When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs.
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ABSTRACT:
SUBMITTER: Bilinski A
PROVIDER: S-EPMC5624570 | biostudies-literature | 2017 Oct
REPOSITORIES: biostudies-literature
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When cost-effective interventions are unaffordable: Integrating cost-effectiveness and budget impact in priority setting for global health programs.
Bilinski Alyssa A Neumann Peter P Cohen Joshua J Thorat Teja T McDaniel Katherine K Salomon Joshua A JA
PLoS medicine 20171002 10
Potential cost-effective barriers in cost-effectiveness studies mean that budgetary impact analyses should also be included in post-2015 Sustainable Development Goal projects says Joshua Salomon and colleagues. ...[more]
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Project description:BackgroundThis paper forms part of an update of the World Health Organization Choosing Interventions that are Cost-Effective (WHO-CHOICE) programmes. It provides an assessment of global health system performance during the first decade of the 21st century (2000-2010) with respect to allocative efficiency in HIV, tuberculosis (TB) and malaria control, thereby shining a spotlight on programme development and scale up in these Millennium Development Goal (MDG) priority areas; and examining the cost-effectiveness of selected best-practice interventions and intervention packages commonly in use during that period.MethodsGeneralized cost-effectiveness analysis (GCEA) was used to determine the cost-effectiveness of the selected interventions. Impact modelling was performed using the OpenMalaria platform for malaria and using the Goals and TIME (TB Impact Model and Estimates) models in Spectrum for HIV and TB. All health system costs, regardless of payer, were included and reported in international dollars. Health outcomes are estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. Analysis was restricted to eastern sub-Saharan Africa and Southeast Asia.ResultsAt the reference year of 2010, commonly used interventions for HIV, TB and malaria were cost-effective, with cost-effectiveness ratios less than I$ 100/HLY saved for virtually all interventions included. HIV, TB and malaria prevention and treatment interventions are highly cost-effective and can be implemented through a phased approach to full coverage to achieve maximum health benefits and contribute to the progressive elimination of these diseases.ConclusionDuring the first decade of the 21st century (2000-2010), the global community has done well overall for HIV, TB, and malaria programmes as regards both economic efficiency and programmatic selection criteria. The role of international assistance, financial and technical, arguably was critical to these successes. As the global community now tackles the challenge of universal health coverage, this analysis can reinforce commitment to Sustainable Development Goal targets but also the importance of continued focus on these critical programme areas.
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Project description:Countries around the world are experiencing an ever-increasing need to make choices in investments in health and healthcare. This makes it incumbent upon them to have formal processes in place to optimize the legitimacy of eventual decisions. There is now growing experience among countries of the implementation of stakeholder participation, and a developing convergence of methods to support decision-makers within health authorities in making tough decisions when faced with the stark reality of limited resources. We call for further interaction among health authorities, and the research community to develop best practices in order to confront the difficult choices that need to be made.
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Project description:ObjectivesPriority setting in health directly impacts the general public as payers and final consumers, so the public preferences must be considered. The present study aimed to provide public preferences about health intervention allocation criteria for the optimal allocation of public health budget in Iran.MethodsA choice-based survey method was used to assess the general public's preferences regarding 8 critical criteria with a societal aspect. One thousand sixty-four adult citizens of Tehran, Iran, participated in the study. Participants were asked to allocate a hypothetical budget between the two groups with differences in allocation criteria. Public preferences were inferred from absolute majority responses i.e., more than 50% of participants' allocation for a criterion. The Logistic Regression Model was used to investigate the factors affecting the preferences regarding the importance of allocation criteria.ResultsBased on expressed participants' preferences, criteria of disease severity, age, daily care needs, Number of alternative interventions, individual's economic status, and diseases with absence from work were important. Thus, 77, 69, 61, 57, 54, and 51% of participants preferred to allocate the hypothetical budget to the treatment of patients with poor economic status, treatment of patients with diseases leading to absence from work, treating patients with severe diseases, treatment of diseases in need of daily care and treatment of children's diseases, respectively. Findings from the factors affecting participants' preferences regarding allocation criteria also showed that people with different characteristics had different preferences.ConclusionsIranian general public pays special attention to the criteria of equitable allocation, including patients' economic status, criteria with societal aspects such as absenteeism from work and the need for daily care, as well as criteria with medical aspects such as disease severity and access to alternative interventions which may sometimes be less considered in decision making.
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Project description: Not available
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Project description:BackgroundWhile there has been progress in controlling the HIV epidemic, HIV still remains a disease of global concern. Some of the progress has been attributed to increased public awareness and uptake of public health interventions, as well as increased access to anti- retroviral treatment and the prevention of vertical HIV transmission. These interventions would not have been possible without substantial investments in HIV programs. However, donor fatigue introduces the need for low income countries to maximize the benefits of the available resources. This necessitates identification of priorities that should be funded. Evaluating prioritization processes would enable decision makers to assess the effectiveness of their processes, thereby designing intervention strategies. To date most evaluations have focused on cost-benefit analyses, which overlooks additional critical impacts of priority setting decisions. Kapiriri & Martin (2010) developed and validated a comprehensive framework for evaluating PS in low income countries. The objective of this paper report findings from a comprehensive evaluation of priority setting for HIV in Uganda, using the framework; and to identify lessons of good practice and areas for improvement.MethodsThis was a qualitative study based on forty interviews with decision makers and policy document review. Data were analysed using INVIVO 10, and based on the parameters in Kapiriri et al's evaluation framework.ResultsWe found that HIV enjoys political support, which contributes to the availability of resources, strong planning institutions, and participatory prioritization process based on some criteria. Some of the identified limitations included; undue donor and political influence, priorities not being publicized, and lack of mechanisms for appealing the decisions. HIV prioritization had both positive and negative impacts on the health system.ConclusionsThe framework facilitated a more comprehensive evaluation of HIV priority setting. While there were successful areas, the process could be strengthened by minimizing undue influence of external actors, and support the legitimate institutions to set priorities and implement them. These should also institute mechanisms for publicizing the decisions, appeals and increased accountability. While this paper looked at HIV, the framework is flexible enough to be used in evaluating priority setting for other health programs within similar context.
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Project description:BackgroundIndigenous populations around the world have consistently been shown to bear a greater burden of disease, death and disability than their non-Indigenous counterparts. Despite this, little is known about what constitutes cost-effective interventions in these groups. The objective of this paper was to assess the global cost-effectiveness literature in Indigenous health to identify characteristics of successful and unsuccessful interventions and highlight areas for further research.Methods and findingsA systematic review of the published literature was carried out. MEDLINE, PSYCINFO, ECONLIT, EMBASE and CINAHL were searched with terms to identify cost-effectiveness evaluations of interventions in Indigenous populations around the world. The WHO definition was followed in identifying Indigenous populations. 19 studies reporting on 27 interventions were included in the review. The majority of studies came from high-income nations with only two studies of interventions in low and middle-income nations. 22 of the 27 interventions included in the analysis were found to be cost-effective or cost-saving by the respective studies. There were only two studies that focused on Indigenous communities in urban areas, neither of which was found to be cost-effective. There was little attention paid to Indigenous conceptions of health in included studies. Of the 27 included studies, 23 were interventions that specifically targeted Indigenous populations. Outreach programs were shown to be consistently cost-effective.ConclusionThe comprehensive review found only a small number of studies examining the cost-effectiveness of interventions into Indigenous communities around the world. Given the persistent disparities in health outcomes faced by these populations and commitments from governments around the world to improving these outcomes, it is an area where the health economics and public health fields can play an important role in improving the health of millions of people.
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Project description:The aim of the ACE-Obesity Policy study was to assess the economic credentials of a suite of obesity prevention policies across multiple sectors and areas of governance for the Australian setting. The study aimed to place the cost-effectiveness results within a broad decision-making context by providing an assessment of the key considerations for policy implementation. The Assessing Cost-Effectiveness (ACE) approach to priority-setting was used. Systematic literature reviews were undertaken to assess the evidence of intervention effectiveness on body mass index and/or physical activity for selected interventions. A standardised evaluation framework was used to assess the cost-effectiveness of each intervention compared to a 'no intervention' comparator, from a limited societal perspective. A multi-state life table Markov cohort model was used to estimate the long-term health impacts (quantified as health adjusted life years (HALYs)) and health care cost-savings resulting from each intervention. In addition to the technical cost-effectiveness results, qualitative assessments of implementation considerations were undertaken. All 16 interventions evaluated were found to be cost-effective (using a willingness-to-pay threshold of AUD50,000 per HALY gained). Eleven interventions were dominant (health promoting and cost-saving). The incremental cost-effectiveness ratio for the non-dominant interventions ranged from AUD1,728 to 28,703 per HALY gained. Regulatory interventions tended to rank higher on their cost-effectiveness results, driven by lower implementation costs. However, the program-based policy interventions were generally based on higher quality evidence of intervention effectiveness. This comparative analysis of the economic credentials of obesity prevention policies for Australia indicates that there are a broad range of policies that are likely to be cost-effective, although policy options vary in strength of evidence for effectiveness, affordability, feasibility, acceptability to stakeholders, equity impact and sustainability. Implementation of these policies will require sustained co-ordination across jurisdictions and multiple government sectors in order to generate the predicted health benefits for the Australian population.
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Project description:BackgroundTheory-based methods to support the uptake of evidence-based practices (EBPs) are critical to improving mental health outcomes. Implementation strategy costs can be substantial, and few have been rigorously evaluated. The purpose of this study is to conduct a cost-effectiveness analysis to identify the most cost-effective approach to deploying implementation strategies to enhance the uptake of Life Goals, a mental health EBP.MethodsWe used data from a previously conducted randomized trial to compare the cost-effectiveness of Replicating Effective Programs (REP) combined with external and/or internal facilitation among sites non-responsive to REP. REP is a low-level strategy that includes EBP packaging, training, and technical assistance. External facilitation (EF) involves external expert support, and internal facilitation (IF) augments EF with protected time for internal staff to support EBP implementation. We developed a decision tree to assess 1-year costs and outcomes for four implementation strategies: (1) REP only, (2) REP+EF, (3) REP+EF add IF if needed, (4) REP+EF/IF. The analysis used a 1-year time horizon and assumed a health payer perspective. Our outcome was quality-adjusted life years (QALYs). The economic outcome was the incremental cost-effectiveness ratio (ICER). We conducted deterministic and probabilistic sensitivity analysis (PSA).ResultsOur results indicate that REP+EF add IF is the most cost-effective option with an ICER of $593/QALY. The REP+EF/IF and REP+EF only conditions are dominated (i.e., more expensive and less effective than comparators). One-way sensitivity analyses indicate that results are sensitive to utilities for REP+EF and REP+EF add IF. The PSA results indicate that REP+EF, add IF is the optimal strategy in 30% of iterations at the threshold of $100,000/QALY.ConclusionsOur results suggest that the most cost-effective implementation support begins with a less intensive, less costly strategy initially and increases as needed to enhance EBP uptake. Using this approach, implementation support resources can be judiciously allocated to those clinics that would most benefit. Our results were not robust to changes in the utility measure. Research is needed that incorporates robust and relevant utilities in implementation studies to determine the most cost-effective strategies. This study advances economic evaluation of implementation by assessing costs and utilities across multiple implementation strategy combinations.Trial registrationClinicalTrials.gov Identifier: NCT02151331 , 05/30/2014.
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Project description:BackgroundGuidelines recommend offering cessation interventions to smokers eligible for lung cancer screening, but there is little data comparing specific cessation approaches in this setting. We compared the benefits and costs of different smoking cessation interventions to help screening programs select specific cessation approaches.MethodsWe conducted a societal-perspective cost-effectiveness analysis using a Cancer Intervention and Surveillance Modeling Network model simulating individuals born in 1960 over their lifetimes. Model inputs were derived from Medicare, national cancer registries, published studies, and micro-costing of cessation interventions. We modeled annual lung cancer screening following 2014 US Preventive Services Task Force guidelines plus cessation interventions offered to current smokers at first screen, including pharmacotherapy only or pharmacotherapy with electronic and/or web-based, telephone, individual, or group counseling. Outcomes included lung cancer cases and deaths, life-years saved, quality-adjusted life-years (QALYs) saved, costs, and incremental cost-effectiveness ratios.ResultsCompared with screening alone, all cessation interventions decreased cases of and deaths from lung cancer. Compared incrementally, efficient cessation strategies included pharmacotherapy with either web-based cessation ($555 per QALY), telephone counseling ($7562 per QALY), or individual counseling ($35 531 per QALY). Cessation interventions continued to have costs per QALY well below accepted willingness to pay thresholds even with the lowest intervention effects and was more cost-effective in cohorts with higher smoking prevalence.ConclusionAll smoking cessation interventions delivered with lung cancer screening are likely to provide benefits at reasonable costs. Because the differences between approaches were small, the choice of intervention should be guided by practical concerns such as staff training and availability.
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