Discussion of Cost Effectiveness Interventions to Improve Low and Middle Income Health Care Systems

Achieving efficiency for a limited amount of resources (cost-effectiveness) is one of the challenges low and middle-income countries face in effectuating health reforms. Sinha, et al. illustrate this challenge in their article, Cost-effectiveness of Pneumococcal Conjugate Vaccination in the Prevention of Child Mortality, by utilizing cost-effectiveness decision tree modeling to evaluate a pneumococcal vaccination program in The Gambia (facilitated through the GAVI program). They determined that vaccination have an average cost effectiveness ratios of $80 per disability adjusted life year averted.  Investing in basic vaccination is one of the greatest opportunities to strengthen health infrastructure, particularly because these programs directly counteract child and infant mortality.

There are always opportunity costs associated with choosing one policy intervention over another in the hopes of attaining universal healthcare.  It is ideal to maximize the impact of those resources, even though some will be left behind.  Drummond, et al. in their book, Methods for the Economic Evaluation of Health Care Programmes, specifically highlight economic evaluation as a tool to evaluate the cost effectiveness of competing health interventions, although they are careful to distinguish between different analytical approaches such as (1) cost-effectiveness analysis, (2) cost-utility analysis, and (3) cost-benefit analysis, which can lead to different policy recommendations depending on whether the goals of the analysis are health outcome optimization, societal value creation, or cost savings.

Left unstated, the decision to even entertain these cost effectiveness methodological debates in public discourse can obfuscate the decision-making process and exhaust policy makers into compromising for a weaker system to appease all stakeholders.

Robinson, et al., in their article, Understanding and Improving the One and Three Times GDP Per Capita Cost-Effectiveness Thresholds, discuss an alternative threshold-based approach as a prerequisite for intervention authorization, which requires some minimum return on investment before decision makers can proceed to implement changes to their health care infrastructure.

On a related note, highly cost-effective interventions can sometimes require large and intimidating initial investments, as discussed by Stover et al., in their article What is Required to End the AIDS Epidemic as a Public Health Threat by 2030?  The Cost and Impact of the Fast-Track Approach, in which they discuss abandoning the underperforming 2011 Investment Framework strategy of scaling-up HIV eradication efforts after it became apparent that this strategy would plateau and not actually eradicate HIV by 2030, as had been previously anticipated.  These authors instead advocate for a “fast-track” $26.1B annual investment in HIV eradication strategies in order to achieve a “0-0-0 result” (0 deaths, 0 new infections, and 0 discrimination) by 2030.  After the initial scale-up of resources, these authors determined that annual resources required to achieve this would decline by 9% annually by 2030, yielding substantial cost savings (although quite far downstream).

Additionally, decisions like these, involving relatively large initial financial commitments, implicate the strength of political systems to muster sufficient political will to facilitate resource intensive commitments that may not immediately pay off.  An example of a strong political system would be that of Prime Minister Meles Zenawi in Ethiopia, as described by Balabanova et al, in their article Good Health at Low Cost 25 Years On:  Lessons for the Future of Health Systems Strengthening.  Zenawi was able to coordinate with outside development partners to overcome a fragmented system and target cost effective interventions in essential services.

Similarly, Bangladesh is a paragon of what a civil war-torn, impoverished nation can achieve for its health system by prioritizing fairly simple interventions (i.e., longest life expectancy, lowest fertility rate, lowest infant and under-5 mortality rates in Southeast Asia, despite underspending its peer nations) when it prioritizes cost effective health interventions as a matter of public policy (specifically, (1) family planning, (2) generic drug access, (3) progressive policies generally such as gender empowerment and disaster preparedness, and (4) research and development).

A report from the Children’s Investment Fund from 2014, discussing Nigeria’s healthcare initiative, Saving One Million Lives, is an example ofunderperformance, despite commendable progress, which can happen when funding initiatives fall short. While under-5 mortality has fallen by 36% over the last decade, Nigeria stands out amongst its peer nations in West Africa (such as Senegal, Chad, and Ghana) for having relatively low life expectancy, relatively high HIV prevalence, and disparities in access to healthcare, as well as child malnutrition scattered inequitably across the northern and western parts of the country.  Because of the initial decision to underinvest in the health system, Nigeria faced the prospect of needing to overcompensate going forward in order to stymy advanced disease progression and health infrastructure degradation.  Private sector cooperation, for example through the Private Sector Alliance, in Nigeria, could help close this funding gap. International donors (including the Global Fund, GAVI, PEPFAR) can also help supplement spending, although the allocation may be constrained by the specific disease targets.

-Andrew Hennessy-Strahs

(This post is based upon work I have completed toward my Master’s in Public Health Degree at Yale University.  I hope it may be of some use to practitioners in the field.)


Bibliography

Balabanova, et al., Good Health at Low Cost 25 Years On:  Lessons for the Future of Health Systems Strengthening, The Lancet (2013).

Children’s Investment Fund, Spending to Save:  Challenges and Opportunities for Financing Nigeria’s Saving One Million Lives Initiative, Results for Development Institute (2014).

Drummond, et al., Methods for the Economic Evaluation of Health Care Programmes, Oxford University Press (2015).

Robinson, et al., Understanding and Improving the One and Three Times GDP Per Capita Cost-Effectiveness Thresholds, Health Policy and Planning (2017).

Sinha, et al., Cost-effectiveness of Pneumococcal Conjugate Vaccination in the Prevention of Child Mortality: An International Economic Analysis, The Lancet (2007).

Stover, et al., What is Required to End the AIDS Epidemic as a Public Health Threat by 2030?  The Cost and Impact of the Fast-Track Approach, Plos One (2016).

—image credit: http://www.pmlive.com/pharma_intelligence/amazing_africa_908695

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