health services package r.askari ph.d. candidate in healthcare management email: r.asqari@yahoo.com

Health services Health services PackagePackage

R.AskariR.AskariPh.D. Candidate in Healthcare ManagementPh.D. Candidate in Healthcare ManagementEmail: r.asqari@yahoo.comEmail: r.asqari@yahoo.com

TerminologyTerminology• Health package

• Benefit package

• Health services package

• Essential package

• Basic package

• Basic services package• Minimal Package of Services

• Basic basket of health services

Key words Key words • Prioritizing• Cost-effectiveness• Payment• Need, demand, supply• Subsidizing• Rationing• Insurance• Coverage• Choice• DALY study• Burden of Disease

What is the differenceWhat is the difference between between

Minimum Initial Ser vice Minimum Initial Ser vice PackagePackage (MISP) (MISP) and and

comprehensivecomprehensiveRH services?RH services?

Co….Co….• Determination of basic package is a

public action• Aim to Basic package is coverage of

population• Basic package is a key policy in

resource management in health sector • Aim to Basic package isn't coverage

of all services but essential services

Definition Definition

بسته پايه مداخالت بهداشت عمومي و سرويسهاي کلينيکي •اساسي که با بودجه عمومي براي همگان بدون در نظرگرفتن

توان پرداخت مالي آنها توسط دولت ارايه ميشود.

4-Basic Package of Services offered to each individual depending on the epidemiological situation in the country and on available resources.

5-Basic health package lists health services/goods which are paid by the society because these are deemed to be basic or have priority (Benabbas, 2001).

1-A limited subset of all health care interventions

2-Interventions result from a prioritization process

3-Interventions not independent from each other (integrated services)

DefinitionDefinition

Minimum servicesBUT

Maximum gain

SynergisticSynergistic nature of package nature of package interventions: interventions:

•Individual inputs can complement each other

•The whole will be greater than the sum of its parts. In practical terms

A package is a universal A package is a universal or comparable productor comparable product which which

helps; helps;

• Increases Consumers Choices (health plans, insurers, or different

providers)

• Simplifies the choices

• Promote equity

Limited scope of the basic Limited scope of the basic package: package:

• It cannot include everything

• Many services will be omitted

• those in the package are the ones value the most.

Before..

After...

Tradeoff

• tradeoff between access and benefits of insurance package

Types of ServicesTypes of Services are are in the Package?in the Package?

•Public health interventions For instance: maternity care

•Clinical health interventions

For instance: global surgery or nursing Package

Public health Public health interventions interventions

• Services that foster changes in personal behavior

• Services that control environmental hazards

• Services give specific health care to the population

Clinical health interventions Clinical health interventions

• Different levels of facilities may provide different responses to similar health problems

• The clinical intervention itself may not be significantly different from one facility to another; However, the resources that may be required may be very different

Preventive vs. CurativePreventive vs. Curativeinterventions:interventions:

• It is important to reach an appropriate balance between the two.

Minimal Package of Minimal Package of پيش نياز انتخاب مداخالت در تهيهپيش نياز انتخاب مداخالت در تهيهServices Services

ارزيابي مداوم جزئيات ريسك فاكتورهاي اساسي، •بار بيماريها و الگوي استفاده جامعه هدف.

اطالعات كلي برروي هزينه و اثر بخشي مداخالت •و تطابق آنها با هزينه هاي ملي.

Rationing priory , شفاف سازي سياستهاي •setting مداخالت به منظور اطمينان از صرف

منابع محدود براي اولويتهاي بيشتر. ایجاد بستر اطالعات سالمت در سیستم سالمت•

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

Horizontal rationing

Highpriority

Lowpriority

Floating line determined by available resources and number of eligible people

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

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

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

Irregular(chaotic)rationing

پيش نيازهاي تعيين بسته خدمات پايهپيش نيازهاي تعيين بسته خدمات پايه

مي تواند Minimal Package of Servicesتهيه براساس موارد زير صورت مي گيرد:

اولويت بندي•سن• شدت نياز• دسترسي• زمان • فاصله• پوشش بيمه• قيمت (بازار) •

رويکرد بانک جهاني در تهيه بسته پايه خدماترويکرد بانک جهاني در تهيه بسته پايه خدمات

هيچ پولي از بودجه عمومي نبايد صرف سرويس هايي •شود که در دسترس فقرا نيست.

در صورت محدوديت منابع انتخاب سرويس هاي •بهداشتي بر اساس حداکثر منفعت حاصل از استفاده

منابع در دسترس صورت ميگيرد.کارآيي و کيفيت باال تر در محيطي رقابتي •

رويکردهاي دیگر در تعيين بسته پايهرويکردهاي دیگر در تعيين بسته پايهمدنظراست. QuantitativeQuantitativeرويکرد کميرويکرد کمي

مبتني برهزينه اثربخشي مداخالت به منظور بدست آوردن حداکثر سالمتي از مبتني برهزينه اثربخشي مداخالت به منظور بدست آوردن حداکثر سالمتي از منابع موجود.منابع موجود.

qualitativequalitative رويکرد کيفيرويکرد کيفيمبتني بر نيازمبتني بر نياز

In IraqIn Iraq

Mismach of Need, Demand

& Supply

Perceptions of NeedPerceptions of Need

Community

Perceived

Need

Professionally

Perceived

Need

Perceptions of NeedPerceptions of Need

Community

Perceived

Need

Professionally

Perceived

Need

Demand:Demand:Means needs of which money is available fo

paying

Willingness to pay

Need, Demand and Need, Demand and SupplySupply for Health Care for Health Care

NEED

SUPPLY DEMAND

High Cost

Market Incentives

Lack of Information (*)

Poverty

High Cost

Lack of Information (*)

Supplier Induced Demand (*)

Externalities (*)

Public Goods (*)

Lack ofInformation (*)

Other Barriers toCompetition (*)

Non-MarketIncentives

(*) Sources of Market Failure

IsPrioritizing

Useful ?

Prioritization to determine Prioritization to determine package contents: package contents:

• Need to criteria that are agreed upon

• The agreement can be among policy-makers, the medical profession, or society as a whole

• criteria can include, among others,

cost- effectiveness of treatments, burden of disease, and/or some combination

Why Prioritizing Why Prioritizing Could Be Useful? Could Be Useful?

• Scarcity makes us not be able to provide all of the health services we would like to

• We have to make hard choices

Selection of a Choice means deleting many

choices

International Issues:International Issues:Demographic & epidemiological phenomena:• 1) aging population; • 2) more education and awareness on health

issues increase demand; • 3) changing life styles toward risky behavior; • 4) cost of diagnostic and curative technology

has increased rapidly during past 20 years (Mosley et al, 1993, Berman and Ormond, 1988, Bobadilla and Costello, 1961, Bronzino et al, 1990).

Prioritization task?Prioritization task?

Difficulty of task:1. Rationing of care; so, some

services not provided or some people may not receive care

2. People react very negatively

Why Prioritize?Why Prioritize?

• Forcing decision-makers to discussions about what is good or not in terms of being an effective response to health problems

Netherlands;

physicians view of really effective

services (covered by social Ins)

ranged between 20 and 40%.

Why Prioritize?Why Prioritize?

• less critical services , can still be offered through:

1. out of pocket expenditures or 2. private health insurance

• Gov don’t omit less important services, don’t finance them

How to Prioritize How to Prioritize Different ApproachesDifferent Approaches

1. Categories of care 2. Specific criteria

– Severity– Community needs – Effectiveness – Efficiency– Necessity of services

How to Prioritize How to Prioritize Different ApproachesDifferent Approaches

Cont,Cont,

3. guidelines or technology assessment methods

4. Adopt models or formulas that incorporate economic principles

5. Program budgeting and marginal analysis approach

Why Design a PackageWhy Design a PackageBenefits Benefits

• The link between treatment and prevention

• Multiple outputs from inputs• Identification of all required

inputs• Coordination of resources• Directing demand for services

Why Design a PackageWhy Design a PackagePolitical BenefitsPolitical Benefits

• Defining a package of high priority helps Gov. to overcome its inabilities

Design a PackageDesign a PackageProblemsProblems

• Consumers may still demand other services and bypass those in the package

1. Unpopular package2. Lack credibility among People &

Doctors

• Unavailable information

Health sector allocation of Health sector allocation of resources is not fairresources is not fair

• There are serious mismatches between the disease profile of population and the distribution of resources.

This is attributed to: 1. the use of oversimplified models for

setting health care priorities; 2. lack of appropriate quantitative

information (Bobadilla, 1998).

• Resources for health are either shrinking or are not growing fast enough. Many low and middle-income countries have reduced per capita public spending on health (Lafond, 1995).

در ساير در ساير Minimal Package of ServicesMinimal Package of Services وضعيتوضعيتكشورها:كشورها:

بر اساس معیار هزینه اثر بخشی خدماتبر اساس معیار هزینه اثر بخشی خدمات

مراقبتهاي قبل و حين . شامل كموتراپي براي سلپيشنهاد بانك جهاني :•كنترل الكل و تنباكو و پيشگيري از ايدز. آموزش بهداشت در مدارس .زايمان

بهداشت دوران بارداري، بهداشت اطفال، كنترل بيماريهاي مسري، بنگالدش:•مراقبت هاي درماني محدود و تغييرات رفتار اجتماعي

:سوئيس•شان و مرتبه انساني ( همه انسانها داراي حقوق يكسان هستند ).

نياز ( منابع بايد به بيشترين نيازها اختصاص يابد ).–همبستگي و اتحاد اجتماعي ( تمامي گروههاي آسيب پذير بايد توجهات ويژه اي –

دريافت كنند ).حاد • شرايطپيشگيري•نوتواني•برخوردارند • كمتري شدت از كه مواردي و مزمن شرايط

: هلند•است؟ – الزم جامعه در افراد عملكرد پذيرش براي مداخله آيااست؟ – مؤثر درمان اين آياكارآست؟ – درمان اين آياشود؟ – گرفته نظر در افراد مسئوليت براي موضوعي عنوان به تواند مي آيا

:نيوزلند•–. كند ايجاد پول براي ارزش و سود بايد درمان يا سرويسمنابع – از خوبي و منصفانه استفاده باشد بايد .داشتهباشد – سازگار جامعه ارزشهاي با .بايد

نروژ :• سطح اولويت بر پايه شدت بيماريها و امكان درمان آنها پايه 5سيستم نروژي براساس –

گذاري شده است.براي مثال، بيماراني كه عدم درمان آنهامنجر به عواقب تاسف بار وجدي در طي زمان

ماه درمان شوند به شرطي كه اين درمانها در 6مي شود. حق قانوني دارند كه طي نروژ در دسترس باشد

::در ساير كشورهادر ساير كشورها Minimal Package of ServicesMinimal Package of Services وضعيتوضعيت

Basic package in GuatemalaBasic package in Guatemala• Women’s health:

– Antenatal care– TT vaccine– Complimentary

supplements (iron and folic acid)– Birth delivery– Postnatal care– Birth spacing– Detection of breast

and cervical cancer

• Child health :– Immunizations– ARI control– Cholera control– Feed supplementation (iron and vitamin A)– Growth promotion (under 2 years old)

•emergencies and morbidity :–Dengue control–Malaria control–Rabies vaccination for dogs and cats–Vector control–TB control–STD/HIV control–Emergency referral

Achievements up to December 1999

• 3 million people covered with a basic package of health services• The cost of the program is almost entirely funded by the MoH• Key factor for this coverage is the alliance with 74 NGO’s and the contribution/participation of communities.• A basic package of cost-effective health care services has been defined and regulated.  

Approaches to direct package Approaches to direct package to whom?to whom?

• Single, Universal Package (Iran)

• Targeted Package for Population Subgroups

• Multiple Packages

Single, Universal Single, Universal PackagePackage

• The package serves as a minimum

• The wealthier, will receive at least the same package as the poor, from public resources

• Such expenditures could be directed to the neediest and assist in poverty alleviation

• Wealthier will be able to get additional services beyond what is offered in the package.

• Such an approach creates a two-tier system.

Targeted Package for Targeted Package for Population SubgroupsPopulation Subgroups

• Target the package to specific groups such as poor, pregnant women and children, or those living in particular geographic areas

• Equity, Efficiency, Health gains that and access

• An example of such an approach is the basic package developed for Bolivia’s Maternal and Child National Insurance Program

Maternal and Child National Maternal and Child National Insurance in BoliviaInsurance in Bolivia

• In June 1996 the Government of Bolivia established the Seguro Nacional de Maternidad y Niñez (Maternal and Child National Insurance-SNMN) as a tool to combat high maternal and child mortality efficiently and equitably. The package is financed from municipality funds earmarked for SNMN on a capitated basis during a first phase, the Government decided to include only a very limited number of interventions in the package.

• Maternal Insurance• Prenatal care• Prenatal care for pregnancy with obstetric risk• Care for normal, complicated and cesarean deliveries• Post-partum care• Obstetric emergency care (e.g., third trimester hemorrhaging, pre-eclampsia,

premature birth)• Child Insurance• Acute diarrheal diseases• Acute respiratory infections• Neo-natal care• Six months later, following an interim evaluation of the program’s

finances and utilization rates, it was determined that there was a financial surplus; the government thus decided to expand the scope of the SNMN basic package by adding another set of priority health interventions for mothers and children.

• Source: Escobar, M.L., R. Bitrán and others, 1997.

Multiple PackagesMultiple Packages • define different packages for different populations

or different circumstances

• where there are significant geographical variations in costs and disease profiles

MexicoMexico• Mexico’s government proposed three

different packages:-1One was to expand coverage and provide

universal access to essential health services. -2Another was for additional cost-effective clinical

services that would be available to the working population and their families through a compulsory insurance program.

-3A third package included all clinical services currently provided through the social security program, but which were too expensive to be financed through the compulsory program.

• Progressively “higher” packages thus were directed to smaller and smaller groups,

• Sources: Bobadilla, 1996. Harvard University School of Public Health, 1996.

A Basic HealthA Basic HealthServices Package for Services Package for IraqIraq

Components of the BHSPComponents of the BHSP

قسمت عمده مداخالتنمونه

مداخالت ، تجويز كمو تراپي كوتاه مدت Dot برنامه مشاهده مستقيم درمان

استاندارد براي موارد اثبات شده اسمير مثبت كه در فاز ابتدايي به ماه تحت كنترل باشند 2ـ3مدت

درمان توبركولوز

تنظيم خانواده، مراقبت هاي قبل و حين زايمان، زايمان سالم به وسيله ماماي آموزش ديده، مراقبتهاي پس از زايمان و

مراقبت هاي اساسي براي زنان مراقبت هاي

مادران حامله پر خطر و مشكل دار

اطالع رساني و آموزش و در دسترس قراردادن كنتراسپتيوها واستفاده صحيح از آنها تنظيم خانواده

مداخالت تغذيه اي و آموزش بهداشت، شامل درمان هاي ضد انگل، تغذيه مدارس و امالح و ويتامينهاي كمكي

مداخالت بهداشت مدارس

درمان موارد عفونت هاي تنفسي فوقاني، اسهال، ماالريا، سرخك، سوء تغذيه، واكسيناسيون. تغذيه با شير مادر، مشاوره، آهن و

ويتامينهاي كمكي، درمان ضد انگل

درمان جامع كودكان بيمار

اطالع رساني به گروههاي فعال جنسي، آموزش هاي گروهي، مشاوره، بيمار يابي، درمان گروهي بيماريهاي مقاربتي، تهيه

خون سالم

پيشگيري از ايدز

درمان موارد با استفاده از الگوريتم تشخيص و درمان استاندارد

درمان بيماريهاي مقاربتي

و 10،6 واكسن ب.ث.ژ در بدو تولد، فلج اطفال در بدو تولد ، در بدو B، هپاتيت 14 و 10،6 در هفته هاي DPT هفتگي، 14

واکسیناسیون ماهگي اختياري 9 و6تولد،

درمان موارد ( ارزيابي اوليه و تشويق به درمان ) و انتخاب روشهاي پيشگيري ( سمپاشي عليه حشرات) ماالريا

ماليات براي تنباكو، اطالع رساني جايگزيني نيكوتين، منطقي سازي رفتارها كنترل سيگار

انتخاب بيماريابي اوليه و پيشگيري سطح ثانويه بيماريهاي غير

واگير و حوادث

Th

e W

HO

Mod

el of

Essen

tial serv

ices L

ist

Th

e W

HO

Mod

el of

Essen

tial serv

ices L

ist

Source:WHO Report2000

The WHO Model of Essential Drugs ListThe WHO Model of Essential Drugs List

According to WHO, 95% of products on the EDL are off-patent. The EDL concept focuses on those drugs that represent the best balance of quality, safety, efficacy and cost for a given health setting.

Basic health systems such as those to be found in most developing countries recognize the therapeutic and economic benefits of such an approach, with drug selections regularly updated with additional products in light of new therapeutic options, changing therapeutic needs and better drug quality.

Choosing a package of health services for a population requires a range of data as well as the necessary technical expertise to know how to use the data; this data needs to be updated regularly to ensure adjustments made to health systems reflect the changing conditions.

conclusionconclusionPublic money should be used to deliver a package of essential public health interventions and essential clinical services. Delivering this package should be a government responsibility, and the essential package of health services should be available to everyone, independent of one's ability to pay.

Proposed model Proposed model (Torabi)(Torabi)

patient

Govprovider

insurer

BSP

-Financing-coverage-type of services

-accessibility

-universality-price-quality

-payment-motivation-guidelines