Basic packages: origin, rationale and costs

1
Basic packages origin, rationale and costs

• Jane Doherty
• Health service delivery in fragile states for 5
  per person per year myth or reality?
• 24-25 October 2007

2
Rationale

• funding never sufficient to meet all health needs
• need to prioritise interventions objectively
• packaging interventions allows
• exploit shared use of inputs
• reduce costs to patients
• synergy between interventions
• reach related individuals
• screening of patients at first level to increase
  efficiency of referral
• assists planning
• ?equity

3
Origins and evolution (1)

• Alma Ata and the Primary Health Care Approach
  (late 1970s)
• health care interventions described in broad
  terms but not costed
• comprehensive
• Selective Primary Health Care (early 1980s)
• focused on limited components (eg. child health ,
  tropical diseases)
• tended towards vertical programmes

4
Origins and evolution (2)

• the World Banks 1993 World Bank Development
  Report, Investing in Health
• cost-effectiveness of interventions (/DALY)
• size of disease burden they address
• minimum package

5
Origins and evolution (3)

• World Banks Better Health in Africa (1994)
• focus on Africa
• services divided into primary level and
  first-level referral (district hospital)
• included costs of institutional support
• WHOs World Health Report 2000
• listed some cost-effective interventions but did
  not cost
• expanded HIV/AIDS-related prevention
• referred to NCD screening and prevention

6
Origins and evolution (4)

• Commission on Macroeconomics and Health (2002)
• focus on poorest countries
• close-to-client services
• scaling-up potential
• more detailed consideration of HIV/AIDS
• additional costs management, improving
  absorptive capacity, improving quality, improving
  salaries
• additional 40 to 52 billion by 2015 to scale up

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Origins and evolution (5)

• WHOs World Health Report 2002
• focus on risk factors, incl. NCD
• notes that cost-effectiveness depends on
  circumstances
• Clustering of services into integrated programmes
  (early 2000s) e.g. IMCI
• uses common delivery strategy/point of contact
• allows development of specialist skills
• avoids problems of vertical interventions
• provides focus

8
Origins and evolution (6)

• WHOs CHOICE project (around 2005)
• cost-effectiveness of selected interventions,
  focusing on those related to MDGs
• confirmed that these tend to be cost-effective
• analysed synergies between different interventions

9
Origins and evolution (7)

• Disease Control Priorities in Developing
  Countries (2nd edition) (around 2006)
• comprehensive updating and expansion of work on
  which Investing in Health was based
• more emphasis on levels of care, implementation
  challenges and financing
• package and its costs not calculated

10
Origins and evolution (8)

• highlighted as neglected
• neonatal care (1/2 child deaths)
• interruption of HIV transmission
• controlling tobacco use most important NCD
  intervention
• lifelong medical management of risk factors in
  people at high risk of heart attack/stroke
• surgical capacity at district hospitals

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Overall trend

• expansion of original set of interventions
• more flexibility in choice of interventions
• variation in cost of packages - different
  interventions, different input costs, different
  overheads
• confirmation that need mix of preventive and
  curative interventions
• more awareness that also need referral services
• Many more interventions than countries can
  afford to fund are classified as highly cost
  effective. Evans et al. 2005

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Comparison of the total annual per capita costs
of minimum packages calculated by different
reports (2001 prices)
Source Doherty and Govender (2004) Higher
range of services, higher input costs, applies to
a small sub-group of countries
13
Cost of meeting MDG Health Goals

• UN Millennium Project
• in 2006, needed 13-25 per capita
• In 2015, will need 30-48 per capita
• In Rwanda (Foster and Gottret 2006)
• additional 22 per capita (close to child
  mortality target)
• additional 10 per capita (3/4 child mortality
  target, 2/3 maternal mortality) interventions
  up to district hospital but excluding further
  roll-out of ART

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Critiques (1)

• methods for calculating the burden of disease,
  incl. value-laden
• methods for calculating cost-effectiveness e.g.
  exclusion of patient costs, non-health
  costs/benefits
• generalisability
• disease-based, encouraging verticalisation
  rather than patient-centred and responsive
• operational problems in implementing

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Critiques (2)

• equity concerns
• prioritises interventions that cheap for the
  health system
• discourages providing access for the
  hard-to-reach
• focus on health benefits ignores wider benefits
  of interventions that address e.g. power
  relations, social stigma
• interventions that are difficult to measure are
  excluded under-representation of geographic
  areas, needs of certain population groups
• example of sexual and reproductive health
  abortion, infertility treatment, heavy menstrual
  bleeding, uterine prolapse, vesico-vaginal and
  recto-vaginal fistulae, ovarian and uterine
  cancers (see Alvarez-Castillo, Ravindran and de
  Pinho 2005)
• real problem is political will, weak health
  systems

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Using the package (1)

• Bangladesh
• diversion of resources to priority services and
  primay care
• persistent barriers to access
• unit costs varied 10-fold across 20 areas studies
• problems with quality, referral

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Using the package (2)

• Tanzania (TEHIP)
• identified burden of disease
• eliminated cost-ineffective interventions
• no ranking of highly cost-effective interventions
• additional funding plus management/information
  support
• increase in resources on important interventions
• increase in utilisation
• rapid decline in mortality

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Current challenges

• Need a functional health system, especially to
  achieve equity benefits e.g. IMCI experience
• Importance of integration versus continuing
  verticalisation
• Provision of hospital services?
• avoid catastrophic costs
• some highly cost-effective and address high
  burden of disease
• Most-hospital based interventions to address
  maternal and neonatal mortality are also highly
  cost-effective and without universal access to
  these the millennium development goals for
  maternal and child health will not be met. Adam
  et al. 2005

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Relevance to fragile states

• Package needs to
• be highly context-specific
• consciously promote equity
• be supported by actions to strengthen the health
  system
• avoid on-going reliance on vertical programmes
• discourage cost-ineffective interventions
• be monitored

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• References up until 2003 included in
• Doherty J, Govender R. 2004. The
  cost-effectiveness of primary care services in
  developing countries a review of the
  international literature. Literature review
  prepared for the Disease Control Priorities
  Project.
• Some useful references after 2003
• Adam T, Lim SS, Mehta S, Bhutta ZA, Fogstad H,
  Mathai M, Zupan J, Darmstadt GL. 2005.
  Cost-effectiveness analysis of strategies for
  maternal and neonatal health in developing
  countries. BMJ 331 1107-1112.
• Alvarez-Castillo F, Ravindran STK, de Pinho H.
  2005. Priority setting. In Ravindran STK, de
  Pinho H. 2005. The Right Reforms? Health
  Sector Reform and Sexual and Reproductive Health.
  Johannesburg Womens Health Project, University
  of Johannesburg.
• Evans DB, Adam T, Edejer TT, Lim SS, Cassels A,
  Evans TG, WHO MDG Team. 2005. Time to reassess
  strategies for improving health in developing
  countries. BMJ 331 1133-1136.
• Evans DB, Lim SS, Adam T, Edejer TT, CHOICE MDG
  Team. 2005. Evaluation of current strategies
  and future priorities for improving health in
  developing countries. BMJ 331 1457-1461.
• Foster M, Gottret P. 2006. Scaling up to
  achieve the health MDGs in Rwanda. A background
  study for the high-level forum meeting in Tunis,
  June 12th-13th 2006. Ministry of Economics and
  Finance, and Ministry of Health.
• Jamison DT, Breman JG, Measham AR, Alleyne G,
  Claeson M, Evans DB, Jha P, Mills A, Musgrove P.
  2006. Disease Control Priorities in Developing
  Countries (2nd edition). Washington Oxford
  University and the World Bank.

21
The per capita costs of delivering the World Bank
minimum package (2001 prices)
22

Source Jha and Mills (200252)
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Overview

• the rationale behind the concept
• origins and evolution of the concept of a
  package
• the costs of different packages
• critiques of the concept
• using the package
• lessons for fragile states

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Relevance to fragile states (1)

• context of stark
• resource constraints
• inequities
• useful as
• tool for priority-setting
• strategy for promoting access to vulnerable and
  marginalised populations
• needs to be sensitive to different disease
  burden, costs, health system features, equity
  concerns