Bergen Centre for Ethics and Priority Setting in Health (BCEPS)

Universal Health Coverage (UHC) Zanzibar

UHC Zanzibar is led by Omar Mwalim and Kjell Arne Johansson. The 5-year project started in 2019 and aims at providing decision support to the Ministry of Health (MoH) to help define and implement an essential health service package  (EHCP) for Zanzibar.

Omar Mwalim and Kjell Arne Johansson during the launch event of EHCP Report in Zanzibar
Omar Mwalim and Kjell Arne during the offical launch of the Essential Health Care Package (EHCP) Report in Zanzibar on 16 November 2022 -
Johnny Holmvåg

Main content

Original project plan

The original objective for the Zanzibar project team was to provide decision support to the Ministry of Health to help define and implement a highest priority package for Non-Communicable Diseases and Injuries (NCDIs). Capacity building at the Ministry of Health was to be achieved through advanced courses and the training of one PhD candidate. 

Change of plan from 2020 -

Full revision of the Essential Health Care Package (EHCP)

In 2020, a major change to the original project plan took place when The Ministry of Health in Zanzibar asked BCEPS (in collaboration with the regional WHO office) to conduct a full revision of the national essential health care package and not only focus on NCDIs. In addition, the Ministry of Health also asked for a full budget of the health system that can be used in the next 5-year health plan in Zanzibar (Health Sector Strategy Plan - HSSP), a document that is essential for allocating health budgets in Zanzibar.

Main objectives

  • Assist the Ministry of Health in the revision of Zanzibar’s essential health care package (EHCP) by establishing explicit criteria for priority setting and identifying fair, efficient and cost-effective health interventions, linking these to financing mechanisms.
  • Assess the conditions for EHCP implementation, with a particular focus on Non-Communicable Diseases and Injuries (NCDIs).  
  • Build capacity at the Ministry of Health (MoH) in standard priority setting methods and how to translate such into policy.

Revised Essential Health Care Package completed

After three years of hard work, a revised Essential Health Care Package was launched in November 2022. The steps along the way are outlined below:

Zanzibar - Revision of Essential Health Care Package

BCEPS professor Kjell Arne Johansson and PhD candidate Omar Mwalim explain the content of the EHCP in Zanzibar and how it came about.

  1. Establishment of a roadmap
  2. Sharing the roadmap with stakeholders 
  3. Creation of a local management team 
  4. Criteria selection for priority setting 
  5. Identification of interventions 
  6. Priority setting of interventions 
  7. Collection of evidence for determining baseline coverage and future targets 
  8. Economic analysis 
  9. Development of an implementation plan 
  10. Political approval of the package

    The core management group, comprising 12 members from the Ministry of Health, Ministry of Finance and national statistics agency, completed an extensive round of stakeholder meetings with technical working groups (clinicians, policy makers and patient representatives) and district managers to reach an agreement on which criteria to use for priority setting.   

    The key criteria for priority setting in health in Zanzibar have been defined as:  

    • i. Cost-effectiveness  
    • ii. Priority to worse-off  
    • iii. Financial risk protection 
    • iv: Disease burden 
    • v. Budget impact 
    • vi. Political and public acceptability

    Milestones achieved by December 2022 

    • November 2019: Workshop in Addis Ababa: “Evidence-based priority setting” (12 participants from Zanzibar)  
    • February 2020: Workshop in Zanzibar: “Cost-effectiveness analysis and costing of health interventions using the OneHealth tool (OHT)” (12 participants from Zanzibar)
    • July 2022: Approval of the EHCP by the President and the Government. The healthcare budget is planned to double in 10 years. 
    • November 2022: Launch of the EHCP Report by the Ministry of Health in Zanzibar, with the presence of the Second Vice President, Hemed Suleiman Abdullah
    • The Deputy Director of Health Services wanted to have the EHCP easily available for the health insurance team, partners, collaborators, and for the population in the country. For this reason, an app containing the information of the EHCP was developed by the IT department at the University of Zanzibar and is currently being disseminated in the country. The app can be seen as “making an excel file available to the people”. It can be downloaded from the Ministry of Health website.

        FairChoices DCP Analytics Tool ​

        The FairChoices DCP Analytics Tool has been developed by a BCEPS team of researchers to assist policy makers in a comprehensive revision of essential health care packages by analysing and visualising the expected outcomes of applying explicit criteria for priority setting. It is designed as a user-friendly tool that can be tailored to priority setting processes and make evidence on cost-effectiveness, equity impact and financial risk protection (FRP) more easily available to policy makers who have little technical background in these methods. It has been used as the main analytical tool in the revision of the Essential Health Care Package in Zanzibar (Aug 2019 – July 2022).

        The results from FairChoices were used in deliberations at all stakeholder meetings and the potential consequences of various scale-up scenarios of all interventions were presented. This triggered important discussions about the opportunity cost of various scale-up scenarios. The cost estimations for health interventions and the burden of disease in Zanzibar were incorporated in FairChoices to generate more tailored and accurate scenarios for the country.   

        This was important for making decisions on which interventions to prioritise in the EHCP.  

        Estimates on expected cost and effects of the ≈350 health service interventions on all delivery platforms were produced based on scientific evidence collected and FairChoices modelling.

        More information about the FairChoices DCP Analytics tool

        Next steps 

        Zanzibar Health Finance Reform 

        As part of the implementation strategy of the EHCP, the government of Zanzibar is now planning a major health finance reform. Zanzibar is developing the Health Financing Strategy where a Universal Health Insurance (UHI) and a health Equity Fund will be implemented from 2023. 

        Health insurance is planned to cover services for formal sectors and funded by a compulsory health tax as a premium and the Equity Fund will cover services for the destitute that are not eligible for the health insurance. The latter will generate funding both domestically (from various non-health type of taxes) and development partner. The EHCP is key in both the health insurance and the Equity Fund for defining what services to include 

        BCEPS have been working with other agencies on the ground such as PharmAcess, Health Insurance team of the Ministry of Health, D-Tree and other partners to ensure harmonization and alignment with EHCP. The BCEPS Zanzibar team in the fall of 2022 participated in many meetings to ensure that the interventions in the EHCP are included in plans and given the priority that is intended by decision makers. For example, the Health Insurance team are now working on having the same interventions listed in the insurance benefit package as the list of priority interventions in the EHCP. EHCP interventions will be provided free of charge and used both for estimating the premium needed to charge and serve the basis for an activity-based costing reimbursement for facilities.   

        Assessing the readiness of health care facilities 

        In order to ensure effective implementation of the ECHP, a survey was conducted to all health facilities (n=52) providing NCD care. They were assessed for readiness of the health system to provide NCD care in accordance to EHCP aims and priorities. The main domains assessed include human resource, medicine, equipment and supplies and infrastructures. This survey will provide baseline information about health facilities and serve as the starting point when monitoring the implementation of the EHCP and assessment of whether the scale-up is on-track or off-track in the next 10 years in Zanzibar.