Country-Level Decision Making for Control of Chronic Diseases Workshop Summary (2012) / Chapter Skim
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4 Examples of Tools for Costing, Economic Modeling, and Priority Setting
4 Examples of Tools for Costing, Economic Modeling, and Priority Setting
Pages 41-62
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From page 41... ...
Therefore, any tool or process to support decision making for chronic disease control needs to provide information about costs to support budgeting as well as, ideally, information on cost effectiveness and potential return on investment to help convince policy makers of the benefits of allocating resources to support intervention. Even more ambitiously, Nugent added, the toolkit might also be used to address more "big picture" types of economic questions that may also play a role in priority setting -- for example, the relationship between the prevalence of chronic diseases and economic development.
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From page 42... ...
Chapter 6 provides a summary of the considerations raised in this session along with the presentations and discussions throughout the workshop. TOOLS FOR COSTING AND ECONOMIC MODELING Developing a Country-Validated Price Tag for Chronic Disease Prevention Knowing how much it would cost to prevent or reduce noncommunicable diseases can be important for advocacy and to promote spending from international donors, Andrew Mirelman of Johns Hopkins University commented, as well as to establish priority setting at the national and subnational levels.
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From page 43... ...
The key variables were risk factor prevalence, intervention coverage, and unit prices for drugs and health staff salaries. The researchers used demographic projections based on United Nations (UN)
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The researchers hope to build on the work that has already been done, Mirelman said, by developing more comprehensive data calculating the burden of diseases used to support cost-effectiveness analysis. The researchers hope to develop a league table to rank potential interventions based on cost effectiveness as well as decision weights for such criteria as disease severity and equity (multiple criteria decision analysis, an approach described in a subsequent presentation summarized in this chapter, is one way to develop such weights, he noted)
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From page 45... ...
Elevated blood pressure leads to a major financial burden from both the efforts to manage the high blood pressure and the treatment of the health problems it causes. A variety of data regarding the economic impact of treating heart attacks and stroke are available, but much less information is available concerning treatment of individual risk factors at a country level.
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From page 46... ...
The calculated net savings from the physical activity intervention were about $1 per person. For salt reduction, the net savings were $2 per person.
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From page 47... ...
This life course approach is important because such lifestyle factors as excessive salt intake, consumption of trans fats, and insufficient physical activity may start to have effects early in life, and these and other factors become risk factors in individuals, which in turn increase the probability of disease. Primary prevention strategies at either the population or individual level may help control these risk factors, and secondary prevention or acute medical treatment -- both of which are more expensive than primary prevention -- come into play if primary prevention strategies are not effective.
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From page 48... ...
The researchers assumed a low level of hospital access in low- and middle-income countries, but that hospital access could improve, which would "vastly affect the costs over time." During the discussions following his presentation, Gaziano and other participants commented on how, from the perspective of a potential toolkit, these models could be applied at the country level by using country-specific estimates of the costs of interventions and by adjusting the anticipated effects of treatment and lifestyle interventions based on how they would actually be implemented in a country and the evidence for effectiveness in a similar population or context. There is also the potential to expand the models to use them to explore different scenarios in a country, such as setting different treatment targets or shifting treatment costs by changes in the system's current guidelines or standards, such as using lower-cost personnel or changing the frequency of clinic visits for managing treatment.
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From page 49... ...
The study included analysis of data from 42 lowand middle-income countries;4 these countries account for 90 percent of the noncommunicable disease burden in developing countries. The scope of the costing study was limited to the diseases and risk factors highlighted in WHO's Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases, specifically cardiovascular disease, diabetes, cancers, and respiratory disorders (asthma and chronic obstructive pulmonary disease)
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The researchers developed cost estimates for each of these elements. The costing method was straightforward, Stenberg said, and it was similar to those described in other previous presentations.
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NOTE: NCD = noncommunicable disease. SOURCE: Stenberg (2011a)
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From page 52... ...
The researchers produced estimates for each of the 42 countries, using country data as well as standard assumptions, and then totaled these numbers to come up with the global price tag of noncommunicable disease interventions. This particular study concentrated on the worldwide totals of certain interventions; however, perhaps its most useful product when it comes to actual health care planning is the tool that was developed to analyze country-specific costs of noncommunicable disease interventions.
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From page 53... ...
This lack of synchronicity among various health plans in different countries can be seen clearly in the WHO planning cycle database, Stenberg said, which tracks the development of different health plans across the world.6 For example, in Afghanistan, the National Health Plan covers the years 2007-2013, the immunization plan covers 2011-2015, the TB plan covers 2009-2013, and so on. The OneHealth model is a tool intended to support medium-term planning and promote integration.
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, which can be used to demonstrate achievable health gains and to predict reductions in disease prevalence resulting from specific health care models. The software is also very user-friendly, Stenberg added.
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From page 55... ...
As funding permits, the development team will continue to add new elements to the model, such as a health information systems module and models for health gains for noncommunicable diseases. Stenberg closed with her recommendations for designing and applying a costing model as part of a toolkit: • Be very clear about the specific policy questions to be answered, how the tools will be used and by whom.
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From page 56... ...
To use LiST, users begin by plugging in data for a particular country or region, such as neonatal and maternal mortality rates, current health coverage and interventions, and background information (e.g., vitamin A or zinc deficiencies or exposure to P falciparum)
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More than 40 developing countries have used it to support their strategic planning, though only six or seven have used it as part of their national planning processes. LiST has also been used for the evaluation of programs, for example by the Global Fund and Roll Back Malaria.
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From page 58... ...
Because of the involvement of WHO and UNICEF, LiST has been integrated with several models with broader scopes, but there are many other disease-specific models as well, so the harmonization of LiST with other models remains a challenge. Walker's last word of advice was that it is very important to "define your primary task and try to stick to it -- don't let mission creep take over." A Multi-Criteria Decision Analysis Framework The key question in setting health system priorities, said Mireille Goetghebeur of BioMedCom and the EVIDEM collaboration, is which interventions will contribute most to an equitable, efficient, and sustainable health care system.
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From page 59... ...
. Those principles yielded a set of 15 universal normative criteria in the core model, based on the assumptions that the highest value or priority should be assigned to interventions that • address severe diseases; • address common diseases; • address diseases with many unmet needs; • are recommended by expert consensus; • confer major improvements in efficacy/effectiveness over current standard care; • confer major improvement in patients' perceived health over cur rent standard care; • either confer major risk reduction or major alleviation of suffering; • result in savings in health care intervention, medical, or non medical expenditures; and • are supported by sufficient data that are fully reported, valid, and relevant.
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The MCDA framework can also be used to inform the development stage for new health care interventions or new health care programs. Finally, the framework can be used as a tool to communicate validated information to a range of stakeholders in a digestible format.
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From page 61... ...
61 TOOLS FOR COSTING, ECONOMIC MODELING, AND PRIORITY SETTING Utility to Policy Makers • Adaptable to local context • Systematizes decision-making process • Combines quantitative and qualitative inputs • Identifies applicable criteria and perspectives • Based on a wide set of criteria • Transparent But • Perceived as very complex • May be difficult to integrate with existing processes • There is a risk that MCDA may be used in a formulaic way rather than as a support to priority setting. Methodology • Pragmatic, user-friendly and modular • Instructions are detailed • Open-source -- so users benefit from others' work But • Criteria selection and weighting process may be challenging.
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From page 62... ...
62 COUNTRY-LEVEL DECISION MAKING But • Expertise with MCDA is limited in the health care sector. The EVIDEM framework, Goetghebeur concluded, provides a mechanism for priority setting that is transparent and consistent and that can help users identify the interventions that will contribute most to sustainable and efficient disease control and that will reflect the priorities and preferences of decision makers across a wide range of criteria.
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