How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations.

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Coping with the impact of AIDS.

PIP: While some countries still have the chance to avert a major AIDS epidemic, others are already dealing with widespread HIV infection. All patients who have illnesses for which treatment does not affect transmission, regardless of cause, should be equally eligible for public assistance. Furthermore, governments should focus upon helping poor people equally, regardless of the cause of their poverty. The first and most basic impact of HIV/AIDS is upon those people who contract the disease. As AIDS cases begin to appear, governments should move quickly to ensure that health personnel and people with AIDS know how to obtain and use the necessary drugs. However, due to their high cost, the most aggressive therapies against HIV infection and AIDS are currently unavailable and unfeasible for widespread use in developing countries . A generalized AIDS epidemic also taxes the health care system, increasing the demand for medical care and reducing the supply of care at a given quality and price. The third major impact of an AIDS epidemic is upon households and the extent and depth of national poverty. In addition to working to prevent the spread of HIV infection, governments can help ease the varied impacts of HIV/AIDS by prohibiting discrimination against HIV-infected people in health care settings and in the work force, and by strengthening anti-poverty policies.^ieng

Adult health: a legitimate concern for developing countries.

Adults, defined here as people between 15 and 59 years of age, in developing countries have a high risk of premature death and suffer from frequent morbidity and high rates of chronic impairment. Their ill health imposes a major burden on health services and large negative consequences on families, communities, and societies. This paper describes the level and impact of adult mortality and morbidity, and highlights some of its characteristics and causes, which in some cases contradict commonly held beliefs. It concludes that "adult health" is a legitimate public health concern for developing countries that is not being addressed. An agenda for remedial research and action is proposed.

[The economic effects of the AIDS epidemic in Sub-Saharan Africa: a general equilibrium analysis]. / Les effets economiques de l'epidemie du SIDA en Afrique subsaharienne: une analyse d'equilibre general.

PIP: The authors attempt to estimate the economic impact of the spread of AIDS and the subsequent rise in adult mortality on the countries of Sub-Saharan Africa. In particular, they consider the extent to which spending on AIDS-related problems will absorb a large and growing portion of national savings and thus impede capital formation. (SUMMARY IN ENG)^ieng

Guidelines for rapid estimation of the direct and indirect costs of HIV infection in a developing country.

The economic impact of AIDS may be especially severe in developing nations because of the additional burden on scarce health care resources and the potential loss of human capital. We describe a methodology for estimating the direct and indirect costs of HIV infection. Our approach is designed for the typical environment of international economic consulting, where time is short, and data sparse. We focus on HIV rather than AIDS because the only way now known to prevent AIDS is to prevent HIV infection.

PIP: Methodology centered upon determining the cost to society per HIV-infected person is provided for use in international economic consultancy where quick answers are needed from weak data. Leaving the epidemiologist to determine the total number of infected persons in the country of interest, this methodology determines the cost of society of the HIV-infected person expected to eventually develop AIDS, then sums the individual costs across the population to find overall costs to the country. Costs are identified and determined as either direct or indirect. Direct costs are the average costs per episode of treating all types of opportunistic illnesses encountered by an AIDS patient discounted to present value, then multiplied by the number of episodes. Indirect costs are regarded as the value of discounted life-years lost back to the moment of HIV infection. The use of weights to represent differences in subjective relative values and productivity is explored. The authors call for the use of discounted healthy-life-years, discounted, productivity-weighted healthy-life-years, and discounted, earnings-weighted health-life-years instead of quality-adjusted life-years as feasible tools for policymakers. The authors encourage more rigorous studies, and recognize their method as filling the niche for fast response studies.

AIDS: costs of care in the developed and the developing world.

PIP: The costs of care for AIDS patients in developed and developing countries, expressed in patient-years and in patient lifetimes, as well as by total national costs are analyzed here. In industrialized countries, known as WHO Pattern I countries, the costs of AIDS care is generally proportional to GNP, and has been declining as caregivers learn how to manage the disease. Much of the decline is due to less intensive hospital care and more ambulatory care. Although the U.S. has the highest number of AIDS cases, the countries with the highest rate of disease are Canada (59.2/million), Australia (48.1) and New Zealand (22.4). In the U.S. 92% of patients are male, and 87% are 20-49 years old. In Pattern II countries, the sex ratio is less than 2.0. Cost information is very sparse, especially for children. Some representative lifetime costs for Pattern I countries are $19,000-147,000 in the U.S., $21,000 in France, $40,200 in Germany, $13,400-46,000 in U.K., and $15,800 in Australia. Costs per person-year are generally comparable, depending on whether hospitalization is more or less common in given countries. In the developing world, expenditures are much lower, because of the limited budget for health care available. Although costs tend to be in line with a country's GNP, costs are expected to become more standardized in the future as clinical experience with AIDS treatment increases and costing methodology becomes more uniform. Estimates of AIDS treatment costs for the U.S. in the near future range widely, but range from 1% to 3.3% of the total personal health-care expenditures of the nation. An estimate for Australia predicts $58.5 million by 1991, including hospital expenses only. None of the available costs estimates even deal with the costs of managing HIV-infected persons who have not developed AIDS. Needs in cost estimation methodology are discussed.^ieng

The effect of scale on cost projections for a primary health care program in a developing country.

Accurate estimation of the recurrent costs of primary health care (PHC) activities is essential in light of the need for governments to assess whether and how these costs can be financed. This paper argues that expansion of the PHC activites will result in diseconomies of scale that are not captured by constant average cost projections of recurrent costs. An alternative estimation method which captures the effect of rising average unit costs is proposed with application of this method to data from the Republic of Niger. Results of the analysis show that the 'r-coefficient' (ratio of investment to recurrent costs) for PHC activities can double and costs can be 3 times larger after 12 years.