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Distributional impact of the Malawian Essential Health Package.

ABSTRACT: In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health and reducing health inequality. We conduct aggregate DCEA of potential health benefits package interventions to demonstrate the feasibility of this approach in LMICs, using the case of the Malawian health benefits package. We use publicly available survey and census data common to LMICs and describe what challenges we encountered and how we addressed them. We estimate that diseases targeted by the health benefits package are most prevalent in the poorest population quintile and least prevalent in the richest quintile. The survey data we use indicate socioeconomic patterns in intervention uptake that diminish the population health gain and inequality reduction from the package. We find that a similar set of interventions would be prioritized when impact on health inequality is incorporated alongside impact on overall population health. However, conclusions about the impact of individual interventions on health inequalities are sensitive to assumptions regarding the health opportunity cost, the utilization of interventions, the distribution of diseases across population groups and the level of aversion to inequality. Our results suggest that efforts to improve access to the Essential Health Package could be targeted to specific interventions to improve the health of the poorest fastest but that identifying these interventions is uncertain. This exploratory work has shown the potential for applying the DCEA framework to inform health benefits package design within the LMIC setting and to provide insight into the equity impact of a health benefits package.

SUBMITTER: Arnold M

PROVIDER: S-EPMC7294245 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Distributional impact of the Malawian Essential Health Package.

Arnold Matthias M Nkhoma Dominic D Griffin Susan S

Health policy and planning 20200701 6

In low- and middle-income countries (LMICs), making the best use of scarce resources is essential to achieving universal health coverage. The design of health benefits packages creates the opportunity to select interventions on the basis of explicit objectives. Distributional cost-effectiveness analysis (DCEA) provides a framework to evaluate interventions based on two objectives: increasing population health and reducing health inequality. We conduct aggregate DCEA of potential health benefits ...[more]

PMID: 32361730

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Project description:ObjectivesReducing inequalities in health and financial risk are key goals on the path toward universal health coverage, particularly in low-income and middle-income countries. The design of the health benefit package creates an opportunity to select interventions through established criteria. The aim of this study is to examine the health equity and financial protection impact of selected interventions, along with their costs, at the national level in Ethiopia.DesignDistributional cost-effectiveness analysis.PopulationThe eligible population for all selected interventions is assumed to be 10 million.Data sourcesData on disease prevalence and population size were gathered from the Global Burden of Disease database, and average health benefits and program costs are sourced from the Ethiopian Essential Health Service Package (EHSP) database, national surveys and other publicly available sources.InterventionA total of 30 interventions were selected from the latest EHSP revision and analysed over a 1-year period.Outcome measuresHealth benefits, social welfare indices and financial protection metrics across income quintiles were reported.ResultsWe found 23 interventions that improve population health and reduce health inequality and four interventions reduce both population health and health inequality. Additionally, three interventions improve population health while increasing health inequality. Overall, the EHSP interventions provide a 0.021 improvement in health-adjusted life expectancy (HALE) per person, with a positive distributional equity impact: 0.029 (26.9%) HALE gained in the poorest and 0.015 (14.0%) in the richest quintile. Similarly, a total of 1 79 475 cases of catastrophic health expenditure were averted, including 82 100 (46.0%) cases in the poorest and 17 900 (10.0%) in the richest quintile.ConclusionIncreasing access to the EHSP improves health equity and financial protection. Improved access to selected EHSP interventions also has the potential to provide greater benefits to the poorest and thereby improve social welfare.

Project description:BackgroundCost effectiveness was a criterion used to revise Ethiopia's essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average cost-effectiveness ratios (ACERs) of 159 health interventions used in the revision of Ethiopia's EHSP.MethodsIn this study, we estimate ACERs for 77 interventions on reproductive maternal neonatal and child health (RMNCH), infectious diseases and water sanitation and hygiene as well as for 82 interventions on non-communicable diseases. We used the standardised World Health Organization (WHO) CHOosing Interventions that are cost effective methodology (CHOICE) for generalised cost-effectiveness analysis. The health benefits of interventions were determined using a population state-transition model, which simulates the Ethiopian population, accounting for births, deaths and disease epidemiology. Healthy life years (HLYs) gained was employed as a measure of health benefits. We estimated the economic costs of interventions from the health system perspective, including programme overhead and training costs. We used the Spectrum generalised cost-effectiveness analysis tool for data analysis. We did not explicitly apply cost-effectiveness thresholds, but we used US$100 and $1000 as references to summarise and present the ACER results.ResultsWe found ACERs ranging from less than US$1 per HLY gained (for family planning) to about US$48,000 per HLY gained (for treatment of stage 4 colorectal cancer). In general, 75% of the interventions evaluated had ACERs of less than US$1000 per HLY gained. The vast majority (95%) of RMNCH and infectious disease interventions had an ACER of less than US$1000 per HLY while almost half (44%) of non-communicable disease interventions had an ACER greater than US$1000 per HLY.ConclusionThe present study shows that several potential cost-effective interventions are available that could substantially reduce Ethiopia's disease burden if scaled up. The use of the World Health Organization's generalised cost-effectiveness analysis tool allowed us to rapidly calculate country-specific cost-effectiveness analysis values for 159 health interventions under consideration for Ethiopia's EHSP.

Project description:Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6-36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6-36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4-6.2 billion ($1.5-1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.

Project description:BackgroundThe National Essential Public Health Service Package (NEPHSP) was launched in 2009 to tackle poor blood pressure control in Chinese people with hypertension; however, it's effect is still unclear.ObjectiveIn a retrospective population-based longitudinal study, we aimed to evaluate effect of the NEPHSP on blood pressure control.MethodsA total of 516,777 patients registered in the NEPHSP were included. The blood pressure control data were assessed based on the Residence Health Record System dataset. We longitudinally evaluated the effects of the NEPHSP on blood pressure control by analyzing changes in blood pressure at quarterly follow-ups. Both the degree and trend of the blood pressure changes were analyzed. We conducted stratified analysis to explore effects of the NEPHSP on blood pressure control among subgroups of participants with specific characteristics.ResultsThe mean baseline systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 147.12 (SD 19.88) mm Hg and 85.11 (SD 11.79) mm Hg, respectively. The control rates of baseline SBP and DBP were 39.79% (205,630/516,777) and 69.21% (357,685/516,777). Compared to baseline, the mean SBP decreased in each quarter by 5.06 mm Hg (95% CI -5.11 to -5.00; P<.001), 6.69 mm Hg (95% CI; -6.74 to -6.63; P<.001), 10.30 mm Hg (95% CI -10.34 to -10.23; P<.001), and 6.63 mm Hg (95% CI -6.68 to -6.57; P<.001). The SBP control rates increased in each quarter to 53.12% (274,493/516,777; β coefficient=0.60, 95% CI 0.59-0.61; P<.001), 56.61% (292,537/516,777; β coefficient=0.76, 95% CI 0.75-0.77; P<.001), 63.4% (327,648/516,777; β coefficient=1.08, 95% CI 1.07-1.09; P<.001), and 55.09% (284,711/516,777; β coefficient=0.69, 95% CI 0.68-0.70; P<.001). Compared to baseline, the mean DBP decreased in each quarter by 1.75 mm Hg (95% CI -1.79 to -1.72; P<.001), 2.64 mm Hg (95% CI -2.68 to -2.61; P<.001), 4.20 mm Hg (95% CI -4.23 to -4.16; P<.001), and 2.64 mm Hg (95% CI -2.68 to -2.61; P<.001). DBP control rates increased in each quarter to 78.11% (403,641/516,777; β coefficient=0.52, 95% CI 0.51-0.53; P<.001), 80.32% (415,062/516,777; β coefficient=0.67, 95% CI 0.66-0.68; P<.001), 83.17% (429,829/516,777; β coefficient=0.89, 95% CI 0.88-0.90; P<.001), and 79.47% (410,662/516,777; β coefficient=0.61, 95% CI 0.60-0.62; P<.001). The older age group had a larger decrease in their mean SBP (β coefficient=0.87, 95% CI 0.85-0.90; P<.001) and a larger increase in SBP control rates (β coefficient=0.054, 95% CI 0.051-0.058; P<.001). The participants with cardiovascular disease (CVD) had a smaller decrease in their mean SBP (β coefficient=-0.38, 95% CI -0.41 to -0.35; P<.001) and smaller increase in SBP control rates (β coefficient=-0.041, 95% CI -0.045 to -0.037; P<.001) compared to the blood pressure of participants without CVD.ConclusionsThe NEPHSP was effective in improving blood pressure control of Chinese people with hypertension. Blood pressure control of older individuals and those with CVD need to be intensified.

Project description:BackgroundThe sector wide approach (SWAp) used in many developing countries is difficult to assess. One way is to consider the essential health package (EHP) which is commonly the vehicle for a SWAp's policies and plans. It is not possible to measure the impact of an EHP by measuring health outcomes in countries such as Malawi. But it is possible to assess the choice of interventions and their delivery in terms of coverage. This paper describes an attempt to assess the Malawi SWAp through its EHP using these available measures of technical efficiency.MethodsA burden of disease model was used to identify the priority diseases and their estimated incidence. Data from the health management information system (HMIS) were used to measure the coverage of these interventions. A review of the cost-effectiveness of the chosen and potential interventions was undertaken to assess the appropriateness of each intervention used in the EHP. Expenditure data were used to assess the level of funding of the EHP.Results33 of the 55 EHP interventions were found to be potentially cost-effective (<$150/DALY), 12 were not so cost-effective (>$150/DALY) and cost-effective estimates were not available for ten. 15 potential interventions, which were cost-effective and tackling one of the top 20 ranked diseases, were identified.Provision had increased in nearly all EHP services over the period of the SWAp. The rates of out patient attendances and inpatient days per 1000 population had both increased from 929 attendances in 2002/3 to 1135 in 2007/08 and from 124 inpatient days in 2002/03 to 179 in 2007/08.However, by 2007/08 the mean gap between what was required and what was provided was 0.68 of the estimated need. Two services involving the treatment of malaria were overprovided, but the majority were underprovided, with some such as maternity care providing less than half of what was required.The EHP was under-funded throughout the period covering on average 57% of necessary costs. By 2007/08 the funding paid by SWAp partners including the government of Malawi to fund the EHP was at US$13.5 per capita per annum, which was almost half of the revised EHP estimated required expenditure per capita per annum.DiscussionThe SWAp had invested in some very cost-effective health interventions. In terms of numbers of patients treated, the EHP had delivered two thirds of the services required. This was despite serious under-funding of the EHP, an increase in the population and shortage of staff.ConclusionsThe identification of interventions of proven effectiveness and good value for money and earmarked funding through a SWAp process can produce measurable improvement in health service delivery at extremely low cost.

Project description:BackgroundCountries designing a health benefit package (HBP) to support progress towards universal health coverage (UHC) require robust cost-effectiveness evidence. This paper reports on Pakistan's approach to assessing the applicability of global cost-effectiveness evidence to country context as part of a HBP design process.MethodsA seven-step process was developed and implemented with Disease Control Priority 3 (DCP3) project partners to assess the applicability of global incremental cost-effectiveness ratios (ICERs) to Pakistan. First, the scope of the interventions to be assessed was defined and an independent, interdisciplinary team was formed. Second, the team familiarized itself with intervention descriptions. Third, the team identified studies from the Tufts Medical School Global Health Cost-Effectiveness Analysis (GH-CEA) registry. Fourth, the team applied specific knock-out criteria to match identified studies to local intervention descriptions. Matches were then cross-checked across reviewers and further selection was made where there were multiple ICER matches. Sixth, a quality scoring system was applied to ICER values. Finally, a database was created containing all the ICER results with a justification for each decision, which was made available to decision-makers during HBP deliberation.ResultsWe found that less than 50% of the interventions in DCP3 could be supported with evidence of cost-effectiveness applicable to the country context. Out of 78 ICERs identified as applicable to Pakistan from the Tufts GH-CEA registry, only 20 ICERs were exact matches of the DCP3 Pakistan intervention descriptions and 58 were partial matches.ConclusionThis paper presents the first attempt globally to use the main public GH-CEA database to estimate cost-effectiveness in the context of HBPs at a country level. This approach is a useful learning for all countries trying to develop essential packages informed by the global database on ICERs, and it will support the design of future evidence and further development of methods.

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Distributional impact of the Malawian Essential Health Package.

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Distributional impact of the Malawian Essential Health Package.

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