Editorial

BMJ Glob Health: first published as 10.1136/bmjgh-2022-010724 on 19 January 2023. Downloaded from http://gh.bmj.com/ on February 1, 2023 by guest. Protected by copyright.
Essential packages of health services in
low-­income and lower-­middle-­income
countries: what have we learnt?
Ala Alwan,1 Gavin Yamey ‍ ‍ ,2 Agnès Soucat3

To cite: Alwan A, Yamey G, In September 2015, all United Nations (UN) roadmap to 2030.3 The essential UHC package
Soucat A. Essential packages Member States adopted the Sustainable includes 218 health sector interventions for
of health services in low-­
income and lower-­middle-­
Development Goals (SDGs) as an integrated lower-­middle-­income countries and a subset
income countries: what have global agenda to chart a new era for develop- of these are distilled into a ‘highest priority
we learnt?BMJ Global Health ment and poverty reduction.1 One of the key package’ of 108 interventions recommended
2023;8:e010724. doi:10.1136/ targets (SDG 3.8) is for countries to achieve for low-­income countries. In addition to its
bmjgh-2022-010724
universal health coverage (UHC) by 2030.2 focus on investing in high-­priority interven-
Four years later, in September 2019, Heads tions, DCP3 also addresses the three UHC
Received 16 September 2022 of State and Government convened a high-­ dimensions. A properly designed package
Accepted 24 December 2022 level meeting at the UN General Assembly of essential health interventions, funded
and committed to scale up efforts to accel- publicly or through prepayment schemes,
erate progress towards SDG 3.8, adopting the will reach all people, improve access to these
most effective, evidence-­ based, high-­
impact services and reduce financial risk.
and quality-­assured interventions and using The demand for technical assistance to
public spending as the main driver. Achieving LLMICs in UHC-­ related public policies is
UHC has three dimensions: increasing popu- growing, and an increasing number of coun-
lation coverage for all, expanding the range of tries have been using the DCP3 evidence and
health services and reducing financial risk. A approach to develop and implement their
key question, addressed in a new collection in own essential packages of health services
the BMJ Global Health (box 1), is: how best can (EPHS). Some of these countries have been
low-­income and lower-­middle-­income coun- technically supported by the DCP3 Country
tries (LLMICs) optimise the use of public Translation Project, based at the London
funds, and design and implement afford- School of Hygiene & Tropical Medicine and
able packages of health services to achieve funded by the Bill & Melinda Gates Foun-
the three UHC dimensions and ensure that dation.4 Besides the provision of technical
all people have access to the health care they support, the project is also reviewing the
need? experience of these countries, with the aim of
One strategic framework used by LLMICs extracting lessons learnt and updating tech-
to identify the services to be prioritised for nical guidance for other countries. A network
© Author(s) (or their public subsidy is the evidence provided and of 60 experts has been involved in reviewing
employer(s)) 2023. Re-­use the approach adopted by the third edition the experience of six countries in developing
permitted under CC BY.
Published by BMJ.
of the Disease Control Priorities (DCP3) and their national packages: Afghanistan, Ethi-
1 its model service packages. DCP3 provides a opia, Pakistan, Somalia, Sudan and Zanzibar-­
DCP3 Country Translation
Project, London School of systematic review of the evidence, including Tanzania. The review process has involved
Hygiene & Tropical Medicine, cost-­effectiveness, of a wide range of health seven groups of professionals addressing
London, UK services to support policymakers in decision-­ specific areas of EPHS development and
2
Duke Global Health Institute, making on the highest impact investments in three review meetings organised in Geneva
Duke University, Durham, North
Carolina, USA
the context of limited resources. Based on and London between September 2021 and
3
Division of Health and Social the DCP3 evidence, two generic model UHC March 2022. The collaboration resulted in
Protection, French Development packages of essential health services were the seven papers published in this collection
Agency (AFD), Paris, France launched in December 2017 as a starting (box 1).
Correspondence to
point for evidence-­informed country-­specific Achieving UHC in 8 years from now is chal-
Professor Ala Alwan; analysis of priorities that LLMICs can consider lenging for most countries, but it is even more
​ala.​alwan@​lshtm.​ac.​uk in designing their packages and charting the complex in LLMICs. There are major health

Alwan A, et al. BMJ Global Health 2023;8:e010724. doi:10.1136/bmjgh-2022-010724  1

BMJ Glob Health: first published as 10.1136/bmjgh-2022-010724 on 19 January 2023. Downloaded from http://gh.bmj.com/ on February 1, 2023 by guest. Protected by copyright.
processes in developing or revising their EPHS can have
Box 1 The seven papers in the collection
far-­reaching consequences for the scope, content, fair-
Paper 1. Alwan et al. Country readiness and prerequisites for ness and impact of the EPHS. All six countries included
successful design and transition to implementation of essential in the review followed a similar stepwise approach in their
packages of health services: Experience from six countries.5 decision-­making process. Nevertheless, they organised
Paper 2. Baltussen et al. Decision-­making processes for essential the specific steps and choice of decision criteria differ-
packages of health services: experience from six countries.6 ently. Here again, the authors advise countries to prior-
Paper 3. Gaudin et al. Using costing to facilitate policy making toward itise stakeholder involvement, which is key to fostering
Universal Health Coverage: findings and recommendations from fairness in decision making. For sustained impact,
country-­level experiences.7 countries should institutionalise their decision-­ making
Paper 4. Soucat et al. From Universal Health Coverage health
process, through a legal framework, to ensure ongoing
services packages to budget appropriation: the long journey to
EPHS revision.
implementation.8
Paper 5. Reynolds et al. Building implementable packages for Costing is important to ensure that such packages go
universal health coverage.9 beyond aspiration—they should be feasible for a country
Paper 6. Siddiqi et al. The role of the private sector in delivering to implement within its budget. In paper 3, Gaudin et al7
essential packages of health services: lessons from country reviewed how five of the six countries estimated the cost
experiences.10 of their EPHS and found wide variation in the way costing
Paper 7. Danforth et al. Monitoring and evaluating the implementation methodologies were implemented. According to the
of essential packages of health services.11 analysis presented in this paper, the variation was particu-
larly stark with respect to common health systems-­related
costs, methodologies used, capacity constraints and the
system gaps in all countries and policymakers often lack of integration between costing and budgeting. They
struggle in their efforts to address the gaps in know-­how recommend building long-­term institutional capacity in
and in capacity to address them. A solid grasp of the costing for better reliability and policy relevance. Costing
barriers impeding progress is essential. By building on and budgeting should be integrated, and EPHS costing
existing knowledge and experience on priority setting should be linked to budget cycles.
and design and implementation of UHC packages, we There are usually high expectations for what an EPHS
believe the review and analysis of country experience can achieve for health financing. In particular, some poli-
published in this collection provide important messages cymakers hope that the packages will lead to an increase in
and lessons learnt that other countries can consider. public resources. However, Soucat et al8 in paper 4 argue
It is clear from country experience that designing essen- that using EPHS to directly leverage funds for health has
tial packages of health services does not always contribute rarely been effective—though it can provide the basis
to UHC policies and programmes. Countries have little to for pooling funds. The authors also note that EPHS
gain if there is no transition from package development can translate indirectly into increased revenue through
to roll-­out. In paper 1, Alwan et al5 use country experience fiscal measures, and that the development and revisions
to review barriers to package design and transition to of EPHS are essential to core strategic purchasing activi-
implementation and highlight certain prerequisites that ties. Ultimately, packages need to translate into adequate
determine a successful outcome. For example, high-­level public financing appropriations through country health
political commitment translated into concrete actions programme design.
is paramount; setting or revising an EPHS must be led, Reynolds et al9 highlight, in paper 5, areas that are
executed and owned by countries. Early and meaningful important in building implementable packages. Key
engagement of all relevant stakeholders, especially the elements of package design, structure and content, they
planning and finance government sectors, is essential. argue, can affect the chances of successful implemen-
Affordability and health system strengthening are critical tation. As is also stressed by Alwan et al,5 the failure to
for the transition to implementation. There is limited incorporate delivery considerations already at the prior-
value in investing in package development without a itisation and design stage can result in packages that
realistic financing plan along the timeline for reaching undermine feasibility of implementation and the goals
UHC targets. Aspirational packages and those developed that countries have for service delivery. In contrast, a
with inadequate engagement of national authorities are well-­designed package can support a country in bridging
less likely to be implemented. Finally, sustainability for effectively from prioritisation to implementation.
implementing UHC packages requires leadership, polit- EPHS are mostly being delivered by the public sector.
ical stability, sustained resources and institutionalisation However, Siddiqi et al10 argue in paper 6 that the role
of technical and managerial capacity within Ministries of of the private health sector, which too often remains
Health and partner institutions. untapped, is essential for package design and imple-
Priority setting is central to package development in mentation. Many LLMICs have mixed health systems,
the context of UHC. In paper 2, Baltussen et al6 describe with an extensive and heterogeneous private health
a stepwise approach for prioritisation of health services. sector and varying degrees of governance effectiveness.
The way countries organise their decision-­ making In such countries, it is not realistic—at least in the short

2 Alwan A, et al. BMJ Global Health 2023;8:e010724. doi:10.1136/bmjgh-2022-010724

BMJ Glob Health: first published as 10.1136/bmjgh-2022-010724 on 19 January 2023. Downloaded from http://gh.bmj.com/ on February 1, 2023 by guest. Protected by copyright.
term—to provide EPHS using the public sector alone. Funding The editorial is part of a series of papers, published as a supplement,
Nevertheless, there remain important unanswered ques- coordinated by the DCP3 Country Translation Project, which is funded by the Bill &
Melinda Gates Foundation (Grant OPP1201812).
tions about engaging the private sector in implementing
Disclaimer The sponsor had no involvement in the writing of the editorial.
EPHS, including questions of accountability, quality, effi-
ciency and governance. Competing interests None declared.
Paper 7 of the supplement focuses on monitoring and Patient consent for publication Not applicable.
evaluation (M&E) of EPHS in the context of UHC.11 Provenance and peer review Not commissioned; internally peer reviewed.
EPHS development and implementation processes have Data availability statement Data sharing not applicable as no datasets generated
historically paid little attention to M&E efforts. Danforth and/or analysed in this editorial.
et al in paper 7 believe there is a lack of empirical, Open access This is an open access article distributed in accordance with the
country-­derived precedent on how to conceptualise and Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
others to copy, redistribute, remix, transform and build upon this work for any
execute M&E activities around EPHS-­related reforms. purpose, provided the original work is properly cited, a link to the licence is given,
M&E plans need to be integrated into the UHC policy and indication of whether changes were made. See: https://creativecommons.org/​
process right from the start and these plans should be licenses/by/4.0/.
aligned with the global monitoring framework for UHC ORCID iD
and national health information system structures and Gavin Yamey http://orcid.org/0000-0002-8390-7382
processes building from the SDG 3.8.1 and 3.8.2 indi-
cators on service coverage and catastrophic expendi-
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project. All authors contributed to the development of the editorial. https://www.who.int/publications/i/item/9789240026360

Alwan A, et al. BMJ Global Health 2023;8:e010724. doi:10.1136/bmjgh-2022-010724 3