Costing Interventions for Developing an Essential Package of Health Services: Application of a Rapid Method and Results From Pakistan.

BACKGROUND: The Federal Ministry of National Health Services, Regulations and Coordination (MNHSR&C) in Pakistan has committed to progress towards universal health coverage (UHC) by 2030 by providing an Essential Package of Health Services (EPHS). Starting in 2019, the Disease Control Priorities 3rd edition (DCP3) evidence framework was used to guide the development of Pakistan's EPHS. In this paper, we describe the methods and results of a rapid costing approach used to inform the EPHS design process. METHODS: A total of 167 unit costs were calculated through a context-specific, normative, ingredients-based, and bottom-up economic costing approach. Costs were constructed by determining resource use from descriptions provided by MNHSR&C and validated by technical experts. Price data from publicly available sources were used. Deterministic univariate sensitivity analyses were carried out. RESULTS: Unit costs ranged from 2019 US$ 0.27 to 2019 US$ 1478. Interventions in the cancer package of services had the highest average cost (2019 US$ 837) while interventions in the environmental package of services had the lowest (2019 US$ 0.68). Cost drivers varied by platform; the two largest drivers were drug regimens and surgery-related costs. Sensitivity analyses suggest our results are not sensitive to changes in staff salary but are sensitive to changes in medicine pricing. CONCLUSION: We estimated a large number of context-specific unit costs, over a six-month period, demonstrating a rapid costing method suitable for EPHS design.

Monitoring and evaluating the implementation of essential packages of health services.

Essential packages of health services (EPHS) are a critical tool for achieving universal health coverage, especially in low-income and lower middle-income countries. However, there is a lack of guidance and standards for monitoring and evaluation (M&E) of EPHS implementation. This paper is the final in a series of papers reviewing experiences using evidence from the Disease Control Priorities, third edition publications in EPHS reforms in seven countries. We assess current approaches to EPHS M&E, including case studies of M&E approaches in Ethiopia and Pakistan. We propose a step-by-step process for developing a national EPHS M&E framework. Such a framework would start with a theory of change that links to the specific health system reforms the EPHS is trying to accomplish, including explicit statements about the 'what' and 'for whom' of M&E efforts. Monitoring frameworks need to consider the additional demands that could be placed on weak and already overstretched data systems, and they must ensure that processes are put in place to act quickly on emergent implementation challenges. Evaluation frameworks could learn from the field of implementation science; for example, by adapting the Reach, Effectiveness, Adoption, Implementation and Maintenance framework to policy implementation. While each country will need to develop its own locally relevant M&E indicators, we encourage all countries to include a set of core indicators that are aligned with the Sustainable Development Goal 3 targets and indicators. Our paper concludes with a call to reprioritise M&E more generally and to use the EPHS process as an opportunity for strengthening national health information systems. We call for an international learning network on EPHS M&E to generate new evidence and exchange best practices.

Bentall procedure as a lifesaving surgery: A single center experience.

The Bentall procedure is a surgical technique used in the management of aortic root abnormalities with ascending aorta and aortic valve issues. The present study aimed to evaluate the outcomes of 18 patients treated with the Bentall procedure in a single center. The present study was a single-center retrospective case series conducted over a period of 3 years. The patients had either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction. The Bentall procedure was performed via standard median sternotomy. St. Jude Medical composite grafts with a valve were applied in all cases. A total number of 18 patients with either acute ascending dissection and/or dilated ascending aorta with aortic valve dysfunction were included in the study. The age of the participants ranged from 27-60 years. The ratio of males to females was 16:2 (males, 88.8%). The symptoms developed 3-4 days prior to hospital admission. Chest pain was the most common presenting symptom (n=10, 55.5%). Hypertension was the most common risk factor (n=12, 66.6%). In total, 14 cases underwent emergency surgery (77.7%). The emergency surgery was performed in 9 patients within 24 h of arrival owing to the association of aortic root dissection with tamponade. For the other cases, the surgery was performed within 2 and 7 days (n=5, 27.7% and n=4, 22.2%) respectively. Early post-operative complications occurred in 5 patients (27.7%). On the whole, as demonstrated herein, the modifications of the Bentall procedure have a notable impact on decreasing the overall mortality rates. Raising the awareness of clinicians and the general population as regards aortic dissection may aid in the early referral of patients to specialized centers and may thus decrease the overall mortality rate.

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition.

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected.

Carbachol-induced colonic mucus formation requires transport via NKCC1, K⁺ channels and CFTR.

The colonic mucosa protects itself from the luminal content by secreting mucus that keeps the bacteria at a distance from the epithelium. For this barrier to be effective, the mucus has to be constantly replenished which involves exocytosis and expansion of the secreted mucins. Mechanisms involved in regulation of mucus exocytosis and expansion are poorly understood, and the aim of this study was to investigate whether epithelial anion secretion regulates mucus formation in the colon. The muscarinic agonist carbachol was used to induce parallel secretion of anions and mucus, and by using established inhibitors of ion transport, we studied how inhibition of epithelial transport affected mucus formation in mouse colon. Anion secretion and mucin exocytosis were measured by changes in membrane current and epithelial capacitance, respectively. Mucus thickness measurements were used to determine the carbachol effect on mucus growth. The results showed that the carbachol-induced increase in membrane current was dependent on NKCC1 co-transport, basolateral K(+) channels and Cftr activity. In contrast, the carbachol-induced increase in capacitance was partially dependent on NKCC1 and K(+) channel activity, but did not require Cftr activity. Carbachol also induced an increase in mucus thickness that was inhibited by the NKCC1 blocker bumetanide. However, mice that lacked a functional Cftr channel did not respond to carbachol with an increase in mucus thickness, suggesting that carbachol-induced mucin expansion requires Cftr channel activity. In conclusion, these findings suggest that colonic epithelial transport regulates mucus formation by affecting both exocytosis and expansion of the mucin molecules.

Monitoring and surveillance of chronic non-communicable diseases: progress and capacity in high-burden countries.

The burden of chronic, non-communicable diseases in low-income and middle-income countries is increasing. We outline a framework for monitoring of such diseases and review the mortality burden and the capacity of countries to respond to them. We show data from WHO data sources and published work for prevalence of tobacco use, overweight, and cause-specific mortality in 23 low-income and middle-income countries with a high burden of non-communicable disease. Data for national capacity for chronic disease prevention and control were generated from a global assessment that was done in WHO member states in 2009-10. Although reliable data for cause-specific mortality are scarce, non-communicable diseases were estimated to be responsible for 23·4 million (or 64% of the total) deaths in the 23 countries that we analysed, with 47% occurring in people who were younger than 70 years. Tobacco use and overweight are common in most of the countries and populations we examined, but coverage of cost-effective interventions to reduce these risk factors is low. Capacity for prevention and control of non-communicable diseases, including monitoring and surveillance operations nationally, is inadequate. A surveillance framework, including a minimum set of indicators covering exposures and outcomes, is essential for policy development and assessment and for monitoring of trends in disease. Technical, human, and fiscal resource constraints are major impediments to the establishment of effective prevention and control programmes. Despite increasing awareness and commitment to address chronic disease, concrete actions by global partners to plan and implement cost-effective interventions are inadequate.

Raising the priority of preventing chronic diseases: a political process.

Chronic diseases, especially cardiovascular diseases, diabetes, cancer, and chronic obstructive respiratory diseases,are neglected globally despite growing awareness of the serious burden that they cause. Global and national policies have failed to stop, and in many cases have contributed to, the chronic disease pandemic. Low-cost and highly effective solutions for the prevention of chronic diseases are readily available; the failure to respond is now a political, rather than a technical issue. We seek to understand this failure and to position chronic disease centrally on the global health and development agendas. To identify strategies for generation of increased political priority for chronic diseases and to further the involvement of development agencies, we use an adapted political process model. This model has previously been used to assess the success and failure of social movements. On the basis of this analysis,we recommend three strategies: reframe the debate to emphasise the societal determinants of disease and the interrelation between chronic disease, poverty, and development; mobilise resources through a cooperative and inclusive approach to development and by equitably distributing resources on the basis of avoidable mortality; and build one merging strategic and political opportunities, such as the World Health Assembly 2008­13 Action Plan and the high level meeting of the UN General Assembly in 2011 on chronic disease. Until the full set of threats­which include chronic disease­that trap poor households in cycles of debt and illness are addressed, progress towards equitable human development will remain inadequate.

A review of non-communicable disease in low- and middle-income countries.

Non-communicable disease (NCD)-primarily heart and stroke disease, cancer, chronic obstructive pulmonary disease and diabetes-caused an estimated 35 million deaths in 2005, 80% of which occurred in low- and middle-income countries (LAMICs). By 2030, 8 of 10 leading causes of death will be linked to these conditions. The burden of NCDs poses serious implications for social and economic development worldwide but particularly for LAMICs. WHO and member states have developed a clear vision represented by the Global Strategy for the Prevention and Control of Noncommunicable Diseases and an implementation plan to tackle this epidemic, incorporating lessons learned from international experience and the work of WHO in member states. The 2008 NCD Action Plan, which advocates an integrated approach to NCD prevention and control, with emphasis on the role of primary health care, is based on current scientific knowledge, available evidence and a review of international experience. It comprises a set of actions to tackle the growing public-health burden imposed by NCDs. For the plan to be implemented successfully, high-level political commitment and the concerted involvement of governments, communities and health-care providers are required; in addition, public-health policies will need to be reoriented and allocation of resources improved.

Jordan palliative care initiative: a WHO Demonstration Project.

A model for pain relief and palliative care for the Middle East has been established in Jordan. King Hussein Cancer Centre (KHCC) in Amman is now a truly comprehensive cancer center as it includes palliative care for inpatients, outpatients, and patients at home. This is especially important in a country and a region where over 75% of the cancer patients are incurable when diagnosed. To support effective palliative care delivery, there have been many significant changes in Jordan between 2001 and 2006. Regulations governing opioid prescribing have been changed to facilitate effective pain management. The national opioid quota has been increased. Cost-effective, generic, immediate-release morphine tablets are being produced in Jordan. Intensive, interactive bedside training courses for doctors, nurses, and clinical pharmacologists have started to overcome opiophobia and motivate health care professionals to take up palliative care as a profession. "Champions" for palliative care have emerged who are leading the development of palliative care in Jordan's health care systems and starting to support neighboring countries to develop pain relief and palliative care. While before 2003, fewer than 250 patients per year received palliative care, by 2006 more than 800 patients per year were receiving pain relief and palliative care through the KHCC and Al Basheer Hospital. The achieved changes and the unusually rapid and effective institutionalization of palliative care serve as a model for other countries in the Middle East region as to what should be done and how.