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Choosing services
Integrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off
Ole F. NorheimProfessor in Medical Ethics and Philosophy of Science
Dept. of Global Public Health and Primary CareUniversity of Bergen
Plan
• Background
• Cost-effectiveness• Financial protection• Priority to the worse off
• Classification of priority health services
Key question
• Should financial protection and distributional concerns be incorporated into decision rules for publicly financed health services?
Priority group classification
• Universal Coverage can be defined as access to key health services for all at an affordable cost
1. High-priority services2. Normal-priority services3. Low-priority services
Key
services
How to classify services?
• Cost-effectiveness thresholds< 1 GDP per capita
1-2 GDP per capita
> 3 GDP per capita
(Macroeconomics and Health 2002, WHO CHOICE)
Example
• Selected 65 health services from WHO-CHOICE database (AfrE)
• Child health services• Maternal and newborn health services• Infectious disease services• Non-communicable disease services
• Converted all costs to Int $ 2005
(WHO-CHOICE team BMJ series 2005-2012)
0 2 4 6 8 10 12 14 16
Incremental cost-effectiveness for 65 selected interventions
DALYs/1000 $
Trichiasis surgery to prevent BLINDNESS
TUBERCULOSIS: Testing and treatment
MALARIA: All prevention and treatment
Medical treatment of stroke and heart attack + primary prevention (>35)
Normal and complicated birth + Community newborn care package +pneumonia treatment
ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl.,
HIV: Prevention and treatment of HIV including PMTC
Seatbelts, motorcycle helmets, speed cameras, breath-testing
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps, treatment
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
DALYs/1000 $
Two problems with CEA
• Ignores financial risk protection• Ignores distribution of healthy life years
Financial risk protection
• Publicly financed health services provide– Financial risk protection– Health
• Peter Smith : – If no one buys supplementary services, or – a well-functioning voluntary supplementary insurance marketservice selection on the basis of standard cost-effectiveness ratios
will maximize welfare (health + income) (P. Smith, Health Economics 2012)
• When there is substantial out-of-pocket payment for supplementary services, this is not so.
• High cost services may be favored over low cost services, at least among services with similar cost-effectiveness ratios.
• My interpretation:– Financial risk protection could act at least as a
tiebreaker for services with identical cost-effectiveness ratios.
Trichiasis surgery to prevent BLINDNESS
TUBERCULOSIS: Testing and treatment
MALARIA: All prevention and treatment
Medical treatment of stroke and heart attack + primary prevention (>35)
Normal and complicated birth + Community newborn care package +pneumonia treatment
ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl.,
HIV: Prevention and treatment of HIV including PMTC
Seatbelts, motorcycle helmets, speed cameras, breath-testing
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps, treatment
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
DALYs/1000 $
Two problems with CEA
• Ignores financial risk protection• Ignores distribution of healthy life years
Condition B
Condition A
25
60
20
20
Who are worst off without the health service?Healthy lifeyears without service Additional healthy life years with service
Integrating distributive concerns with CEA
• An “Atkinson’s” social welfare function applied to health would judge:– (60, 45) as better than (80, 25)
(Adler, OUP 2012)
• Health prioritarianism would assign higher weights to benefits for B
(Ottersen, JME 2013)
Condition B
Condition A
25
60
20
20
Healthy lifeyears without serviceAdditional healthy life years with service
Maternal sepsis
HIVRoad injury
Tuberculosis
Cervical cancer
Colon and rectum cancers
Hypertensive heart disease
0 10 20 30 40 50 60 70 80 90 100
Individual disease burden (Source: Calculated from GBD 2010, Eastern sub-
Saharan Africa)Years of life lost
Maternal sepsis
HIVRoad injury
Tuberculosis
Cervical cancer
Colon and rectum cancers
Hypertensive heart disease
0 10 20 30 40 50 60 70 80 90 100
Individual disease burden (Source: Calculated from GBD 2010, Eastern sub-
Saharan Africa)Years of life lost
1 1.5 2
0 2 4 6 8 10 12 14 16 18
Incremental cost-effectiveness for 65 selected interventions
DALYs/1000 $
0 2 4 6 8 10 12 14 16 18
Distribution-weighted cost-effectiveness for 65 selected interventions
Priority-weighted DALYs/1000 $
DALYs/1000 $
Trichiasis surgery to prevent BLINDNESS
TUBERCULOSIS: Testing and treatment
MALARIA: All prevention and treatment
Medical treatment of stroke and heart attack + primary prevention (>35)
Normal and complicated birth + Community newborn care package +pneumonia treatment
ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl.,
HIV: Prevention and treatment of HIV including PMTC
Seatbelts, motorcycle helmets, speed cameras, breath-testing
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps, treatment
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0
DALYs/1000 $
MALARIA: All prevention and treatment
TUBERCULOSIS: Testing and treatment
Trichiasis surgery to prevent BLINDNESS
Normal and complicated birth + Community newborn care package +pneumonia treatment
ORT, Case management of pneumonia, Measles vaccination, Vit. A and Zinc Suppl.,
Medical treatment of stroke and heart attack + primary prevention (>35)
HIV: Prevention and treatment of HIV including PMTC
Seatbelts, motorcycle helmets, speed cameras, breath-testing
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps, treatment
0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0
Distribution-weighted DALYs/1000 $
Distribution-weighted DALYs/1000$ DALYs/1000$
Opportunity cost of implementing top 5 interventions for 5 mill $
42748 DALYs 41190 DALYs
= 1558 DALYs
Opportunity cost
• Health prioritarianism
• Knows the cost in terms of DALYs NOT averted
• Can provide reasons for re-ranking:– some priority to the worse off
Priority group classification – tentative proposal
0 10 20 30 40 50 60 70 80 90 100
Years of life lost
Ex ante / ex post prioritarianism
• Distributive weights based on final – not expected – individual disease burden for various conditions
Imagine you can help group A or B – who would you help?
Imagine you can help group A or B – who would you help?
Ex post: Even if we only know the outcome, but not who will be affected, we can evaluate alternative outcomes