Designing Health Service Packages in Northern Syria

MSH is helping countries in the Middle East and WHO Eastern Mediterranean region design, finance, and deliver health service packages toward universal health coverage (UHC). Two MSH representatives, David Collins and David Lee, attended a meeting in Cairo recently to discuss the way forward. They presented ideas on health service packages for countries in crisis and how these are necessary to help countries transition from humanitarian health services to long-term, sustainable health systems. Other  international experts presented on service packages for Palestinian refugees and lessons learned from Afghanistan, South Sudan, Liberia, Somalia, Iraq, and Yemen.

David Collins discussed the results of his work for WHO Turkey with NGOs in northern Syria. The WHO Gaziantep Office coordinates cross-border health services provided in northern Syria by more than 40 NGOs (mostly Syrian) to 5.5 million people – residents and Internally Displaced Persons (IDPs). The ongoing conflict in Syria has had a major impact on the health of its people and has resulted in fragmentation of services and danger to both providers and patients. To overcome service fragmentation, WHO and the NGO Health Cluster, developed an Essential Health Service Package (EHSP) for northern Syria.

Costing tool for essential health service package in northern Syria

MSH modeled the cost of the package to help mobilize sufficient resources for the NGOs as well as to improve planning and budgeting, review efficiency and increase accountability. MSH’s CORE Plus Tool was used for the costing – having been designed specifically for the bottom-up modeling of primary health care package costs and has been used in many countries (currently in Afghanistan and Uganda as well as northern Syria). The tool is dynamic and open-source, and MSH trains local organizations to use the tool so that changes to the package contents or inputs can be costed quickly.

MSH developed a generic cost model for the northern Syria package in March 2017 and followed by training NGO staff to cost their services in August 2017. During the training workshop the NGOs developed cost models for some of their facilities. An analysis showed that the NGOs were only providing about 75% of the services in the package due to several reasons, including the lack of trained staff and donor unwillingness to fund certain services. Secondly, the facility appeared to be under-utilized by the people (although the NGO acknowledged that it is very difficult to calculate the catchment population and it may have been over-estimated). The most underutilized services were mental health (which is a major health problem due to the crisis). However, increasing utilization to meet the estimated need of the population would require at least three times the current resources and funding, which may be difficult. The program with the highest cost is non-communicable diseases, with the treatment of diabetes the highest cost service. Most of the funding would go on medicines, supplies and laboratory tests, driven largely by the non-communicable diseases.

Given that some of the facilities are not providing the whole package and most of the services that are provided are underutilized, the donors and NGOs need to decide whether to prioritize expanding the package or scaling up existing services. Also, the NGOs may need to prioritize certain services if resources are not enough, bearing in mind that the highest cost services are personal services (NCDs) and that some key low-cost child health and infectious disease services are under-utilized. The crisis has resulted in a shortage of doctors and task shifting (for example to nurses and community health workers) may be needed to expand coverage. Efficiency improvements are also needed, such as the rationalization of equipment and strategic purchasing of medicines and supplies.

Developing provider networks: A pilot project

Important improvements in cost-effectiveness and efficiency can also be made by developing provider networks. WHO and six NGOs are piloting the development of a network in one of the stable areas of northern Syria. A mixture of mobile clinics and static health centres will cover the whole population of the area, each one with an assigned population and referral pathway. Also the NGOs will share resources, for example a specialist doctor or specialized laboratory and imaging equipment. The pilot will run for an initial 6 months with careful monitoring of results and MSH will assist with its evaluation. There is much interest among donors in replicating this approach in northern Syria and in other countries in crisis.

Countries represented at the meeting in Cairo included Afghanistan, Bahrain, Egypt, Iraq, Iran, Jordan, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Somalia, Sudan, Syria, Tunisia, and the United Arab Emirates. Presentations were made by country representatives as well as by international experts.  Some of the countries in the region are experiencing humanitarian crises with severe health problems, ranging from physical and mental trauma to cholera, and depleted and fragmented health systems. Some others have stable health systems but are struggling to meet the needs of refugees. Meanwhile, others have well-functioning health systems but have challenges with financing them and are looking to develop, expand or improve health insurance coverage.

Addressing medicine benefits programs

MSH’s David Lee emphasized that it is not possible to achieve UHC without addressing medicines since they strongly impact individuals’ and populations’ health, use scarce household resources and challenge the economic viability of systems. Lee presented examples of insurance programs in Ghana, Colombia, India and South Africa and referenced MSH guidelines “Management of Medicines Benefit Programs in Low- and Middle-Income Settings” and “Managing Access to Medicines and Health Technologies.”