Academic journal article Bulletin of the World Health Organization

Design, Content and Financing of an Essential National Package of Health Services

Academic journal article Bulletin of the World Health Organization

Design, Content and Financing of an Essential National Package of Health Services

Article excerpt

Introduction

No country in the world can provide health services to meet all the possible needs of the population, so it is advisable to establish criteria for which services to provide. Two basic criteria are the size of the burden caused by a particular disease, injury or risk factor and the cost-effectiveness of interventions to deal with it. The World Bank's World development report 1993: investing in health (1) applies these criteria to the design of an essential national package of health services. Because epidemiological profiles differ among countries, even at the same income level, the national package must be tailored to a country's circumstances. However, it should always include a minimum package of both public health measures and individual clinical services which are highly cost-effective and help resolve major health problems. Governments should ensure universal access to its national package by financing it directly or, when public resources are inadequate, by promoting private expenditure on the clinical interventions in the package. This article makes a case to justify such a package. It explains what the minimum package contains and how the component services were chosen, and estimates what it could cost, how much it could improve health, and what it implies for investment in facilities, equipment and personnel. Defining a package also clarifies the trade-off between coverage of the population and the cost-effectiveness of health care interventions that are provided, especially in poor countries.

Creating a package

Justification

Why is it advisable to collect various health services into a "package", and what does that mean? Governments could and often do proceed in other ways. They can simply agree to pay for, or guarantee to provide, any of a list of services, without considering possible relations between one intervention and

another. Or they could choose not to specify outputs at all, and agree to pay for, or provide, a particular collection of inputs: medical professionals would then decide which services were actually provided, whether by delivering services they thought were justified or by responding to patients' demand. The second approach is incompatible with maximizing value for money, or getting the maximum health gain per dollar spent, because people often demand services offering little health improvement and do not always seek those that cost less or provide a greater health gain. Medical professionals also commonly seek to provide, and to generate demand for, services of questionable value. In any case, it is impossible to decide which inputs to finance without some idea of what services they are meant to provide. The first approach--choosing interventions but not packaging them--takes no account of joint costs or co-morbidity; so the interventions chosen in this way will cost more than they should, or will reach fewer people.

The principal argument for a collection of services to be provided jointly is to minimize the total cost of the package by exploiting the shared use of inputs and by reducing the cost to patients of obtaining services. Clustering of interventions improves cost-effectiveness through at least three mechanisms: synergism between treatment or prevention activities; joint production costs; and improved use of specialized resources through the screening of patients at the first level of care, to ensure that a small share of high-risk cases can be recognized and referred to hospital. Sometimes a cluster of diseases can be treated together, because they share diagnostic procedures or treatment protocols, or even the same drugs. And sometimes services can be organized to reach related individuals, e.g., integration of maternal and child care. Thus the package becomes more than simply a list of interventions: properly understood, it is also a vehicle for orienting demand and improving referral.

These are primarily medical reasons why services should be packaged in order to increase the health gain from a given collection of inputs. …

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