Essential Health Package Research Articles

From adversity to advancement: leveraging war-tested approaches for the post-conflict reformation of the Ukrainian healthcare landscape.

The Russo-Ukrainian Conflict has had significant repercussions on Ukraine's healthcare system, resulting in civilian casualties and damage to healthcare institutions. The disruption of personnel, medical supplies, and patient transportation has created considerable challenges for healthcare services. However, there are successful approaches from comparable contexts that can serve as a catalyst for post-conflict healthcare reformation in Ukraine. Key strategies include improving healthcare accessibility for marginalized populations through standardized essential health and surgical care packages, rehabilitating damaged facilities, strengthening primary care provisions, and supporting war survivors with disabilities. By adopting these proven practices, Ukraine can strengthen its healthcare system and facilitate a sustainable recovery, contributing to the country's resilience and ensuring essential healthcare services for its population.

The human right to health, inclusion and essential health care packages in low income countries: “health for all” in Malawi

PurposeHealth in low-income countries has become associated with the provision of minimum guaranteed public health services though Essential Health Packages (EHPs). How far do EHPs deliver the human right to health for all? This study addresses this question through qualitative research into access to health care for vulnerable communities, using Malawi as a case study. This study shows that there are significant accountability gaps and perceptions of weak service provision in Malawi’s EHP in relation to some particularly marginalised (and stigmatised) groups that limit the right to health and the promise of “health for all”.Design/methodology/approachThis study extends the body of qualitative work on EHPs in general and on Malawi in particular by exploring the perceptions of key stakeholders in relation to inclusivity and the delivery of health policies to particularly vulnerable groups. To do so, this study adopted an approach based on interpretive epistemologies (Scott, 2014). This study conducted largely unstructured interviews with a range of health stakeholders, speaking to stakeholders individually, rather than through focus groups due to the potentially sensitive nature of the topic.FindingsThe findings of this study are as follows: limited inclusion of civil society actors and local communities; local communities and local policymakers feel frustration with the gap between the promises of consultation in the EHP and the reality, and the difficulties of not having effective channels of communication; and exclusionary health practices for particularly vulnerable groups.Research limitations/implicationsThere are limitations based on the qualitative methodology, and in terms of the particularly vulnerable groups – the authors studied two such groups (people with disabilities and those who identify as LBTQ) but a wider survey of vulnerable groups is needed to extend and confirm the findings.Practical implicationsGreater attention to the health rights of vulnerable groups would improve access and services, even in the context of resource restrictions. This study suggests that a deeper engagement with human rights-based approaches would pay dividends in terms of increasing access to health in Malawi, even within the constraints of the EHP process. Furthermore, without this, there is the risk that discrimination and exclusion will become more embedded in health policies, rather than progressively minimised.Social implicationsWithout addressing these issues, there is the risk that discrimination and exclusion will become more embedded in health policies, rather than progressively minimised.Originality/valueThis paper makes an important contribution to the growing literatures on EHP in sub-Saharan Africa and Malawi in particular and to the importance of listening to stakeholder perceptions. It provides original data on stakeholder perspectives of the challenges associated with universalising health care in resource-constrained countries. To the best of the authors’ knowledge, it is one of the first papers to focus on the rights of disabled and LBTQ people in relation to EHPs.

How equitable is health spending on curative services and institutional delivery in Malawi? Evidence from a quasi-longitudinal benefit incidence analysis

BackgroundMalawi is one of a handful of countries that had resisted the implementation of user fees, showing a commitment to providing free healthcare to its population even before the concept of Universal Health Coverage (UHC) acquired global popularity. Several evaluations have investigated the effects of key policies, such as the essential health package or performance-based financing, in sustaining and expanding access to quality health services in the country. Understanding the distributional impact of health spending over time due to these policies has received limited attention. Our study fills this knowledge gap by assessing the distributional incidence of public and overall health spending between 2004 and 2016.MethodsWe relied on a Benefit Incidence Analysis (BIA) to measure the socioeconomic inequality of public and overall health spending on curative services and institutional delivery across different health facility typologies. We used data from household surveys and National Health Accounts. We used a concentration index (CI) to determine the health benefits accrued by each socioeconomic group.ResultsSocioeconomic inequality in both public and overall health spending substantially decreased over time, with higher inequality observed in overall spending, non-public health facilities, curative health services, and at higher levels of care. Between 2004 and 2016, the inequality in public spending on curative services decreased from a CI of 0.037 (SE 0.013) to a CI of 0.004 (SE 0.011). Whiles, it decreased from a CI of 0.084 (SE 0.014) to a CI of 0.068 (SE 0.015) for overall spending in the same period. For institutional delivery, inequality in public and overall spending decreased between 2004 and 2016 from a CI of 0.032 (SE 0.028) to a CI of -0.057 (SE 0.014) and from a CI of 0.036 (SE 0.022) to a CI of 0.028 (SE 0.018), respectively.ConclusionsThrough its free healthcare policy, Malawi has reduced socioeconomic inequality in health spending over time, but some challenges still need to be addressed to achieve a truly egalitarian health system. Our findings indicate a need to increase public funding for the health sector to ensure access to care and financial protection.

Developing Malawi's Universal Health Coverage Index.

The inclusion of Universal Health Coverage (UHC) in the Sustainable Development Goals (target 3.8) cemented its position as a key global health priority and highlighted the need to measure it, and to track progress over time. In this study, we aimed to develop a summary measure of UHC for Malawi which will act as a baseline for tracking UHC index between 2020 and 2030. We developed a summary index for UHC by computing the geometric mean of indicators for the two dimensions of UHC; service coverage (SC) and financial risk protection (FRP). The indicators included for both the SC and FRP were based on the Government of Malawi's essential health package (EHP) and data availability. The SC indicator was computed as the geometric mean of preventive and treatment indicators, whereas the FRP indicator was computed as a geometric mean of the incidence of catastrophic healthcare expenditure, and the impoverishing effect of healthcare payments indicators. Data were obtained from various sources including the 2015/2016 Malawi Demographic and Health Survey (MDHS); the 2016/2017 fourth integrated household survey (IHS4); 2018/2019 Malawi Harmonized Health Facility Assessment (HHFA); the MoH HIV and TB data, and the WHO. We also conducted various combinations of input indicators and weights as part of sensitivity analysis to validate the results. The overall summary measure of UHC index was 69.68% after adjusting for inequality and unadjusted measure was 75.03%. As regards the two UHC components, the inequality adjusted summary indicator for SC was estimated to be 51.59% and unadjusted measure was 57.77%, whereas the inequality adjusted summary indicator for FRP was 94.10% and unweighted 97.45%. Overall, with the UHC index of 69.68%, Malawi is doing relatively well in comparison to other low income countries, however, significant gaps and inequalities still exist in Malawi's quest to achieve UHC especially in the SC indicators. It is imperative that targeted health financing and other health sector reforms are made to achieve this goal. Such reforms should be focused on both SC and FRP rather than on only either, of the dimensions of UHC.

Project Planning and Sustainability; Versus Community Involvement in Essential Nutrition and Health Package Project

Project Planning and Sustainability; Versus Community Involvement in Essential Nutrition and Health Package Project

How actors, processes, context and evidence influenced the development of Malawi's Health Sector Strategic Plan II.

Health sector strategic plans are health policies outlining health service delivery in low- and middle- income countries, guiding health sectors to meet health needs while maximizing resources. However, little research has explored the formulation of these plans. This study utilized qualitative methods to explore the formulation of Malawi's Health Sector Strategic Plan II, including processes utilized, actors involved, important contextual factors and the use of evidence-based decision-making. Thirteen semi-structured key informant interviews with health policy actors were conducted to explore perceptions and experiences of formulating the policy. Data analysis used an inductive-deductive approach and interpretation of the data was guided by an adapted version of the Walt and Gilson Health Policy Triangle. Our results indicate that HSSP II formulation was complex and inclusive but that the Ministry of Health may have given up ownership of the formulation process to development partners to ensure their continued involvement. Disagreements between actors centered around inclusion of critical services in the Essential Health Package and selection of performance-based financing as purchasing strategy. Resource constraints and the Cashgate Scandal are critical contextual elements influencing the formulation and content of the policy. Evidence-based decision-making contributed to the plan's development despite respondents' divergent opinions regarding evidence availability, quality and the weight that evidence carried. The study raises questions regarding the roles of policy actors during health policy formulation, the inclusivity of health policy processes and their potential influence on government ownership of health policy, as well as the use of evidence in developing health sector strategic plans.

Allocating resources to support universal health coverage: development of a geographical funding formula in Malawi

BackgroundUniversal health coverage (UHC) requires that local health sector institutions—such as local authorities—are properly funded to fulfil their service delivery commitments. In this study, we examine how formula funding can...

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Towards evidence-based integration of services for HIV, non-communicable diseases and substance use: insights from modelling.

Distributional impact of the Malawian Essential Health Package.

In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health and reducing health inequality. We conduct aggregate DCEA of potential health benefits package interventions to demonstrate the feasibility of this approach in LMICs, using the case of the Malawian health benefits package. We use publicly available survey and census data common to LMICs and describe what challenges we encountered and how we addressed them. We estimate that diseases targeted by the health benefits package are most prevalent in the poorest population quintile and least prevalent in the richest quintile. The survey data we use indicate socioeconomic patterns in intervention uptake that diminish the population health gain and inequality reduction from the package. We find that a similar set of interventions would be prioritized when impact on health inequality is incorporated alongside impact on overall population health. However, conclusions about the impact of individual interventions on health inequalities are sensitive to assumptions regarding the health opportunity cost, the utilization of interventions, the distribution of diseases across population groups and the level of aversion to inequality. Our results suggest that efforts to improve access to the Essential Health Package could be targeted to specific interventions to improve the health of the poorest fastest but that identifying these interventions is uncertain. This exploratory work has shown the potential for applying the DCEA framework to inform health benefits package design within the LMIC setting and to provide insight into the equity impact of a health benefits package.

Strengthening primary health care at district-level in Malawi - determining the coverage, costs and benefits of community-directed interventions

BackgroundCommunity-Directed Interventions (CDI) is a participatory approach for delivery of essential healthcare services at community level. It is based on the values and principles of Primary Health Care (PHC). The CDI approach has been used to improve the delivery of services in areas that have previously applied Community-Directed Treatment with ivermectin (CDTi). Limited knowledge is available about its added value for strengthening PHC services in areas without experience in CDTi. This study aimed to assess how best to use the CDI approach to strengthen locally identified PHC services at district level.MethodsThis was a comparative intervention study carried out over a period of 12 months and involving four health centres and 16 villages assigned to 1) a conventional Essential Health Package (EHP)/PHC approach at health centre level or 2) an EHP/PHC/CDI approach at community level in addition to EHP/PHC at health centre level. Communities decided which intervention components to be included in the intervention. These were home management of malaria (HMM), long lasting insecticide treated nets (LLIN), vitamin A and treatment against schistosomiasis. The outcomes of the two strategies were compared quantitatively after the intervention was completed with regard to intervention component coverage and costs. Qualitative in-depth interviews with involved health professionals, implementers and beneficiaries were carried out to determine the benefits and challenges of applied intervention components.ResultsImplementation of the EHP/PHC/CDI approach at community level as an add-on to EHP/PHC services is feasible and acceptable to health professionals, implementers and beneficiaries. Statistically significant increases were observed in intervention components coverage for LLIN among children under 5 years of age and pregnant women. Increases were also observed for HMM, vitamin A among children under 5 years of age and treatment against schistosomiasis but these increases were not statistically significant. Implementation was more costly in EHP/PHC/CDI areas than in EHP/PHC areas. Highest costs were accrued at health centre level while transport was the most expensive cost driver. The study identified certain critical factors that need to be considered and adapted to local contexts for successful implementation.ConclusionThe CDI approach is an effective means to increase accessibility of certain vital services at community level thereby strengthening delivery of EHP/PHC services. The approach can therefore complement regular EHP/PHC efforts.Trial registrationThe study was retrospectively registered with the Pan African Clinical Trial Registry TRN: PACTR201903883154921.

The impact and cost-effectiveness of user fee exemption by contracting out essential health package services in Malawi

ObjectivesTo examine the impact and cost-effectiveness of user fee exemption by contracting out essential health package services to Christian Health Association of Malawi (CHAM) facilities through service-level agreements (SLAs) to...

Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries

BackgroundAn effective continuum of maternal care ensures that mothers receive essential health packages from pre-pregnancy to delivery, and postnatally, reducing the risk of maternal death. However, across Africa, coverage of skilled birth attendance is lower than coverage for antenatal care, indicating mothers are not retained in the continuum between antenatal care and delivery. This paper explores predictors of retention of antenatal care clients in skilled birth attendance across Africa, including sociodemographic factors and quality of antenatal care received.MethodsWe pooled nationally representative data from Demographic and Health Surveys conducted in 28 African countries between 2006 and 2015. For the 115,374 births in our sample, we estimated logistic multilevel models of retention in skilled birth attendance (SBA) among clients that received skilled antenatal care (ANC).ResultsAmong ANC clients in the study sample, 66% received SBA. Adjusting for all demographic covariates and country indicators, the odds of retention in SBA were higher among ANC clients that had their blood pressure checked, received information about pregnancy complications, had blood tests conducted, received at least one tetanus injection, and had urine tests conducted.ConclusionsHigher quality of ANC predicts retention in SBA in Africa. Improving quality of skilled care received prenatally may increase client retention during delivery, reducing maternal mortality.

Essential Health Package for India: Approach and Costing

This work analyses the disease burden and health systems indicators for states, and for the country as a whole, to understand how India might implement an Essential Health Package (EHP) under the Universal Health Coverage (UHC) programme. The analysis indicates much disparity among states, and suggests that they will need flexibility in terms of contents and mix of services as well as operational design in their EHP; one standard, countrywide EHP will not help. The operational part will depend on the availability of health infrastructure and personnel on the one hand and on the ability to raise resources for health on the other.

The economic burden of chronic non-communicable diseases in rural Malawi: an observational study.

BackgroundEvidence from population-based studies on the economic burden imposed by chronic non-communicable diseases (CNCDs) is still sparse in Sub-Saharan Africa. Our study aimed to fill this existing gap in knowledge by estimating both the household direct, indirect, and total costs incurred due to CNCDs and the economic burden households bear as a result of these costs in Malawi.MethodsThe study used data from the first round of a longitudinal household health survey conducted in 2012 in three rural districts in Malawi. A cost-of-illness method was applied to estimate the economic burden of CNCDs. Indicators of catastrophic spending and impoverishment were used to estimate the economic burden imposed by CNCDs on households.ResultsA total 475 out of 5643 interviewed individuals reported suffering from CNCDs. Mean total costs of all reported CNCDs were 1,040.82 MWK, of which 56.8 % was contributed by direct costs. Individuals affected by chronic cardiovascular conditions and chronic neuropsychiatric conditions bore the highest levels of direct, indirect, and total costs. Using a threshold of 10 % of household non-food expenditure, 21.3 % of all households with at least one household member reporting a CNCD and seeking care for such a condition incurred catastrophic spending due to CNCDs. The poorest households were more likely to incur catastrophic spending due to CNCDs. An additional 1.7 % of households reporting a CNCD fell under the international poverty line once considering direct costs due to CNCDs.ConclusionOur study showed that the economic burden of CNCDs is high, causes catastrophic spending, and aggravates poverty in rural Malawi, a country where in principle basic care for CNCDs should be offered free of charge at point of use through the provision of an Essential Health Package (EHP). Our findings further indicated that particularly high direct, indirect, and total costs were linked to specific diagnoses, although costs were high even for conditions targeted by the EHP. Our findings point at clear gaps in coverage in the current Malawian health system and call for further investments to ensure adequate affordable care for people suffering from CNCDs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1716-8) contains supplementary material, which is available to authorized users.

Provision of essential health package in public hospitals: a case of Homabay County hospitals, Kenya.

IntroductionEssential Health Packages (EHP) delivery is likely to strengthen service delivery. Healthcare utilization rate is 77% for the sick. 44% and 18% who don't seek care are hindered by cost and distance respectively. The overall child mortality rate in Kenya is 121/1000. In Homabay County, child mortality rate is 91/1000, and maternal mortality rate of 583/100000. The study looked into the provision of EHP in public hospitals in Homabay County.MethodsCross-sectional research design was used. Two hospitals were conveniently due to their municipality location. The study targeted 213 Health workers and 350 patients. Stratified sampling and proportionate sampling was used among different health workers. Sample size was determined by Yamane Formula. The study sampled 138 health workers and 186 patients. Questionnaire and key interview guide were used to collect data.ResultsThere are inadequate health workers based on 138 (100%) health workers. Insufficient drugs were reported by 138 (100%) health workers, and 120 (64.5%) patients. 115 (83.3%) health workers say ambulances are not operational. 26 (18.8%) health workers noted lack medical equipment, 138 (100%) are aware of patients referred elsewhere due to lack of medical equipment. 153 (82.3%) and 135 (72.6%) patients’ health access is hindered by cost and distance respectively. 159 (85.5%) patients don't always find services needed. 159 (85.5%) patients affected by long waiting time.ConclusionLow service provision/utilization rate in Homabay County results from lack of health workers, inadequate drugs, poor health infrastructure, and lack of access in terms of affordability, availability and distance.

Evaluating essential health packages from a human rights perspective

ABSTRACTMany countries at all levels of development have formulated an essential health package, sometimes also referred to as a health benefit plan or a health benefit basket. As defined by the World Health Organization (WHO), essential health packages (EHPs) are “health service interventions that are considered important and that society decides should be provided to everyone.” Although EHPs are not often formulated from an explicitly human rights perspective, since they are conceptualized as a guaranteed minimum of health services, much like core health obligations, they have obvious human rights import. This article evaluates the principles from which the plans are developed, the content of the packages, and the experience of countries seeking to implement them from a human rights perspective. In the process, it seeks to gain greater clarity about the health service requirements of the right to health.

Leveraging HIV platforms to work toward comprehensive primary care in rural Malawi: the Integrated Chronic Care Clinic

This case study describes an integrated chronic care clinic that utilizes a robust HIV program as a platform for NCD screening and treatment. A unique model, the integrated chronic care clinic provides longitudinal care for patients with an array of chronic diseases including HIV and common NCDs, allowing for a single visit for all of a patient's conditions. Set in Malawi's remote Neno District, this clinic structure aims to (1) increase access to care for NCD patients, (2) maximize efficiency given the severe human resource shortages, and (3) replicate strong HIV outcomes for patients with other chronic conditions. The goal is to increase the number of health facilities in Neno capable of fully delivering Malawi’s Essential Health Package, the set of cost-effective interventions endorsed by Malawi MOH to reduce burden of disease and leading causes of death.While implementation is ongoing and processes are evolving, this model of healthcare delivery has already improved the accessibility of NCD care by allowing patients to have all of their chronic conditions treated on the same day at their nearest health facility, notably without additional investment of human and financial resources. Currently, 6781 patients on antiretroviral therapy and 721 patients with NCDs are benefitting, including 379 with hypertension, 187 with asthma, 144 with epilepsy, and 76 with diabetes. Among the NCD patient population, 15.1% are HIV-positive. Success hinged largely on several factors, including clear leadership and staff ownership of their specific duties, and a well-defined and uniform patient flow process. Furthermore, deliberate and regular conversations about challenges allowed for constant iteration and improvement of processes.Moving forward, several tasks remain. We are refining the data management process to further consolidate medical records, along with integrating our tracking processes for clients who miss appointments. Additionally, we are exploring opportunities for further integration, including family planning. A follow-up patient satisfaction survey is planned for the coming months to track the impact of the clinic’s redesign.Given limited human and financial resources, innovative solutions are required to address the growing burden of chronic disease in Malawi. We have found that an integrated, patient-centered approach maximizes efficiency and reduces barriers to care for the hardest to reach patients.

Designing and Costing of an Adaptable and Flexible Essential Health Package (EHP) for Indian States

This document develops a framework for an Essential Health Package comprising 34 health categories. It provides detailed care pathways and associated costs and path-dependent conditional probabilities for Anaemia, Cardio Vascular Disease, Diabetes, and Tuberculosis. Using the frameworks developed here designers of health systems can provide detailed pathways and estimate resource requirements for all the elements of the Essential Health Package.

Public health workforce around the globe

reading through the rich mix of content in this special issue, i was intrigued by a number of things. one was the scaling up of a community health workforce in one country, which is able to reach a staggering 75% of the 160 million population, against a backdrop of a massive deficit in the medical, nursing and midwifery workforce. another was a system in which the direction of travel - in order to meet the daunting challenge of the long-term conditions burden and a public health system 'in disarray' - is seeking transformation to a 'culture of health' with a central role for the 'Community Chief Health Strategist'. i will leave you, the reader, to discover just which of the health systems are taking steps in these directions.it is obvious that the challenges of public health differ across the globe. Generally, lower income countries struggle with the more basic problems of keeping populations free from infectious diseases, while higher income countries tend to have the infrastructure to prevent many infectious diseases, and can respond quickly when there are outbreaks, but face problems of lifestyle and growing older populations with complex needs. and these countries' systems do not exist in isolation from each other. Globalization has brought opportunities for trained health workers to leave their homes and find better paid jobs elsewhere - leaving lower income countries with gaps in provision in already fragile health systems.How do we deploy the public health workforce to respond? this was a question the editorial Board of the journal thought could be a worthy topic, and we set about commissioning papers from around the world. You will find in this issue a collection of papers from different regions, each of which takes some kind of view of the public health workforce.What struck us early on was that we were faced with significant definitional problems. Just what do we mean by the public health workforce anyway? the paper from Malawi1 describes a community midwife assistant workforce operating within the context of the Essential Health Package, which resembles primary and secondary healthcare in a different context, and in other nations would be considered to be outside public health per se. the Spanish public health workforce2 tends to be deployed in occupational health, environmental health and food safety, and fascinatingly includes medics alongside pharmacists and veterinarians. While in Quebec, Canada,3 the spirit of the 1970s collective action is being reawakened so that community organisers work alongside other public health actors such as doctors, epidemiologists and health promotion workers, to reduce health inequalities from the ground up.Vivian lin's discussion of universal health coverage and the public health workforce explores this definitional issue in the context of major worldwide initiatives, and draws our attention to the focus on population health interventions being secondary to that on individual healthcare interventions - a problem many of us in public health experience at regional and local levels as well. …

Community-based management of acute malnutrition (CMAM) in sub-Saharan Africa: case studies from Ghana, Malawi, and Zambia.

Recent success with community-based management of acute malnutrition (CMAM) has spurred interest on how to improve coverage while maintaining treatment outcomes. To document, as case studies, the experience of three African countries, Malawi, Ghana, and Zambia, in scaling up CMAM. Desk review using published and unpublished data and country programmatic data and key informant interviews. All three countries, with different motivations for startup, have successfully integrated CMAM into their essential health packages for children under 5 years of age, at least in their policy and strategic documents. Strong leadership by the ministries of health has been instrumental, complemented by key stakeholders and donor partners. Implementation is at variable stages, depending on when the program rolled out, with Malawi having achieved the most integration, followed by Ghana and Zambia. Using CMAM, the three countries have significantly extended service coverage and improved treatment outcomes, with cure rates ranging from 73% in Ghana to 90% in Malawi, while maintaining very low death rates: 1.7% in Malawi, 2% in Ghana, and 5% in Zambia. CMAM is a viable option to improve service coverage and outcomes in health systems where inpatient therapeutic care alone cannot suffice.