The Essential Health Package (EHP)

Objective

The aim of the EHP is to ensure timely universal free access to a quality Essential Health Package, irrespective of ability-to-pay, to all the people in Malawi.

Background

The drive for Universal Health Coverage (UHC) has been endorsed by WHO, World Bank and the UN’s SDGs and is now increasingly being pursued in country health sector strategies. In attempting to move towards UHC, countries face difficult choices about how to prioritise health issues and expenditure such as which services to expand, whom to include and how to shift from out-of-pocket payments to prepayment.

The WHO Consultative Group on Equity and UHC proposed a three-part strategy for “countries seeking a fair progressive realization of UHC”:

1.      Categorize services into priority classes using relevant criteria;

2.      First expand coverage for high-priority services to everyone;

3.      While doing so, ensure disadvantaged groups are not left behind. This will often include low-income groups and rural population.

These principles explain the decisions taken regarding the definition of the Essential Health Package (EHP).

For more detail around the EHP and its development please see chapter 4 of the HSSPII.

Since 2004 Malawi has implemented an EHP, containing cost effective interventions delivered free of charge at the point of use to Malawians. The below table outlines the interventions included in the revised EHP:

LIST OF INTERVENTIONS IN EHP

Outstanding EHP Issues

While the re-definition of the EHP has attempted to address many of the issues that faced its predecessor package, there are many issues that remain outstanding and will need further attention to resolve. 

Inadequate resources 

As shown in the HSSPII, despite the cost of the revised EHP being closer to the resources available for its provision than before, the cost continues to outstrip resources. The result of this is that, even assuming no health system constraints, it will not be possible to deliver the new EHP to the entire population in need. It is important that ongoing discourse around the EHP focuses on the budgets available for its provision. 

Lack of awareness about EHP among stakeholders 

Only 33% of managers for health centres knew about existence of the EHP. Clearly, there are many issues related to the provision of the package that this re-definition does not address. It is vitally important that the revision of the package is complemented with a wider EHP strategy encouraging its promotion and implementation.

Lack of EHP policy enforcement 

Relatedly, simple awareness of the policy is a necessary but not sufficient condition for its implementation. EHP policy has consistently lacked the enforcement necessary to translate the policy decisions into implementation. This constrains delivery of the EHP. Similarly, greater attention needs to be given to the health system constraints to delivering the EHP. Removal of these constraints should receive much priority. 

Lastly, currently financing and payment is not explicitly linked to EHP interventions. This means that, in effect, EHP interventions are treated in the same way as non-EHP interventions. A system of financing and payment to providers that separates EHP interventions from non-EHP interventions must be developed for the package – and health care in general – to be delivered effectively.

Inequalities in EHP utilization

While the EHP is theoretically available to all Malawians free at the point of access, there remain large variations in its utilization. Rural, uneducated and poor populations continue to underutilize health care services. DHOs and partners must strengthen or introduce initiatives for increased access for the poor, rural and uneducated women in Malawi. 

Linking health systems inputs to EHP provision

To the extent possible, health systems inputs and standards should be explicitly linked to the EHP. The Malawi Standard Treatment Guidelines and the Essential Medicines List (EML) should also reflect the interventions included in the EHP.