1. IN THE NAME OF GOD Flagship Course on Health Sector Reform and Sustainable Financing; Module 4: : How to construct

2. How to toConstruct A BASIC PACKAGE OF HEALTH SERVICES A BASIC PACKAGE OF HEALTH SERVICES

3. Information needed for prioritization 1. Many different types of information will need to be combined in order to adequately define a package of services 2. All of the different information that is required may not be readily available, but it may be possible to simplify the data requirements in practice

4. Historical Context (1) Most dev. countries have been reluctant to accept the notion of prioritization in the health sector. Most dev. countries have been reluctant to accept the notion of prioritization in the health sector. Instead, they have attempted to offer all services, ranging from the simplest to the most complex. Instead, they have attempted to offer all services, ranging from the simplest to the most complex. This approach has resulted in de facto rationing, through queues, shortages of inputs, and simply an inefficient and inequitable use of resources. This approach has resulted in de facto rationing, through queues, shortages of inputs, and simply an inefficient and inequitable use of resources.

5. Historical Context (2) The focus of this session will be on how to make the admittedly difficult choices that can avoid this problem The focus of this session will be on how to make the admittedly difficult choices that can avoid this problem

6. Principles for Making Difficult Decisions in Difficult Times 1. The financial resources for health limited. 2. Consider the financial costs of the treatments. 3. Limitation make it necessary to set priorities. 4. It isn’t possible to cover every treatment 5. The goal is to maximize the health of the population served, subject to the available resources. 6. The priority a treatment should not depend on the patient who would receive that related to us 7. Determining the priority needs magnitudes of its benefits, harms, and costs

7. 1. Estimates of benefits, harms, and costs should be based on empirical evidence. when empirical evidence contradicts subjective judgments, empirical evidence should take priority. 2. Before its use, a treatment should satisfy three criteria: 1- There is convincing evidence it is effective in improving health outcomes 1- There is convincing evidence it is effective in improving health outcomes 2- Its beneficial effects should outweigh any harmful effects on health outcomes 2- Its beneficial effects should outweigh any harmful effects on health outcomes 3- Compared to the next best alternative treatment, the treatment should represent a good use of resources and satisfies Principle #5 above. 3- Compared to the next best alternative treatment, the treatment should represent a good use of resources and satisfies Principle #5 above. 1. Judgments should reflect the preferences of the individuals who will actually receive the treatments. Principles for Making Difficult Decisions in Difficult Times

8. Approaches to toprioritizing

9. Different Approaches to Prioritizing Defining categories of care Defining categories of care Using explicit criteria Using explicit criteria Using guidelines or technology assessment Using guidelines or technology assessment Using formulas or models Using formulas or models

10. Defining categories of care Leaving more specific decisions to both politicians and health professionals Leaving more specific decisions to both politicians and health professionals Its advantages are: Its advantages are: 1. Flexibility 2.It can minimize political resistance 3.There are no explicit exclusions which can serve as a focal point for opposition Its disadvantages are: Its disadvantages are: 1.not be able to achieve an efficient allocation of resources 2.health professional incentives may not closely match with those of society as a whole.

11. Using explicit criteria 1) the identification of community needs and preferences for defining a priority list of services -Oregon, USA, 1) the identification of community needs and preferences for defining a priority list of services -Oregon, USA, 2) the criteria of effectiveness, efficiency, and necessity, and a determination of whether the service can be left to individual responsibility- Netherlands 2) the criteria of effectiveness, efficiency, and necessity, and a determination of whether the service can be left to individual responsibility- Netherlands 3) the criteria that a health problem involves a large number of people, services are available and effective, and quantified targets can be set - UK 3) the criteria that a health problem involves a large number of people, services are available and effective, and quantified targets can be set - UK

12. The disadvantages difficult for the population to agree on what criteria difficult for the population to agree on what criteria Difficulties in measurement Difficulties in measurement

13. Using guidelines or technology assessment informing both patients and practitioners informing both patients and practitioners distinct advantage of clearly defining when a service may be technically beneficial or not distinct advantage of clearly defining when a service may be technically beneficial or not does not include an economic component, nor does it incorporate community values or seek public opinion about social preferences. does not include an economic component, nor does it incorporate community values or seek public opinion about social preferences.

14. Using formulas or models Select the best mix of services Select the best mix of services based on assessments of the burden of disease and cost-effectiveness analysis to determine the best way to meet health objectives based on assessments of the burden of disease and cost-effectiveness analysis to determine the best way to meet health objectives

15. The advantages & Disadvantages It explicitly considers efficiency, and can incorporate social preferences through the valuation of distinct health states or outcomes It explicitly considers efficiency, and can incorporate social preferences through the valuation of distinct health states or outcomes need for detailed (and often unavailable) data (both technical and social) need for detailed (and often unavailable) data (both technical and social)

16. Combine 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

17. Quantifying Burden of Disease Measuring Mortality Measuring Mortality not the only measure of health status Measuring Morbidity Measuring Morbidity depend on what data are available, and the relative “weights” of death for sickness Combined Measures of Morbidity and Mortality Combined Measures of Morbidity and Mortality

18. Combined Measures of Morbidity and Mortality The Disability Adjusted Life Year Approach (DALY) The Disability Adjusted Life Year Approach (DALY) DALY approach includes discounting over time

19. Main Criticisms of DALY 1. The DALY imposes social preferences that have not been validated 1. The DALY imposes social preferences that have not been validated 2. The age weights do not reflect common preferences among health specialists, economists and general population 2. The age weights do not reflect common preferences among health specialists, economists and general population 3. The disability weights ignore the handicap attached to some permanent disabilities in different societies 3. The disability weights ignore the handicap attached to some permanent disabilities in different societies 4. DALYs are not applicable in countries with scarce health information 4. DALYs are not applicable in countries with scarce health information 5. The exclusion of late fetal deaths is unjustifiable 5. The exclusion of late fetal deaths is unjustifiable

20. Population Behavior and Preferences Focusing on current utilization of services Focusing on current utilization of services People may not necessarily seek the type of care that they should. This may result from lack of information, or perhaps a lack of supply of the type of care they should be seeking. People may not necessarily seek the type of care that they should. This may result from lack of information, or perhaps a lack of supply of the type of care they should be seeking. ignore the question of unmet demand ignore the question of unmet demand

21. Population Behavior and Preferences Potential result of ignoring population behavior: A package may be rejected politically if it does not correspond to society’s values Potential result of ignoring population behavior: A package may be rejected politically if it does not correspond to society’s values

22. Health Interventions and Outcomes How effective a given health intervention may be depends on at least three factors: How effective a given health intervention may be depends on at least three factors: the coverage rate the coverage rate the efficacy rate the efficacy rate the compliance rate the compliance rate 1- Use of expert judgment 2- Multiple impacts of an intervention

23. “Think it over...”

24. Cost &prioritizing

26. 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

27. 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

28. 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

29. 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