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Choosing services
Integrating Concerns for Cost-Effectiveness,
Financial Protection, and the Worse Off
Ole F. Norheim
Professor in Medical Ethics and Philosophy of Science
Dept. of Global Public Health and Primary Care
University of Bergen
[email protected]
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
Key
services
1. High-priority services
2. Normal-priority services
3. Low-priority 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 WHOCHOICE 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)
Incremental cost-effectiveness for 65 selected interventions
0
2
4
6
8
10
12
14
16
DALYs/1000 $
DALYs/1000 $
0.0
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, breathtesting
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps,
treatment
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
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
market
service 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 costeffectiveness ratios.
DALYs/1000 $
0.0
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, breathtesting
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps,
treatment
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Two problems with CEA
• Ignores financial risk protection
• Ignores distribution of healthy life years
Who are worst off without the health service?
Healthy lifeyears without service
Condition A
Condition B
60
25
Additional healthy life years with service
20
20
Integrating distributive concerns with CEA
• An “Atkinson’s” social welfare
function applied to health
would judge:
Healthy lifeyears without service
Additional healthy life years with service
– (60, 45) as better than (80, 25)
Condition A
60
(Adler, OUP 2012)
Condition B
• Health prioritarianism would
assign higher weights to
benefits for B
(Ottersen, JME 2013)
25
20
20
Individual disease burden
(Source: Calculated from GBD 2010, Eastern sub-Saharan Africa)
0
Sepsis of the newborn baby
Rotaviral enteritis
Malaria
Maternal sepsis
Obstructed labor
HIV
Road injury
Tuberculosis
Schizophrenia
Livercirrhosis secondary to…
Cervical cancer
Chronic obstructive pulmonary…
Colon and rectum cancers
Diabetes mellitus
Hypertensive heart disease
10
20
30
40
50
60
70
80
Years of life lost
90
100
Individual disease burden
(Source: Calculated from GBD 2010, Eastern sub-Saharan Africa)
0
10
20
30
40
50
60
70
Sepsis of the newborn baby
Rotaviral enteritis
Malaria
Maternal sepsis
Obstructed labor
HIV
Road injury
Tuberculosis
Schizophrenia
Livercirrhosis secondary to…
Cervical cancer
Chronic obstructive pulmonary…
Colon and rectum cancers
Diabetes mellitus
Hypertensive heart disease
1
1.5
2
80
Years of life lost
90
100
Incremental cost-effectiveness for 65 selected interventions
0
2
4
6
8
10
12
14
16
18
DALYs/1000 $
Distribution-weighted cost-effectiveness
for 65 selected interventions
0
2
4
6
8
10
12
14
16
18
DALYs/1000 $
Priority-weighted
DALYs/1000 $
DALYs/1000 $
0.0
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, breathtesting
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps,
treatment
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
Distribution-weighted DALYs/1000 $
0.0
2.0
4.0
6.0
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, breathtesting
Breast cancer treatment all stages
Colonoscopy at age 50, surgical removal of polyps,
treatment
DALYs/1000$
Distribution-weighted DALYs/1000$
8.0
10.0
12.0
14.0
16.0
18.0
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
Ex ante / ex post prioritarianism
• Distributive weights based on final – not expected
– individual disease burden for various conditions
0
20
40
60
80
100
Years of life lost
Imagine you can help group A or B – who would you help?
Persons
1
1
Group A
Expected burden
60
1
1
18
Group B
6
Imagine you can help group A or B – who would you help?
Persons
1
1
Group A
Expected burden
60
1
1
18
Group B
Actual burden
60
60
60
60
0
6
Persons
1
1
Group C
Expected burden
6
1
1
18
Group D
6
Actual burden
Persons
1
1
Group C
Expected burden
6
1
1
18
Group D
Actual burden
6
6
60
60
0
6
Ex post: Even if we only know the outcome, but not who will
be affected, we can evaluate alternative outcomes