HEALTH ECONOMICS, MST3: BALANCE of EFFICIENCY & EQUITY

Louis Niessen MD Reg PH PhD

Chair of Health Economics, LSTM/JHSPH

Involvement Investment Cases

1. Member for Equity & Efficiency WHO WG Investment for Impact in the control of neglected tropical diseases - under STAG NCDS, lead C Fitzpatrick, WHO. TOR

2. Member Erasmus Group, BMGF: Estimating the socio-economic impact of achieving the London declaration targets on neglected tropical diseases

3. COUNTDOWN Programme of implementation research to inform the effective and sustainable scaling-up of integrated neglected tropical disease control initiatives

Earlier: WHO-CHOICE; Child Survival (IMCI, GAPP); vaccines (GAVI)

Results: Poor & Malaria 18yr-cohort PMI-CDC; Poor & NCDs 24yr-Matlab,BD

Other networks: HTAi, GENI, IHEA, ISPOR, IEA,

Background Poverty And Disease

• Catastrophic health expenditure + loss of household income cause poverty

• Half of the poor are poor because of illness, increasing with sophistication of health care

• Also in advanced settings (EU, USA) health systems are regressive: burden of disease and

finances falls to low SES.

To do:Universal health coverage is about choosing efficient package AND equity impact i.e. willingness to subsidize others to provide protection against catastrophic expenditure

Background Health Economics Approach

2.5 Towards an investment case for NTDs under UHC

Three-step process:1) categorize services into priority classes2) expand coverage for high-priority services to everyone3) ensure that disadvantaged groups are not left behind.

2.5.1 The investment case based on cost−effectiveness2.5.2 Towards an investment case including equity

Background Health Economics Approach

1. WHO’s Guidance for Priority Setting in Health Care, or GPS-Health, offers equity criteria for “priority classes” to be considered in addition to cost−effectiveness analysis.

2. Disease criteria: severity of disease, capacity to benefit and past health loss;

Specific groups: socio-economic status, area of living, gender, etc;

Non-health consequences: financial protection, economic productivity & care for others.

3. Presence of multi-criteria approaches (MCDA) to priority-setting in health, also emerging within NTD world.

4. Will the NTD community use socioeconomic / non-health evidence to inform policy?

Equity: Conceptual Terms

Many vulnerable groups and definitions of vulnerable groups

Distributional concepts:

Horizontal and vertical equity (Socrates)

Inequalities (UK), disparities (USA) (J Tinbergen, J Rawls)

Fairness and willingness-to-subsidize (A Sen, D Kahneman)

Capability approach (overarching concept: A Sen)

Policy making & priorities setting in health (A4R, Daniels)

Severity of diseaseAverage population healthEase of implementationEmergency situationsBurden of diseaseEconomic growthIrresponsible behaviourVulnerable populationsBudget impactDisease of the poorCost - effectiveness

Rational Priority SettingRank ordering of

interventions

1.2.3.4.5.6.7.8.

Multi - criteria decision analysis

Burden of disease analysis

Cost -effectiveness

analysis

Equity analysis

Evidence -based

medicine

Severity of diseaseAverage population healthEase of implementationEmergency situationsBurden of diseaseEconomic growthIrresponsible behaviourVulnerable populationsBudget impactDisease of the poorCost - effectiveness

Rational Priority SettingRank ordering of

interventions

1.2.3.4.5.6.7.8.

Multi - criteria decision analysis

Burden of disease analysis

Cost -effectiveness

analysis

Equity analysis

Evidence -based

medicine

Summary measure: health adjusted life expectancy

Balancing Equity & Efficiency in National Policy

Ongoing multi-country studies

Brazil

China

Cuba

Uganda

NorwayNepal

0

0.2

0.4

0.6

0.8

1

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1Equity

Efficiency

Value in Health. 2012 May;15(3):534-9.

Health Economics Research Theme In MDA Scale-up

IntegratedComplementary Strategy Theme

ICST 1

ICST 2

Liberia GhanaCameroon

MDA Scale-up Themes (MST 1 – 3)

elimination

Country & context-specific setting of MDA

MST 1: Evidence synthesisPaul Garner and Cochrane group

MST 2: Applied social scienceSally Theobald and Margaret Gyapong

MST 3: Health economicsLouis Niessen and Health Economcs Unit

scale-up in Nigeria

COUNTDOWN Questions And MST 3 Answers

Q1) What are effective, cost-effective, sustainable and acceptable current and complementary strategies for scale-up?

MST3 Health economics: household impact through population surveys &, routine data, and costing studies; can be combined with MST1-2

Q2) What generalizable factors influence the acceptance, effectiveness, efficiency, and equityimpact of scale-up within the health system?

MST3 Health economics: economic outcomes adjusted for other qualitative and quantitative findings; can be combined MST2

Research uptake (EE2P): Evidence for priority setting for national programmes based on equity and efficiency

Example: Historical And Future Population Scenarios NTDs

?PC NTDs

ONCH

LF

SCH

STH

TRA

BOD projections

by age and sex

Counterfactual

London

Declaration

targets

Example: Socio-economic Impact Of Control Or Elimination Of Five Neglected Tropical Diseases - Literature Review And Societal Costs (Lenk EJ. Erasmus ,ASTMH, 2014)

Aim: Economic impact of meeting the targets for the five diseases eligible for MDA: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma.

Methods A systematic literature review to identify empirical costs related NTDs, including out of pocket payments (OPP), productivity loss, and impoverishment. Cost estimates per person are combined with population projections suffering from clinical manifestations per NTD, country, and year, for the periods 2011-2020 and 2021- 2030, comparing to business-as-usual scenarios.

Results Averted burden: productivity loss associated for about 3% for infestation & mild symptoms, about 15% for more severe manifestations (lymphedema and hydrocele), and up to 38% -79% for severe vision loss & blindness.

Income loss averted reaching the LONDON goals may amount to US$240 billion for 2011-2020 and US$390 billion for 2021-2030, excluding OPPs & productivity loss due to deaths.

Soil-transmitted helminthiasis accounted for approximately half of this amount.

Intended Impact And Pathways To Achievement

IMPACT:

Reduced morbidity, mortality, and poverty associated with NTDs through increased knowledge and evidence for cost effective scale-up and sustainable control and elimination of NTDs as a public health problem

Community

Global

Regional

National

District

IMPACT: Value-for-Money in COUNTDOWN

Value-for-money

= cost-effectiveness selected interventions & equity gains in access, coverage, finance

Expected outcomes

1. Increased coverage / access among target populations:

2. Enhanced equity by socio-economic group, gender, geography, through reduced exposure reduction, out-of-pockets expenditure, and ..

3. Affordable scale-up budget impact estimates for national investments and other financing sources

Expected contributions: national & international policy

1. Evidence for prioritization most attractive – value-for-money- options in NTD control

2. Evidence and advocacy to include equity criteria in NTD decisions