Uganda’s Minimum Health Care Package: Rationing within the Minimum?

Essential/minimum health care packages (MHCP) have appeared on the primary health care scene as a means of setting priorities for national health budgets. A technical approach of cost-effectiveness was sought to guide the political and group bargaining approaches. In Uganda, the application of the cost-effectiveness techniques seem not to have had an effect on the priority setting. A package of minimum services that is written into the sector plan has turnout to be more then the resources available in the medium term. At the operational level, the delivery of the minimum package has been rendered ineffective and inefficient, by trying to attain universal access with $ 8 per capita instead of $28. System capacity constraints for effective and equitable delivery of the MCHP are traced at the infrastructure-based planning and in explicit and implicit re-prioritization and rationing within the minimum package. Introduction The overriding aim in setting an essential or minimum health care package (MHCP) is for the state to guarantee free access of its population to a set of health services it can afford. In essence, the minimum health package represents a health insurance that the state provides its population (WHO 2000). The purpose of developing and using the minimum package approach was to assist in resource allocation in the health sector especially in the face of a huge and growing health burden that has to be addressed with small public budgets, that characterize developing countries like Uganda. Due to demographic changes, lifestyles like obesity and smoking, and new technology and information, the health care needs are increasing at a pace that is not matched by the growth of the national budgets. The MHCPs is an explicit rationing of health services by the state. Services that fall outside the boundaries are not guaranteed to the population and therefore additional financing (e.g. private insurance or out-of-pocket payments) are needed (World Bank 1993). The flip side of this is that the state, by defining a minimum package, commits itself to make this package available and effective to all those in position to benefit from it. The aim of establishing MHCP is also to achieve the best possible value for available resources by allocating them to interventions that have the most benefits in improving population’s health. This “costeffectiveness” approach, it is argued, is preferable to alternative approaches to setting priorities in the health sector (World Bank 1993; Mahapatra 2002). Priority setting in health sector Sometimes decisions regarding allocation of resources are ad hoc, based on professional opinions or on strong lobby groups, political expediency or outright public hysteria. For example, the most important single determinant of the annual health budget and its composition, for most districts in Uganda, is the previous year's expenditure pattern with some marginal additions to compensate for inflation and budget growth. This basis of allocation creates a financial inertia that perpetuates the deficiencies and inefficiencies in the system. Governments of developing countries are also usually sensitive to international initiatives and fashions as to what deserves priority in the health sector at any given time. External assistance through the earmarking of loans and grants influences country priority setting. For example, Global Fund to Fight HIV, TB and Malaria and other grants for HIV/AIDS have raised the priority of these conditions even when the ordering of needs at the population level may have been different. Provision of ARVs now tops the list of health system concerns and MOH has pronounced its commitment to provide universal free access to ARV to all persons living with HIV despite statements to the contrary in its Health Sector Strategic Plan (MOH 2000). The commitment in rolling out ARVs in the Ugandan health system although carries tremendous public health benefits, is an example of international priorities confronting national systems starved of resources to address their own set of needs. Unfortunately, health priorities stemming from international agencies with resources may not always be derived from studies of cost-effectiveness, but often from implicit judgments such as the threat of contagion that “global village” imposes on the international community as reflected below: “Recognizing that, in an age of worldwide travel by people from all over the world, disease can move rapidly from country to country and continent to continent, so that the health of Americans is intricately interwoven with health measures taken elsewhere, .....applaud President Bush's initiative proposing $15 billion over the next five years for prevention and treatment programs for HIV/AIDS and other serious infectious diseases in fourteen countries” (UNA-USA 2003) Other considerations that may influence the definition of health priorities are: the perceived interest of the politicians, medical profession and other groups in society. All these stakeholders have own interests in the priority setting process ranging from having access to complex medical technology for doctors and medical workers, ideological standpoints of the government lobby groups and political capital for politicians. Others may champion issues of equity, patients and provider’s rights and freedoms. Resource allocations based on such consensus decision processes have in the past been a source of inefficient budget allocation. For example, inappropriate large share of resources at tertiary hospitals around the world reflect the strong lobby of the powerful medical professionals who seek to adopt more technology and professional status accruing from extensive technical capacity of the hospitals even when needy clients cannot afford such hospitals (Cooper 1990). Despite the aforementioned influences on the health priority-setting context, over the past 10 years, major progress has been made in evaluating the health needs at the population level and developing the appropriate interventions for addressing them. The World Bank and WHO set out a process for establishing a rational and globally applicable method of guiding priority setting by using objective and technical criteria. This process has variously developed measures of effectiveness from health interventions which includes quality adjusted life years (QALY), disability adjusted Life years (DALY) and most recently, the health adjusted life expectance (HALE) (Mahapatra 2002). However, the measures have been in a state of flux indicating the difficulty of having very technical tools that can be applied across different countries, health, culture and value systems (Reidpath 2001). Economic evaluation of interventions and programs, mainly through costeffectiveness analysis, has been introduced and applied more widely. More importantly, the rationale of economic evaluation is slowly permeating the process of decision making in the Ugandan health sector (MOH 2003). The socio-political dimensions of priority setting Resource allocation is essentially a socio-political process although technical inputs such as cost effectiveness are important for evidence-based policy making (Walt 1994). Political expedience tends to drive the package beyond the available resources due to the distasteful concept of rationing in the political debates especially due to strong lobby groups such as women and human rights activists (Tengs 1996, Maynard 1998). Universal access to all possible care is commonly implied although the way the health system is planned, financed and its overall capacity grossly reduces this scope by adjusting both service quality and availability. As a product of the cost-effectiveness approach to priority setting in health care, a list interventions are identified that provide the best value for money in achieving the most reduction in the disease burden. The overall principal in constituting the minimum package is to match the package of interventions with the available resources (financial human and technology). The process of matching the interventions with resources is a technical process whose tools are limited to mostly to two dimensions: 1.) what the costs of interventions are, and 2.) how effective are the interventions in improving health status. Most of these are derived from ideal contexts that do not pertain in Uganda. On the political side, however other dimensions are needed. For example, is access to services equitable? To the individuals using the services, the convenience of access, the out-of-pocket expenditures and the utility/benefits derived from using the interventions are major consideration. In this paper an attempt is made to illustrate how the priorities set using the technical measures above (ie costs and effectiveness) may not have been usefully applied in Ugandan context. Data from national surveys is abstracted as indicative of the problems and promise in the minimum package approach. The paper tries to illuminate the problems, both in the technical processes of evaluating costs and effectiveness of interventions as well as in the process of planning and delivery of actual services that make the approach of fail to deliver better health. The paper argues that MHCP approach as used in Uganda’s health sector strategic plan far outstrip the available resources in the short and medium term, and can not be guaranteed by the state. The paper also illustrates the access problems that arise due to explicit and implicit rationing that takes place as attempts at policy and provider levels are made to provide a minimum package estimated at $28 per capita with only $8 par capita currently available (MOH 2002). System financing and the minimum health care packages The MHCP services typically include preventive services such as childhood immunization, health promotion and education as well as treatment and control of common and infectious disease such as malaria, HIV/AIDS and TB. The use of MHCP presupposes three main issues: 1) that government has a good estimate of the resources that are going to be available for health service delivery, 2) that the delivery system has the capacity to deliver the package of services, and 3) that the costs of the services to be delivered and their benefits to the population are available. Mostly due to lack of reliable cost data about interventions effectiveness in Ugandan context, the selected interventions are of unknown effectiveness in the local circumstances and have turned out to be beyond the reach of available resources as reflected in figure 1. Figure1: Financial resources available and projections for health sector plan 2000/01 to 2003/04 (billion shillings) 0 100 200 300 400 500 600 700 80