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Awad Mataria¹, Reza Majdzadeh², Deena Al Asfoor¹, Hassan Salah¹ and Zafar Mirza^1,3

¹Universal Health Coverage and Health Systems Department, World Health Organization Regional Office for the Eastern Mediterranean, Cairo, Egypt (Correspondenceto D Al Asfoor: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ). ²Interdisciplinary Research and Practice Division, School of Health and Social Care, University of Essex, Colchester, United Kingdom. ³Shifa Tameer-i-Millat University, Islamabad, Pakistan.

Abstract

Background: Many countries in the Eastern Mediterranean Region (EMR) have developed packages of services for achieving Universal Health Coverage (UHC), however, policymakers, especially in resource-constrained countries, still face challenges in delivering equitable, efficient and sustainable health services.

Aims: To provide guidance for EMR countries and develop packages of services for UHC.

Methods: We used information gathered from narrative reviews, national experiences and expert consultations to develop step-by-step guidance for the development of national packages of services for the achievement of UHC by countries in the EMR.

Results: The processes used to develop packages of services varied between EMR countries and these processes may not have involved all relevant stakeholders. We highlight in this paper the iterative processes, including several phases and steps, to be used by EMR countries for developing packages of services for UHC. These processes also make provision for continuous monitoring and revision to make necessary improvements as morbidity patterns evolve.

Conclusion: Developing a package of services for the achievement of UHC is a significant milestone for EMR countries and it is central to shaping the healthcare system for effective delivery of services.

Keywords: UHC, PHC, health systems, service delivery, EMR

Citation: Mataria A, Majdzadeh R, Al Asfoor D, Salah H, Mirza Z. Translating political commitments into actions to enhance Universal Health Coverage in the Eastern Mediterranean Region. East Mediterr Health J. 2023;29(12):980–986. https://doi.org/10.26719/emhj.23.112 Received: 29/11/22; Accepted: 26/04/23

Copyright © Authors 2023; Licensee: World Health Organization. EMHJ is an open access journal. This paper is available under the Creative Commons Attribution Non-Commercial ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

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Introduction

Universal Health Coverage (UHC) means that all individuals and communities receive the health services they need, with good quality and without suffering financial hardship (1). The health services should include promotion, prevention, treatment, rehabilitation, and palliative care (2). However, limited resources, evolving health needs, increasing expectations of individuals, and rapid technological developments all challenge the realization of UHC in most countries (3,4). To address the equity and efficiency dilemma associated with the trade-offs between the 3 UHC dimensions of whom to cover, what to cover, and to what extent to cover, the Lancet Commission on Investing in Health proposed in 2013 the progressive universalism approach (4). This approach hinges on defining a high-priority package of interventions for the entire population, while ensuring financial protection for all and introducing additional interventions as resources are made available.

In 2018, Member States of the WHO Eastern Mediterranean Region (EMR) endorsed the Salalah Declaration on UHC as a regional roadmap to achieve UHC by 2030 (5). This declaration is anchored on defining what to cover under a national health agenda as a basis for advancing UHC through progressive universalism. The programmes, services, and interventions to be considered are labelled packages of priority services for UHC (6,7). Designing and implementing such a package allows governments to focus their financial, technical, and managerial support on prioritized programmes, services, and interventions with maximum impact on the health and well-being of the population (8).

Defining a package of services for UHC

The EMR defines a package of services for UHC as a set of health interventions to which a population is guaranteed access through a range of government assurance mechanisms. These mechanisms may include direct financing or direct service provision for some groups, mandatory contribution and prepayment schemes,

and regulatory structures that indicate what public and private entities must pay for or deliver. Packages are usually designed to: include interventions that are essential to meet people’s needs throughout their

lifespan; include services for many diseases and population-specific programmes; and span the full spectrum of promotive, preventive, resuscitative, curative, rehabilitative, and palliative care (9,10). Identifying what to include in a package of services for UHC should be based on several principles, such as: (1) high quality and patient-centred care; (2) support of progressive universalism; (3) context specificity and explicit criteria; (4) coverage through relevant financial arrangements; (5) democracy and inclusiveness; (6) support for health system planning and implementation; (7) strengthening of health security; (8) use of evidence-informed and deliberative processes; and (9) openness and transparency in all steps of the process (11). Deciding upon what should be in and what should be out of a package of services for UHC requires a systematic and institutionalized process with clearly defined criteria. To support countries in designing their packages, the WHO Regional Office for the Eastern Mediterranean (WHO/EMRO) has outlined a set of key considerations for Member States (12,13).

Regional status and challenges

Natural and human-made emergencies in the EMR contribute to many challenges that undermine performance of the health system and limit health outcomes. Currently, 8 of 22 countries in the EMR face complex humanitarian emergencies (14). More than 30 million people in the EMR are displaced, and 108 million need humanitarian assistance (15). At the same time, changes in lifestyle and the environment are affecting the morbidity and mortality patterns in all countries, including in countries affected by fragility, conflict, and violence (16). Those factors, in addition to weak performing health systems in some countries that have inefficient governance structures and processes, inadequate financial protection arrangements, unregulated private sector delivery, shortage in the health workforce, and limited access to essential drugs and vaccines, have slowed progress towards achieving UHC (17). In the EMR, the Service Coverage Index ranged between 25.0% and 77.0% in 2020, and in the same year, 6.1 million people experienced catastrophic health expenditure (18, 19). The situation became more challenging following the COVID-19 pandemic as essential health services in almost all countries were interrupted (20).

In most EMR countries, it is unclear which health services have been chosen based on defined criteria, such as the burden of disease or health needs, and whether those services were updated following any change in the epidemiological situation and population characteristics. Provision of relevant health services across the various levels of the health system, and defining clear patient pathways and referral systems, can improve the quality, equity, and efficiency of the health system. It is our conviction that all EMR countries could benefit from instituting evidence-informed decisions to expand their service coverage (21).

Many countries in the EMR have developed packages of services for UHC. However, some still maintain implicit entitlements, leaving room for inequity, ambiguity, and health system inefficiencies. Despite ample support of donors for development of packages of services for UHC in countries affected by fragility, conflict, and violence, the packages developed are not always adequately implemented, further compromising service coverage and financial protection (22). We argue that an evidence-informed approach to developing explicit packages of services for UHC can promote efficient use of resources, and enhance health equity, service quality, and governance structures and mechanisms.

Status of packages of UHC services in selected EMR countries

Several countries have explicit packages of UHC services under various names. The processes for developing those packages vary between countries, and it is unclear whether all relevant stakeholders were engaged in the process in many countries. The packages agreed upon may or may not be provided, and the quality standards of the services are unclear. Table 1 describes the process and stage of development of the packages in some EMR countries.

Designing a national package of UHC services

We propose a set of steps to be followed by countries as they define their packages of UHC services. Some of these steps could be implemented simultaneously.

Phase 1: Preparation

Advocacy and awareness: initially, an advocacy campaign should be planned to mobilize policy-makers and stakeholders, including academia, civil society, and parliamentarians, at the national and subnational levels.

Establishment of an organizational structure and mechanism: with Ministry of Health leadership, a committee responsible for the planning and development of the package should be established. This committee should be composed of: policy-makers; health service managers; representatives of the national health insurance agency; representatives of the Ministry of Finance; epidemiologists; health economists; health system experts; patient associations; and representatives of nongovernmental organizations, WHO, and other development partners.

Stakeholder engagement: the stakeholder analysis should identify relevant groups and institutions and examines their perceptions, attitudes, and influence, and accordingly develop an engagement plan, taking stock of stakeholder power dynamics, and should make use of available resources within the country (23). Potential stakeholders who should be considered when mapping are: patients, the public and carers (the community), opinion leaders, healthcare providers and health professionals, purchasers, payers, policy-makers, product makers (manufacturers and technology producers), and academia (24).

Phase 2: Development

Situation analysis: this should describe the current package, health system functions and architecture, governance, and administrative arrangements, and the human and financial resources and capacities.

Data and evidence: priority health problems should be identified from available data sources, such as the Global Burden of Diseases Study, electronic medical records, national official statistics, and peer-reviewed and grey literature. The mapping should also include the geographic and socioeconomic factors of illness.

Dialogue and selection criteria: the responsible focal point should coordinate the choice of a reference list of interventions as a benchmark. For this, the WHO Service Package Delivery & Implementation Tool is a valuable resource that incorporates several packages such as the EMRO reference package, EMRO reference package for emergency situations, and national service packages. While choosing their respective packages, countries should consider the benefits and drawbacks of the available resources and choose from the ones most consistent with the local context (13,25–27). The package of UHC services focal point and working groups should determine the criteria that guide the selection of interventions through a consultative process. Some of the criteria used are (28): availability of resources; feasibility of implementation; cost-effectiveness of the proposed interventions; socioeconomic distribution of the health concern; availability and sustainability of funding; budget impact; political and community acceptance; and political interest and commitment. After the national team (the focal point and relevant working group) has decided on the criteria, the package of services should be chosen quantitatively using multiple-criteria decision analysis. Alternatively, the package focal point should use qualitative methods, such as policy dialogues and nominal group techniques, to choose relevant interventions (29–31).

Decision: at this stage, legal instruments should be issued to adopt the package of services nationally. The laws and regulations should be issued in compliance with the country’s legal and administrative environment.

Phase 3: Implementation

Communication: the package of UHC services should be disseminated to relevant stakeholders, such as policy-makers, funders, service providers, and the community, using appropriate communication strategies and channels.

Institutionalization: implementation bodies should be aware of the package and their role in implementing it. Each body should be responsible for establishing the necessary institutional arrangements for implementation. Operational capacities and resource gaps could surface at this stage, and a mechanism should be established to identify those gaps and coordinate relevant solutions.

Monitoring and evaluation: a monitoring body should develop indicators for measuring the status of implementation of the package, identifying implementation gaps, and evaluating the impact of the package. Also, a separate entity should monitor the epidemiological situation and highlight any population health risks.

It is crucial to establish a systematic review process through which interventions could be added, removed, or modified according to the changing morbidity and mortality pattern in the country. The frequency of the review is country-specific, and depends on the evolving epidemiological situation and anticipated modifications or health system reforms. For example, where the disease pattern is consistent, and no human-made or natural crises are anticipated, the package of services could be revised every 5 years. In more volatile situations, or in the event of a crisis, or a drastic change in the population or epidemiological structure, such as when migrant numbers suddenly increase, health authorities may wish to revise the package more frequently, every 2 years, or even immediately after a crisis.

Conclusion

Despite the COVID-19 pandemic, health policy-makers worldwide must sustain progress towards achieving UHC. Lack of access to services during the pandemic precipitated a broader healthcare access gap and drove more people into financial hardship (32). Undoubtedly, UHC indicators have worsened, and the disruption of essential health services has created a global rise in mortality and morbidity (33). The pandemic has revealed gaps in the current service delivery, and the need to develop country-specific, fit-for-context models of care. Recovery from the pandemic provides an opportunity for integrating vertical health programmes, for example: communicable and noncommunicable diseases; mental health; and reproductive, maternal, neonatal, child, and adolescent health, to enhance people-centeredness, responsiveness, and efficiency, and define integrated, comprehensive, essential health service packages (34).

Competing priorities and financial pressures often influence the choice of health services to be maintained during emergencies. In such conditions, the need for rapid solutions makes evidence-informed policy decisions unlikely. However, having a package of UHC services can help countries in defining a priority list of essential health services, thus fostering efficient and fair solutions in times of crisis (35).

A well-developed package of UHC services can be the centrepiece of a healthcare system and help shape all other elements in the health system (6). Designing a package is the first step in ensuring that health services reach those who need them. All health system components must be reorganized to deliver those entitlements. Well-defined, coherent processes, an adequately trained health workforce, accountable institutions, rationally selected drugs and technologies, equitable and sustainable financing arrangements, and high-performing health information systems are all prerequisites for effective implementation of the UHC package (36). Eliciting and managing people’s expectations and educating them about their entitlements are essential to advance the UHC goals of equity in access, quality, and financial protection (7). During implementation, countries could prioritize certain disadvantaged groups, such as poor people, and strengthen the referral systems between various delivery platforms to ensure timely and uninterrupted health services, and consequently, successful implementation of the package.

Health entitlements supported by the legislative tools can help mitigate the impact of protracted fragility and increased healthcare needs in countries affected by violence, natural disaster, or war. Intense efforts are needed to build the capacity of Member States in priority setting, evidence generation and utilization, fiscal space analysis, intersectoral and community engagement, and the rule of law (37).

Funding: None.

Competing interests: None declared.

Traduire les engagements politiques en actions visant à renforcer la couverture sanitaire universelle dans la Région de la Méditerranée orientale

Résumé

Contexte : De nombreux pays de la Région de la Méditerranée orientale ont mis au point des ensembles de services pour assurer la couverture sanitaire universelle (CSU), mais les responsables de l'élaboration des politiques, en particulier dans les pays aux ressources limitées, sont encore confrontés à des difficultés pour fournir des services de santé équitables, efficaces et durables.

Objectif : Fournir aux pays de la Région de la Méditerranée orientale des orientations et mettre en place des ensembles de services visant à renforcer la couverture sanitaire universelle.

Méthodes : Nous avons utilisé les informations recueillies à partir d'examens narratifs, d'expériences menées au niveau national et de consultations avec des experts pour élaborer des orientations détaillées. Ces dernières ont pour objectif de mener à la création d'ensembles de services nationaux visant à garantir la couverture sanitaire universelle dans les pays de la Région.

Résultats : Les procédures utilisées pour mettre au point ces ensembles de services variaient d'un pays à l'autre et n'ont pas nécessairement impliqué toutes les parties prenantes concernées. Dans le présent article, nous mettons en évidence les processus itératifs, comprenant plusieurs phases et étapes, que ces pays doivent suivre pour mettre en place les ensembles de services permettant de garantir la CSU. Ces processus prévoient également un suivi et une révision continus afin d'apporter les améliorations nécessaires en fonction de l'évolution des tendances en matière de morbidité.

Conclusion : La mise au point d'un ensemble de services permettant de réaliser la CSU constitue une étape majeure pour les pays de la Région de la Méditerranée orientale et joue un rôle central dans la conception d'un système de santé capable de fournir des services efficaces.

تحويل الالتزامات السياسية إلى إجراءات من أجل تعزيز التغطية الصحية الشاملة في إقليم شرق المتوسط

عوض مطرية، رضا مجدزادة، دينا العصفور، حسن صلاح، ظفر ميرزا

الخلاصة

الخلفية: أعد العديد من البلدان في إقليم شرق المتوسط حُزم خدمات من أجل تحقيق التغطية الصحية الشاملة، ولكن لا يزال راسمو السياسات، لا سيَّما في البلدان ذات الموارد المحدودة، يواجهون تحديات في تقديم خدمات صحية مُنصِفة وفعَّالة ومستدامة.

الأهداف: هدفت هذه الدراسة الى تقديم الإرشادات لبلدان إقليم شرق المتوسط وإعداد حزم الخدمات من أجل تحقيق التغطية الصحية الشاملة.

طرق البحث: استخدمنا المعلومات المجمعة من الاستعراضات السردية والخبرات الوطنية ومشاورات الخبراء لإعداد إرشادات مُفصَّلة لإعداد حزم وطنية من الخدمات من أجل تحقيق التغطية الصحية الشاملة في بلدان إقليم شرق المتوسط.

النتائج: تباينت العمليات المستخدمة في إعداد حزم الخدمات بين بلدان إقليم شرق المتوسط، وقد لا تشمل هذه العمليات جميع أصحاب المصلحة المعنيين. ونسلط الضوء في هذه البحث على العمليات المتكررة، التي تتضمن عدة مراحل وخطوات، لتستخدمها بلدان إقليم شرق المتوسط في إعداد حزم الخدمات من أجل تحقيق التغطية الصحية الشاملة. وتنص هذه العمليات كذلك على الرصد والتنقيح المستمريْن لإدخال التحسينات اللازمة مع تطور أنماط المراضة.

الاستنتاجات: يُعَد إعداد حزمة من الخدمات لتحقيق التغطية الصحية الشاملة مرحلة رئيسية مهمة لبلدان إقليم شرق المتوسط، ولها دور محوري في تشكيل نظام الرعاية الصحية من أجل تقديم الخدمات بفاعلية.

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