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Priority Setting in Universal health coverage: Choosing services. The Three Dimensions (policy choices). Coverage. Health. Universal. How does one choose needed services?. What types of services to consider: preventive, promotive, curative, rehabilitative, palliative

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Priority Setting

in Universal health coverage:

Choosing services


The Three Dimensions (policy choices)

Coverage

Health

Universal


How does one choose needed services
How does one choose needed services?

  • What types of services to consider:

    • preventive, promotive, curative, rehabilitative, palliative

    • Across the life course

    • Across different levels of health facilities

    • procedures and pharmaceuticals and other medical goods

    • positive or negative lists

  • Main criterion:

    • Cost-effectiveness to maximize health; Getting the most out of the available funding

    • Quantifying opportunity costs when choosing less cost effective interventions

  • Implementation issues:


Millions miss out on needed health services percentage of births by medically trained persons
Millions miss out on needed health servicesPercentage of births by medically trained persons


Mdg tracer conditions cea threshold defined de facto
MDG Tracer Conditions: CEA threshold defined de facto?

  • Antenatal care: 4+ visits

  • Birth attended by skilled health personnel

  • Measles, DTP3, Hib3, HepB3

  • Children < 5: ARI visit; sleeping under ITN; ORT diarrhoea

  • ART HIV; MCTC HIV + pregnant women

  • TB: case detection rate

  • Additional as possible (based on burden, CEA threshold, budget, logistical feasibility)


But cost effectiveness is not that straighforward
But cost-effectiveness is not that straighforward:

  • Cost-effectiveness might correlate with the other axes.

    • Many cost-effective interventions are for traditional diseases of the poor

    • But many cost-ineffective interventions are costly (trauma surgery, cancer drugs, renal replacement therapy)

  • Cost-effectiveness may change:

    • Because of drop in prices due to national/global volume of sales /international pressure (tiered pricing)

    • Because of bundling of services (economies of scope);

    • Start up costs- special problem

  • Even if cost-effective, it may still not be affordable (budget constraints)


Shifting from pure cost-effectiveness to cost effectiveness ++« Quantitative analysis for qualitative insight »

Begin from CHOICE results (cluster of disease or health sector as a whole)

Use checklist to identify excluded interventions of equity or priority setting interest

Use quantitative techniques to explore concerns & illustrate impact of alternative choices

What resources will be released or foregone?

What existing treatments will have to be displaced?

What health benefits will be foregone?

What is society willing to pay for a more equitable choice of interventions?

11


Example mental health cluster
Example: Mental health (cluster) ++

At a mental health budget level of $3.50 per capita (India), efficiency results from CHOICE suggest funding the following conditions:

Epilepsy

Alcohol treatment

Depression treatment

No funding would be allocated to treatment of bipolar disorder or schizophrenia on efficiency grounds alone

However, equity & priority-setting considerations (checklist):

Conditions severe, chronic, lifelong

Not curable, limited capacity to benefit

Bad luck in the health lottery

Interventions are the only means to help

12



Implementation issues
Implementation issues ++

  • There are already pre-existing services being provided by governments of varying cost-effectiveness; e.g SHI providing coverage for hospitalization with a cap; no description of the disease or intervention being covered (subsidy).

  • Administrative ease

  • The patient does not know on consultation what diseases s/he has or what procedure/medication will be needed



Fig. 2. Health care choices in a low-income and middle-income country. The vertical axis indicates the level of public subsidy, the right-side horizontal axis refers to the population volume classified as poor and non-poor, and the left-side horizontal axis represents clinical health services divided into the minimum and the essential packages. Public subsidies should be close to 100% for the minimum package for the poor. In low-income countries the subsidy should fall, perhaps quite sharply, as resources extend to the non-poor or to interventions outside the minimum package. In middle-income countries the subsidy could extend to the non-poor and can finance part of the essential package only if the minimum package is assured for the poor and all cost-effective services are covered for the entire population (WDR93).

MIDDLE-INCOME COUNTRY

LOW-INCOME COUNTRY

Public fiannce share

Public fiannce snare

S/DALY

S/DALY

Poverty line

Total

population

Minimum

package

iNCOME

Essential

package

Minimum

package

Income

Essential

package

Total

population


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