Upload
lekhuong
View
216
Download
2
Embed Size (px)
Citation preview
国家卫生计生委卫生发展研究中心China National Health Development Research Center
http://www.nhdrc.cn
Cost effectiveness analysis of CSS
-preliminary results
Kun Zhao
China National Health Development Research Center
Center for Health Policy Evaluation and Technology Assessment
October 2015,Beijing
2. Methods
Content
3. Results
4. Preliminary recommendations
1. Background
Infant mortality rate: 8.9 / 1,000
Under-5 mortality rate: 11.7 /1,000
Maternal mortality: 21.7 / 100,000
Challenge:• Large population
• Imbalanced urban and
rural development
• Limited resources
Lead:NHFPC and UNICEF
Aim:Reduce children’s mortality, improve
children's health
Intervention:106 items
Based on international evidence, combined with
real situation in China
Infant mortality rate :8 / 1,000
Under-5 mortality rate :10 /1,000
Maternal mortality : 18/100,000
Developer:WHO, Futures institute
Usage:Support health programs in low-income
countries
Feature:Evidence-based effect estimation, health
budget estimation, priority identification
1. Background
Priority input areas
Effectiveness?Funding?
Cost-effectiveness?
Eliminate newborn and under-5
preventable deaths
During 12th Five-Year Plan
13th Five-Year Plan
Preliminary objectives
UN SDGs
China Child Survival Strategy (CSS) OneHealth Tool(OHT)
2. Method
2.1 Research framework
• Develop effective intervention package based on CSS
Prioritize intervention
• Background parameters
• Intervention parameters
• Cost data
Parameter identification
and data collection • Based on OHT
• Cost analysis
• Effect analysis
• Cost-effectiveness analysis
Data analysis
• Provide suggestion for the next 5-year plan
Policy suggestion
Determining standard:(1)with evidence-based effectiveness in OHT(2)WHO
suggestion(3)Expert suggestion
2.2 Effective intervention package development
Expert group (5 rounds of consultation, 43 person-times): Health policy formulation and planning experts,
maternal and child specialists, clinical experts, health economists
CSS
(106 items) 44 items
Expert opinion
24
items
Deleted:62 items
not suggested by
WHO
33
items
Deleted:16 items without
determined evidence
3 items not suitable for China
situation
Combined:4 items to 2 items
Expanded:4 items to 12 items
expert opinion
Combined:4 items to 2
items
Deleted:7 items
already full coverage or
effects not measurable
2.2 Effective intervention package development
Effective
intervention
package
(33 items)
Effective
intervention
package
(44 items)
1. Collapse same interventions. Safe termination of pregnancy and Safe termination of
pregnancy for unintended pregnancy; Preventive antibiotics for mothers with high risk of
infection and Use of antibiotic for preterm birth with premature rupture of membranes
2. Deleted irrelevant items. Safe childbirth, promote vaginal delivery, Post-natal nutrition: iron,
folic acid, VD, calcium, iodine, etc., Management of severe acute malnutrition
3. Deleted items excluded from LiST. Unintended pregnancy prevention, Early screening of
HIV, syphilis, and hepatitis B., Intervention, treatment, visiting and management of HIV, syphilis
and hepatitis B patients, Labor induction for full-term baby with premature rupture of
membranes, Timely detection of HIV, syphilis and hepatitis B status, special treatment and aid on
delivery, Treatment for postpartum hemorrhage, Prevention of post-natal bleeding, Antiretroviral
drugs for newborns of HIV-infected mother; promote breast feeding, eliminate mixed feeding;
Antiretroviral drugs for both mother and child, Neonatal jaundice (pathological and breast milk)
and other critical illness identification and referral, Preventive antiretroviral therapy for newborn
exposed to HIV, Preventive antibiotic treatment for newborn with high risk of viral infection, Use
of Continuous Positive Airway Pressure (CPAP) for respiratory distress syndrome in premature
newborn, Treatment of neonatal jaundice (pathological), Treatment of anemia in post-natal
mother, Visit and monitor of children born to HIV or syphilis-infected mother, Timely treatment
and integrated care if infected
4. Broken items. Prevention of pregnancy complications broken
into“hypertension”and“gestational diabetes”;“Newborn: breast feeding, umbilical cord and
skin care, keep warm, VD supplement” into“breastfeeding counseling”,“keep
warm”;“Routine vaccination”into“DPT”,“BCG”,“Polio vaccine”,“HepB
vaccine”and“Measles vaccine”;“Secondary vaccination”into“Hib
vaccine”,“PCV”and“rotavirus vaccine”
2.2 Effective intervention package development
Effective
intervention
package
(33 items)
1. Further collapsed items.“breastfeeding
counseling”with“Breast feeding within six month”;“keep
warm”and“Kangaroo Mother Care”2. Deleted items excluded from LiST.“treatment of local
infections(newborn)”“Management of low birth weight
and preterm birth”3. Deleted items with 100% coverage or without clear and
calculable effectiveness.“Polio vaccine”,“BCG”,“HepB
vaccine”,“gestational diabetes”,“Induction of labor for
pregnancies lasting 41+ weeks”
Effective
intervention
package
(24 items)
Maternal Interventions
Monitoring and treatment of syphilis
Safe termination of pregnancy
Folic acid, iron, calcium and nutrient supplement
Oral folic acid and other nutrients supplements
Prevention of pregnancy-induced hypertension
Prevention of complications of abortion
Prevention and management of postpartum hemorrhage
Caesarean section on indication
Newborn interventions
Use of antibiotics for premature rupture of membranes (PROM)
Neonatal resuscitation
Kangaroo Mother Care
Neonatal sepsis (fully supportive care)
Neonatal sepsis (antibiotic injections)
Child Interventions
Exclusive breastfeeding for six months
Continued breastfeeding from 6 months onwards with appropriate complementary feeding
DPT vaccine
Measles vaccine
Haemophilus influenzae vaccine
Pneumococcal vaccine
Rotavirus vaccine
Pneumonia management (antibiotics)
Diarrhea management (ORS)
Diarrhea management (zinc)
Antibiotic treatment of dysentery
Effective intervention package
Treatment
intervention,
14
Preventive
intervention,
10
Public health
project/Basic
medical insurance, 15
OOP, 9
Pregnant
woman, 8
Newborn, 5
Children under
5, 11
Grouping of (cost) effective intervention packages
By target population By intervention type By funding source
高效包及需要人群、覆盖率详见附件一:高效包明细及需要人群、覆盖率.xlsx
Analytical tool:OneHealth Tool
Time:2015-2020
Costing range: National
Costing perspective: Government
Costing estimation methods: Standard costing method
Costing items: medicines, supplies and test programs
Performance indicators: Child / maternal mortality
Cause of
death
Intervention population:Demographic characteristics
Population health status
(Epidemiology)
Effect:Prevention of
child and
maternal deaths
Effective intervention package
Need to invest (drugs,
supplies and test)
2.3 Analytical tool
Baselinecoverage rate (2015)
Target coveragerate (2020)
Cost Effect
Intervention 1
# # # #
Intervention 2
# # # #
Intervention 3
# # # #
………. # # # #
2.4 CSS Model building
Main parameters Source Note
Background data
Demographic characteristics Sixth census
Population health status OHT system default dataChange IMR,U5M,MMR based on China
data
Intervention coverage5 times expert meetings, 43 person times
consultations
Target population Expert consultation
Proportion of need intervention among
the target populationExpert consultation
Baseline coverage (2015)Literature review, report and Expert
consultationAverage of urban and rural coverage rate
Target coverage (2020) Expert consultation
Target value will be up to 90% for
interventions with baseline coverage of
90% or less
Target value will be 100% for
interventions with baseline coverage more
than 90%
Intervention cost data
drugs / supplies / tests required OHT system default and Expert
consultationActivity Based Costing
Drug / test / Supplies price
National Drug bidding information
platform, Guangdong / Guizhou /
Qinghai pilot data
Based on the information platform, pilot
data as a supplement, and take the lowest
price
Intervention effect OHT system default data RR of various causes of death
2.5 Data collection
2.5 Data collection
序号干预措施
实施渠道
目标人群
药品/耗材 医务人员 门诊人次和住院天数
药物/耗材/检验
接受这一治疗百分比
标注单位数
每日次数
所需天数
所需总量
单位成本
平均每例病人花费
人员类型
接受治疗的比例
分钟天/访问数
总分钟数
类型接受百分比
备注单位次数
总访问量
1
梅毒的监测与治疗
乡级/县级及以上
孕妇
采血包(采血针,采血管,棉拭子,隔离垫,一次性手套,输液贴)
100 1 1 1 护士 100 15 1门诊人次
100 1
Intervention coverage rate increases consistently annually
- Cost Estimation
Intervention funds required annually = intervention unit cost * number * intervention
coverage
Intervention unit cost = Drugs / Supplies / test * Number * Price
Number of people requiring intervention =
Number of whole population *proportion of the target population *proportion of need
intervention among the target population
- Effect Estimation
Child and maternal deaths averted= baseline deaths – deaths averted by year
- Cost-effectiveness analysis
Average cost-effectiveness ratio = cost / averted deaths
2.6 Data analysis
3. Preliminary results
7.70
5.39
8.98
6.28
12.00
8.47
0.00
2.00
4.00
6.00
8.00
10.00
12.00
14.00
2015 2016 2017 2018 2019 2020
M
o
r
t
a
l
i
t
y(
‰)
Newborn mortality
Infant mortality
Under-5 mortality
2020 target(under-5 mortality)
2020 target (infant mortality)
RR=30.0%
RR=30.1%
RR=29.4%
Figure 1 2015-2020 Effect of implementation of intervention package
on children mortality rate
3.1 Effect estimate (24 intervention items)
2015-2020 accumulation:
120,000 newborn deaths prevented
263,000 under-5 deaths prevented
23.2
14.61
0.00
5.00
10.00
15.00
20.00
25.00
2015 2016 2017 2018 2019 2020
De
ath
pe
r 1
00
,00
0 p
regn
ant
po
pu
lati
on
Maternal mortality
2020 target
3.1 Effect estimate (24 intervention items)
2015-2020:
4243maternal death averted
Figure 2 2015-2020 Effect of implementation of intervention package
to maternal mortality rate
RR=37.0%
7.06
7.7
5.73
4
5
6
7
8
9
10
2015 2016 2017 2018 2019 2020
M
o
r
t
a
l
i
t
y
(
‰)
Newborn mortality rate
8.08
8.98
7.2
4
5
6
7
8
9
10
2015 2016 2017 2018 2019 2020
M
o
r
t
a
l
i
t
y
(
‰)
Infant mortality rate
10.64
12
9.62
8
9
10
11
12
13
14
2015 2016 2017 2018 2019 2020
M
o
r
t
a
l
i
t
y
(
‰)
Under-5 mortality rate
22.93
23.2
14.92
10
12
14
16
18
20
22
24
26
28
30
2015 2016 2017 2018 2019 2020
Maternal mortality rate Death
per 1
00
,00
0 p
regnan
t p
op
ulatio
n
3.1 Effect Estimation(Public health/basic medical insurance VS. OOP)
OOP Public health/BMI
5.39
8.4714.61
24 items
RR=25.6%
RR=8.3%
RR=30.0%
RR=10.0%
6.28
RR=19.8%
RR=30.1%
RR=11.3%
RR=19.8%
RR=29.4%
RR=1.2%
RR=35.7%
RR=37.0%
3.1 Effect Estimation
(Public health/basic medical insurance VS. OOP)
InterventionAverted total deaths
Averted under-5 deaths
Averted 1-59month child deaths
Averted <1month child deaths
Avertedmaternal deaths
OOP(9 items) 100655 50281 29247 21034 93
Public health/Medical insurance(15items)
175046 86092 35592 50499 2863
Intervention package 24items
275701 136373 64839 71533 2956
0% 20% 40% 60% 80% 100%
Prevented maternal deaths
Prevented <1month child deaths
Prevented 1-59 month child deaths
Prevented under-5 deaths
Prevented total deaths
OOP
Public health/ medical insurance
2151
3228
7250
7558
8734
9422
9846
12101
14054
35690
0 5000 10000 15000 20000 25000 30000 35000 40000
列1
2015-2020 averted child and maternal deaths
Caesarean section on indication
Child Pneumonia management (antibiotics)
Kangaroo Mother Care
Exclusive breastfeeding for six months
Pneumococcal vaccine
Haemophilus influenzae vaccine
Diarrhea management (ORS)
Neonatal resuscitation
Pregnant women Folic acid, iron, calcium and nutrient supplement
Neonatal sepsis (fully supportive care)
Continued breastfeeding from 6 months onwards with appropriatecomplementary feedingRotavirus vaccine
Oral folic acid and other nutrients supplements for woman aroundpregnancyUse of antibiotics for premature rupture of membranes (PROM)
Diarrhea management (zinc)
Neonatal sepsis (antibiotic injections)
DPT vaccine
Prevention and management of postpartum hemorrhage
Prevention of pregnancy-induced hypertension
Measles vaccine
Antibiotic treatment of dysentery
Monitoring and treatment of syphilis
Safe termination of pregnancy
Prevention of complications of abortion
90.4% of total averted deaths
3.1 Effect estimation (24items)
3.2 Cost estimation(24 items)
2015-2020, total cost was 123.921 billion yuan
94.52
145.92
191.23
232.54
270.03
304.95
0.00
50.00
100.00
150.00
200.00
250.00
300.00
350.00
2015 2016 2017 2018 2019 2020
Co
st (0.1
billio
n)
Treatment
intervention,
53.09
Preventive
intervention
(Pneumococca
l vaccin…
Preventive
intervention
(others),
417.18
Public health
project/Basic medical insurance,
90.86
OOP
(Pneumococc
al vaccine), 768.94
OOP (others), 379.41
Maternal, 347.91
New born,
7.8Children under 5, 883.49
3.2 Cost structure(24 items)
By target population
(0.1billion)
By intervention type
(0.1billion)
By funding source
(0.1billion)
81801.33
80365.74
78276.05
40551.29
37664.29
18913.50
10649.35
6477.04
4903.87
534.19
0.00 2000000.00 4000000.00 6000000.00 8000000.00 10000000.00 12000000.00
成本-
效果
Cost effectiveness ratio (RMB/ one death prevented)
Child Pneumonia management (antibiotics)
Kangaroo Mother Care
Caesarean section on indication
Exclusive breastfeeding for six months
Neonatal resuscitation
Neonatal sepsis (antibiotic injections)
Prevention of complications of abortion
Prevention and management of postpartum hemorrhage
Neonatal sepsis (fully supportive care)
Continued breastfeeding from 6 months onwards withappropriate complementary feedingDiarrhea management (ORS)
Monitoring and treatment of syphilis
Use of antibiotics for premature rupture of membranes(PROM)Haemophilus influenzae vaccine
Antibiotic treatment of dysentery
Oral folic acid and other nutrients supplements for womanaround pregnancyRotavirus vaccine
Measles vaccine
Prevention of pregnancy-induced hypertension
Diarrhea management (zinc)
DPT vaccine
Safe termination of pregnancy
Pneumococcal vaccine
Pregnant women Folic acid, iron, calcium and nutrientsupplement
3.4 Cost-effective analysis(24 items)
Treatment,
7
Preventive ,
3
Medical
insurance
covered, 7
OOP, 3
Maternal, 3
Newborn, 4
Children
under 5, 3
3.4 Cost-effective analysis
Top 10 most cost-effective interventions are categorized as below:
By target population By intervention type By funding source
治疗
性措
施, 6.47
预防
性措
施, 3.3
Medical insurance covered,
6.47
OOP, 3.30
3.4 Cost-effectiveness analysis
Investment cost for top 10 most cost-effective interventions
maternal
2.88
newborn,
4.12
Children
under 5, 2.78
Treatment, 6.47
preventive,
3.3
By target population
(0.1billion)
By intervention type
(0.1billion)
By funding source
(0.1billion)
Top 10 cost-effective interventions
Childhood pneumonia management (use of antibiotics)
Kangaroo Mother Care
Indication of cesarean section
Exclusive breastfeeding for six months
Neonatal resuscitation
Neonatal sepsis - antibiotic injection
Prevention of complications of abortion
Prevention and management of postpartum hemorrhage
Neonatal sepsis - fully supportive care
Continued breastfeeding from 6 monthsonwards with appropriate complementary feeding
Top 10 effective interventions
Cesarean section on indication
Child pneumonia management (use of antibiotics)
Kangaroo Mother Care
six months exclusive breastfeeding
Pneumococcal vaccine
Haemophilus influenzae vaccine
Diarrhea Management (ORS)
Neonatal resuscitation
Maternal nutrition package
Neonatal sepsis - fully supportive care
3.5 Scenario Analysis
Overlapping intervention:
Child pneumonia management (antibiotics)
Cesarean section on indication
Kangaroo Mother Care
Exclusive breastfeeding for six months
Neonatal resuscitation
Neonatal sepsis (fully supportive care)
Top10 effective remaining
items:• Pneumococcal
vaccination
• Haemophilus influenzae
vaccination
• ORS
• Maternal nutritional
supplements (iron, folic
acid, calcium, iodine)
Top10 cost-effective
remaining items :Neonatal sepsis –(antibiotic i)
Management of abortion
complications
Prevention of postpartum
hemorrhage
Continued breastfeeding from
6 months onwards with
appropriate complementary
feeding
6 items 4 items4 items
Overlapping 6 interventions:
Child pneumonia management
(antibiotics)
Cesarean section on indication
Kangaroo Mother Care
Exclusive breastfeeding for six months
Neonatal resuscitation
Neonatal sepsis –(fully supportive care)
6 items 10
ite
ms
14
ite
ms
Top10 effective remaining 4
items:
• Pneumococcal vaccination
• Haemophilus influenzae
vaccination
• ORS
• Maternal nutritional
supplements (iron, folic acid,
calcium, iodine)
Top10 cost-effective remaining 4
items :Neonatal sepsis - antibiotic
injection
Management of abortion
complications
Prevention of postpartum
hemorrhage
Continued breastfeeding from 6
months onwards with appropriate
complementary feeding
other 10
items
24 items
Intervention
Cost (0.1billion)
Ratio of cost(%)
Averted deaths(10,000)
Ratio of effectiveness(%)
6 items 7.13 0.57 9.15 75.60
10 items 9.77 0.78 9.38 77.51
14 items 1141.56 92.12 11.63 96.11
24 Items 1239.21 100.00 12.10 100.00
3.5 Scenario Analysis
6 items 10 items 14 items 24 items
Total cost(0.1 billion) 7.13 9.77 1141.56 1239.21
Effect(2020)
Maternal mortality rate(per 100,000 Live Births)
17.62 15.9 15.81 14.61
Newborn mortality rate(‰ LB) 5.86 5.83 5.73 5.39
Infant mortality rate(‰ LB) 6.89 6.86 6.64 6.28
Under-5 mortality rate(‰ LB) 9.48 9.44 8.87 8.47
2015-2020 Cost and effectiveness estimation of difference intervention packages
3.5 Scenario Analysis
3.6 Scenario Analysis
1239
493
0
200
400
600
800
1000
1200
1400
Current price Lowest price
5 y
ear total co
st
(0.1
billio
n
)
Reduce 60%
5 years’ total cost for effective intervention package with 24 items
Pneumococcal vaccine
Current price in China:¥777/shot
International lowest price:¥22.5/shot
81801.33
80365.74
78276.05
40551.29
37664.29
18913.50
10649.35
6477.04
4903.87
534.19
0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000
成本-
效果
成本效果比(元/避免1例死亡)
Child Pneumonia management (antibiotics)
Kangaroo Mother Care
Caesarean section on indication
Exclusive breastfeeding for six months
Neonatal resuscitation
Neonatal sepsis (antibiotic injections)
Prevention of complications of abortion
Prevention and management of postpartum hemorrhage
Neonatal sepsis (fully supportive care)
Continued breastfeeding from 6 months onwards withappropriate complementary feedingDiarrhea management (ORS)
Monitoring and treatment of syphilis
Pneumococcal vaccine
Use of antibiotics for premature rupture of membranes(PROM)Haemophilus influenzae vaccine
Antibiotic treatment of dysentery
Oral folic acid and other nutrients supplements for womanaround pregnancyRotavirus vaccine
Measles vaccine
Prevention of pregnancy-induced hypertension
Diarrhea management (zinc)
DPT vaccine
Safe termination of pregnancy
Pregnant women Folic acid, iron, calcium and nutrientsupplement
Cost-effectiveness ratio increase from
ranking 23 to 13
Cost-effectiveness analysis on
effective intervention package with 24 items
6 items 10
items
14
items
Other 10
items
24
items
Intervention Cost (0.1billion)
Ratio of cost(%)
Averted deaths(10,000)
Ratio of effectiveness(%)
6 items 7.13 0.57 9.15 75.60
10 items 9.77 0.78 9.38 77.51
14 items(International)
395.52 31.92 11.63 96.11
14 items(China)
1141.56 92.12 11.63 96.11
24 items(International)
493.17 39.80 12.10 100.00
24 items(China)
1239.21 100.00 12.10 100.00
3.5 Scenario AnalysisCoincide 6 interventions:
Childhood pneumonia management (use
of antibiotics)
Cesarean section
Implementation of Kangaroo Mother Care
six months of exclusive breastfeeding
Neonatal resuscitation
Neonatal sepsis - fully supportive care
Top10 effective remaining 4
items:
• Pneumococcal
• Haemophilus influenzae
• ORS
• Maternal nutritional
supplements (iron, folic acid,
calcium, iodine)
Top10 cost-effective remaining 4
items :Neonatal sepsis - antibiotic
injection
Management of abortion
complications
Prevention of postpartum
hemorrhage
6 months to 2 years breastfeeding
and complementary feeding
6 items 10 items14 items
(China)14 items
(International)24 items
(China)24 items
(International)
Total cost(0.1 billion) 7.13 9.77 395.52 1141.56 493.17 1239.21
Effect(2020)
Maternal mortality
(per 100,000 maternal
population)17.62 15.9 15.81 15.81 14.61 14.61
Newborn mortality(‰) 5.86 5.83 5.73 5.73 5.39 5.39
Infant mortality(‰) 6.89 6.86 6.64 6.64 6.28 6.28
Under-5 mortality(‰) 9.48 9.44 8.87 8.87 8.47 8.47
2015-2020 Cost and effectiveness estimation for difference intervention packages, if
pneumococcal vaccine price at International lowest market price
3.6 Scenario Analysis
Conclusions
• Many more child deaths can be averted at a cost that China can afford
• Out of pocket expenditure (OOP) for child health (for both prevention and
care) can be reduced significantly
• Three key internationally recommended interventions (low osmolarity oral
rehydration salts (LOORS), pneumococcal conjugate vaccine (PCV) and
Haemophilus influenza type b (Hib)) are vastly overpriced in China
compared to international market prices:
• 1 sachet ORS China USD 4 vs UNICEF USD 0.05 [80x]
• 1 dose PCV China USD 125 vs UNICEF/GAVI USD 3.54 [35x]
• 1 dose Hib China USD 12.90-24.19 vs UNICEF/GAVI pentavalent
vaccine USD 1.19 [11-20x]
Preliminary Recommendations
Maximize impact and efficiency for child survival, while minimizing cost:
• Define a national essential package of child survival interventions, based on
maximizing # death averted and cost effectiveness ratios;
• Ensure nation-wide implementation of such an essential package;
• Pool finances from various sources to support nation-wide implementation;
• In the next five years, Ensure to include in the essential package for children, in
accordance with the priority sequence of the effectiveness and cost-effectiveness
– Tier 1: C-section on indication, newborn resuscitation, newborn sepsis
management, pneumonia management with antibiotics, exclusive breastfeeding,
Kangaroo Mother Care
– Tier 2: management of abortion complications, prevention of post partum
haemorrrhage, newborn sepsis management (with injectable antibiotics),
continued breastfeeding with appropriate complementary feeding
– Tier 3: diarrhoea management with ORS, pneumococcal vaccine, Hib vaccine,
maternal micronutrient supplementation “YYB” (Fe, Fo, Ca, etc)
Thank you!