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Background: Pakistan embarked on a process of designing an essential package of health services (EPHS) as a pathway towards universal health coverage (UHC). The EPHS design followed an evidence-informed deliberative process; evidence on 170 interventions was introduced along multiple stages of appraisal engaging different stakeholders tasked with prioritising interventions for inclusion. We report on the composition of the package at different stages, analyse trends of prioritised and deprioritised interventions and reflect on the trade-offs made. Methods: Quantitative evidence on cost-effectiveness, budget impact, and avoidable burden of disease was presented to stakeholders in stages. We recorded which interventions were prioritised and deprioritised at each stage and carried out three analyses: (1) a review of total number of interventions prioritised at each stage, along with associated costs per capita and disability-adjusted life years (DALYs) averted, to understand changes in affordability and efficiency in the package, (2) an analysis of interventions broken down by decision criteria and intervention characteristics to analyse prioritisation trends across different stages, and (3) a description of the trajectory of interventions broken down by current coverage and cost-effectiveness. Results: Value for money generally increased throughout the process, although not uniformly. Stakeholders largely prioritised interventions with low budget impact and those preventing a high burden of disease. Highly cost-effective interventions were also prioritised, but less consistently throughout the stages of the process. Interventions with high current coverage were overwhelmingly prioritised for inclusion. Conclusion: Evidence-informed deliberative processes can produce actionable and affordable health benefit packages. While cost-effective interventions are generally preferred, other factors play a role and limit efficiency. [ABSTRACT FROM AUTHOR]

Background: Pakistan developed its first national essential package of health services (EPHS) as a key step towards accelerating progress in achieving universal health coverage (UHC). We describe the rationale, aims, the systematic approach followed to EPHS development, methods adopted, outcomes of the process, challenges encountered, and lessons learned. Methods: EPHS design was led by the Ministry of National Health Services, Regulations & Coordination (MNHSR&C). The methods adopted were technically guided by the Disease Control Priorities 3 (DCP3) Country Translation project and existing country experience. It followed a participatory and evidence-informed prioritisation and decision-making processes. Results: The full EPHS covers 117 interventions delivered at the community, health centre and first-level hospital platforms at a per capita cost of US$ 29.7. The EPHS also includes an additional set of 12 population-based interventions at US$ 0.78 per capita. An immediate implementation package (IIP) of 88 district-level interventions costing US$ 12.98 per capita will be implemented initially together with the population-based interventions until government health allocations increase to the level required to implement the full EPHS. Interventions delivered at the tertiary care platform were also prioritised and costed at US$ 6.5 per capita, but they were not included in the district-level package. The national EPHS guided the development of provincial packages using the same evidence-informed process. The government and development partners are in the process of initiating a phased approach to implement the IIP. Conclusion: Key ingredients for a successful EPHS design include a focus on package feasibility and affordability, national ownership and leadership, and solid engagement of national stakeholders and development partners. Major challenges to the transition to implementation are to continue strengthening the national technical capacity, institutionalise priority setting and package design and its revision in ministries of health, address health system gaps and bridge the current gap in financing with the progressive increase in coverage towards 2030. [ABSTRACT FROM AUTHOR]

Background: Countries designing a health benefit package (HBP) to support progress towards universal health coverage (UHC) require robust cost-effectiveness evidence. This paper reports on Pakistan's approach to assessing the applicability of global cost-effectiveness evidence to country context as part of a HBP design process. Methods: A seven-step process was developed and implemented with Disease Control Priority 3 (DCP3) project partners to assess the applicability of global incremental cost-effectiveness ratios (ICERs) to Pakistan. First, the scope of the interventions to be assessed was defined and an independent, interdisciplinary team was formed. Second, the team familiarized itself with intervention descriptions. Third, the team identified studies from the Tufts Medical School Global Health Cost-Effectiveness Analysis (GH-CEA) registry. Fourth, the team applied specific knock-out criteria to match identified studies to local intervention descriptions. Matches were then cross-checked across reviewers and further selection was made where there were multiple ICER matches. Sixth, a quality scoring system was applied to ICER values. Finally, a database was created containing all the ICER results with a justification for each decision, which was made available to decision-makers during HBP deliberation. Results: We found that less than 50% of the interventions in DCP3 could be supported with evidence of cost-effectiveness applicable to the country context. Out of 78 ICERs identified as applicable to Pakistan from the Tufts GH-CEA registry, only 20 ICERs were exact matches of the DCP3 Pakistan intervention descriptions and 58 were partial matches. Conclusion: This paper presents the first attempt globally to use the main public GH-CEA database to estimate costeffectiveness in the context of HBPs at a country level. This approach is a useful learning for all countries trying to develop essential packages informed by the global database on ICERs, and it will support the design of future evidence and further development of methods. [ABSTRACT FROM AUTHOR]

Background: The Disease Control Priorities 3 (DCP3) project provides long-term support to Pakistan in the development and implementation of its universal health coverage essential package of health services (UHC-EPHS). This paper reports on the priority setting process used in the design of the EPHS during the period 2019-2020, employing the framework of evidence-informed deliberative processes (EDPs), a tool for priority setting with the explicit aim of optimising the legitimacy of decision-making in the development of health benefit packages. Methods: We planned the six steps of the framework during two workshops in the Netherlands with participants from all DCP3 Pakistan partners (October 2019 and February 2020), who implemented these at the country level in Pakistan in 2019 and 2020. Following implementation, we conducted a semi-structured online survey to collect the views of participants in the UHC benefit package design about the prioritisation process. Results: The key steps in the EDP framework were the installation of advisory committees (involving more than 150 members in several Technical Working Groups [TWGs] and a National Advisory Committee [NAC]), definition of decision criteria (effectiveness, cost-effectiveness, avoidable burden of disease, equity, financial risk protection, budget impact, socio-economic impact and feasibility), selection of interventions for evaluation (a total of 170), and assessment and appraisal (across the three dimensions of the UHC cube) of these interventions. Survey respondents were generally positive across several aspects of the priority setting process. Conclusion: Despite several challenges, including a partial disruption because of the COVID-19 pandemic, implementation of the priority setting process may have improved the legitimacy of decision-making by involving stakeholders through participation with deliberation, and being evidence-informed and transparent. Important lessons were learned that can be beneficial for other countries designing their own health benefit package such as on the options and limitations of broad stakeholder involvement. [ABSTRACT FROM AUTHOR]

Policy-makers making decisions on the implementation of school-based sexuality education (SE) programmes face two important questions: (1) what are the costs of implementing and scaling up SE programmes, and (2) what are the impacts? This paper responds to these questions by retrospectively assessing costs, impact and cost-effectiveness of the national school-based SE programme in Estonia 1997-2009. The three-year curriculum had been taught to 190,000 students at the end of 2009. The cost of reaching one student was USD 32.90 and the total costs were USD 5.6 million. There has been a remarkable improvement in sexual health indicators in the age groups 15-19 and 20-24 years in Estonia between 2001 and 2009. During this period, annual abortions, STIs and diagnosed HIV infections in the age groups were reduced by 37%, 55% and 89%, respectively. It is difficult to assess to what extent the improvements in these sexual health indicators are attributable to the SE programme. Nevertheless, our conservative threshold analysis indicates that the Estonian SE programme could be considered cost-saving if only 4% of the observed reductions in HIV infections are attributable to the programme. There is strong evidence, therefore, to support that the Estonian school-based sexuality programme has been cost-effective.

Drawing on evidence from a wider study on the cost and cost-effectiveness of sexuality education programmes in six countries, and focusing on the examples of India and Nigeria, this paper argues that advocacy is a key, yet often neglected component of school-based sexuality education programmes, especially where sex and sexuality are politically or culturally sensitive issues. It also suggests that advocacy is not a one-off activity but needs to be carried out continuously and adapted as contexts and needs change. Overall, this piece recommends that advocacy should be a key component of sexuality education work, and needs to be planned and budgeted for. Without such investment, country-level sexuality education programmes are likely to fail. (Contains 1 table and 6 notes.)

OBJECTIVE: To estimate the population health effects, costs and cost effectiveness of selected cataract surgery interventions in areas of the world with different epidemiological profiles. METHODS: Effectiveness estimates are based on a review of the literature taking into account factors such as operative failure, complications and patient non-compliance. A population model was applied to follow the lifelong impact on individuals having cataract surgery. Costing estimates are based on primary data collected in 14 epidemiological subregions by regional costing teams and on a literature review. Costings were estimated for different geographical coverage levels using non-linear cost functions. FINDINGS: Intra- and extra-capsular cataract surgeries are cost-effective ways to reduce the impact of cataract-blindness. Extra-capsular cataract surgery is more cost-effective than intra-capsular surgery in all regions considered. Providing extra-capsular cataract surgery to 95% of those who need it (95% coverage level) would avert over 3.5 million disability-adjusted life years (DALYs) per year globally. The cost-effectiveness ranges from 57 International dollars (I$) per DALY in the WHO South-East Asia Region where there is high overall child and adult mortality to I$ 2307 per DALY in the WHO Western Pacific Region where there is low overall child and adult mortality. CONCLUSION: Extra-capsular surgery for cataracts at a high level of coverage is the most cost-effective way of restoring sight in all epidemiological subregions considered. Analysts from countries within a region are encouraged to further contextualize the results based on their own country's specific parameters.