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”:
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
|
Category |
Intervention Package |
Intervention |
Level of Care |
|
RMNCH |
ANC Package |
Tetanus toxoid (pregnant women) |
Community/Primary/Secondary |
|
Deworming (pregnant women) |
Community/Primary/Secondary |
||
|
Daily iron and folic acid supplementation (pregnant women) |
Community/Primary/Secondary |
||
|
Syphilis detection and treatment (pregnant women) |
Community/Primary/Secondary |
||
|
IPT (pregnant women) |
Community/Primary/Secondary |
||
|
ITN distribution to pregnant women |
Community/Primary/Secondary |
||
|
Urinalysis (4 per pregnant woman) |
Primary/Secondary |
||
|
Modern Family Planning |
Injectable |
Community/Primary/Secondary |
|
|
IUD |
Primary/Secondary |
||
|
Implant |
Primary/Secondary |
||
|
Pill |
Community/Primary/Secondary |
||
|
Female sterilization |
Secondary |
||
|
Male condom |
Community/Primary/Secondary |
||
|
Delivery Package |
Clean practices and immediate essential newborn care (in facility) |
Primary/Secondary |
|
|
Active management of the 3rd stage of labour |
Primary/Secondary |
||
|
Management of eclampsia/pre-eclampsia (Magnesium sulphate, Methyldopa, Nifedipine, Hydralazine) |
Primary/Secondary |
||
|
Neonatal resuscitation (institutional) |
Primary/Secondary |
||
|
Caesarean section with indication |
Secondary |
||
|
Caesarean section with indication (with complication) |
Secondary |
||
|
Vaginal delivery, skilled attendance (including complications) |
Primary/Secondary |
||
|
Management of obstructed labour |
Primary/Secondary |
||
|
Newborn sepsis - full supportive care |
Primary/Secondary |
||
|
Newborn sepsis – injectable antibiotics |
Primary/Secondary |
||
|
Antenatal corticosteroids for preterm labor |
Primary/Secondary |
||
|
Maternal sepsis case management |
Primary/Secondary |
||
|
Cord Care Using Chlorhexidine |
Primary/Secondary |
||
|
|
Hysterectomy |
Primary/Secondary |
|
|
|
Post-abortion case management |
Secondary |
|
|
|
Treatment of antepartum haemorrhage |
Primary/Secondary |
|
|
|
Treatment of postpartum haemorrhage |
Secondary |
|
|
|
Antibiotics for pPRoM |
Primary/Secondary |
|
|
Vaccine Preventable diseases |
Essential Vaccines Package |
Rotavirus vaccine |
Community/Primary/Secondary |
|
Measles Rubella vaccine |
Community/Primary/Secondary |
||
|
Pneumococcal vaccine |
Community/Primary/Secondary |
||
|
BCG vaccine |
Community/Primary/Secondary |
||
|
Polio vaccine |
Community/Primary/Secondary |
||
|
DPT-Heb-Hib / Pentavalent vaccine |
Community/Primary/Secondary |
||
|
HPV vaccine |
Community/Primary/Secondary |
||
|
Malaria |
First Line uncomplicated Malaria treatment |
Uncomplicated (adult, <36 kg) |
Community/Primary/Secondary |
|
Uncomplicated (adult, >36 kg) |
Community/Primary/Secondary |
||
|
Uncomplicated (children, <15 kg) |
Community/Primary/Secondary |
||
|
Uncomplicated (children, >15 kg) |
Community/Primary/Secondary |
||
|
Complicated Malaria treatment |
Complicated (adults, injectable artesunate) |
Primary/Secondary |
|
|
Complicated (children, injectable artesunate) |
Primary/Secondary |
||
|
Malaria Diagnosis |
RDTs |
Community/Primary/Secondary |
|
|
Microscopy for Malaria |
Primary/Secondary |
||
|
Integrated management of childhood illnesses (IMCI) |
ARIs |
Pneumonia treatment (children) |
Community/Primary/Secondary |
|
Treatment of severe pneumonia (Oxygen) |
Primary/Secondary |
||
|
Diarrhoeal Disease |
ORS |
Community/Primary/Secondary |
|
|
Zinc |
Community/Primary/Secondary |
||
|
Treatment of severe diarrhoea (IV Fluids) |
Primary/Secondary |
||
|
Nutrition |
Community management of nutrition in under-5 - Plumpy Peanut |
Community/Primary |
|
|
Community management of nutrition in under-5 - micronutrient powder |
Community/Primary |
||
|
Community management of nutrition in under-5 - vitamin A |
Community/Primary |
||
|
Malaria Diagnosis |
RDTs for under-5 |
Community/Primary |
|
|
Community Health |
Community Health Package |
Growth Monitoring |
Community/Primary |
|
Vermin and Vector Control & Promotion |
Community/Primary |
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|
Disease Surveillance |
Community/Primary |
||
|
Community Health Promotion & Engagement |
Community/Primary |
||
|
Village Inspections |
Community/Primary |
||
|
Promotion of hygiene (hand washing with soap) |
Community/Primary |
||
|
Promotion of Sanitation (latrine refuse, drop hole covers, solid waste disposal, hygienic disposal of children’s stools) |
Community/Primary |
||
|
Occupational Health Promotion |
Community/Primary |
||
|
Household water quality testing and treatment |
Community/Primary |
||
|
Home-based care of chronically ill patients |
Community/Primary |
||
|
Child Protection |
Community/Primary |
||
|
NTDs |
Treatment and MDA |
Schistosomiasis mass drug administration |
Community/Primary |
|
Case finding and treatment of Trypanosomiasis |
Primary |
||
|
Trachoma mass drug administration |
Community/Primary |
||
|
HIV/AIDS |
HIV Prevention |
Cotrimoxazole for children |
Community/Primary/Secondary |
|
PMTCT |
Community/Primary/Secondary |
||
|
HIV Testing |
HIV Testing Services (HTS) |
Community/Primary/Secondary |
|
|
HIV Treatment |
HIV Treatment for all ages – ART & Viral Load |
Community/Primary/Secondary |
|
|
Nutrition |
|
Vitamin A supplementation in pregnant women |
Community/Primary/Secondary |
|
|
Management of severe malnutrition (children) |
Community/Primary/Secondary |
|
|
|
Deworming (children) |
Community/Primary/Secondary |
|
|
|
Vitamin A supplementation in infants and children 6-59 months |
Community/Primary/Secondary |
|
|
TB |
|
Isonized Preventive Therapy for children in contact with TB patients |
Primary/Secondary |
|
|
First line treatment for new TB Cases for adults |
Primary/Secondary |
|
|
|
First line treatment for retreatment TB Cases for adults |
Primary/Secondary |
|
|
|
First line treatment for new TB Cases for children |
Community/Primary/Secondary |
|
|
|
First line treatment for retreatment TB Cases for children |
Community/Primary/Secondary |
|
|
|
Case management of MDR cases |
Primary/Secondary |
|
|
TB Testing |
LED test |
Primary/Secondary |
|
|
Xpert test |
Primary/Secondary |
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|
MGIT test |
Primary/Secondary |
||
|
LJ test |
Primary/Secondary |
||
|
NCDs |
|
Treatment of Injuries |
Primary/Secondary |
|
Mental Health treatment |
Basic psychosocial support, advice, and follow-up |
Community/Primary/Secondary |
|
|
Anti-epileptic medication |
Community/Primary/Secondary |
||
|
Treatment of depression (first line) |
Community/Primary/Secondary |
||
|
|
Testing of pre-cancerous cells (vinegar) |
Primary/Secondary |
|
|
Diabetes treatment |
Diabetes Type I |
Primary/Secondary |
|
|
Diabetes Type II |
Primary/Secondary |
||
|
|
Hypertension |
Primary/Secondary |
|
|
Oral Health |
Tooth pain treatment |
Management of severe tooth pain, tooth extraction |
Primary/Secondary |
|
Management of mild tooth pain, tooth filling |
Primary/Secondary |
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.