|Year : 2020 | Volume
| Issue : 1 | Page : 52-54
Why do many basic packages of health services stay on the shelf? A look at potential reasons in the WHO South-East Asia Region
Lluís Vinyals Torres1, Valeria de Oliveira Cruz1, Xavier Modol2, Phyllida Travis3
1 Department of Health Systems Development, World Health Organization Regional Office for South-East Asia, New Delhi, India
2 Independent consultant, Madrid, Spain
3 Independent consultant, Bristol, United Kingdom
|Date of Web Publication||26-Apr-2020|
Mr Lluís Vinyals Torres
Department of Health Systems Development, World Health Organization Regional Office for South-East Asia, New Delhi
Basic packages of health services (BPHSs) are often envisaged primarily as political statements of intent to provide access to care, in an era of commitment to universal health coverage. They are often produced with little attention paid to health systems’ capacity to deliver these benefit packages or other implementation challenges. Many countries of the World Health Organization (WHO) South-East Asia Region have invested in developing BPHSs. This perspective paper reflects on the issues that do not receive enough attention when packages are developed, which can often jeopardize their implementation. Countries of the region refer to burden-of-disease assessments and consider the cost-effectiveness of the listed interventions during their BPHS design processes. Some also conduct a costing study to generate “price tags” that are used for resource mobilization. However, important implementation challenges such as weak supply-side readiness, limited scope for reallocation of existing resources and management not geared for accountability are too often ignored. Implementation and its monitoring is further hampered by the limitations of existing health information systems, which are often not ready to collect and analyse data on emerging interventions such as noncommunicable disease management. Among the countries of the WHO South-East Asia Region, those with better chances of executing their BPHSs have adapted their packages to their implementation, financing and monitoring capacities, and have considered the need for a modified service delivery model able to provide the agreed services.
Keywords: basic packages of health care, health economics, health policy, public health
|How to cite this article:|
Vinyals Torres L, Oliveira Cruz V, Modol X, Travis P. Why do many basic packages of health services stay on the shelf? A look at potential reasons in the WHO South-East Asia Region. WHO South-East Asia J Public Health 2020;9:52-4
|How to cite this URL:|
Vinyals Torres L, Oliveira Cruz V, Modol X, Travis P. Why do many basic packages of health services stay on the shelf? A look at potential reasons in the WHO South-East Asia Region. WHO South-East Asia J Public Health [serial online] 2020 [cited 2022 Jan 22];9:52-4. Available from: http://www.who-seajph.org/text.asp?2020/9/1/52/282997
| Background|| |
Packages of health services, often dubbed “essential” or “basic”, have become popular among policy-makers in a variety of countries. The potential uses of these basic packages of health services (BPHSs) include defining the entitlement of the population to the listed services and setting priorities for the use of limited resources. They are also used in helping to structure facilities and delivery systems by describing the range of services that should be provided at each level, estimating the financial resources required to deliver the agreed service components (and not others) and using those estimates for resource mobilization, and assisting in decisions on training packages or staffing norms. In many countries, the BPHS is envisaged primarily as a political statement of intent to provide access to care in support of a stated commitment to universal health coverage (UHC). Often, however, little attention is paid to implementation challenges, and the BPHS simply remains on the shelf.
In the past few years, most countries of the World Health Organization (WHO) South-East Asia Region have been designing BPHSs. Bangladesh, Myanmar, Nepal, Sri Lanka and Timor-Leste have opted to draw up a detailed list of health interventions, following what is known as a positive list approach, as opposed to selecting what will be excluded from the list, known as a negative list approach. India has taken an alternative approach. A few years ago, India defined the standards of services by level of care. More recently, India has also adopted two complementary approaches: it defines standards for primary health care while using a benefit package for inpatient/hospital reimbursements. Thailand’s health benefit package, with its extensive coverage by various insurance schemes prior to UHC, is implicit, with no detailed list of interventions, but with explicit exclusions., This perspective paper reflects on lessons learnt by the authors in supporting package design in certain countries of the region between 2015 and 2019.
| Considerations for the BPHS design process|| |
Despite the efforts devoted to the detailed design of packages, evidence of the link between the development of a BPHS and any substantial influence on service utilization and coverage is unclear. This relates to package implementation. In 2018, El-Jardali et al. identified a number of barriers to and facilitators of implementation in low- and middle-income countries. Barriers ranged from limited involvement of consumers and stakeholders in package design to inadequate availability of staff or supplies; facilitators ranged from government commitment to funding delivery of the package to the existence of a functioning health-care delivery system. Similar examples of barriers to implementation can be identified in the WHO South-East Asia Region.
Developing a BPHS is a government’s policy decision. The reasons vary. In Nepal, it was in response to a constitutional mandate. In Sri Lanka, the development of a package was part of a reorganization of primary health care. In Bangladesh, the package was developed as a tool to progress towards UHC. Thailand had been using benefit packages as a key component of its various public purchasing schemes, with the aim of increasing efficiency and equity.
BPHS design is commonly seen as a technical exercise. However, although burden-of-disease and cost-effectiveness analyses are often mentioned as tools for the selection of interventions, there is little evidence of these having been conducted. Moreover, most countries of the region have neither the information nor the full capacity to perform such comprehensive analyses without external support. An exception to this is Thailand, which uses health technology assessment to appraise new and high-cost services before their adoption. The decision to adopt new interventions is supported by adequate funding through cabinet-level decisions to prevent “unfunded mandates”. Whatever approaches are used, the resulting package content is a remarkably similar list of services across countries. Moreover, the package content tends consistently to go well beyond the current scope of services and fiscal capacity, which creates the risk that these packages will remain aspirational, calling for strong prioritization.
Prioritization involves multiple processes, some political and some technical. During negotiations by policy-makers, expensive services may be added as a way of preventing conflict among programme managers, thereby undermining attempts at prioritization. In Nepal and Timor-Leste, there were deliberate technical decisions to focus exclusively on services provided in front-line primary care facilities, excluding critical life-saving services such as emergency caesarean section.
A costing exercise is often conducted as part of the BPHS design process. Formally, the aim is to assess affordability, on the assumption that in the – unsurprising – case that the estimated cost exceeds projected funding, package content will need to be revised to match available resources. Thailand seems to be the only country in the region where this review is done systematically. At times, costing figures are interpreted by BPHS advocates as price tags and as targets in negotiations for resource mobilization. It is seldom acknowledged that funding is insufficient to meet the target amounts, or that current spending is not easy to reallocate, in particular from hospitals to primary health care or away from fixed commitments such as wages.
| Barriers to and facilitators of delivery and implementation|| |
Delivering a BPHS usually implies that new and different services, such as palliative care, are to be provided; that some of the existing ones, such as management of noncommunicable diseases, are to be provided differently; and that some services are to be provided in a different place, such as in primary health- care facilities rather than in hospitals. Even if available money and staff are sufficient, package implementation is likely to require substantial changes in service organization and resource management, as well as adaptation of staff, their skill mix and redistribution in line with changes in services and workloads. For this reason, a feasibility analysis is done with the intention of identifying implementation bottlenecks and corrective measures, but the results do not always translate into actual reforms. However, in some countries, management changes have improved implementation and enhanced accountability in relation to some essential package components.,
A key feature of package implementation is target setting, understood as defining the expected coverage of interventions, and making providers accountable for these targets. In Thailand, age-adjusted capitation paid to providers according to a catchment population area has helped to improve accountability. In Sri Lanka, the planned introduction of explicitly defined geographical coverage areas and cluster managers is intended to increase overall accountability in the curative sector. Elsewhere, such reforms in service delivery organization and public financial management to deliver a revised basic package are not yet happening. For example, Bangladesh and Timor-Leste have maintained supply-side financing through line-item budgeting with historical-based incremental growth; no changes in management, financial autonomy and accountability, or linking of payment to the BPHS have been introduced.
Another requirement for effective BPHS implementation is monitoring. Tracking the delivery of some services (e.g. maternal and child health, communicable disease control) may not represent a challenge, as they are already included in the current health information system. However, this does not equal monitoring the delivery of the package in its entirety (i.e. the accessibility of all the services defined in the package to the whole population). The challenge, though, is that the existing routine health information system in most countries of the WHO South-East Asia Region are not yet able to routinely record key interventions such as noncommunicable disease screening and care. This is a particular issue in countries developing new service delivery arrangements, such as municipalities in Nepal and shared care clusters in Sri Lanka. Thailand, however, has successfully introduced measures of noncommunicable disease coverage, for example of well-controlled diabetes, which are used to set performance incentives. Quite often, the lack of a proper baseline – composed of proxy indicators (e.g. coverage of selected services) — hinders monitoring of implementation progress.
| Conclusion|| |
In conclusion, the service package is – and should be seen as – a tool with great potential to help improve service delivery. However, if developed in isolation, and without clear commitment to its effective implementation, a BPHS will be a time-consuming and potentially pointless exercise. The changes required to implement the package can be complex and include reforms in the way decisions are made and how services are planned, financed and organized, as well as in the information systems used to monitor package implementation. Only health systems that integrate package development into a broader reform process are likely to succeed in implementation and in making progress towards UHC. By contrast, packages that do not recognize and address the implementation challenges are likely to stay on the shelf.
Source of support: None.
Conflict of interest: None declared.
Authorship: LVT and VOC conceived the study, identified the policy-relevant lessons from the support processes and drafted the first versions of the manuscript. XM, as one of the key providers of technical assistance, revised the subsequent draft and added the relevant references. PT critically reviewed the manuscript. All authors read and approved the final manuscript.
| References|| |
Comprehensive services package for primary health care. Dili: Ministry of Health; 2015.
Tangcharoensathien V, Witthayapipopsakul W, Panichkriangkrai W, Patcharanarumol W, Mills A. Health systems development in Thailand: a solid platform for successful implementation of universal health coverage. Lancet. 2018 Mar;391(10126):1205–23. https://doi.org/10.1016/S0140-6736(18)30198-3 PMID:29397200
Tangcharoensathien V, Patcharanarumol W, Suwanwela W, Supangul S, Panichkriangkrai W, Kosiyaporn H, et al. Defining the benefit package of Thailand universal coverage scheme: from pragmatism to sophistication. Int J Health Policy Manag. 2020 Apr;9(4):133–7. https://doi.org/10.15171/ijhpm.2019.96
El-Jardali F, Fadlallah R, Daouk A, Rizk R, Hemadi N, El Kebbi O, et al. Barriers and facilitators to implementation of essential health benefits package within primary health care settings in low-income and middle-income countries: a systematic review. Int J Health Plann Manage. 2019 Jan;34(1):15–41. https://doi.org/10.1002/hpm.2625 PMID:30132987
Wangchuk D, Virdi NK, Garg R, Mendis S, Nair N, Wangchuk D, et al. Package of essential noncommunicable disease (PEN) interventions in primary health-care settings of Bhutan: a performance assessment study. WHO South-East Asia J Public Health. 2014 Apr-Jun;3(2):154–60. https://doi.org/10.4103/2224-3151.206731 PMID:28607301
Tuangratananon T, Wangmo S, Widanapathirana N, Pongutta S, Viriyathorn S, Patcharanarumol W, et al. Implementation of national action plans on noncommunicable diseases, Bhutan, Cambodia, Indonesia, Philippines, Sri Lanka, Thailand and Viet Nam. Bull World Health Organ. 2019 Feb;97(2):129–41. https://doi.org/10.2471/BLT.18.220483 PMID:30728619
Allen LN, Pullar J, Wickramasinghe KK, Williams J, Roberts N, Mikkelsen B, et al. Evaluation of research on interventions aligned to WHO “Best Buys” for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015. BMJ Glob Health. 2018 Feb;3(1):e000535. https://doi.org/10.1136/bmjgh-2017-000535 PMID:29527342