Cost-effectiveness thresholds: pros and cons Bertram, Melanie Y; Lauer, Jeremy A; De Joncheere, Kees ...
Bulletin of the World Health Organization,
12/2016, Letnik:
94, Številka:
12
Journal Article
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Cost-effectiveness analysis is used to compare the costs and outcomes of alternative policy options. Each resulting cost-effectiveness ratio represents the magnitude of additional health gained per ...additional unit of resources spent. Cost-effectiveness thresholds allow cost-effectiveness ratios that represent good or very good value for money to be identified. In 2001, the World Health Organization's Commission on Macroeconomics in Health suggested cost-effectiveness thresholds based on multiples of a country's per-capita gross domestic product (GDP). In some contexts, in choosing which health interventions to fund and which not to fund, these thresholds have been used as decision rules. However, experience with the use of such GDP-based thresholds in decision-making processes at country level shows them to lack country specificity and this - in addition to uncertainty in the modelled cost-effectiveness ratios - can lead to the wrong decision on how to spend health-care resources. Cost-effectiveness information should be used alongside other considerations - e.g. budget impact and feasibility considerations - in a transparent decision-making process, rather than in isolation based on a single threshold value. Although cost-effectiveness ratios are undoubtedly informative in assessing value for money, countries should be encouraged to develop a context-specific process for decision-making that is supported by legislation, has stakeholder buy-in, for example the involvement of civil society organizations and patient groups, and is transparent, consistent and fair.
The global burden of non-communicable diseases (NCDs) is growing, and there is an urgent need to estimate the costs and benefits of an investment strategy to prevent and control NCDs. Results from an ...investment-case analysis can provide important new evidence to inform decision making by governments and donors. We propose a methodology for calculating the economic benefits of investing in NCDs during the Sustainable Development Goals (SDGs) era, and we applied this methodology to cardiovascular disease prevention in 20 countries with the highest NCD burden. For a limited set of prevention interventions, we estimated that US$120 billion must be invested in these countries between 2015 and 2030. This investment represents an additional $1·50 per capita per year and would avert 15 million deaths, 8 million incidents of ischaemic heart disease, and 13 million incidents of stroke in the 20 countries. Benefit–cost ratios varied between interventions and country-income levels, with an average ratio of 5·6 for economic returns but a ratio of 10·9 if social returns are included. Investing in cardiovascular disease prevention is integral to achieving SDG target 3.4 (reducing premature mortality from NCDs by a third) and to progress towards SDG target 3.8 (the realisation of universal health coverage). Many countries have implemented cost-effective interventions at low levels, so the potential to achieve these targets and strengthen national income by scaling up these interventions is enormous.
Reduction of the non-communicable disease (NCD) burden is a global development imperative. Sustainable Development Goal (SDG) 3 includes target 3·4 to reduce premature NCD mortality by a third by ...2030. Progress on SDG target 3·4 will have a central role in determining the success of at least nine SDGs. A strengthened effort across multiple sectors with effective economic tools, such as price policies and insurance, is necessary. NCDs are heavily clustered in people with low socioeconomic status and are an important cause of medical impoverishment. They thereby exacerbate economic inequities within societies. As such, NCDs are a barrier to achieving SDG 1, SDG 2, SDG 4, SDG 5, and SDG 10. Productivity gains from preventing and managing NCDs will contribute to SDG 8. SDG 11 and SDG 12 offer clear opportunities to reduce the NCD burden and to create sustainable and healthy cities.
The World Health Organization's (WHO's) Choosing Interventions that are Cost-Effective (CHOICE) programme has been a global leader in the field of economic evaluation, specifically cost-effectiveness ...analysis for almost 20 years. WHO-CHOICE takes a "generalized" approach to cost-effectiveness analysis that can be seen as a quantitative assessment of current and future efficiency within a health system. This supports priority setting processes, ensuring that health stewards know how to spend resources in order to achieve the highest health gain as one consideration in strategic planning. This approach is unique in the global health landscape. This paper provides an overview of the methodological approach, updates to analytic framework over the past 10 years, and the added value of the WHO-CHOICE approach in supporting decision makers as they aim to use limited health resources to achieve the Sustainable Development Goals (SDGs) by 2030.
The disability adjusted life year (DALY) is a composite measure of disease burden that includes both morbidity and mortality, and is relevant to conditions such as epilepsy that can limit productive ...functioning. The 2010 Global Burden of Disease (GBD) study introduced a number of new methods and definitions, including a prevalence-based approach and revised disability weights to calculate morbidity and new standard life expectancies to calculate premature mortality. We used these approaches, and local, population-based data, to estimate the burden of convulsive epilepsy in rural South Africa.
Comprehensive prevalence, incidence and mortality data on convulsive epilepsy were collected within the Agincourt sub-district in rural northeastern South Africa between 2008 and 2012. We estimated DALYs using both prevalence- and incidence-based approaches for calculating years of life lived with disability. Additionally, we explored how changing the disease model by varying the disability weights influenced DALY estimates. Using the prevalence-based approach, convulsive epilepsy in Agincourt resulted in 332 DALYs (95% uncertainty interval (UI): 216-455) and 4.1 DALYs per 1,000 individuals (95%UI: 2.7-5.7) annually. Of this, 26% was due to morbidity while 74% was due to premature mortality. DALYs increased by 10% when using the incidence-based method. Varying the disability weight from 0.072 (treated epilepsy, seizure free) to 0.657 (severe epilepsy) caused years lived with disability to increase from 18 (95%UI: 16-19) to 161 (95%UI: 143-170).
DALY estimates are influenced by both the methods applied and population parameters used in the calculation. Irrespective of method, a significant burden of epilepsy is due to premature mortality in rural South Africa, with a lower burden than rural Kenya. Researchers and national policymakers should carefully interrogate the methods and data used to calculate DALYs as this will influence policy priorities and resource allocation.
Excess intake of sugar sweetened beverages (SSBs) has been shown to result in weight gain. To address the growing epidemic of obesity, one option is to combine programmes that target individual ...behaviour change with a fiscal policy such as excise tax on SSBs. This study evaluates the literature on SSB taxes or price increases, and their potential impact on consumption levels, obesity, overweight and body mass index (BMI). The possibility of switching to alternative drinks is also considered.
The following databases were used: Pubmed/Medline, The Cochrane Database of Systematic Reviews, Google Scholar, Econlit, National Bureau of Economics Research (NBER), Research Papers in Economics (RePEc). Articles published between January 2000 and January 2013, which reported changes in diet or BMI, overweight and/or obesity due to a tax on, or price change of, SSBs were included.
Nine articles met the criteria for the meta-analysis. Six were from the USA and one each from Mexico, Brazil and France. All showed negative own-price elasticity, which means that higher prices are associated with a lower demand for SSBs. Pooled own price-elasticity was -1.299 (95% CI: -1.089 - -1.509). Four articles reported cross-price elasticities, three from the USA and one from Mexico; higher prices for SSBs were associated with an increased demand for alternative beverages such as fruit juice (0.388, 95% CI: 0.009 - 0.767) and milk (0.129, 95% CI: -0.085 - 0.342), and a reduced demand for diet drinks (-0.423, 95% CI: -0.628 - -1.219). Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity.
Taxing SSBs may reduce obesity. Future research should estimate price elasticities in low- and middle-income countries and identify potential health gains and the wider impact on jobs, monetary savings to the health sector, implementation costs and government revenue. Context-specific cost-effectiveness studies would allow policy makers to weigh these factors.
To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries’ universal health coverage ...packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium.
We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario.
Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested.
This is the first-ever global investment case for integrating ear and hearing care interventions in countries’ universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services.
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In the context of an epidemiologic transition in South Africa, in which cardiovascular disease is increasing, little is known about the stroke burden, particularly morbidity in rural populations. ...Risk factors for stroke are high, with hypertension prevalence of more than 50%. Accurate, up-to-date information on disease burden is essential in planning health services for stroke management. This study estimates the burden of stroke in rural South Africa using the epidemiological parameters of incidence, mortality and disability adjusted life year (DALY) metric, a time-based measure that incorporates both mortality and morbidity.
Data from the Agincourt health and socio-demographic surveillance system was utilised to calculate stroke mortality for the period 2007-2011. Dismod, an incidence-prevalence-mortality model, was used to estimate incidence and duration of disability in Agincourt sub-district and 'mostly rural' municipalities of South Africa. Using these values, burden of disease in years of life lost (YLL), years lived with disability (YLD) and DALYs was calculated for Agincourt sub-district.
Over 5 years, there were an estimated 842 incident cases of stroke in Agincourt sub-district, a crude stroke incidence rate of 244 per 100,000 person years. We estimate that 1,070 DALYs are lost due to stroke yearly. Of this, YLDs contributed 8.7% (3.5 - 10.5%) in sensitivity analysis). Crude stroke mortality was 114 per 100,000 person-years in 2007-11 in Agincourt sub-district. Burden of stroke in entire rural South Africa, a population of some 13,000,000 people, was high, with an estimated 33, 500 strokes occurring in 2011.
This study provides the first estimates of stroke burden in terms of incidence, and disability in rural South Africa. High YLL and DALYs lost amongst the rural populations demand urgent measures for preventing and mitigating impacts of stroke. Longitudinal surveillance sites provide a platform through which a changing stroke burden can be monitored in rural South Africa.
The WHO-CHOICE (World Health Organization CHOosing Interventions that are Cost-Effective) approach is unique in the global health landscape, as it takes a "generalized" approach to cost-effectiveness ...analysis (CEA) that can be seen as a quantitative assessment of current and future efficiency within a health system. CEA is a critical contribution to the process of priority setting and decision-making in healthcare, contributing to deliberative dialogue processes to select services to be funded. WHO-CHOICE provides regional level estimates of cost-effectiveness, along with tools to support country level analyses. This series provides an update to the methodological approach used in WHO-CHOICE and presents updated cost-effectiveness estimates for 479 interventions. Five papers are presented, the first focusing on methodological updates, followed by three results papers on maternal, newborn and child health; HIV, tuberculosis and malaria; and non-communicable diseases and mental health. The final paper presents a set of example universal health coverage (UHC) benefit packages selected through only a value for money lens, showing that all disease areas have interventions which can fall on the efficiency frontier. Critical for all countries is institutionalizing decision-making processes. A UHC benefit package should not be static, as the countries needs and ability to pay change over time. Decisions will need to be continually revised and new interventions added to health benefit packages. This is a vital component of progressive realization, as the package is expanded over time. Developing an institutionalized process ensures this can be done consistently, fairly, and transparently, to ensure an equitable path to UHC.
To determine the health system costs and health-related benefits of interventions for the prevention and control of non-communicable diseases (NCDs), including mental health disorders, for the ...purpose of identifying the most cost-effective intervention options in support of global normative guidance on the best-buy interventions for NCDs. In addition, tools are developed to allow country contextualisation of the analyses to support local priority setting exercises.
This analysis follows the standard WHO-CHOICE (World Health Organization-Choosing Interventions that are Cost-Effective) approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and South-East Asia. The scope of the analysis is all NCD and mental health interventions included in WHO guidelines or guidance documents for which the health impact of the intervention is able to be identified and attributed. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, both for a period of 100 years.
There are many interventions for NCD prevention and management that are highly cost-effective, generating one year of healthy life for less than Int. $100. These interventions include tobacco and alcohol control policies such as taxation, voluntary and legislative actions to reduce sodium intake, mass media campaigns for reducing physical activity, and treatment options for cardiovascular disease (CVD), cervical cancer and epilepsy. In addition a number of interventions fall just outside this range, including breast cancer, depression and chronic lung disease treatment.
Interventions that represent good value for money, are technically feasible and are delivered for a low per-capita cost, are available to address the rapid rise in NCDs in low- and middle-income countries. This paper also describes a tool to support countries in developing NCD action plans.
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