HomeEssential Health Package

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

 

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
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
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.