Translation: Pakistan

Translating the DCP3 Evidence in Pakistan

In 2018, reaffirming its commitment to accelerating progress towards UHC, the Ministry of National Health Services, Regulations and Coordination (MNHSR&C) established a collaboration with the DCP3 Secretariat and the World Health Organization to develop a national Essential Package of Health Services (EPHS) based on the DCP3 evidence and guided by its model essential UHC package.

Following the decision of the Inter-ministerial Health & Population Forum, Pakistan became the first country to translate the DCP3 evidence into the development of a national Essential Package of Health Services or UHC Health Benefit package. The EPHS aims to address the current disparities and inequalities in access to health care, and establish and clarify health priorities and direct resource allocation in Pakistan. The EPHS became a cornerstone of the 12th Five Year Plan (2018-2023) Health chapter and the National Action Plan (2019-2023) for Pakistan's health sector.

Designing and costing the UHC Essential Package of Health Services, together with capacity building in the Ministry of Health and external institutions, provided valuable learning experiences moving forward. It is hoped that Pakistan’s experience in developing and implementing a national UHC EPHS is harnessed to help other low- and middle-income countries accelerate progress towards UHC by adapting the DCP3 packages to their country context, taking into account their specific epidemiological needs, health system capacity, and available financing.

Current Work

	Provincial adaptation of UHC Package DCP3 is supporting the sensitization, planning and localization workshops in the Khyber Pakhtunkhwa Province, including technical support to provincial Departments of Health in setting priorities and adapting the UHC benefit package.
	Implementation phase of the UHC Benefit Package In partnership with the University of Manitoba and the Health Services Academy, DCP3 developed a Monitoring & Evaluation framework and is providing technical expertise for the development of implementation plans after provincial adaptation of the national EPHS.
	Knowledge and experience sharing DCP3 is conducting a review of the experience and lessons learned in developing the national EPHS. The Pakistan experience will be soon shared with other partners and countries through a series of publications and special events.
	Package of intersectoral policies DCP3 is finalizing a multisectoral analysis on the current status of the DCP3 core intersectoral policies and assessing priority needs in Pakistan. It will also develop a national package for high level discussion with government sectors and other partners.
	Health finances strategy DCP3 is engaging with the World Bank in the development of a health financing strategy for Pakistan. It will provide technical support in reviewing available data on fiscal space and health financing, including joint missions with the World Bank and relevant partners.

Designing and costing the UHC Essential Package of Health Services counted with the leadership of Ministry officials and the technical support from the DCP3 Secretariat and national and international partners. The process of developing and setting the EPHS was country-owned and executed, and followed a number of steps, including:

assessing disease burden, health challenges, priorities, and health system capacity
establishing a governance structure for deliberation on priorities and services
agreeing on goals/criteria for setting priorities and selecting services/interventions
implementing an evidence-based priority setting process
conducting detailed costing of the package by interventions and delivery platforms
assessing health system capacity to identify actions to implement the package
assessing the budget impact and translating decisions to resource allocation and use
establishing a monitoring & evaluation framework to assess performance/outcomes
adapting and piloting the package at the provincial level
reviewing the package periodically based on new evidence.

In October 2020, a UHC EPHS for Pakistan containing 107 interventions was approved by the Steering Committee and the Inter-ministerial Health & Population Forum. The package is context appropriate, affordable and meets the most pressing health needs of the Pakistani population.

The implementation process of the UHC EPHS follows a phased approach, which will begin with the implementation of 88 health interventions at per capita cost of US$12.9 and be expanded to cover all 107 interventions in the UHC EPHS once more resources become available. Following the recommendations of the Inter-ministerial Health & Population Forum, a decision was taken to implement the EPHS in Islamabad and pilot districts in four provinces, and conduct additionally a fiscal assessment and a financing strategy. Following recent consultations with MoNHSR&C and the Bill & Melinda Gates Foundation, DCP3 will continue its collaboration with Pakistan to provide technical support during provincial pilot rollouts and implement additional activities requested by the Government.

Governance Structure

Translating project objectives into concrete actions in Pakistan required building a robust and effective governance structure. The UHC EPHS governance structure aims to ensure effective coordination and decision-making and consists of:

a core team, composed of the Health Planning unit at the Ministry of Health. The Health Planning unit is supported by DCP3-recruited national consultants and the Department of Community Health Sciences, Aga Khan University with backup technical support from the Secretariat of the DCP3 Country Translation Project at the London School of Hygiene & Tropical Medicine (LSHTM), the World Health Organization, UNICEF and other relevant partners;
four technical working groups (TWGs) with membership representing different public health, health system, academic and clinical professions;
the National Advisory Committee (NAC), which is co-chaired by the Director General of Health;
an International Advisory Group chaired by the Principal Investigator of the DCP3 Country Translation Project and members representing international expertise, DCP3 editors and authors and relevant international agencies;
a Steering Committee, which is chaired by the Minister of Health.

Following the successful development of the Essential Package of Health Services, DCP3 is committed to supporting a provincial localization and adaptation of the EPHS in Pakistan, starting with the Khyber Pakhtunkhwa (KP) province. DCP3 is support ingthe sensitization, planning and localization workshops in KP and the recruitment of a public health coordinator and research staff for the provincial UHC component.

The EPHS will be tailored to match the disease burden, local evidence, special needs and available resources of KP. Consultations will be held with MoNHSR&C and the Department of Health to plan for capacity building meetings on data collection, priority setting, and costing and adapting the UHC benefit package.

In parallel with the EPHS development, the DCP3 Country Translation Project contributed to the development of a package of 71 intersectoral interventions to reduce behavioural and environmental risk factors. The interventions relate to taxes and subsidies (15), regulations and related enforcement mechanisms (38), built environment (11), and information (7). Following a meeting in January 2020, an early intersectoral package containing 29 interventions has been approved by the MoNHSR&C for use in Pakistan. Work is under way to further prioritize the most essential interventions, develop an operational joint action plan, and launch the intersectoral interventions. A National Workshop on Intersectoral Policies for Health was held on 24 February 2021, with the aim of building consensus on a multisectoral work plan to prioritize intersectoral policies for Pakistan.

In collaboration with national and international partners, including UNICEF, WHO and CDC, DCP3 developed a sub-package of health and basic water, sanitation, and hygiene services for implementation in 40 high-risk polio-endemic union councils. Following assessments of the health and WASH infrastructure in high-risk union councils in 2020, a sub-package covering prioritized basic services contained in the Essential Package of Health Services has been developed, with special focus on strengthening routine immunization and providing basic nutrition and antenatal services, and developing innovative and low-cost WASH interventions.The sub-package has been incorporated in the Integrated Services and Routine Immunization Initiative of the National Polio Programme.

Plans are under way to transition from design and planning to pilot implementation at the provincial level, which will require a significant investment in basic infrastructure to ensure full coverage of essential WASH and health services. DCP3 will continue to support Pakistan in implementing and scaling up the activities initiated under this project.