IN THE NAME OF GOD

Flagship Course on Health Sector Reform and Sustainable Financing; Module 4:

: How to construct

How How

toto

ConstructConstruct

A BASIC PACKAGE OF A BASIC PACKAGE OF HEALTH SERVICESHEALTH SERVICES

Information needed for Information needed for prioritizationprioritization

1.1. Many different types of information will Many different types of information will need to be combined in order to need to be combined in order to adequately define a package of adequately define a package of servicesservices

2.2. All of the different information that is All of the different information that is required may not be readily available, required may not be readily available, but it may be possible to but it may be possible to simplifysimplify the the data requirements in practicedata requirements in practice

HistoricalHistorical Context (1)Context (1)

Most dev. countries have been reluctant to Most dev. countries have been reluctant to accept the notion of prioritization in the health accept the notion of prioritization in the health sector. sector.

Instead, they have attempted to offer all Instead, they have attempted to offer all services, ranging from the simplest to the services, ranging from the simplest to the most complex. most complex.

This approach has This approach has resulted in de facto resulted in de facto rationing, through queues, shortages of inputs, rationing, through queues, shortages of inputs, and simply an inefficient and inequitable use and simply an inefficient and inequitable use of resourcesof resources..

HistoricalHistorical Context (2)Context (2)

The focus of this session will The focus of this session will be on how to make the be on how to make the admittedly admittedly difficult choicesdifficult choices that can avoid this problemthat can avoid this problem

Principles for Making Principles for Making Difficult Decisions in Difficult Decisions in Difficult TimesDifficult Times

1.1. The financial resources for health limited.The financial resources for health limited.2.2. Consider the financial costs of the treatments.Consider the financial costs of the treatments.3.3. Limitation make it necessary to set priorities.Limitation make it necessary to set priorities.4.4. It isn’t possible to cover every treatment It isn’t possible to cover every treatment 5.5. The goal is to The goal is to maximize the health of the maximize the health of the

population servedpopulation served, subject to the available , subject to the available resources.resources.

6.6. The priority a treatment should The priority a treatment should not not depend on the depend on the patient who would receive that related to uspatient who would receive that related to us

7.7. Determining the priority needs magnitudes of its Determining the priority needs magnitudes of its benefits, harms, and costsbenefits, harms, and costs

1.1. Estimates of benefits, harms, and costs should be based on Estimates of benefits, harms, and costs should be based on empirical evidence. when empirical evidence contradicts empirical evidence. when empirical evidence contradicts subjective judgments, empirical evidence should take priority.subjective judgments, empirical evidence should take priority.

2.2. Before its use, a treatment should satisfy three criteria:Before its use, a treatment should satisfy three criteria: 1- There is convincing evidence it is effective in improving 1- There is convincing evidence it is effective in improving

health outcomeshealth outcomes 2- Its beneficial effects should outweigh any harmful effects 2- Its beneficial effects should outweigh any harmful effects

on health outcomeson health outcomes 3- Compared to the next best alternative treatment, the 3- Compared to the next best alternative treatment, the

treatment should represent a good use of resources and treatment should represent a good use of resources and satisfies Principle #5 above.satisfies Principle #5 above.

1.1. Judgments should reflect the preferences of the individuals Judgments should reflect the preferences of the individuals who will actually receive the treatments.who will actually receive the treatments.

Principles for Making Difficult Principles for Making Difficult Decisions in Difficult TimesDecisions in Difficult Times

Approaches Approaches

toto

prioritizingprioritizing

Different Approaches Different Approaches to Prioritizing to Prioritizing

Defining categories of careDefining categories of care Using explicit criteria Using explicit criteria Using guidelines or technology Using guidelines or technology

assessmentassessment Using formulas or modelsUsing formulas or models

Defining categories of Defining categories of carecare

Leaving more specific decisions to both Leaving more specific decisions to both politicians and health professionalspoliticians and health professionals

Its advantages are:Its advantages are:1.1. FlexibilityFlexibility2.2. It can minimize political resistance It can minimize political resistance 3.3. There are no explicit exclusions which can serve There are no explicit exclusions which can serve

as a focal point for oppositionas a focal point for opposition Its disadvantages are:Its disadvantages are:

1.1. not be able to achieve an efficient allocation of not be able to achieve an efficient allocation of resourcesresources

2.2. health professionalhealth professional incentives may not closely incentives may not closely match with those of society as a whole.match with those of society as a whole.

Using explicit criteriaUsing explicit criteria

1) the identification of community needs 1) the identification of community needs and preferences for defining a priority list and preferences for defining a priority list of services -Oregon, USA , of services -Oregon, USA ,

2) the criteria of effectiveness, efficiency, 2) the criteria of effectiveness, efficiency, and necessity, and a determination of and necessity, and a determination of whether the service can be left to whether the service can be left to individual responsibilityindividual responsibility-- Netherlands Netherlands

3) the criteria that a health problem 3) the criteria that a health problem

involves a involves a large number of peoplelarge number of people, , services are available and effective, and services are available and effective, and quantified targets can be set - UKquantified targets can be set - UK

The disadvantages The disadvantages

difficult for the population to difficult for the population to agreeagree on what criteria on what criteria

DDifficulties in measurementifficulties in measurement

Using guidelines or Using guidelines or technology assessmenttechnology assessment

informing both patients and practitioners informing both patients and practitioners

distinct advantage of clearly defining distinct advantage of clearly defining when a servicewhen a service may be technically may be technically beneficial or notbeneficial or not

does not include an does not include an economic economic componentcomponent, nor does it incorporate , nor does it incorporate community valuescommunity values or seek public opinion or seek public opinion about about social preferencessocial preferences..

Using formulas or modelsUsing formulas or models

SSelect the best mix of serviceselect the best mix of services

based on assessments of the based on assessments of the burden of disease and cost-burden of disease and cost-effectiveness analysis to effectiveness analysis to determine the best way to meet determine the best way to meet health objectiveshealth objectives

The advantageThe advantages & s & DisadvantagesDisadvantages It explicitly considers efficiency, It explicitly considers efficiency,

and can incorporate social and can incorporate social preferences through the valuation preferences through the valuation of distinct health states or of distinct health states or outcomesoutcomes

need for detailed (and often need for detailed (and often unavailable) data (both technical unavailable) data (both technical and social)and social)

Combine methodsCombine methods

It may be possible to combine certain aspects of each into a more comprehensive approach to defining priorities and constructing a basic package of health services

Quantifying Burden of Quantifying Burden of DiseaseDisease

Measuring MortalityMeasuring Mortalitynot the only measure of health statusnot the only measure of health status Measuring MorbidityMeasuring Morbiditydepend on depend on what data are availablewhat data are available, and the , and the

relative “weights” of death for sicknessrelative “weights” of death for sickness

Combined Measures of Morbidity Combined Measures of Morbidity and Mortalityand Mortality

Combined Measures of Combined Measures of Morbidity and MortalityMorbidity and Mortality

The Disability The Disability Adjusted Life Year Adjusted Life Year Approach (DALY)Approach (DALY)

DALY approach includes DALY approach includes discounting over timediscounting over time

Main Criticisms of Main Criticisms of DALYDALY 1. The DALY imposes social preferences that have not 1. The DALY imposes social preferences that have not

been validatedbeen validated

2. The age weights do not reflect common preferences 2. The age weights do not reflect common preferences among health specialists, economists and general among health specialists, economists and general populationpopulation

3. The disability weights ignore the handicap attached to 3. The disability weights ignore the handicap attached to some permanent disabilities in different societiessome permanent disabilities in different societies

4. DALYs are not applicable in countries with scarce 4. DALYs are not applicable in countries with scarce health informationhealth information

5. The exclusion of late fetal deaths is 5. The exclusion of late fetal deaths is unjustifiableunjustifiable

Population BehaviorPopulation Behavior and Preferences and Preferences

Focusing on current utilization of Focusing on current utilization of servicesservices

People may not necessarily seek the type of People may not necessarily seek the type of care that they should. This may result from lack care that they should. This may result from lack of information, or perhaps a lack of supply of of information, or perhaps a lack of supply of the type of care they should be seeking.the type of care they should be seeking.

ignore the question of unmet demandignore the question of unmet demand

Population BehaviorPopulation Behavior and Preferences and Preferences

Potential result of ignoring Potential result of ignoring population behaviorpopulation behavior: A package : A package may be rejected politically if it may be rejected politically if it does not correspond to society’s does not correspond to society’s valuesvalues

Health Interventions Health Interventions and Outcomesand Outcomes

How effective a given health intervention How effective a given health intervention may be depends on at least three factors:may be depends on at least three factors:

the coverage ratethe coverage rate the efficacy rate the efficacy rate the compliance ratethe compliance rate

1- 1- Use of expert judgmentUse of expert judgment2- 2- Multiple impacts of an interventionMultiple impacts of an intervention

“Think it over...”

Cost Cost

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prioritizingprioritizing

intervention 12

High priority

0% Coverage 100%

Floating line determined by available resources

intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11

Basic package of health services

Horizontal rationing

intervention 12

High priority

0% Coverage 100%

intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11

Basic package of health services

vertical rationing

intervention 12

High priority

0% Coverage 100%

intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11

Basic package of health services

diagonal rationing

intervention 12

High priority

0% Coverage 100%

intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11

Basic package of health services

combined rationing