Global Health Priorities

A joint research and capacity strengthening programme by Radboudumc and University College London

Category: country

  • Kazakhstan

    Kazakhstan

    Overview

    As part of Kazakhstan’s wider health financing reform related to the rollout of Mandatory Social Health Insurance (MSHI), the country sought to clarify entitlements, improve financial sustainability, and introduce more structured priority setting mechanisms.

    Our support included capacity building and analytical assistance to enhance the use of HTA in designing benefit packages. By applying evidence-based deliberative processes (EDPs), we aimed to improve the legitimacy and transparency of priority-setting decisions.

    Kazakhstan

    Context & Objectives

    Kazakhstan’s health system has undergone significant reform over the past decade, moving toward expanded insurance coverage and stronger state stewardship. The government therefore sought to:

    • Improve transparency in priority setting processes
    • Align benefit design with available public financing
    • Strengthen analytical capacity for structured priority setting

    Approach & Methods Used

    • Development of HTA reports for 25 selected health technologies
    • Online surveys, workshops with key stakeholders to define decision-making criteria and processes
    • Testing two prioritisation approaches: quantitative multicriteria decision analysis (MCDA) and qualitative MCDA with decision rules

    The process combined stakeholder deliberation with evidence-informed evaluation to structure priority decisions.

    Outcomes

    The advisory committee expressed a preference for quantitative MCDA as the primary decision‑making approach, applying decision rules only when MCDA results generated uncertainty or disagreement.

    Key lessons include:

    • Structured deliberation strengthens the legitimacy and transparency of priority setting
    • EDPs integrate multiple forms of evidence into a coherent appraisal framework
    • The EDP framework promotes more structured, reasoned decision-making through tools like MCDA
    • Applying EDPs enhances capacity strengthening for the use of HTA
    • EPDs remain resilient and adaptable even under challenging circumstances, such as the COVID-19 pandemic

    The implementation of EDPs proved feasible and is expected to significantly strengthen transparent, evidence‑informed benefit package design in Kazakhstan.

    Collaborating Partners

    Our work in Kazakhstan has been done in collaboration with the Ministry of Healthcare of Kazakhstan. 

    Related Publications & Reports

  • Indonesia

    Indonesia

    Overview

    In collaboration with provincial authorities, we developed and implemented an Evidence-Informed Deliberative Process (EDP) to translate international HIV treatment guidelines into locally legitimate priorities in West Java province. The process supported the Provincial AIDS Commission in developing its 2014–2018 strategic plan for HIV control.

    Rather than focusing solely on expanding antiretroviral therapy (ART), the process structured deliberation around how treatment, prevention and mitigation interventions should be prioritised within limited provincial resources. The West Java case represents the first documented implementation of EDPs in HIV control and demonstrates how structured stakeholder deliberation can improve both the legitimacy and the evidence base of priority setting decisions.

    Context & Objectives

    Indonesia faces a concentrated HIV epidemic among key populations, with growing pressures on provincial health systems. West Java, one of the country’s most populous provinces, carries a substantial share of the national HIV burden. While national regulations expanded ART eligibility, provincial authorities faced difficult trade-offs between treatment expansion and other prevention and mitigation priorities under constrained budgets.

    Previous strategic planning processes lacked systematic stakeholder involvement, explicit decision criteria and structured prioritisation. The reform therefore aimed to:

    • Translate international HIV guidelines into context-specific priorities
    • Strengthen stakeholder participation and transparency
    • Improve the systematic use of evidence in decision-making
    • Enhance the legitimacy of provincial HIV policy decisions

    Approach & Methods Used

    • The West Java AIDS Commission implemented the six-step EDP framework:
    • Situational analysis, including epidemiological modelling
    • Formation of a multistakeholder Consultation Panel (23 stakeholders from government and civil society)
    • Selection of explicit decision criteria
    • Identification of 50 candidate interventions
    • Systematic assessment of interventions against agreed criteria: impact on the epidemic, stigma reduction, cost-effectiveness and universal coverage
    • Structured deliberation adapted to local cultural norms favouring consensus
    • Selection of funding and implementing responsibilities

    The process combined stakeholder deliberation with evidence-informed evaluation to structure priority decisions.

    Outcomes

    Compared to previous planning cycles, both stakeholder involvement and the systematic use of evidence improved. Explicit criteria were used, trade-offs were openly discussed and broad consensus was achieved for the selected mix of treatment, prevention and mitigation interventions.

    Key lessons include:

    Priority setting should be iterative and supported by institutional development

    Structured deliberation strengthens legitimacy in politically sensitive areas

    Making criteria explicit improves transparency and consistency

    The EDP framework is adaptable to local institutional and cultural contexts

    Collaborating Partners

    • Padjadjaran University
    • West Java province AIDS commission

    Related Publications & Reports

  • Ghana

    Ghana

    Overview

    Ghana has been a regional leader in institutionalising HTA. Rather than designing a new essential package from scratch, the country focused on strengthening decision-making processes for including and reimbursing medicines and services.

    Through collaboration with the Ministry of Health and the National Health Insurance Authority (NHIA), we supported the development of structured HTA processes to improve transparency, consistency and the systematic use of evidence in reimbursement decisions. The Ghana experience represents a transition from implicit priority setting toward institutionalised, evidence-informed appraisal embedded within national governance structures.

    Context & Objectives

    Ghana’s National Health Insurance Scheme covers a large share of the population, but rising costs, increasing demand and fiscal pressure created the need for more explicit and systematic priority setting. Historically, inclusion of services and medicines in the benefits package was not consistently guided by structured economic evaluation.

    The government therefore aimed to:

    • Establish formal HTA processes within national decision-making
    • Strengthen analytical capacity for economic evaluation
    • Introduce transparent appraisal criteria for reimbursement decisions
    • Improve alignment between technical evidence and policy decisions
    • Institutionalise priority setting within existing governance structures

    The reform process was aligned with Ghana’s broader UHC ambitions and health financing sustainability agenda.

    Approach & Methods Used

    • Supporting the establishment of related governance structures including the HTA Steering Committee and HTA working groups 
    • Development of national HTA process guidelines 
    • Capacity building in evidence appraisal
    • Structured appraisal processes with explicit decision criteria
    • Integration of multiple criteria including cost-effectiveness, budget impact, and equity.

    Outcomes

    Ghana successfully embedded HTA processes for evidence-informed decision-making that prioritises efficiency, equity, and sustainability in healthcare resource allocation. These guidelines enhance the transparency and accountability of health policy decisions and serve as a model for other countries seeking to institutionalise health decision-making processes in their healthcare systems

    Key lessons include:

    • Institutional anchoring within the Ministry of Health is critical
    • HTA must be aligned with real reimbursement timelines
    • Capacity building is as important as methodological development
    • Clear procedural rules improve legitimacy and predictability
    • Sustained political commitment is required to protect evidence-based processes from short-term pressures

    Ghana demonstrates that middle-income countries can move from ad hoc priority setting toward structured, institutionalised HTA systems that support financially sustainable health coverage.

    Related Publications & Reports

  • Liberia

    Liberia

    Overview

    Liberia developed a Universal Health Coverage Essential Package of Health Services (UHC EPHS) as a central reform to define healthcare entitlements and strengthen progress toward UHC. The reform was undertaken within the framework of the Disease Control Priorities 3 (DCP3) Country Translation Programme, led by Ala Alwan, which supported countries in translating global priority-setting evidence into national benefit packages.

    The process was led by the Ministry of Health and implemented using an Evidence-Informed Deliberative Process (EDP) developed and operationalised by our team to support the design of an affordable and implementable package under severe fiscal constraints.

    The final package focuses primarily on high-impact primary healthcare interventions. It comprises 128 interventions organised into a publicly financed core subpackage and a complementary subpackage funded through cost-sharing and partner support. The adopted package balances disease burden, cost-effectiveness, financial risk protection and feasibility within a constrained fiscal envelope of approximately US$12–14 per capita.

    Context & Objectives

    Liberia is a low-income country facing significant health system gaps and fiscal limitations. In 2019, nearly 2 million disability-adjusted life years (DALYs) were lost, largely due to communicable, maternal, child and nutritional conditions. Public financing remains limited, with high dependence on donor funding and substantial out-of-pocket expenditure.

    Mapping of existing services revealed that only around one quarter of essential interventions were available at adequate coverage levels. At the same time, projected declines in donor funding created additional urgency for structured prioritisation.

    In 2022, the Ministry of Health initiated development of a UHC EPHS in collaboration with the Disease Control Priorities 3 (DCP3) Country Translation Project. The objectives were to:

    • Define a transparent and affordable essential package
    • Align services with national disease burden and social values
    • Ensure fiscal feasibility within projected government resources
    • Strengthen institutional capacity for structured priority setting
    • Facilitate transition from package design to implementation

    Strong political leadership and alignment with national planning processes were central to the process.

    Approach & Methods Used

    • Ministry-led governance structure with technical working groups and a dedicated secretariat
    • Mapping of existing services against the DCP3 model package
    • Shortlisting of 240 candidate interventions for prioritisation
    • Application of Evidence-Informed Deliberative Processes (EDPs)
    • Use of eight explicit decision criteria: disease burden, effectiveness, cost-effectiveness, quality of evidence, financial risk protection, budget impact, feasibility and equity considerations
    • Use of the Health Intervention Prioritisation Tool (HIPTool) to contextualise global evidence
    • Fiscal space analysis to define an affordable public financing envelope
    • Scenario development to align priorities with available government resources

    Outcomes

    The final EPHS includes:

    • 78 interventions in a core publicly financed subpackage (US$6.93 per capita government cost; 874,000 DALYs averted)
    • 50 complementary interventions funded through cost-sharing (US$5.35 per capita government cost)
    • Total government cost of US$12.28 per capita, averting approximately 1.17 million DALYs

    Key lessons:

    • Evidence-informed prioritisation is feasible in low-income settings
    • Under severe fiscal constraints, focusing on high-impact primary healthcare is the most realistic strategy
    • Fiscal sustainability remains a major challenge due to declining donor funding
    • Implementation requires continued strengthening of health system building blocks and stronger engagement of the finance sector
    • Institutionalisation of priority setting and ongoing capacity development are essential for future package revisions

    Collaborating partners 

    • Republic of Liberia Ministry of Health
    • London School of Hygiene & Tropical Medicine
    • University College London
    • International Centre for Migration Switzerland

    Related Publications & Reports

  • Pakistan

    Pakistan

    Overview

    Pakistan developed its first national Essential Package of Health Services (EPHS) as a central step toward Universal Health Coverage. The process was led by the Ministry of National Health Services and implemented using an Evidence-Informed Deliberative Process (EDP) developed and operationalised by our team to support transparent and systematic prioritisation.

    The resulting EPHS defines a fiscally grounded package of 117 district-level interventions, with phased implementation based on available fiscal space. The process combined technical analysis, stakeholder deliberation and explicit trade-offs across coverage, services and financial protection dimensions.

    Context & Objectives

    Pakistan, a lower-middle-income country with a decentralised health system, faces significant gaps in access to essential services, particularly in non-communicable diseases and health service access. Public health expenditure is limited, and out-of-pocket spending remains high.

    In 2018, the government initiated development of a national EPHS drawing on the Disease Control Priorities 3 (DCP3) evidence base. The objective was to:

    • Develop an evidence-informed and affordable essential package
    • Institutionalise a structured priority setting process
    • Align package design with fiscal realities
    • Support phased implementation toward UHC

    A dedicated governance structure was established, including Technical Working Groups (TWGs), a National Advisory Committee (NAC), and a Steering Committee under ministerial leadership.

    Approach & Methods Used

    • Evidence-Informed Deliberative Processes (EDPs) to structure priority setting and enhance legitimacy
    • Installation of formal advisory committees (150+ stakeholders across TWGs and NAC)
    • Explicit decision criteria: cost-effectiveness, avoidable burden of disease, equity, financial risk protection, budget impact, feasibility, socio-economic impact
    • Systematic assessment of 170 candidate interventions
    • Ingredients-based costing methodology for context-specific unit costs
    • Deliberative appraisal separating unconstrained prioritisation from fiscal-constrained decision-making
    • Explicit fiscal space analysis to define an Immediate Implementation Package

    Outcomes

    The final EPHS includes:

    • 117 district-level interventions (US$ 29.7 per capita for full package)
    • An Immediate Implementation Package of 88 interventions (US$ 12.98 per capita) aligned with fiscal constraints
    • Additional prioritisation of tertiary-level services

    Key lessons:

    • Structured deliberation enhances perceived legitimacy of decisions
    • Fiscal space analysis is essential for realistic package design
    • Broad stakeholder engagement is feasible but requires strong facilitation
    • Institutionalisation beyond package design remains the critical next step
    • Transition from design to implementation requires continued capacity building and financing reform

    The national EPHS guided subsequent provincial adaptation processes.

    Related Publications & Reports