Module 7. Analysing Patterns of Health Care Provision:
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Essential Health Service Packages
Packages of essential (or basic) health services have been formulated in several health sectors, for different reasons, not always explicit. The package inspired to the PHC concept promoted by the Alma Ata Conference stressed social justice and empowerment. On the other hand, efficiency-oriented packages of low cost and modest ambition have been advocated by aid agencies of considerable clout. The concept retains considerable appeal, because of its promise of explicit, evidence-based, rational priority setting. The objective way the package formulation process is presented by its proponents raises hopes of reaching uncontroversial conclusions. However, as Tarimo (1997) has persuasively argued, the package concept is prone to misconstructions and abuses.
Given the fragmentation prevailing in troubled health sectors, the perspective of introducing a standard package tempts many players, like in Afghanistan in 2003. The formulation of a service package is one of the proposals commonly tabled at the start of a recovery process. Before embarking on it, decision-makers might take advantage of the experience gained to date:
- As other areas of health planning, formulating an essential service package is a value-laden exercise, even when wrapped in apparently objective cloths. Negotiation plays a central role in it.
- The packages eventually chosen at the end of long and labour-intensive formulation processes are frequently unimaginative versions of the standard set of PHC services. Even components of arguable effectiveness, like ante-natal care, growth monitoring, TBAs and CHWs, tend to be maintained, instead of being suppressed, at least on paper.
- The formulation of basic packages may incur in high opportunity costs, particularly during transitions from war to peace, when many pressing priorities compete for the attention of decision-makers, and existing technical capacity is overstretched.
- The choice of launching a package formulation exercise may represent a decision-postponing tactic, rather than a priority-setting effort. Additionally, the elaboration of a package may contribute to disguising (rather than clarifying) crippling levels of under-resourcing.
- Packages may include all basic services seen as desirable by health professionals, without paying adequate attention to what might be affordable, given existing and foreseeable resource constraints. Packages without a cost attached are meaningless, whereas optimistically-costed ones are misleading. A rule of thumb worth considering is that health service packages tend to cost more to deliver in field conditions than reckoned at the drawing board. The roots of this recurrent underestimation of true costs are frequently traceable in political expedience, rather than in technical flaws.
- Essential packages rarely if ever fully translate into service delivery realities. Patient pressure force health workers to pay attention to conditions not included in the package. Professional preferences expand the weight given to complex conditions and sophisticated treatments, regardless of their importance and effectiveness. And capacity constraints inadequately taken into account during the formulation of the package jeopardise its delivery.
- Package formulation exercises fail often to consider the variety of settings that exist within a country, particularly a large one. The single package eventually chosen may be appropriate only to a sub-set of situations. Additionally, disease patterns may vary within a country to such an extent, that they impose the formulation of multiple packages, or the neglect of the standard one. In Southern Sudan, three service packages must be developed, for densely-populated areas, for sparsely-settled ones, and for nomadic groups. To these packages, a fourth one devoted to returnees must be added. The cost of providing the same basic services in each of these different situations differs substantially. Alternatively, for the same financing level packages of remarkably different content have to be expected.
- The package formulation exercise has rarely if ever the political clout to challenge established special programmes. The services provided by them are therefore included in the package, regardless of their objective worth. And the management arrangements of special programmes remain in most cases separated from those of standard services. Behind the supposedly integrated package of basic services, a patchwork of ill-assorted production lines, with nobody truly in control of delivering the full range of services, can be found.
- The main challenge faced by health managers is not choosing the services to be delivered, but rather finding ways to materialise a predictable set of them within tough capacity and resource constraints. Problem-solving skills are likely to be more important than detailed blueprints for health service delivery at different levels of care. This becomes even more important in unstable environments, where health managers are not in full control of information, events and resources.
- Most existing service packages fail to fully incorporate the vastly expanded financial and technical implications of handling AIDS patients in increasing number and at multiple sites. Even without providing HAART, upgrading basic health services to cope with the mounting toll of AIDS-related conditions implies massive investments in facilities, staff, equipment, drug supply and management systems, with associated soaring recurrent costs. Cheap PHC delivery in a country stricken by HIV/AIDS is now out of question. Instead of working out the implications of the epidemic for standard basic services and redesign them accordingly, the frequent response has been the introduction of special programmes, implemented by dedicated agencies and NGOs. The predictable results of this approach are high delivery costs and further damage to standard basic services starved of resources and capacity.
Against the just-mentioned shortcomings, efforts to develop packages that stand true chances of thriving should focus on fostering an environment conducive to the delivery of equitable, standardised essential services of acceptable quality. Favourable structural conditions include good technical and management training for the eventual providers of essential services, adequate resource levels, consistent allocative decisions, sound professional tools made available across services (information, relevant guidelines for action, realistic targets, functioning monitoring mechanisms).
When most favourable conditions are not granted (which is usually the case), a heavy investment in formulating service packages may fail to return proportional gains. Interim packages, developed quickly and at low cost, by taking advantage of expert opinion and of what is already done in the field, might turn out as a sensible alternative.
Module 7. Analysing Patterns of Health Care Provision:
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