Retooling cost-effectiveness analysis for global health relevance

Retooling cost-effectiveness analysis for global health relevance

Joshua A Salomon

Harvard School of Public Health

Global Health Metrics and Evaluation Conference

June 17, 2013

Salomon – Cost-effectiveness - 2

An observation

• Hundreds of cost-effectiveness analyses are published each year

• Relatively few examples of these analyses being used in formulation or modification of policies in global health

Source: Tufts CEA Registry

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June 2011


Secretary Clinton, November 8, 2011:“…our efforts have helped set the stage for a historic opportunity, one that the world has today: to change the course of this pandemic and usher in an AIDS-free generation.”

President Obama, December 1, 2011:“…Today, we come together as a global community … to renew our commitment to ending the AIDS pandemic once and for all.”

Global Fund for world health halts new programsBy JOHN HEILPRIN, Associated Press – Nov 24, 2011

GENEVA (AP) — The world's biggest financier in the fight against three killer diseases says it has run out of money to pay for new grant programs for the next two years — a situation likely to hit poor AIDS patients around the world.

November - December 2011


HPTN 052: Preventing transmission with early ART

Cohen et al. NEJM, July 2011


Treatment as prevention: ‘breakthrough of the year’

Science, December 2011


Fifteen years earlier…

WHO Press Release, March 1997


March 1997


Boehme et al. NEJM, September 2010 Small & Pai NEJM, September 2010

Game change for TB diagnosis? (September 2010)


Sputum smear microscopy Xpert MTB/RIF


Xpert MTB/RIF• Automated, cartridge-based PCR• Simplified procedures, rapid turn-

around (<2 hours)• Specificity: 98%• Sensitivity: 92% (sm+), 73% (sm–)

• WHO, Dec 2010: “the foundation for a revolution in the diagnosis of TB and drug-resistant TB”

• Vassall et al. 2011 (PLoS Med): Xpert appears highly cost-effective in South Africa

Game changer?


An observation

• Hundreds of cost-effectiveness analyses are published each year

• Relatively few examples of these analyses being used in formulation or modification of policies in global health

Why?Source: Tufts CEA Registry

19901992

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20062008

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An agenda for cost-effectiveness analysis in global health

Intervention $ / DALY averted

Condoms + treatment of STI for sex workers

1

Blood safety 1 – 43

Peer education for sex workers

4 – 7

Voluntary counseling and testing

18 – 22

Prevention of mother-to-child transmission

1 – 730

Treatment of other STIs 12

Antiretroviral therapy 1,000 – 2,000

Source: Creese et al. Lancet 2002

Example: Estimated cost-effectiveness of HIV/AIDS interventions in Africa

• Published evidence on cost-effectiveness often seems too good to be true

• Agenda item #1: More ex-post analysis of cost-effectiveness

• Not only impact but also efficiency should be submitted to rigorous evaluation in real-world programs


• CEA often fails to focus on actionable decisions in real-world contexts

• Need information on cost-effectiveness of strategies, which are more than just technologies.

Strategy = technology + specific implementation plan





Granich et al. Lancet 2009Granich et al. PLoS ONE 2012

Costs for different ART eligibility scenarios, compared to status quo


Source: Menzies et al. (in preparation)



20122014

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Projected TB mortality in Kenya

Reductions in mortality if Xpert is implemented:

• Where culture is available• Where only smear is

available• Where neither smear and

culture currently reach

Example: Xpert test for TB being adopted rapidly based on strong evidence of effectiveness and preliminary analysis of CE


Source: Menzies et al. 2012


• Agenda item #2: Emphasize analysis of adoptable strategies through a health systems lens, with explicit and credible accounting for all relevant costs, outcomes and constraints relevant to a specific implemen-tation approach


Example: Xpert test for TB being adopted rapidly based on strong evidence of effectiveness and preliminary analysis of CE

…but most CE analyses to date have ignored the single biggest associated cost because it is not borne by the TB program


Source: Salomon et al, PLoS Med 2006

Example: New, shorter TB drug regimens could avert millions of TB deaths

Decision analysis may be missing key opportunities to address problems most amenable to the approach

e.g. investment choices on R&D toward new health technologies


TB

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mil

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Example: New, shorter TB drug regimens could avert millions of TB deaths…but delay in investment has been costly




TB

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mil

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Example: New, shorter TB drug regimens could avert millions of TB deaths…but delay in investment has been costly…and further delay will continue to erode potential benefits



• Agenda item #3: Define a “global health technology portfolio” by assessing potential health returns on R&D investments


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Summary and final thoughts

• In the US, resistance to cost-effectiveness analysis in healthcare is strong

• In resource-poor countries, the need is greater, and resistance may be weaker

• To be truly useful for global health policy, we need to re-evaluate the way we go about decision analysis: Establish more credible evidence based on ex post evaluation Move from identifying what can work under optimal

circumstances to evaluating how we can maximize delivery of promising interventions within real-world systems

Take a long-term portfolio view on prioritizing investments in future health technologies

Health & Medicine

Retooling cost-effectiveness analysis for global health relevance