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 populations.

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.