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Choosing services Integrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off Ole F. Norheim Professor in Medical Ethics and Philosophy of Science Dept. of Global Public Health and Primary Care University of Bergen [email protected] Plan • Background • Cost-effectiveness • Financial protection • Priority to the worse off • Classification of priority health services Key question • Should financial protection and distributional concerns be incorporated into decision rules for publicly financed health services? Priority group classification • Universal Coverage can be defined as access to key health services for all at an affordable cost Key services 1. High-priority services 2. Normal-priority services 3. Low-priority services How to classify services? • Cost-effectiveness thresholds < 1 GDP per capita 1-2 GDP per capita > 3 GDP per capita (Macroeconomics and Health 2002, WHO CHOICE) Example • Selected 65 health services from WHOCHOICE database (AfrE) • • • • Child health services Maternal and newborn health services Infectious disease services Non-communicable disease services • Converted all costs to Int $ 2005 (WHO-CHOICE team BMJ series 2005-2012) Incremental cost-effectiveness for 65 selected interventions 0 2 4 6 8 10 12 14 16 DALYs/1000 $ DALYs/1000 $ 0.0 Trichiasis surgery to prevent BLINDNESS TUBERCULOSIS: Testing and treatment MALARIA: All prevention and treatment Medical treatment of stroke and heart attack + primary prevention (>35) Normal and complicated birth + Community newborn care package +pneumonia treatment ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl., HIV: Prevention and treatment of HIV including PMTC Seatbelts, motorcycle helmets, speed cameras, breathtesting Breast cancer treatment all stages Colonoscopy at age 50, surgical removal of polyps, treatment 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Two problems with CEA • Ignores financial risk protection • Ignores distribution of healthy life years Financial risk protection • Publicly financed health services provide – Financial risk protection – Health • Peter Smith : – If no one buys supplementary services, or – a well-functioning voluntary supplementary insurance market service selection on the basis of standard cost-effectiveness ratios will maximize welfare (health + income) (P. Smith, Health Economics 2012) • When there is substantial out-of-pocket payment for supplementary services, this is not so. • High cost services may be favored over low cost services, at least among services with similar cost-effectiveness ratios. • My interpretation: – Financial risk protection could act at least as a tiebreaker for services with identical costeffectiveness ratios. DALYs/1000 $ 0.0 Trichiasis surgery to prevent BLINDNESS TUBERCULOSIS: Testing and treatment MALARIA: All prevention and treatment Medical treatment of stroke and heart attack + primary prevention (>35) Normal and complicated birth + Community newborn care package +pneumonia treatment ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl., HIV: Prevention and treatment of HIV including PMTC Seatbelts, motorcycle helmets, speed cameras, breathtesting Breast cancer treatment all stages Colonoscopy at age 50, surgical removal of polyps, treatment 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Two problems with CEA • Ignores financial risk protection • Ignores distribution of healthy life years Who are worst off without the health service? Healthy lifeyears without service Condition A Condition B 60 25 Additional healthy life years with service 20 20 Integrating distributive concerns with CEA • An “Atkinson’s” social welfare function applied to health would judge: Healthy lifeyears without service Additional healthy life years with service – (60, 45) as better than (80, 25) Condition A 60 (Adler, OUP 2012) Condition B • Health prioritarianism would assign higher weights to benefits for B (Ottersen, JME 2013) 25 20 20 Individual disease burden (Source: Calculated from GBD 2010, Eastern sub-Saharan Africa) 0 Sepsis of the newborn baby Rotaviral enteritis Malaria Maternal sepsis Obstructed labor HIV Road injury Tuberculosis Schizophrenia Livercirrhosis secondary to… Cervical cancer Chronic obstructive pulmonary… Colon and rectum cancers Diabetes mellitus Hypertensive heart disease 10 20 30 40 50 60 70 80 Years of life lost 90 100 Individual disease burden (Source: Calculated from GBD 2010, Eastern sub-Saharan Africa) 0 10 20 30 40 50 60 70 Sepsis of the newborn baby Rotaviral enteritis Malaria Maternal sepsis Obstructed labor HIV Road injury Tuberculosis Schizophrenia Livercirrhosis secondary to… Cervical cancer Chronic obstructive pulmonary… Colon and rectum cancers Diabetes mellitus Hypertensive heart disease 1 1.5 2 80 Years of life lost 90 100 Incremental cost-effectiveness for 65 selected interventions 0 2 4 6 8 10 12 14 16 18 DALYs/1000 $ Distribution-weighted cost-effectiveness for 65 selected interventions 0 2 4 6 8 10 12 14 16 18 DALYs/1000 $ Priority-weighted DALYs/1000 $ DALYs/1000 $ 0.0 Trichiasis surgery to prevent BLINDNESS TUBERCULOSIS: Testing and treatment MALARIA: All prevention and treatment Medical treatment of stroke and heart attack + primary prevention (>35) Normal and complicated birth + Community newborn care package +pneumonia treatment ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl., HIV: Prevention and treatment of HIV including PMTC Seatbelts, motorcycle helmets, speed cameras, breathtesting Breast cancer treatment all stages Colonoscopy at age 50, surgical removal of polyps, treatment 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 Distribution-weighted DALYs/1000 $ 0.0 2.0 4.0 6.0 MALARIA: All prevention and treatment TUBERCULOSIS: Testing and treatment Trichiasis surgery to prevent BLINDNESS Normal and complicated birth + Community newborn care package +pneumonia treatment ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl., Medical treatment of stroke and heart attack + primary prevention (>35) HIV: Prevention and treatment of HIV including PMTC Seatbelts, motorcycle helmets, speed cameras, breathtesting Breast cancer treatment all stages Colonoscopy at age 50, surgical removal of polyps, treatment DALYs/1000$ Distribution-weighted DALYs/1000$ 8.0 10.0 12.0 14.0 16.0 18.0 Opportunity cost of implementing top 5 interventions for 5 mill $ 42748 DALYs 41190 DALYs = 1558 DALYs Opportunity cost • Health prioritarianism • Knows the cost in terms of DALYs NOT averted • Can provide reasons for re-ranking: – some priority to the worse off Priority group classification – tentative proposal Ex ante / ex post prioritarianism • Distributive weights based on final – not expected – individual disease burden for various conditions 0 20 40 60 80 100 Years of life lost Imagine you can help group A or B – who would you help? Persons 1 1 Group A Expected burden 60 1 1 18 Group B 6 Imagine you can help group A or B – who would you help? Persons 1 1 Group A Expected burden 60 1 1 18 Group B Actual burden 60 60 60 60 0 6 Persons 1 1 Group C Expected burden 6 1 1 18 Group D 6 Actual burden Persons 1 1 Group C Expected burden 6 1 1 18 Group D Actual burden 6 6 60 60 0 6 Ex post: Even if we only know the outcome, but not who will be affected, we can evaluate alternative outcomes