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Cost-Effectiveness Analysis of Results-Based Financing in Zimbabwe and Zambia Nov 3, 2016, World Bank Headquarters, Washington, DC Donald S Shepard, PhD Wu Zeng, MD, PhD Brandeis University, Waltham, MA Schema for cost-effectiveness analysis (CEA) for RBF programs Inputs Administrator’s cost Other donors’ cost Provider’s cost (User’s cost) Intermediate results Component outcomes Cost-effectiveness outcomes Cost Incremental cost Household survey Facility survey HMIS data Quality score card Effects on coverage Effects on quality Incremental lives saved, DALYs or QALYs Incremental cost-effectiveness ratio (ICER) Toolkit Web: http://documents.worldbank.org/curated/ en/2015/09/25069701/costeffectiveness-analysis-results-basedfinancing-programs-toolkit Costs Financial costs Government and donor perspective Effectiveness—coverage Impact evaluation with districts compared Lives Saved Tool (LiST) software Literature and country data Effectiveness--quality Facility surveys Exit interviews Expert opinion (Delphi panel) Incremental cost-effectiveness ratio (ICER) Evaluate cost-effectiveness by the ICER, the price of one unit of good health. The lower the better! 𝐷𝑖𝑓𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑖𝑛 𝑐𝑜𝑠𝑡𝑠 𝐼𝐶𝐸𝑅 = 𝐷𝑖𝑓𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑖𝑛 ℎ𝑒𝑎𝑙𝑡ℎ 𝑜𝑢𝑡𝑐𝑜𝑚𝑒𝑠 Numerator: Added costs of RBF (difference in costs between RBF and control districts) Denominator: Added effectiveness or health outcomes (difference in health outcomes between RBF and controls), often expressed as quality-adjusted life years, QALYs Both quantity (coverage) and quality contribute CEA of RBF in Zimbabwe Annual operating costs of RBF program $2.04 $2.04 RBF subsidy payments, $7,045,211 $0.41 $0.41 Staff costs, $1,434,096 $0.20 $0.10 General administration*, $699,311 Capacity building (meetings, workshops, training)*, $426,644 $0.12 $0.06 HQ support costs*, $372,845 $0.11 $0.05 Transport costs, $299,412 $0.09 $0.09 Capital items for Cordaid*, $298,745 $0.09 $0.04 Supplies / equipment for facilities*, $128,209 The number after each category on the left is the current aggregate annual cost for the intervention districts (population 3.46 million). For categories marked with asterisks, half of the current costs were considered start-up expenses and would be reduced in a mature program. The labels on the right are per capita costs Current per capita costs Mature per capita costs $0.04 $0.02 Total, $10,704,473 $0.00 $2.82 $0.50 $1.00 $1.50 $2.00 $2.50 Per capita annual operating cost $3.00 $3.09 $3.50 Aggregate costs from Nat Pharm (US$)* Group Pre-period Post-period (Jan 2011- (Apr 2012Mar 2012) Jun 2014) Spending /year (Pre) Spending/ year (Post) Net difference Control 6,771,163 33,466,940 5,416,930 14,874,196 Intervention 6,062,025 29,478,515 4,849,620 13,101,562 Adjusted Intervention Difference 13,316,434 Population 2,229,897 -1.63% Spending /capita $6.67 3,461,010 $3.79 3,461,010 $3.85 $0.06 *Source: Nat Pharm data base of drugs distributed representing 92,000 orders to 354 control and 359 intervention customers. Due to the substantial change in expenditure per year, we computed the difference in differences based on the ratios of aggregate expenditure. We calculated the pre-period ratio of intervention to control (0.8953). We computed the “adjusted intervention” by applying this ratio to the control spending/year (post), and computed the net difference by comparing actual and adjusted intervention values. Financial net costs of current RBF per capita per year (USD) Cost components Cost Incremental RBF operational costs $3.09 Incremental costs at World Bank headquarters Subtotal Net costs of consumables from Nat Pharm $0.10 Less Health Transition Fund payments to control districts (no administrative costs included) Subtotal Net cost Subtotal $3.19 -$0.06 -$0.81 -$0.87 $2.32 Impact of RBF in quantity and quality of services Quantity of care Institutional delivery: 13.4% Postpartum care: 13.3% Quality of care Quality indicator Endline RBF Con -trol 0.87 0.83 0.75 0.68 DIDs Pvalue Relative DIDs Vaccination Institutional Delivery Baseline RBF Control 0.87 0.89 0.73 0.75 0.06** 0.10*** 0.009 0.001 6.90% 12.90% Ante-natal care Post-natal care 0.72 0.71 0.79 0.75 0.10*** 0.15*** 0.000 0.000 13.70% 20.00% 0.75 0.77 Note: DID denotes difference-in-differences. 0.72 0.65 Effectiveness (RBF vs. control): quality & quantity Calculated lives and QALYs saved for selected services with RBF and projected from controls: Maternal deaths and lives saved Year RBF Control Deaths in children under five and lives saved Lives saved Year RBF Control Lives saved 2012 416 416 0 2012 9,705 9,705 0 2013 370 414 44 2013 8,613 9,345 732 2014 Total 365 1,151 393 1,223 28 72 2014 8,136 8,875 739 26,454 27,925 1471 Total Quantitative results Annual number of lives saved is 772, i.e., (72+1,471)/2, Equivalent to 18,288 QALYs gained With population of 3.46 million in RBF districts, RBF generates 528 QALYs/100,000 population/year Site visits suggested coaching strengthened RBF Contributions of quality and quantity QALYs gained per 100,000 population per year Projected health impacts 600 Relative shares of quality and quantity 528 500 400 350 Quality improvement, 34% 300 200 178 Quantity (Coverage improvem ent), 66% 100 0 Quantity Quality (Coverage improvement improvement) Overall (effective coverage improvement) Cost-effectiveness results: RBF vs. control Incremental per capita costs: US $2.32 QALY impacts (per 100,000 population per year) Quantity (coverage) alone: 350 QALYs Quality and quantity (effective coverage): 528 QALYs ICERs ($/QALY gained) Quantity (coverage) impacts alone: $2.32/0.00350 = $663 Combined coverage and quality impacts: $2.32/0.00528 = $439 CEA of RBF in Zambia Study design Incentivized services (indicators) and unit prices No Indicator Unit Price US$ 0·20 1 Curative consultation 2 Institutional delivery by skilled birth attendant 6·40 3 Antenatal care (ANC) - prenatal and follow up visits 1·60 4 Postnatal care visit (PNC) 3·30 5 Full immunization of children under one year 2·30 6 Pregnant women receiving 3 doses of malaria intermittent preventive treatment (IPTp) 1·60 7 Family planning (FP) users of modern contraceptive methods 0·60 8 Pregnant women counselled and tested for HIV 1·80 9 HIV+ pregnant women given niverapine (NVP) and zidovudine (AZT) 2·00 Results 12.00 HQ costs Incremental cost per capita ($) 10.00 Program costs MSL costs 8.00 6.00 4.00 2.00 0.00 HQ costs Program costs MSL costs RBF vs INP 0.22 5.90 0.57 RBF vs CON 0.33 8.65 0.97 INP vs CON 0.10 2.75 0.40 Program costs (RBF + input financing) and distribution of incentives Pregnant women counselled and tested for HIV 9.3% Equipment 14.6% Pregnant women given NVP and AZT 0.2% Curative consultations 30.0% Operational costs 7.6% M&E 0.9% Meetings/ Workshops 2.2% Trainings 6.9% Modern FP methods 28.5% Incentive payment 51.4% Third dose of IPTp 3.7% Full vaccination 6.3% Consultancy costs 16.3% PNC 6.6% Institutional deliveries ANC 14.0% 1.4% Coverage and quality of key maternal and child health services at baseline and endline Baseline Services RBF INP Endline CON RBF INP DIDs CON RBF vs INP RBF vs CON INP vs CON Coverage of key maternal and child services Ins Del 68·3% 56·4% 70·9% 80·8% 74·3% 71·2% -5·4% 12·2%** 17·6%*** ANC 97·5% 96·2% 96·3% 98·9% 99·0% 99·1% -1·4% -1·4% 0·0% PNC 70·3% 56·0% 76·4% 82·4% 73·8% 80·7% -5·7% 7·8%* 13·5%*** BCG 95·6% 97·8% 97·6% 100·0% 99·5% 95·6% 2·7% 6·4%* 3·7%* DPT 97·1% 95·2% 95·8% 98·6% 97·6% 91·8% -0·9% 5·5%* 6·4%* HIB 82·5% 88·3% 81·8% 97·9% 88·7% 78·1% 15·0%*** 19·1%*** 4·1% IPT 92·0% 92·4% 95·1% 98·0% 96·1% 98·1% 2·3% 3·0%** 0·7% FP∆ 6·5% 9·9% 7·7% 34·0% 15·6% 15·7% 21·8%** 19·5%** -2·3% Quality index of key maternal and child services Ins Del 65·5% 66·8% 67·0% 73·5% 74·1% 71·9% 0·7% 3·1% 2·4% ANC 66·9% 69·1% 68·6% 75·0% 77·2% 73·8% 0·0% 2·9% 2·8% PNC 66·7% 68·4% 68·3% 74·1% 76·6% 73·4% -0·8% 2·3% 3·0% Vaccination 78·7% 80·7% 81·7% 81·2% 80·0% 80·4% 3·2% 3·8% 0·6% FP 77·7% 78·6% 80·6% 81·6% 77·6% 74·8% 4·9% 9·7% 4·8% QALYs gained from the RBF program in comparison with controls Population RBF vs INP RBF vs CON INP vs CON Mid-point (lower bound-upper bound) Mid-point (lower bound-upper bound) Mid-point (lower bound-upper bound) QALYs gained (unadjusted for quality) QALYs gained QALYs gained (adjusted for quality) (unadjusted for quality) QALYs gained (adjusted for quality) QALYs gained (unadjusted for quality) QALYs gained (adjusted for quality) Pregnant women 237 (216-302) 302 (237-345) 475(425-539) 604(539-626) 237(176-302) 302(237-345) Children under 5 5 088(3 733-6 015) 6 300(4 826-7 323) 11 816(10 480-13 100) 14 574(13 195-15 953) 6728(5 171-8 131) 8 274(6 704-9 843) Total 5 325 (3 948-6 317) 6 602(5 064-7 688) 12 291(10 905-13 639) 15 178(13 734-16 579) 6 966(5 347-8 433) 8 576(6 942-10 188) Incremental cost-effectiveness ratios Cost/life saved (US$) Cost/QALY gained (US$) Mid-point (lower bound- upper bound) Mid-point (lower bound-upper bound) RBF vs INP (unadjusted) 39 621 (33 388 - 53 381) 1 674 (1 411 - 2 258) RBF vs INP (quality adjusted) 31 952 (27 514 - 41 657) 1 350 (1 163 - 1 761) RBF vs CON (unadjusted) 25 553 (23 024 - 28 767) 1 079 (972 - 1 216) RBF vs CON (quality adjusted) 20 689 (18 945 - 22 865) 874 (800 - 966) INP vs CON (unadjusted) 14 786 (12 211 - 19 235) 624 (515 - 813) INP vs CON (quality adjusted) 12 280 (10 110 - 14 837) 507 (427 - 626) Comparison Discussion Discussion: Interpretation of RBF in Zimbabwe Reference: Zimbabwe’s 2012 GDP/capita was $980 If ICER < GDP/capita, program highly cost-effective (WHO) ICER of current RBF Improved coverage alone: $663 or 0.68x GDP/capita, highly cost- effective Including quality gains: $439 or 0.45x GDP/capita, highly costeffective Mature RBF program would lower cost by 9.0% to $2.11 per capita DALYs per100 population per year 704 Discussion: program maturity (Zimbabwe as an example) 528 0 Phase I period Estimated phase in Phase I period Calculated average Phase I period Mature program Calculated average is 528 DALYs vs. mature program (704) Potential increase for mature program: 33% Projected ICER of mature RBF program Projected cost per capita $2.11 Projected impact is 704 QALYs per 100,000 population per year Projected ICER is $300 i.e. $2.11 / (704 / 100,000) or 0.31 x GDP/capita Comparison with Zambia RBF Reference: GDP/capita $1,759 (2013) ICER of RBF Compared to Input-financing: $1,350 or 0.77 GDP/capita, highly cost-effective Compared to pure control: $874 or 0.50 GDP/capita, highly cost-effective ICER of input financing Compared to pure control: $507 or 0.29 GDP/capita, highly cost-effective Comparison with other maternal-child health programs Reproductive health vouchers in Uganda (African Strategies for Health, 2015) $302 / QALY or 0.59 x GDP/capita ($510) Simulated maternal community-based health insurance in Uganda (African Strategies for Health, 2015) $298 / QALY or 0.58 x GDP/capita ($510) RBF is among the very highly cost-effective interventions Potential refinements to RBF 1. Use both penalties and rewards Human nature: people work hard to avoid penalties 2. Establish a threshold and pay only for activities above it e.g. antenatal care: pay only for incremental coverage over 90% 3. Pay for improvements over last year’s average as well as attainment e.g. Last year’s average 4; this quarter 5; improvement 1 4. Pay a fixed dollar amount for remoteness Current incentives as % of volume are too small 5. Combine RBF with more formative supervision and demand side Helps providers learn to improve quantity and quality Acknowledgments Ministry of Finance, Zimbabwe Ministry of Health, Zambia Ministry of Health and Child Care, World Bank, Zambia Zimbabwe World Bank, Zimbabwe Cordaid, Zimbabwe World Bank Headquarters Financial support World Bank Health Results Innovation Trust Fund Contacts Donald S Shepard, PhD Wu Zeng, MD, PhD [email protected] [email protected] +1 781 736 3975 +1 781 736 3888 www.brandeis.edu/~shepard www.brandeis.edu