fragile and conflicted affected settings and offer a range of lessons learnt to inform the implementation of TPM schemes.
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Affiliation(s)
- Sandra Alba
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Eelco Jacobs
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | | | | | - Ahmad Naeem
- Assistance for Families and Indigent Afghans to Thrive (AFIAT), Kabul, Afghanistan
| | | | - Margo Van Gurp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
| | - Nasir Hamid
- Care of Afghan Families (CAF), Kabul, Afghanistan
| | | | | | | | - Farhad Paiman
- Organization for Health Promotion and Management, Kabul, Afghanistan
| | | | | | | | - Egbert Sondorp
- KIT Royal Tropical Institute, Amsterdam, The Netherlands
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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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