Health services Package

1. ای دعا از تو اجابت هم زتو Health services Package R.AskariPh.D. Candidate in Healthcare ManagementEmail: r.asqari@yahoo.com

2. Terminology • Health package • Benefit package • Health services package • Essential package • Basic package • Basic services package • Minimal Package of Services • Basic basket of health services

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

4. What is the difference between Minimum Initial Ser vice Package (MISP) and comprehensiveRH services?

6. 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

7. Definition • بسته پايه مداخلات بهداشت عمومي و سرويسهاي کلينيکي اساسي که با بودجه عمومي براي همگان بدون در نظرگرفتن توان پرداخت مالي آنها توسط دولت ارايه ميشود. 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) 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).

8. Definition

9. Minimum services BUT Maximum gain

10. Synergistic nature of package interventions: • Individual inputs can complement each other • The whole will be greater than the sum of its parts. In practical terms

11. A package is a universal or comparable productwhich helps; • Increases Consumers Choices (health plans, insurers, or different providers) • Simplifies the choices • Promote equity

12. Limited scope of the basic package: • It cannot include everything • Many services will be omitted • those in the package are the ones value the most.

13. tradeoff between access and benefits of insurance package Tradeoff Before.. After...

14. Types of Services arein the Package? • Public health interventions For instance: maternity care • Clinical health interventions For instance: global surgery or nursing Package

15. Public health interventions • Services that foster changes in personal behavior • Services that control environmental hazards • Services give specific health care to the population

16. 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

17. Preventive vs. Curativeinterventions: • It is important to reach an appropriate balance between the two.

18. پيش نياز انتخاب مداخلات در تهيه Minimal Package of Services • ارزيابي مداوم جزئيات ريسك فاكتورهاي اساسي، بار بيماريها و الگوي استفاده جامعه هدف. • اطلاعات كلي برروي هزينه و اثر بخشي مداخلات و تطابق آنها با هزينه هاي ملي. • شفاف سازي سياستهاي , Rationing priory settingمداخلات به منظور اطمينان از صرف منابع محدود براي اولويتهاي بيشتر. • ایجاد بستر اطلاعات سلامت در سیستم سلامت

20. intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11 0% Coverage 100% High priority Horizontal rationing High priority Basic package of health services Floating line determined by available resources and number of eligible people Low priority intervention 12

21. intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11 0% Coverage 100% High priority vertical rationing Basic package of health services intervention 12

22. intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11 0% Coverage 100% diagonal rationing High priority Basic package of health services intervention 12

23. intervention 1 intervention 2 intervention 3 intervention 4 intervention 5 intervention 6 intervention 7 intervention 8 intervention 9 intervention 10 intervention 11 0% Coverage 100% Irregular(chaotic)rationing High priority Basic package of health services intervention 12

24. پيش نيازهاي تعيين بسته خدمات پايه تهيه Minimal Package of Services مي تواند براساس موارد زير صورت مي گيرد: • اولويت بندي • سن • شدت نياز • دسترسي • زمان • فاصله • پوشش بيمه • قيمت (بازار)

25. رويکرد 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 بالا تر در محيطي رقابتي مدنظراست. رويکردهاي دیگر در تعيين بسته پايهرويکرد کميQuantitativeمبتني برهزينه اثربخشي مداخلات به منظور بدست آوردن حداکثر سلامتي از منابع موجود.رويکرد کيفيqualitativeمبتني بر نياز

26. In Iraq

27. Mismach of Need, Demand & Supply

28. Perceptions of Need Community Perceived Need Professionally Perceived Need

29. Community Perceived Need Professionally Perceived Need Perceptions of Need

30. Demand: Means needs of which money is available fo paying Willingness to pay

31. Need, Demand and Supply for Health Care

32. Is Prioritizing Useful ?

33. Prioritization to determine 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

34. Why Prioritizing 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

35. 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).

36. Prioritization task? Difficulty of task: • Rationing of care; so, some services not provided or some people may not receive care • People react very negatively

37. 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%.

38. Why Prioritize? • less critical services , can still be offered through: • out of pocket expenditures or • private health insurance • Gov don’t omit less important services, don’t finance them

39. How to Prioritize Different Approaches • Categories of care • Specific criteria • Severity • Community needs • Effectiveness • Efficiency • Necessity of services

40. How to Prioritize Different ApproachesCont, 3. guidelines or technology assessment methods 4. Adopt models or formulas that incorporate economic principles 5. Program budgeting and marginal analysis approach

41. Why Design a PackageBenefits • The link between treatment and prevention • Multiple outputs from inputs • Identification of all required inputs • Coordination of resources • Directing demand for services

42. Why Design a PackagePolitical Benefits • Defining a package of high priority helps Gov. to overcome its inabilities

43. Design a PackageProblems • Consumers may still demand other services and bypass those in the package • Unpopular package • Lack credibility among People& Doctors • Unavailable information

44. Health sector allocation of resources is not fair • There are serious mismatches between the disease profile of population and the distribution of resources. This is attributed to: • the use of oversimplified models for setting health care priorities; • 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).

45. وضعيت Minimal Package of Services در ساير كشورها:بر اساس معیار هزینه اثر بخشی خدمات • پيشنهاد بانك جهاني : شامل كموتراپي براي سل. مراقبتهاي قبل و حين زايمان. آموزش بهداشت در مدارس .كنترل الكل و تنباكو و پيشگيري از ايدز • بنگلادش: بهداشت دوران بارداري، بهداشت اطفال، كنترل بيماريهاي مسري، 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 ). • شرايط حاد • پيشگيري • نوتواني • شرايط مزمن و مواردي كه از شدت كمتري برخوردارند

46. وضعيت Minimal Package of Services در ساير كشورها: • هلند: • آيا مداخله براي پذيرش عملكرد افراد در جامعه لازم است؟ • آيا اين درمان مؤثر است؟ • آيا اين درمان كارآست؟ • آيا مي تواند به عنوان موضوعي براي مسئوليت افراد در نظر گرفته شود؟ • نيوزلند: • سرويس يا درمان بايد سود و ارزش براي پول ايجاد كند. • بايد استفاده منصفانه و خوبي از منابع داشته باشد. • بايد با ارزشهاي جامعه سازگار باشد. • نروژ : • سيستم نروژي براساس 5 سطح اولويت بر پايه شدت بيماريها و امكان درمان آنها پايه گذاري شده است. براي مثال، بيماراني كه عدم درمان آنهامنجر به عواقب تاسف بار وجدي در طي زمان مي شود. حق قانوني دارند كه طي 6 ماه درمان شوند به شرطي كه اين درمانها در نروژ در دسترس باشد

47. 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) Basic package in Guatemala • 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.

48. Approaches to direct package to whom? • Single, Universal Package (Iran) • Targeted Package for Population Subgroups • Multiple Packages

49. Single, Universal Package • 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.

50. Targeted Package for Population 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