Download The Epidemiology of Non

South Asian Cardiovascular
Research Methodology Workshop
Economics and Health
Thomas Songer, PhD
Economics and Health
Human Development
Income/Economic
Population
Health & Nutrition
Education
Political
Transitions in Human Development
Epidemiologic
Disease - Infectious to Chronic
Demographic
Younger to Older populations
Rural to Urban
Economic
Developing to Developed Economies
Transitions in Human Development
Health Care Systems
Centralized to Decentralized, Cost Containment
Political
Controlled to Free Market Economies
Trends in Death in Developing Areas
Deaths (millions)
NCDs
Comm. Dis.
Injuries
40
30
20
10
0
1990
2000
2010
2020
Global Burden of Disease
DALYs in Developing Areas
1990
Infectious Disease
2020
NCDs
Injury
Economic Transition
Economic Growth
• Many Differing ways of defining growth
• Goods and services produced
• GNP - money value of all goods and
services produced
• GNP per capita; reflects the average
income of a country’s citizens
• GNP per capita; outlines general
standard of living
Gross National Product, per capita
Average Annual
1991
Growth Rate,
$
1980-91(%)
Sub-Saharan Africa
East Asia & Pacific
South Asia
Europe & C.Asia
Mideast/N.Africa
Latin America
OECD members
World
350
650
320
2,670
1,940
2,390
21,530
4,010
- 1.2
6.1
3.1
0.9
- 2.4
- 0.3
2.3
1.2
GNP per capita
Monetary value of goods and services
population
GNP per capita
Impact of Population Changes
• An increasing population makes it more
difficult to increase GNP per capita
• With a stable population, increases in
GNP will increase GNP per capita
How does the
development level of an
economy relate to health?
Economics
and
Health
Higher GNP per capita is
associated with ….
Longer life expectancy
lower infant mortality
better access to safe water
better education
Income and Health Spending
World Bank Development Report
Share of GDP spent on health
12
10
8
6
4
2
0
5000
10000
15000
20000
GDP per capita (1991 dollars)
25000
Economics
Poverty
and
Health
malnutrition
poor sanitation
poor education
poor housing - crowding
no quality health care
Low economic growth
High
fertility
Poverty
Poor health
UNDP Poverty Report 2000
OVERCOMING
HUMAN
POVERTY
Increased productivity
Low
fertility
Rising
incomes
Better health
Economic growth
Economic development
Economic growth
increase in the amount of goods and
services produced
Economic development
combines economic growth with an
improvement in living standards
Economic growth does not
always translate to economic
development
In the 1950s and 1960s, a large
number of 3rd world countries
achieved UN growth targets, yet
the levels of living for most
remained unchanged
GNP per capita is a narrow definition
of growth and development
Todaro 1997
Health used to be viewed as an
end product of the growth
process:
New thinking is that health
enhances economic growth
Economics and Health
Economics and Health
WHO: Commission on
Macroeconomics and Health
• Ill-health undermines economic
development and efforts to reduce
poverty. Investments in people’s health
are vital pre-conditions for economic
growth and human development.
www.who.int/macrohealth/en
Chadwick:
The human being is an investment of
capital
Healthy people are productive people
Chadwick:
The human being is
an investment of capital
Healthy people are productive people
Better sanitation is a good investment
Prevention of disease is a good investment
The Commission on
Macroeconomics and Health
• established
in January 2000
• Mandate: To examine the links between
investment in health, economic
development and poverty reduction
• CMH Structure: 6 working groups, 18
Commissioners, hundreds of experts in
public health, finance and economics.
Summary of key CMH findings
• Ill health undermines economic development and
efforts for poverty reduction
• A few health conditions account for most of the
avoidable deaths in low / middle-income countries
• HIV/AIDS, TB, malaria, maternal & child health,
and tobacco-related illness
• The HIV/AIDS pandemic is a “distinct and
unparalleled catastrophe” not only in its human
dimension but in its implications for economic
development
HIV/AIDS and Economic
Development
• High HIV/AIDS prevalence leads
to…
– decline in labor force participation
– decline in productivity
– decline in human capital
HIV/AIDs in Russia, 2001
World Bank 2002
HIV/AIDs in
Russia
by 2020
• 5.4 to 14.5 million cases
• -2 to -14% change in effective labor supply
• -5 to -25% decline in GDP
Health Economics
Why is there an interest in
health economics?
Economics and health are related
Rising costs of health care
Limited resources for health care
Variations in health outcomes exist
Economic data influence government
decisions regarding health care
Economic Approaches in Health Care
Descriptive
Cost studies
Evaluative
Cost-Benefit Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Explanatory
Demand/Supply issues
Regulation/Taxation
Cost Effectiveness Analysis
• Primary form of economic analysis of
health care interventions
• Very often included in clinical trials that
are testing new interventions
• A method for evaluating the outcomes
and costs of interventions designed to
improve health.
The purpose of economic evaluation,
such as cost effectiveness analysis, is to
identify, measure, value, and compare
the costs and consequences of
alternative interventions.
Costs A
Programme
A
Consequences A
Comparator
B
Consequences B
Choice
Costs B
Cost Effectiveness Calculation
Comparison of interventions examines
differences in cost by the differences in
benefits gained
Cost with intervention [A] - Cost with intervention [B]
Benefit with [A] - Benefit with [B]
in other words
Δ Cost
Δ Benefit
Cost Effectiveness Calculation
Intervention
A
Costs
Effectiveness
$4,000
B
$5,000
3 months 8 months
.
Incremental CE = (5,000 – 4,000)/8-3= $200/month
Cost-effectiveness analysis –
Important Steps
1.
2.
3.
4.
5.
6.
7.
Define the question to be analyzed
Define the audience for the evaluation
Specify the perspective of the analysis
Define the relevant time frame for the analysis
Identify relevant outcomes
Identify relevant costs
Determine the summary measure to be
reported
Defining interventions or the
question to be assessed
• Major increase or decrease in an existing
activity
Or
• Adding a new activity to replace an
existing one or adding a new activity
when there is no current activity
Mulligan/Mills
Selected interventions in malaria control
Drug use
Personal &
Community
Protection
Vector
control
•
•
•
•
•
•
•
•
•
Early diagnosis and effective treatment
Intermittent therapy during pregnancy
Chemoprophylaxis for target groups
Insecticide treated materials
Home repellants and insecticide use
Indoor residual spraying
Larviciding, fogging
Civil engineering: drainage and filling
Mobilization of individual, family and
Social
communities
Action/
Management • Health Education
effectiveness • Surveillance of infection and disease
• Monitoring and evaluation of programs
Mulligan/Mills
Defining the Audience and
Perspective of the study
•
•
•
•
•
•
Health care payers
Health care providers
Patients
Government health plans
Society
among others
Identify Time frame
• Short-term
– Within the time period of the trial
• Long-term
– e.g 5 years
– e.g. 10 years
• Lifetime
– Many interventions in chronic disease
show benefits years later
Summary Outcome Measures
• Quality-adjusted Life Years
Survival weighted by patients’ value of
health-related quality of life
Patients value health states on a 0 (death) to
1 (optimal health) scale
Recommended as a gold standard
• Other Clinical Outcomes: pain, test
results
• Non-Clinical Outcomes: health status,
patient satisfaction
Examples of outcome measures
Logan et al. (1981)
Hypertension 3:2:211-18
Hull et al. (1981)
NEJM 304:1561-67
Hypertension
treatment
Diagnosis of deep
vein thrombosis
Sculpher and Buxton (1993)
Asthma
PharmacoEconomics 4:5:345-52
Mark et al. (1995)
NEJM 332:21:1418-24
Thrombolysis
mmHg
blood pressure
reduction
cases of DTV
detected
episode-free
days
years of life
gained
Cost-Effectiveness Analysis in the TODAY
(Treatment Options for Diabetes in
Adolescents and Youth) Study
• Results expressed as
– Cost per change in HbA1c
– Cost per unit of treatment failure
• e.g. cost per day of treatment failure
avoided
– Cost per unit of clinical improvement
• e.g. change in weight, BMI, obesity
– Cost per quality-adjusted life year
(QALY)