Pakistan's Progress on Universal Health Coverage: Lessons Learned in Priority Setting and Challenges Ahead in Reinforcing Primary Healthcare.

Pakistan developed an essential package of health services at the primary health care level as a key component of health reforms aiming to achieve universal health coverage. This supplement describes the methods and processes adopted for evidence-informed prioritization of services, policy decisions adopted, and the lessons learned in package design as well as in the transition to effective rollout. The papers conclude that evidenceinformed deliberative processes can be effectively applied to design affordable packages of services that represent good value for money and address a major part of the disease burden. Transition to implementation requires a comprehensive assessment of health system gaps, strong engagement of the planning and financing sectors, serious involvement of key national stakeholders and the private health sector, capacity building, and institutionalization of technical and managerial skills. Pakistan's experience highlights the need for updating the evidence and model packages of the Disease Control Priorities 3 initiative and reinforcing international collaboration to support technical guidance to countries in priority setting and UHC reforms.

Routine Pediatric Surgical Emergencies: Incidence, Morbidity, and Mortality During the 1st 8000 Days of Life-A Narrative Review.

BACKGROUND: Many potentially treatable non-congenital and non-traumatic surgical conditions can occur during the first 8000 days of life and an estimated 85% of children in low- and middle-income countries (LMICs) will develop one before 15 years old. This review summarizes the common routine surgical emergencies in children from LMICs and their effects on morbidity and mortality. METHODS: A narrative review was undertaken to assess the epidemiology, treatment, and outcomes of common surgical emergencies that present within the first 8000 days (or 21.9 years) of life in LMICs. Available data on pediatric surgical emergency care in LMICs were aggregated. RESULTS: Outside of trauma, acute appendicitis, ileal perforation secondary to typhoid fever, and intestinal obstruction from intussusception and hernias continue to be the most common abdominal emergencies among children in LMICs. Musculoskeletal infections also contribute significantly to the surgical burden in children. These "neglected" conditions disproportionally affect children in LMICs and are due to delays in seeking care leading to late presentation and preventable complications. Pediatric surgical emergencies also necessitate heavy resource utilization in LMICs, where healthcare systems are already under strain. CONCLUSIONS: Delays in care and resource limitations in LMIC healthcare systems are key contributors to the complicated and emergent presentation of pediatric surgical disease. Timely access to surgery can not only prevent long-term impairments but also preserve the impact of public health interventions and decrease costs in the overall healthcare system.

Surgically Correctable Congenital Anomalies: Reducing Morbidity and Mortality in the First 8000 Days of Life.

BACKGROUND: Congenital anomalies are a leading cause of morbidity and mortality worldwide. We aimed to review the common surgically correctable congenital anomalies with recent updates on the global disease burden and identify the factors affecting morbidity and mortality. METHOD: A literature review was done to assess the burden of surgical congenital anomalies with emphasis on those that present within the first 8000 days of life. The various patterns of diseases were analyzed in both low- and middle-income countries (LMIC) and high-income countries (HIC). RESULTS: Surgical problems such as digestive congenital anomalies, congenital heart disease and neural tube defects are now seen more frequently. The burden of disease weighs more heavily on LMIC. Cleft lip and palate has gained attention and appropriate treatment within many countries, and its care has been strengthened by global surgical partnerships. Antenatal scans and timely diagnosis are important factors affecting morbidity and mortality. The frequency of pregnancy termination following prenatal diagnosis of a congenital anomaly is lower in many LMIC than in HIC. CONCLUSION: Congenital heart disease and neural tube defects are the most common congenital surgical diseases; however, easily treatable gastrointestinal anomalies are underdiagnosed due to the invisible nature of the condition. Current healthcare systems in most LMICs are still unprepared to tackle the burden of disease caused by congenital anomalies. Increased investment in surgical services is needed.

One vaccine to counter many diseases? Modeling the economics of oral polio vaccine against child mortality and COVID-19.

Introduction: Recent reviews summarize evidence that some vaccines have heterologous or non-specific effects (NSE), potentially offering protection against multiple pathogens. Numerous economic evaluations examine vaccines' pathogen-specific effects, but less than a handful focus on NSE. This paper addresses that gap by reporting economic evaluations of the NSE of oral polio vaccine (OPV) against under-five mortality and COVID-19. Materials and methods: We studied two settings: (1) reducing child mortality in a high-mortality setting (Guinea-Bissau) and (2) preventing COVID-19 in India. In the former, the intervention involves three annual campaigns in which children receive OPV incremental to routine immunization. In the latter, a susceptible-exposed-infectious-recovered model was developed to estimate the population benefits of two scenarios, in which OPV would be co-administered alongside COVID-19 vaccines. Incremental cost-effectiveness and benefit-cost ratios were modeled for ranges of intervention effectiveness estimates to supplement the headline numbers and account for heterogeneity and uncertainty. Results: For child mortality, headline cost-effectiveness was $650 per child death averted. For COVID-19, assuming OPV had 20% effectiveness, incremental cost per death averted was $23,000-65,000 if it were administered simultaneously with a COVID-19 vaccine <200 days into a wave of the epidemic. If the COVID-19 vaccine availability were delayed, the cost per averted death would decrease to $2600-6100. Estimated benefit-to-cost ratios vary but are consistently high. Discussion: Economic evaluation suggests the potential of OPV to efficiently reduce child mortality in high mortality environments. Likewise, within a broad range of assumed effect sizes, OPV (or another vaccine with NSE) could play an economically attractive role against COVID-19 in countries facing COVID-19 vaccine delays. Funding: The contribution by DTJ was supported through grants from Trond Mohn Foundation (BFS2019MT02) and Norad (RAF-18/0009) through the Bergen Center for Ethics and Priority Setting.

Estimates of Treatable Deaths Within the First 20 Years of Life from Scaling Up Surgical Care at First-Level Hospitals in Low- and Middle-Income Countries.

BACKGROUND: Surgical care is an important, yet often neglected component of child health in low- and middle-income countries (LMICs). This study examines the potential impact of scaling up surgical care at first-level hospitals in LMICs within the first 20 years of life. METHODS: Epidemiological data from the global burden of disease 2019 Study and a counterfactual method developed for the disease control priorities; 3rd Edition were used to estimate the number of treatable deaths in the under 20 year age group if surgical care could be scaled up at first-level hospitals. Our model included three digestive diseases, four maternal and neonatal conditions, and seven common traumatic injuries. RESULTS: An estimated 314,609 (95% UI, 239,619-402,005) deaths per year in the under 20 year age group could be averted if surgical care were scaled up at first-level hospitals in LMICs. Most of the treatable deaths are in the under-5 year age group (80.9%) and relates to improved obstetrical care and its effect on reducing neonatal encephalopathy due to birth asphyxia and trauma. Injuries are the leading cause of treatable deaths after age 5 years. Sixty-one percent of the treatable deaths occur in lower middle-income countries. Overall, scaling up surgical care at first-level hospitals could avert 5·1% of the total deaths in children and adolescents under 20 years of age in LMICs per year. CONCLUSIONS: Improving the capacity of surgical services at first-level hospitals in LMICs has the potential to avert many deaths within the first 20 years of life.

The East-West Divide in Response to COVID-19.

Coronavirus disease 2019 (COVID-19) deaths per million population in the countries of the West had often exceeded those in the countries of the East by factor of 100 by May 2021. In this paper, we refer to the West as represented by the United States plus the five most populous countries of Western Europe (France, Germany, Italy, Spain, and the United Kingdom), and the East as the 15 countries in East Asia and Oceania that are members of the Regional Comprehensive Economic Partnership, RCEP (Australia, Brunei, Cambodia, China, Indonesia, Japan, the Republic of Korea, Laos, Malaysia, Myanmar, New Zealand, Philippines, Singapore, Thailand, and Vietnam). This paper argues that currently available information points to the factors most responsible for the East-West divide. Warnings by early January 2020 about an atypical viral pneumonia in Wuhan, China, prompted rapid responses in many jurisdictions in East Asia. Publication of the virus's genome on 10 January 2020 provided essential information for making diagnostic tests and launching vaccine development. China's lockdown of Wuhan on 23 January 2020 provided a final, decisive signal of the danger of the new disease. By late March 2020, China had fully controlled its epidemic, and many other RCEP countries had taken early and decisive measures, including restrictions on travel, that aborted serious outcomes. Inaction during the critical month of February 2020 in the United States and most other Western countries allowed the disease to take hold and spread. In both the East and the West, stringent population-wide non-pharmaceutical interventions were widely implemented at great cost to societies, economies, and school systems. Without these measures, the outcomes could have been even worse. Most countries in the East also implemented tightly focused policies to isolate infectious individuals. Even today, most countries in the West allow infectious individuals to mingle with their families, coworkers, and communities. Much of the East-West divide plausibly results from failure in the West to implement the basic public health policies of early action and the isolation of infectious individuals. Widespread immunization in some RCEP and high-income countries will soon attenuate their outbreaks, while the slow rollout of vaccines in lower income countries is replacing the East-West divide in outcomes with a North-South one. The South is thus replacing the West as the breeding ground for more dangerous variants as exemplified by the highly contagious Delta variant, which may undermine hitherto successful control strategies in many countries.

Comparing the impact on COVID-19 mortality of self-imposed behavior change and of government regulations across 13 countries.

OBJECTIVE: Countries have adopted different approaches, at different times, to reduce the transmission of coronavirus disease 2019 (COVID-19). Cross-country comparison could indicate the relative efficacy of these approaches. We assess various nonpharmaceutical interventions (NPIs), comparing the effects of voluntary behavior change and of changes enforced via official regulations, by examining their impacts on subsequent death rates. DATA SOURCES: Secondary data on COVID-19 deaths from 13 European countries, over March-May 2020. STUDY DESIGN: We examine two types of NPI: the introduction of government-enforced closure policies and self-imposed alteration of individual behaviors in the period prior to regulations. Our proxy for the latter is Google mobility data, which captures voluntary behavior change when disease salience is sufficiently high. The primary outcome variable is the rate of change in COVID-19 fatalities per day, 16-20 days after interventions take place. Linear multivariate regression analysis is used to evaluate impacts. DATA COLLECTION/EXTRACTION METHODS: publicly available. PRINCIPAL FINDINGS: Voluntarily reduced mobility, occurring prior to government policies, decreases the percent change in deaths per day by 9.2 percentage points (pp) (95% confidence interval [CI] 4.5-14.0 pp). Government closure policies decrease the percent change in deaths per day by 14.0 pp (95% CI 10.8-17.2 pp). Disaggregating government policies, the most beneficial for reducing fatality, are intercity travel restrictions, canceling public events, requiring face masks in some situations, and closing nonessential workplaces. Other sub-components, such as closing schools and imposing stay-at-home rules, show smaller and statistically insignificant impacts. CONCLUSIONS: NPIs have substantially reduced fatalities arising from COVID-19. Importantly, the effect of voluntary behavior change is of the same order of magnitude as government-mandated regulations. These findings, including the substantial variation across dimensions of closure, have implications for the optimal targeted mix of government policies as the pandemic waxes and wanes, especially given the economic and human welfare consequences of strict regulations.

Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19.

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Old vaccines for new infections: Exploiting innate immunity to control COVID-19 and prevent future pandemics.

The COVID-19 pandemic triggered an unparalleled pursuit of vaccines to induce specific adaptive immunity, based on virus-neutralizing antibodies and T cell responses. Although several vaccines have been developed just a year after SARS-CoV-2 emerged in late 2019, global deployment will take months or even years. Meanwhile, the virus continues to take a severe toll on human life and exact substantial economic costs. Innate immunity is fundamental to mammalian host defense capacity to combat infections. Innate immune responses, triggered by a family of pattern recognition receptors, induce interferons and other cytokines and activate both myeloid and lymphoid immune cells to provide protection against a wide range of pathogens. Epidemiological and biological evidence suggests that the live-attenuated vaccines (LAV) targeting tuberculosis, measles, and polio induce protective innate immunity by a newly described form of immunological memory termed "trained immunity." An LAV designed to induce adaptive immunity targeting a particular pathogen may also induce innate immunity that mitigates other infectious diseases, including COVID-19, as well as future pandemic threats. Deployment of existing LAVs early in pandemics could complement the development of specific vaccines, bridging the protection gap until specific vaccines arrive. The broad protection induced by LAVs would not be compromised by potential antigenic drift (immune escape) that can render viruses resistant to specific vaccines. LAVs might offer an essential tool to "bend the pandemic curve," averting the exhaustion of public health resources and preventing needless deaths and may also have therapeutic benefits if used for postexposure prophylaxis of disease.

Country performance against COVID-19: rankings for 35 countries.

OBJECTIVE: To generate rankings of 35 countries from all continents (except Africa) on performance against COVID-19. DESIGN: International time series, cross-sectional analysis. SELECTED COUNTRIES: Countries having 5500 or more cases (collectively including 85% of the world's cases) as of 16 April 2020 and that had reached 135 days into their pandemic by 30 July. MAIN OUTCOME MEASURES: The initial severity and late-pandemic performance of countries can reasonably be ranked by COVID-19 cases or deaths per million population. For guiding policy and informing public accountability during the pandemic, we propose mid-pandemic performance rankings based on doubling time in days of the total number of cases and deaths in a country. Rank orderings then follow. RESULTS: At day 25 into a country's pandemic, cross-country performance variation was modest: in most countries, cumulative deaths doubled in fewer than 5 days. By day 65, and even more so by day 135, great cross-country variation emerged. By day 135, 9 of the 10 top-performing countries on deaths were European, although they were initially hard hit by the pandemic. Thus, rankings change rapidly enough to point to the value of a dynamic indicator. Five countries-Brazil, Mexico, India, Indonesia and Israel-were among the seven poorest performers at day 135 on both cases and deaths. Doubling times for cases and for deaths are positively correlated, but differ sufficiently to point to the value of both indicators. CONCLUSIONS: Readily available data support transparently generated rankings of countries' performance against COVID-19 based on doubling times of cases and deaths. It is premature to judge the value of these rankings in practice, but the potential and early experience suggest they might help facilitate identification of good policies and inform judgements on national leadership.

Resource requirements for essential universal health coverage: a modelling study based on findings from Disease Control Priorities, 3rd edition.

BACKGROUND: Disease Control Priorities, 3rd edition (DCP3), published two model health benefits packages (HBPs). This study estimates the overall costs and individual component costs of these packages in low-income countries (LICs) and lower-middle-income countries (lower-MICs). METHODS: This study reports on our Disease Control Priorities Cost Model (DCP-CM), developed as part of the DCP3 project to determine the overall costs of the 218 health sector interventions recommended in the model HBP termed essential universal health coverage (EUHC). Model inputs included data on intervention unit costs, demographic and epidemiological data to quantify the populations in need of specific interventions, baseline coverage indicators, and estimates of required health system costs to support direct service delivery. The DCP-CM was informed primarily by published estimates of economic costs of interventions measured from the health system perspective. We estimated counterfactual annual costs for the year 2015. We disaggregated costs according to intervention characteristics (delivery platform, delivery timing, and health system objective) and did one-way and probabilistic sensitivity analyses with determination of 95% credible intervals (Crls). FINDINGS: At 80% population coverage, the annual cost of EUHC would be US$79 (95% Crl 60-110) per capita (in 2016 US dollars) in LICs and US$130 (100-180) per capita in lower-MICs. As a share of 2015 gross national income (GNI), additional investments would require 8·0% (95% Crl 5·7-11·3) in LICs and 4·2% (2·9-5·9) in lower-MICs. A highest priority subpackage comprising 115 of the EUHC interventions would cost approximately half of these amounts (3·7% [2·6-5·3] of 2015 GNI in LICs and 2·0% [1·4-2·8] in lower-MICs). Mortality-reducing interventions would require around two-thirds of the overall package costs, with interventions to reduce mortality at age 5-69 years from non-communicable disease and injury comprising the highest share of total EUHC costs in both income groups (37·6% [37·2-37·9] in LICs and 43·0% [42·6-43·4] in lower-MICs). Interventions addressing chronic health conditions (requiring 45·5% [44·8-46·4] 2015 GNI for LICs and lower-MICs combined) and interventions delivered in health centres (requiring 49·8% [49·5-50·2] 2015 GNI for LICs and lower-MICs combined) would each comprise the plurality of costs. INTERPRETATION: Implementation of EUHC would require costly investment, especially in LICs. DCP-CM is available as an online tool that can inform local HBP deliberation and support efficient investment in UHC, especially as countries pivot towards non-communicable disease and injury care. FUNDING: Bill & Melinda Gates Foundation, Trond Mohn Foundation, and Norwegian Agency for Development Cooperation.

Health-care investments for the urban populations, Bangladesh and India.

OBJECTIVE: To estimate the costs and mortality reductions of a package of essential health interventions for urban populations in Bangladesh and India. METHODS: We used population data from the countries' censuses and United Nations Population Division. For causes of mortality in India, we used the Indian Million Death Study. We obtained cost estimates of each intervention from the third edition of Disease control priorities. For estimating the mortality reductions expected with the package, we used the Disease control priorities model. We calculated the benefit-cost ratio for investing in the package, using an analysis based on the Copenhagen Consensus method. FINDINGS: Per urban inhabitant, total costs for the package would be 75.1 United States dollars (US$) in Bangladesh and US$ 105.0 in India. Of this, prevention and treatment of noncommunicable diseases account for US$ 36.5 in Bangladesh and U$ 51.7 in India. The incremental cost per urban inhabitant for all interventions would be US$ 50 in Bangladesh and US$ 75 in India. In 2030, the averted deaths among people younger than 70 years would constitute 30.5% (1027/3362) and 21.2% (828/3913) of the estimated baseline deaths in Bangladesh and India, respectively. The health benefits of investing in the package would return US$ 1.2 per dollar spent in Bangladesh and US$ 1.8 per dollar spent in India. CONCLUSION: Investing in the package of essential health interventions, which address health-care needs of the growing urban population in Bangladesh and India, seems beneficial and could help the countries to achieve their 2030 sustainable development goals.

Measuring development assistance for health systems strengthening and health security: an analysis using the Creditor Reporting System database.

Background: Health systems strengthening (HSS) and health security are two pillars of universal health coverage (UHC). Investments in these areas are essential for meeting the Sustainable Development Goals and are of heightened relevance given the emergence of the 2019 novel coronavirus disease (COVID-19). This study aims to generate information on development assistance for health (DAH) for these areas, including how to track it and how funding levels align with country needs. Methods: We developed a framework to analyze the amount of DAH disbursed in 2015 for the six building blocks of the health system ('system-wide HSS') plus health security (emergency preparedness, risk management, and response) at both the global (transnational) and country level. We reviewed 2,427 of 32,801 DAH activities in the Creditor Reporting System (CRS) database (80% of the total value of disbursements in 2015) and additional public information sources. Additional aid activities were identified through a keyword search. Results: In 2015, we estimated that US$3.1 billion (13.4%) of the US$22.9 billion of DAH captured in the CRS database was for system-wide HSS and health security: US$2.5 billion (10.9%) for system-wide HSS, mostly for infrastructure, and US$0.6 billion (2.5%) for system-wide health security. US$567.1 million (2.4%) was invested in supporting these activities at the global level. If responses to individual health emergencies are included, 7.5% of total DAH (US$1.7B) was for health security. We found a correlation between DAH for HSS and maternal mortality rates, and we interpret this as evidence that HSS aid generally flowed to countries with greater need. Conclusions : Achieving UHC by 2030 will require greater investments in system-wide HSS and proactive health emergency preparedness. It may be appropriate for donors to more prominently consider country needs and global functions when investing in health security and HSS.

National Burden Estimates of healthy life lost in India, 2017: an analysis using direct mortality data and indirect disability data.

BACKGROUND: Many countries, including India, seek locally constructed disease burden estimates comprising mortality and loss of health to aid priority setting for the prevention and treatment of diseases. We created the National Burden Estimates (NBE) to provide transparent and understandable disease burdens at the national and subnational levels, and to identify gaps in knowledge. METHODS: To calculate the NBE for India, we combined 2017 UN death totals with national and subnational mortality rates for 2010-17 and causes of death from 211 166 verbal autopsy interviews in the Indian Million Death Study for 2010-14. We calculated years of life lost (YLLs) and years lived with disability (YLDs) for 2017 using published YLD-YLL ratios from WHO Global Health Estimates. We grouped causes of death into 45 groups, including ill-defined deaths, and summed YLLs and YLDs to calculate disability-adjusted life-years (DALYs) for these causes in eight age groups covering rural and urban areas and 21 major states of India. FINDINGS: In 2017, there were about 9·7 million deaths and 486 million DALYs in India. About three quarters of deaths and DALYs occurred in rural areas. More than a third of national DALYs arose from communicable, maternal, perinatal, and nutritional disorders. DALY rates in rural areas were at least twice those of urban areas for perinatal and nutritional conditions, chronic respiratory diseases, diarrhoea, and fever of unknown origin. DALY rates for ischaemic heart disease were greater in urban areas. Injuries caused 11·4% of DALYs nationally. The top 15 conditions that accounted for the most DALYs were mostly those causing mortality (ischaemic heart disease, perinatal conditions, chronic respiratory diseases, diarrhoea, respiratory infections, cancer, stroke, road traffic accidents, tuberculosis, and liver and alcohol-related conditions), with disability mostly due to a few conditions (nutritional deficiencies, neuropsychiatric conditions, vision and other sensory loss, musculoskeletal disorders, and genitourinary diseases). Every condition that was common in one part of India was uncommon elsewhere, suggesting state-specific priorities for disease control. INTERPRETATION: The NBE method quantifies disease burden using transparent, intuitive, and reproducible methods. It provides a simple, locally operable tool to aid policy makers in priority setting in India and other low-income and middle-income countries. The NBE underlines the need for many more countries to collect nationally representative cause of death data, paired with focused surveys of disability. FUNDING: Ministry of Health and Family Welfare, Government of India.

Valuing Protection against Health-Related Financial Risks.

There is strong interest in both developing and developed countries towards expanding health insurance coverage. How should the benefits, and costs, of expanded coverage be measured? While the value of reducing the financial risks that result from insurance coverage have long been recognized, there has been less attention in how best to measure such benefits. In this paper, we first provide a framework for assessing the financial value from health insurance. We focus on 3 distinct potential benefits: Pooling the risk of unexpected medical expenditures between healthy and sick households, redistributing resources from high to low income recipients, and smoothing consumption over time. We then use this theoretical framework and an illustrative example to provide practical guidelines for benefit-cost analysis in capturing the full benefits (and costs) of expanding health insurance coverage. We conclude by considering other potential financial effects of broad insurance coverage, such as the ability to consolidate purchases and thus lower input prices.