Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Knowing what you get for what you pay An introduction to cost effectiveness FETP India Objective this lecture Understand how cost effectiveness studies are conducted Key areas • Types of analysis • Conducting a cost effectiveness analysis • Generalized cost effectiveness Cost benefit analysis • Concept Use of dollars as the common metric No use of health outcome Results expressed in benefit-cost ratio • Advantages Allows comparisons with non health programmes Useful when intervention generates non health outcomes • Disadvantages Controversial Assigns a value to human life Public health managerial processes Planning Relevance Programming Adequacy Implementation Inputs Programmed resources ----------Allocated resources Process Output Norms and procedures Agreed objectives / targets ----------------Achieved objectives / targets ---------Applications of norms / procedures Progress Efficiency Outcome Impact Effectiveness Efficiency and effectiveness • Efficiency Relationship between the output obtained and the efforts (input) invested • Effectiveness Degree of attainment of pre-determined objectives of a programme (e.g., in terms of reducing death / disability) Definition of cost effectiveness analysis • Method used to evaluate public health interventions in terms of cost per health outcome • No attempt made to assign a monetary value to disease averted • Outcome used: Cases Deaths Years of life DALYs Cost effectiveness analysis: Relevance • Estimates cost per health outcome • Provide additional information to decision makers • Is not the only criteria to take into account to make decisions Effectiveness • Obtain documented data on effectiveness • Measure effectiveness precisely Meta analysis Confidence intervals • Document assumptions The cheapest way to go to the moon is to jump. However, we don’t do it because it does not work Cost utility analysis • Subset of cost effectiveness analysis • Take YLLs or DALYs as outcome Discounting • • • • Reflect time preference Applies to costs Applies to effects Subject to discussion Conducting a cost effectiveness study 1. 2. 3. 4. 5. 6. 7. Frame the problem Identify interventions Define outcome measures Estimate net costs Estimate effects Compile costs and effects Perform sensitivity analysis 1. Frame the problem • • Write study question Define economic perspective • Chose time frame for intervention • Ministry of health Health system Societal Absorb start up costs Chose analytic horizon for consequences 2. Identify interventions • Take the baseline • “Do nothing” scenario Define potential interventions Describe components Relate to measurable effectiveness 3. Define outcome measures • Intermediate outcomes • Cases identified, treated Final outcomes Cases prevented Life saved YLLs DALYs Cost utility 4. Estimate costs • Cost of the intervention • ? Cost of the disease averted Medical costs Non medical costs • ? Productivity losses Net costs = Cost intervention - Cost disease averted 5. Estimate effects • Burden of disease • Incidence of disease Incidence of complications (natural history) Utility calculations Effectiveness of intervention Documented effectiveness estimates Compliance Coverage 6. Compile costs and effects • Calculation of cost effectiveness ratio • Average Incremental Can address various options Coverage Discounting 7. Perform sensitivity analysis • Parameters to examine Costs • • • ps and qs Discounting Effectiveness Burden of disease Combinations Advanced analysis Key elements of the report of a cost effectiveness study • • • • • • • • Study perspective, time frame and horizon Study question Assumptions Description of interventions Identification of relevant costs Cost effectiveness ratios Sensitivity analysis Discussion Cost effective and cost saving • Some interventions have negative net costs • Cost saving interventions are: Uncommon Subject to distributional effects • Cost effective does not mean cost saving • Human life is not “cost effective” Investment is needed to sustain it Cost effectiveness criteria • Not cost effective Cost per DALY above 3 GDP / capita • Cost effective Cost per DALY under 3 GDP / capita • Highly cost effective Cost per DALY under 1 GDP / capita WHO commission on macroeconomics and health Cost effectiveness versus burden of disease • Cost effective intervention can prevent only a small burden of disease • Some large sources of burden of disease may be preventable through non cost effective interventions Cost effectiveness of various health interventions Limitations of traditional cost-effectiveness studies • • • • • • Different horizons Different types of costs included Different costing methods Different discounting rates Different outcome measures Incremental approach Existing interventions not reconsidered • One dimension • May not address variations by regions • Conflicts of interests The WHO CHOICE project: Generalized cost-effectiveness • • • • • • Identical horizons Standardized approach to including costs Unique costing methods Standardized discounting policy DALY as outcome measures Null case base Existing interventions reconsidered • Multiple dimension • Region specific • Science dissociated from advocacy Generalized cost effectiveness: Challenges • • • • Recent concept Difficulties in adapting theoretical concepts Resource intensive Single study team (at the moment) Generalized cost effectiveness: Example of results for the SEAR D region Intervention costs DALY averted Average CE ratio Disinfection at point of use with education 523,019,455 3,248,440 161 Halving the population without improved water supply 585,826,305 951,318 616 Halving the population without improved water supply and sanitation 5,907,522,335 4,908,162 1,204 Improved water supply and sanitation (98%) 11,578,743,777 9,627,739 1,203 Improved water supply and sanitation with disinfection (98%) 14,184,319,328 25,443,560 557 Piped water supply and sewage with treatment (98%) 39,689,844,066 38,442,566 1,032 Intervention Other criteria to chose an intervention • • • • • Feasibility Ethics Equity Sustainability Acceptability Take home messages • Chose cost effectiveness analysis • Frame the question right • Follow up progress on the generalized cost effectiveness concept