Download HIA-WorldBank

For Discussion and Consultation:
Our Ideas for “Health Impact Accounts”
Dr. Armin H. Fidler
Lead Adviser, Health Policy and Strategy
The World Bank Group
Brussels, February 7, 2012
Outline
Background
Rationale
Challenges to current approach
The need for Health Impact Accounts
Principles for estimates
Next steps
Significant increase in DHA but challenges to sustain
• Recent scale-up of funding for health from
domestic and donor sources
• Several reasons behind expansion of donor
interest in health
• Following 2008 global fiscal crisis, donor
countries are increasingly demanding clear
evidence on the impact of their investment
Demand from donors and tax-payers for funding
organizations to demonstrate results
Multilaterals, in the past, have had two options to
respond to demand for evidence:
1. Ex-ante analyses of global costs and health benefits
– Although ex-ante analyses of global costs and health
benefits have figured prominently in advocacy for global
health programs7 these efforts are often based on the
limited evidence-base available prior to major program
scale-up.
2. Ex-post evaluations of investments.
– These results are often delivered long after project is
completed and methods are not applicable to on-going
review
A recent effort to communicate results: “Lives Saved”
3. Calculation of ‘lives saved’ to provide rapid estimates
based on likely benefits from expenditures
– Provide a timely, compelling, and perceived as meaningful
metrics for impact of investments in the health sector
– While current Lives Saved approach should be applauded,
it does not take into account the entire health system
when measuring outcomes
– Additionally, these results, while faster, face significant
methodological and data challenges
• Due to current challenges, the World Bank has
decided to revise (“upgrade”) its Lives saved
methodology.
5
World Bank – IHME Collaboration on next
Generation of Lives Saved
The World Bank has partnered with IHME to:
• Preserve the benefits of initial Lives Saved approach with
timely, meaningful and compelling information with
comprehensible estimates on the likely impact of health
investments
• Create a framework for the next generation of investment
impact accountability methodology
• Improve metrics that take into account all key components of
the health system that contribute to success
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Rationale
• Demand for metrics that convey the impact of
DAH in a compelling, digestible and timely
manner
• While current Lives Saved approach should be
applauded, it does not take into account the
entire health system when measuring
outcomes
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Lives Saved Approach: Key Challenges
• Current Lives Saved approach diminishes the
importance of the role of Health System
Investments
– Most approaches attribute lives saved to
consumables or commodities
– They neglect to take into account that the
effectiveness of such consumables and
commodities depends upon their reaching
patients and users
– Many components of the delivery-value-chain
may be involved in this
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Currently, Impact linked mostly with commodity
Malaria
treatment
Purchased Malaria
Drug
Efficient Warehousing
and wholesale
distribution
Child Treated
But, effectiveness of treatment requires a well
functioning malaria treatment value chain
Global R & D;
country level quality
control and licensing
Robust and
Efficient
Procurement
Purchased Malaria
Drug
Efficient Warehousing
and wholesale
distribution
Information and HH
demand side
mechanisms
Clinic, and trained
health worker
Motivated and
efficient Health
Worker, diagnosis and
treatment
Child Treated
Malaria
treatment
Key priority disease value chains share same critical components.
Need for System approach to strengthen them
Interventions
Malaria Prevention
through Bed-Net
Syst. Component
Regulatory Capacity
(Stewardship)
Global R & D;
country level quality
control and licensing
Vertical HIV
Transmission
Prevention
Global R & D;
country level quality
control and licensing
Micro Nutrients
Supplement During
Pregnancy (Vit A)
Global R & D;
country level quality
control and licensing
Procurement
Capacity
Robust and
Efficient
Procurement
Robust and
Efficient
Procurement
Robust and
Efficient
Procurement
Consumable or
commodity
Purchased Malaria
Drug
Purchased ARV
Purchased Micro
Nutrient
Logistics and
Distribution
Efficient Warehousing
and wholesale
distribution
Efficient Warehousing
and wholesale
distribution
Efficient Warehousing
and wholesale
distribution
Communications;
CCTs, Health
Insurance
Information and HH
demand side
mechanisms
Information and HH
demand side
mechanisms
Information and HH
demand side
mechanisms
Worker training,
hiring and retention;
Infrastructure
Clinic, and trained
health worker
Clinic, Laboratory and
trained health worker
Clinic, and trained
health worker
Provider Payment
Mechanisms
Motivated and
efficient Health
Worker, diagnosis and
treatment
Motivated and
efficient Health
Worker, diagnosis and
treatment
Motivated and
efficient Health
Worker, prescription
and provision
Child Treated
Mother Treated
Mother
Consuming
MN
Lives Saved Approach: Key Challenges
• Health Impact from Investments in Other Sectors are
underestimated
– For example, the impact of programs on
environmental pollution, transportation, and
indoor air pollution are not yet assessed
– Currently included: education for young girls, road
safety, water and sanitation
Source: This is where your source copy goes.
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Methodological Limitations
• Potential for double-counting
– Current Live Saved methodologies have the potential for the
same life saved to be counted multiple times by different donor
organizations
• Heterogeneity in the timing of benefits
– Deaths prevented through one intervention can be nearly
instantaneous while for others it may be in years to come
• Efficacy versus effectiveness
– Most information currently used comes from randomized
clinical trials, but an extensive literature demonstrates that due
to enhanced provider effort and exclusion criteria used in RCTs,
the likely benefits in most scaled-up programs will be smaller
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Moving Forward
•To sustain investments in global health
– critical to quantify the likely health benefits of the
current investment portfolios
–communicate that impact in a timely and
compelling manner.
• One way: “Health Impact Accounts”
HIAs are a systematic assessment of the health
impact of an investment portfolio compared to the
counterfactual
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1. Assess all investments in terms of critical
value chains
•Improved health from investment comes
through the delivery of interventions to improve
health
•First step to understanding investment impact
is identifying the critical value chains involved in
the implementation
15
2. Assess national changes in inputs and
effective coverage for a value-chain
•HIA must take into account all actors
influencing a value chain in a country
•This requires the most information possible on
NHAs, but in their absence, the projection of a
secular trend in coverage that would have
occurred without donor investments would
suffice
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Bednets Example
ITN Coverage
DAH
lar
secu
GOV
YEAR
start year
Hypothetical case of the trend in investment
and coverage for a value-chain
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3. Allocate national changes in effective coverage to
components and by investors in value-chain
•If one organization is investing in cold chains
and health information and the other in
financing vaccines, the overall changes in
immunization coverage should be allocated
accordingly
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3. Allocate national changes in effective coverage to
components and by investors in value-chain
• If there is clear evidence about the pay-off
from different types of investments this
should be taken into account
• If there is clear evidence that one donor is
more efficient that others in investing DAH on
value chain components, this should be taken
into account
• Otherwise, all donors should be considered
equally efficient
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4. Estimate health impact from changes in coverage with
evidence including national trends in health outcomes
•The strongest possible effort should be made to
map the path for intervention to health gain
•Take into account both demand and supply side
factors to identify gap between efficacy and
effectiveness
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5. Health impact should be disaggregated into
time periods and different metrics
•Different users of the HIA may want to
understand when benefits should occur and
what the magnitude of the gain is for the
affected population
Deaths averted
YLLs
DALYs
Have accrued
Should accrue
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Next Steps
• Demonstrate feasibility of proposed approach
at a global scale for selected value chain both
in and out of the health sector
• Develop strategic messaging of new health
impact accounting to explain, justify and
enhance credibility
• Expand analysis beyond World Bank
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