I RECEIVED a lot of feedback on my article ‘Robotic priorities’, including some from defensive robotic surgeons! Some readers have asked about the essential health services package I referred to. Allow me to elaborate.

Healthcare systems principally act in three ways: by preventing diseases and promoting health at population and individual levels; by providing curative health services at an individual level; and through intersectoral action addressing determinants of health.

These three aspects of healthcare systems are translated into five kinds of health services: preventive, promotive, curative, rehabilitative, and palliative.

Healthcare systems deliver various combinations of these five kinds of services through five levels of the healthcare system (also called delivery platforms): community level (individual household); first-level PHC facility; first-level hospital; tertiary-level hospital; and population level (eg awareness-raising media campaigns).

With this conceptualisation, in low-resource settings, policymakers must make difficult choices. The right health services must be selected for the right levels to ensure the most efficient and effective use of limited resources to maximally benefit the people. Appropriately addressing the burden of various diseases and health risks is key. From here we enter the realm of “disease control priorities (DCP).”

The principle of prioritising health services applies to all healthcare organisations.

A story spanning 30 years, beginning with DCP1, which fed the World Bank annual flagship development report themed Investing in Health in 1993. It was the first time a proper attempt was made to assess the value for money (cost-effectiveness) of health interventions that would address the major sources of disease burden in low- and middle-income countries (L&MICs).

DCP2 came in 2006 with a focus on delivery platforms, with special attention to community-based PHC. A major global effort followed and the launch of DCP3 — which I happened to attend — took place in London, December 2017. This was a major joint effort by the World Bank, the Bill & Melinda Gates Foundation (BMGF) and WHO, housed in the Department of Global Health at the University of Washington, Seattle.

DCP3 took more than five years of analysis involving more than 500 leading global medical experts and 33 editors who produced 172 chapters in nine volumes on health services related to: Essential Surgery (Vol 1); Reproductive, Maternal, Newborn and Child Health (Vol 2); Cancer (Vol 3); Mental, Neurological, and Substance Abuse Disorder (Vol 4); Cardiovascular, Respiratory, and Related Disorders (Vol 5); Major Infectious Diseases (Vol 6); Injury Prevention and Environmental Health (Vol 7); Child and Adolescent Health and Development (Vol 8); and Disease Control Priorities: Improving Health and Reducing Poverty (Vol 9).

This work is a magnum opus on health services — an evidence-based descriptive analysis of the situation in L&MICs, detailing why and which proven cost-effective health services should be provided as a priority. DCP-3.org makes all these volumes freely available.

The ninth volume is a synthesis of the preceding eight. The basic idea is that if countries must achieve universal health care (UHC) by 2030, which health services should be provided to the people. Health services are costed and classified in 21 groups. Systematically sifting and selecting through the maze, DCP3 ultimately proposes a package of only 218 essential health services. If resources are too low then a highly prioritised sub-set package of 108 services is recommended. It was estimated that to provide these packages to a whole population, governments would have to double or triple their current level of health financing.

Two very important conclusions of this colossal work are: out of 218 health services 70 per cent are to be delivered at the PHC level and if we also include first-level hospitals then it comes to 90pc, and secondly, this minimum package must be financed by governments.

The principle of health service prioritisation however, applies to all healthcare organisations. I have noticed that most well-meaning service oriented not-for-profit organisations don’t bother to systematically invest in developing their health services package. This is the centrepiece of healthcare, and once defined, guides everything from human resource needs and training, financing, medicines and diagnostics etc.

The translational phase of this work is L&MICs developing their own packages using DCP3 as a model. As part of UHC-related assistance, WHO has been urging the development of national packages of essential services. As Director of Health System Development in WHO EMRO, I started promoting this idea to Pakistan. Eventually, with the help of DCP3, WHO, BMGF, AKU, HSA and some other partners we started developing the National EHSP.

When I assumed the office of Special Assistant to the Prime Minister, I made this a priority and finally we became the first country to systematically develop an EHSP following DCP3 and even got it costed. I had a wonderful team of young researchers at the Health Planning, System Strengthening, and Information Analysis Unit (HPSIU) in the ministry who managed this work.

Pakistan EHSP was launched in October 2020. It is the result of wide-ranging national consultations with health specialists in the country from public and private sectors. Our analysis showed that only 42 — ie less than one-fifth of the 218 interventions — were available in Pakistan’s public sector facilities, and these gaps were pronounced at the PHC level.

A highly prioritised package was ultimately developed consisting of 170 health services to be delivered at all five levels. Out of this a district-level package consisting of 88 services to be provided at community level, first-level PHC facility and first-level hospital was separated. The costing came to around $13 per person annually.

HPSIU has since worked with provincial health departments and today all provinces have developed their own packages with minor differences. All of these are available online under ‘Knowledge Hub’ on the Ministry of National Health Services, Regulation and Coordination website.

Effective implementation of these packages would effectively advance Pakistan towards universal health coverage.

More on intersectoral service packages next time.

The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.

zedefar@gmail.com

Published in Dawn, January 12th, 2024