RESUMO
The term 'perspective' in the context of economic evaluations and costing studies in healthcare refers to the viewpoint that an analyst has adopted to define the types of costs and outcomes to consider in their studies. However, there are currently notable variations in terms of methodological recommendations, definitions, and applications of different perspectives, depending on the objective or intended user of the study. This can make it a complex area for stakeholders when interpreting these studies. Consequently, there is a need for a comprehensive overview regarding the different types of perspectives employed in such analyses, along with the corresponding implications of their use. This is particularly important, in the context of low-and-middle-income countries (LMICs), where practical guidelines may be less well-established and infrastructure for conducting economic evaluations may be more limited. This article addresses this gap by summarising the main types of perspectives commonly found in the literature to a broad audience (namely the patient, payer, health care providers, healthcare sector, health system, and societal perspectives), providing their most established definitions and outlining the corresponding implications of their uses in health economic studies, with examples particularly from LMIC settings. We then discuss important considerations when selecting the perspective and present key arguments to consider when deciding whether the societal perspective should be used. We conclude that there is no one-size-fits-all answer to what perspective should be used and the perspective chosen will be influenced by the context, policymakers'/stakeholders' viewpoints, resource/data availability, and intended use of the analysis. Moving forward, considering the ongoing issues regarding the variation in terminology and practice in this area, we urge that more standardised definitions of the different perspectives and the boundaries between them are further developed to support future studies and guidelines, as well as to improve the interpretation and comparison of health economic evidence.
RESUMO
Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes-a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators.
Assuntos
Setor Público , Neoplasias do Colo do Útero , Criança , Detecção Precoce de Câncer , Feminino , Humanos , Gravidez , Atenção Primária à Saúde , África do SulRESUMO
Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.
Assuntos
Doenças não Transmissíveis/economia , Doenças não Transmissíveis/prevenção & controle , Países Desenvolvidos/economia , Países em Desenvolvimento/economia , Feminino , Educação em Saúde , Humanos , Masculino , Pobreza , Fatores SocioeconômicosRESUMO
Governments can use fiscal policies to regulate the prices and consumption of potentially unhealthy products. However, policies aimed at reducing consumption by increasing prices, for example by taxation, might impose an unfair financial burden on low-income households. We used data from household expenditure surveys to estimate patterns of expenditure on potentially unhealthy products by socioeconomic status, with a primary focus on low-income and middle-income countries. Price policies affect the consumption and expenditure of a larger number of high-income households than low-income households, and any resulting price increases tend to be financed disproportionately by high-income households. As a share of all household consumption, however, price increases are often a larger financial burden for low-income households than for high-income households, most consistently in the case of tobacco, depending on how much consumption decreases in response to increased prices. Large health benefits often accrue to individual low-income consumers because of their strong response to price changes. The potentially larger financial burden on low-income households created by taxation could be mitigated by a pro-poor use of the generated tax revenues.
Assuntos
Política de Saúde/economia , Promoção da Saúde/economia , Produtos do Tabaco/economia , Financiamento Pessoal , Comportamentos Relacionados com a Saúde , Humanos , Fatores Socioeconômicos , Impostos/economiaRESUMO
Objective: To evaluate a project that integrated essential primary health-care services into the oral polio vaccine programme in hard-to-reach, underserved communities in northern Nigeria. Methods: In 2013, Nigeria's polio emergency operation centre adopted a new approach to rapidly raise polio immunity and reduce newborn, child and maternal morbidity and mortality. We identified, trained and equipped eighty-four mobile health teams to provide free vaccination and primary-care services in 3176 hard-to-reach settlements. We conducted cross-sectional surveys of women of childbearing age in households with children younger than 5 years, in 317 randomly selected settlements, pre- and post-intervention (March 2014 and November 2015, respectively). Findings: From June 2014 to September 2015 mobile health teams delivered 2 979 408 doses of oral polio vaccine and dewormed 1 562 640 children younger than 5 years old; performed 676 678 antenatal consultations and treated 1 682 671 illnesses in women and children, including pneumonia, diarrhoea and malaria. The baseline survey found that 758 (19.6%) of 3872 children younger than 5 years had routine immunization cards and 690/3872 (17.8%) were fully immunized for their age. The endline survey found 1757/3575 children (49.1%) with routine immunization cards and 1750 (49.0%) fully immunized. Children vaccinated with 3 or more doses of oral polio vaccine increased from 2133 (55.1%) to 2666 (74.6%). Households' use of mobile health services in the previous 6 months increased from 509/1472 (34.6%) to 2060/2426(84.9%). Conclusion: Integrating routine primary-care services into polio eradication activities in Nigeria resulted in increased coverage for supplemental oral polio vaccine doses and essential maternal, newborn and child health interventions.
Assuntos
Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Programas de Imunização/métodos , Poliomielite/prevenção & controle , Vacina Antipólio Oral/administração & dosagem , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Adolescente , Adulto , Pré-Escolar , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Imunização/estatística & dados numéricos , Lactente , Recém-Nascido , Entrevistas como Assunto , Pessoa de Meia-Idade , Unidades Móveis de Saúde , Nigéria , Poliomielite/psicologia , Distribuição Aleatória , Pesquisa , Adulto JovemRESUMO
OBJECTIVE: Recent years have witnessed an increased interest in the use of multicriteria decision analysis (MCDA) to support health technology assessment (HTA) agencies for setting healthcare priorities. However, its implementation to date has been criticized for being "entirely mechanistic," ignoring opportunity costs, and not following best practice guidelines. This article provides guidance on the use of MCDA in this context. METHODS: The present study was based on a systematic review and consensus development. We developed a typology of MCDA studies and good implementation practice. We reviewed 36 studies over the period 1990 to 2018 on their compliance with good practice and developed recommendations. We reached consensus among authors over the course of several review rounds. RESULTS: We identified 3 MCDA study types: qualitative MCDA, quantitative MCDA, and MCDA with decision rules. The types perform differently in terms of quality, consistency, and transparency of recommendations on healthcare priorities. We advise HTA agencies to always include a deliberative component. Agencies should, at a minimum, undertake qualitative MCDA. The use of quantitative MCDA has additional benefits but also poses design challenges. MCDA with decision rules, used by HTA agencies in The Netherlands and the United Kingdom and typically referred to as structured deliberation, has the potential to further improve the formulation of recommendations but has not yet been subjected to broad experimentation and evaluation. CONCLUSION: MCDA holds large potential to support HTA agencies in setting healthcare priorities, but its implementation needs to be improved.
Assuntos
Tomada de Decisões , Avaliação da Tecnologia Biomédica/organização & administração , Técnicas de Apoio para a Decisão , Humanos , Avaliação das Necessidades , Anos de Vida Ajustados por Qualidade de Vida , Projetos de Pesquisa , Índice de Gravidade de Doença , Avaliação da Tecnologia Biomédica/normasRESUMO
When facing adverse health from noncommunicable disease (NCD), households adopt coping strategies that may further enforce poverty traps. This study looks at coping after an adult NCD death in rural Bangladesh. Compared with similar households without NCD deaths, households with NCD deaths were more likely to reduce basic expenditure and to have decreased social safety net transfers. Household composition changes showed that there was demographic coping for prime age deaths through the addition of more women. The evidence for coping responses from NCDs in low- and middle-income countries may inform policy options such as social protection to address health-related impoverishment.
Assuntos
Adaptação Psicológica , Família/psicologia , Doenças não Transmissíveis/mortalidade , Adolescente , Adulto , Países em Desenvolvimento , Características da Família , Feminino , Financiamento Pessoal , Gastos em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Doenças não Transmissíveis/economia , Doenças não Transmissíveis/psicologia , População Rural , Fatores Socioeconômicos , Adulto JovemRESUMO
BACKGROUND: In October 2014, Chile implemented a tax modification on sugar-sweetened beverages (SSBs) called the Impuesto Adicional a las Bebidas Analcohólicas (IABA). The design of the tax was unique, increasing the tax on soft drinks above 6.25 grams of added sugar per 100 mL and decreasing the tax for those below this threshold. METHODS AND FINDINGS: This study evaluates Chile's SSB tax, which was announced in March 2014 and implemented in October 2014. We used household-level grocery-purchasing data from 2011 to 2015 for 2,836 households living in cities representative of the urban population of Chile. We employed a fixed-effects econometric approach and estimated the before-after change in purchasing of SSBs controlling for seasonality, general time trend, temperature, and economic fluctuations as well as time-invariant household characteristics. Results showed significant changes in purchasing for the statistically preferred model: while there was a barely significant decrease in the volume of all soft drinks, there was a highly significant decrease in the monthly purchased volume of the higher-taxed, sugary soft drinks by 21.6%. The direction of this reduction was robust to different empirical modelling approaches, but the statistical significance and the magnitude of the changes varied considerably. The reduction in soft drink purchasing was most evident amongst higher socioeconomic groups and higher pretax purchasers of sugary soft drinks. There was no systematic, robust pattern in the estimates by household obesity status. After tax implementation, the purchase prices of soft drinks decreased for the items for which the tax rate was reduced, but they remained unchanged for sugary items, for which the tax was increased. However, the purchase prices increased for sugary soft drinks at the time of the policy announcement. The main limitations include a lack of a randomised design, limiting the extent of causal inference possible, and the focus on purchasing data rather than consumption or health outcomes. CONCLUSIONS: The results of subgroup analyses suggest that the policy may have been partially effective, though not necessarily in ways that are likely to reduce socioeconomic inequalities in diet-related health. It remains unclear whether the policy has had a major, overall population-level impact. Additionally, because the present study examined purchasing of soft drinks for only 1 year, a longer-term evaluation-ideally including an assessment of consumption and health impacts-should be conducted in future research. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02926001.
Assuntos
Bebidas/economia , Comércio/economia , Comportamento do Consumidor/economia , Açúcares da Dieta/economia , Impostos/economia , População Urbana , Adulto , Bebidas/efeitos adversos , Chile , Comportamento de Escolha , Comércio/legislação & jurisprudência , Comércio/tendências , Açúcares da Dieta/administração & dosagem , Açúcares da Dieta/efeitos adversos , Comportamento Alimentar , Feminino , Regulamentação Governamental , Humanos , Masculino , Pessoa de Meia-Idade , Política Nutricional , Formulação de Políticas , Impostos/legislação & jurisprudência , Impostos/tendências , Fatores de Tempo , População Urbana/tendênciasRESUMO
BACKGROUND: Cost-effectiveness analysis (CEA) is frequently used as an input for guiding priority setting in health. However, CEA seldom incorporates information about trade-offs between total health gains and equity impacts of interventions. This study investigates to what extent equity considerations have been taken into account in CEA in low- and middle-income countries (LMICs), using rotavirus vaccination as a case study. METHODS: Specific equity-related indicators for vaccination were first mapped to the Guidance on Priority Setting in Health Care (GPS-Health) checklist criteria. Economic evaluations of rotavirus vaccine in LMICs identified via a systematic review of the literature were assessed to explore the extent to which equity was considered in the research objectives and analysis, and whether it was reflected in the evaluation results. RESULTS: The mapping process resulted in 18 unique indicators. Under the 'disease and intervention' criteria, severity of illness was incorporated in 75% of the articles, age distribution of the disease in 70%, and presence of comorbidities in 5%. For the 'social groups' criteria, relative coverage reflecting wealth-based coverage inequality was taken into account in 30% of the articles, geographic location in 27%, household income level in 8%, and sex at birth in 5%. For the criteria of 'protection against the financial and social effects of ill health', age weighting was incorporated in 43% of the articles, societal perspective in 58%, caregiver's loss of productivity in 45%, and financial risk protection in 5%. Overall, some articles incorporated the indicators in their model inputs (20%) while the majority (80%) presented results (costs, health outcomes, or incremental cost-effectiveness ratios) differentiated according to the indicators. Critically, less than a fifth (17%) of articles incorporating indicators did so due to an explicit study objective related to capturing equity considerations. Most indicators were increasingly incorporated over time, with a notable exception of age-weighting of DALYs. CONCLUSION: Integrating equity criteria in CEA can help policy-makers better understand the distributional impact of health interventions. This study illustrates how equity considerations are currently being incorporated within CEA of rotavirus vaccination and highlights the components of equity that have been used in studies in LMICs. Areas for further improvement are identified.
RESUMO
BACKGROUND: Rapidly increasing healthcare costs and the growing burden of non-communicable diseases have increased the out-of-pocket (OOP) spending (63.3% of total health expenditure) in Bangladesh. This increasing OOP spending for healthcare has catastrophic economic impact on households. To reduce this burden, the Health Economics Unit (HEU) of the Ministry of Health and Family Welfare has developed the Shasthyo Surokhsha Karmasuchi (SSK) health protection scheme for the below-poverty line (BPL) population. The key actors in the scheme are HEU, contracted scheme operator and hospital. Under this scheme, each enrolled household is provided 50,000 BDT (620 USD) coverage per year for healthcare services against a government financed premium of 1000 BDT (12 USD). This initiative faces some challenges e.g., delays in scheme activities, registering the targeted population, low utilization of services, lack of motivation of the providers, and management related difficulties. It is also important to estimate the financial requirement for nationwide scale-up of this project. We aim to identify these implementation-related challenges and provide feedback to the project personnel. METHODS: This is a concurrent process documentation using mixed-method approaches. It will be conducted in the rural Kalihati Upazila where the SSK is being implemented. To validate the BPL population selection process, we will estimate the positive predictive value. A community survey will be conducted to assess the knowledge of the card holders about SSK services. From the SSK information management system, numbers of different services utilized by the card holders will be retrieved. Key-informant interviews with personnel from three key actors will be conducted to understand the barriers in the implementation of the project as per plan and gather their suggestions. To estimate the project costs, all inputs to be used will be identified, quantified and valued. The nationwide scale-up cost of the project will be estimated by applying economic modeling. DISCUSSION: SSK is the first ever government initiated health protection scheme in Bangladesh. The study findings will enable decision makers to gain a better understanding of the key challenges in implementation of such scheme and provide feedback towards the successful implementation of the program.
Assuntos
Atenção à Saúde/economia , Gastos em Saúde/estatística & dados numéricos , Bangladesh , Características da Família , Financiamento Governamental , Programas Governamentais/economia , Serviços de Saúde/economia , Hospitais/estatística & dados numéricos , Humanos , Pobreza/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Inquéritos e Questionários , Cobertura Universal do Seguro de Saúde/economiaRESUMO
OBJECTIVE: To estimate the economic impact likely to be achieved by efforts to vaccinate against 10 vaccine-preventable diseases between 2001 and 2020 in 73 low- and middle-income countries largely supported by Gavi, the Vaccine Alliance. METHODS: We used health impact models to estimate the economic impact of achieving forecasted coverages for vaccination against Haemophilus influenzae type b, hepatitis B, human papillomavirus, Japanese encephalitis, measles, Neisseria meningitidis serogroup A, rotavirus, rubella, Streptococcus pneumoniae and yellow fever. In comparison with no vaccination, we modelled the costs - expressed in 2010 United States dollars (US$) - of averted treatment, transportation costs, productivity losses of caregivers and productivity losses due to disability and death. We used the value-of-a-life-year method to estimate the broader economic and social value of living longer, in better health, as a result of immunization. FINDINGS: We estimated that, in the 73 countries, vaccinations given between 2001 and 2020 will avert over 20 million deaths and save US$ 350 billion in cost of illness. The deaths and disability prevented by vaccinations given during the two decades will result in estimated lifelong productivity gains totalling US$ 330 billion and US$ 9 billion, respectively. Over the lifetimes of the vaccinated cohorts, the same vaccinations will save an estimated US$ 5 billion in treatment costs. The broader economic and social value of these vaccinations is estimated at US$ 820 billion. CONCLUSION: By preventing significant costs and potentially increasing economic productivity among some of the world's poorest countries, the impact of immunization goes well beyond health.
Assuntos
Controle de Doenças Transmissíveis/economia , Controle de Doenças Transmissíveis/métodos , Doenças Transmissíveis/economia , Efeitos Psicossociais da Doença , Programas de Imunização/economia , Vacinação/economia , Doenças Transmissíveis/microbiologia , Doenças Transmissíveis/mortalidade , Análise Custo-Benefício , Países em Desenvolvimento , Saúde Global , Humanos , Método de Monte Carlo , Anos de Vida Ajustados por Qualidade de Vida , Vacinas/economiaRESUMO
This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.
Assuntos
Análise Custo-Benefício/métodos , Equidade em Saúde , Humanos , Formulação de Políticas , Avaliação da Tecnologia BiomédicaRESUMO
PURPOSE OF REVIEW: We highlight recent advances relevant to understanding norovirus infections in the tropics, both in populations living in developing settings and travelers to these regions. RECENT FINDINGS: Because of the decrease in diarrheal disease associated with the global rollout of vaccines against rotavirus, norovirus is emerging as the predominant cause of diarrhea morbidity among children in the tropics, and evidence suggests that it contributes to adult disease in endemic populations and travelers. In addition to identifying potential target populations for preventive measures, we provide an update on norovirus vaccine development and concepts related to their implementation in low-income and middle-income countries. SUMMARY: These current concepts related to norovirus-attributable disease burden, clinical significance, and economic impact can potentially be applied to tailoring efforts to prevent and mitigate the effects of this important enteropathogen.
Assuntos
Infecções por Caliciviridae , Gastroenterite , Norovirus , Viagem , Diarreia , Humanos , Vacinas ViraisRESUMO
BACKGROUND: Diabetes mellitus is a public health challenge worldwide, and roughly 25% of patients with diabetes in developing countries will develop at least one foot ulcer during their lifetime. The gravest outcome of an ulcerated foot is amputation, leading to premature death and larger economic costs. METHODS: This study aimed to estimate the economic costs of diabetic foot in high-risk patients in Peru in 2012 and to model the cost-effectiveness of a year-long preventive strategy for foot ulceration including: sub-optimal care (baseline), standard care as recommended by the International Diabetes Federation, and standard care plus daily self-monitoring of foot temperature. A decision tree model using a population prevalence-based approach was used to calculate the costs and the incremental cost-effectiveness ratio (ICER). Outcome measures were deaths and major amputations, uncertainty was tested with a one-way sensitivity analysis. RESULTS: The direct costs for prevention and management with sub-optimal care for high-risk diabetics is around US$74.5 million dollars in a single year, which decreases to US$71.8 million for standard care and increases to US$96.8 million for standard care plus temperature monitoring. The implementation of a standard care strategy would avert 791 deaths and is cost-saving in comparison to sub-optimal care. For standard care plus temperature monitoring compared to sub-optimal care the ICER rises to US$16,124 per death averted and averts 1,385 deaths. CONCLUSION: Diabetic foot complications are highly costly and largely preventable in Peru. The implementation of a standard care strategy would lead to net savings and avert deaths over a one-year period. More intensive prevention strategies such as incorporating temperature monitoring may also be cost-effective.
Assuntos
Efeitos Psicossociais da Doença , Diabetes Mellitus Tipo 2/economia , Pé Diabético/economia , Adolescente , Adulto , Idoso , Assistência Ambulatorial/economia , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/prevenção & controle , Pé Diabético/prevenção & controle , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peru , Prevenção Secundária/economia , Resultado do Tratamento , Adulto JovemRESUMO
INTRODUCTION: Service inclusion in a country's health benefit package (HBP) is an important milestone towards universal health coverage. This study aimed to explore HBP inclusion of abortion interventions globally. METHODS: Secondary analysis of the WHO HBP survey, in which officially nominated survey focal points were asked which interventions were included within the HBP of their country or area's largest government health financing scheme. Abortion inclusion was compared by region, income, legal status of abortion and HBP design process variables. Abortion inclusion was compared with other sexual and reproductive health (SRH) services. RESULTS: Below half (45%) reported that abortion is included, but treatment of complications from unsafe abortion was more commonly included (63%). Fewer fully included essential abortion medications (22% mifepristone, 42% misoprostol). Abortion was less commonly included than any other SRH service in the survey. Unlike most SRH services, higher cost, higher technology care to treat complications of unsafe abortion was more commonly included than the relatively lower cost, lower technology service of induced abortion. Higher-income contexts and less restrictive legal environments had higher abortion inclusion. Some contexts had additional restrictions, with abortion inclusion dependent on the patient's reason for seeking care. CONCLUSION: This global survey finds that abortion services and medications are often not included within HBPs, while treatment of complications from unsafe abortion is more commonly included. There are opportunities to improve HBP abortion inclusion across different legal contexts, which can improve health outcomes and reduce the need for higher cost treatment of complications from unsafe abortion.
Assuntos
Aborto Induzido , Medicamentos Essenciais , Feminino , Gravidez , Humanos , Inquéritos Epidemiológicos , Financiamento Governamental , Organização Mundial da SaúdeRESUMO
BACKGROUND: Worldwide, there is a need for formalization of the priority setting processes in health. Recent research has used the term multicriteria decision analysis for methods that systematically include preferences for both equity and efficiency. The present study compares decision-makers' preferences at the country level for a set of equity and efficiency criteria according to a multicriteria decision analysis framework. METHODS: Discrete choice experiments were conducted for Brazil, Cuba, Nepal, Norway, and Uganda. By using standardized methods, we elicited preferences for intervention attributes using a individual choice questionnaire. A multinomial logistic regression was applied to estimate the coefficients for all single-policy criteria, per country. Attributes were assigned to an equity group or to an efficiency group. After testing for scale variance, predicted probabilities for interventions with both types of attributes were compared across countries. RESULTS: The Norway and Nepal groups showed considerable preferences for efficiency criteria over equity criteria with percent change in respective predicted sum probabilities of [10%, -84%] and [6%, -79%]. Brazil and Uganda also showed preference for the efficiency criteria though less convincingly ([-34%, -93%], [-18%, -63%], respectively). The Cuban group showed the strongest preferences with equity attributes dominating efficiency ([-52%, 213%]). CONCLUSIONS: Group preferences of policymakers show explicit but varying trade-offs of efficiency and equity in these diverse settings. This multicriteria decision analysis approach, using discrete choice experiments, indicates that systematic setting of health priorities is possible across a variety of countries. It may be a valuable tool to guide health reform initiatives.
Assuntos
Pessoal Administrativo , Comportamento de Escolha , Atenção à Saúde/normas , Eficiência Organizacional , Política de Saúde , Disparidades em Assistência à Saúde , Formulação de Políticas , Brasil , Cuba , Humanos , Modelos Logísticos , Nepal , Noruega , Inquéritos e Questionários , UgandaRESUMO
BACKGROUND: Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. METHODS: In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. RESULTS: The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. CONCLUSIONS: Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
Assuntos
Doenças Cardiovasculares , Técnicas de Apoio para a Decisão , Alocação de Recursos para a Atenção à Saúde/normas , Prioridades em Saúde/normas , Doenças Respiratórias , Fatores Etários , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/prevenção & controle , Doenças Cardiovasculares/terapia , Comportamento de Escolha , Análise Custo-Benefício , Tomada de Decisões , Alocação de Recursos para a Atenção à Saúde/economia , Alocação de Recursos para a Atenção à Saúde/legislação & jurisprudência , Política de Saúde/legislação & jurisprudência , Prioridades em Saúde/economia , Prioridades em Saúde/legislação & jurisprudência , Humanos , Modelos Logísticos , Avaliação das Necessidades , Noruega , Formulação de Políticas , Anos de Vida Ajustados por Qualidade de Vida , Doenças Respiratórias/diagnóstico , Doenças Respiratórias/prevenção & controle , Doenças Respiratórias/terapia , Índice de Gravidade de DoençaRESUMO
Internal armed conflicts have become more common and more physically destructive since the mid-20th century, with devastating consequences for health and development in low- and middle-income countries. This paper investigates the causal impacts of the long-term internal conflict on child health in Colombia, following an identification strategy based on the temporal and geographic variation of conflict intensity. We estimate the effect of different levels of conflict intensity on height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height z-scores among children under five years old, and explore the underlying potential mechanisms, through maternal health behavior and health care utilization. We find a harmful effect of exposure to conflict violence in utero and in early childhood for HAZ and WAZ, in the full sample and even more strongly in the rural sample, yet these estimates are smaller than those found for shorter term conflicts. The underlying pathways appear to operate around the time of the pregnancy and birth (in the form of maternal alcohol use, use of antenatal care and skilled birth attendance), rather than during the post-birth period (via breastfeeding or vaccination), and the impacts accumulate over the childhood. The most adverse impacts of conflict violence on child health and utilization of maternal healthcare were observed in municipalities which suffered from intermittent presence of armed groups.
Assuntos
Conflitos Armados , Saúde da Criança , Aleitamento Materno , Criança , Pré-Escolar , Colômbia/epidemiologia , Feminino , Humanos , Gravidez , Cuidado Pré-NatalRESUMO
BACKGROUND: The marginal productivity of a country's healthcare system refers to the health gains produced per unit change in the level of spending. In budget-constrained settings, this metric reflects the opportunity cost, in terms of health gains forgone, of committing additional or existing resources to alternative uses within the healthcare system. It can therefore assist in evidence-based decisions on whether different interventions represent good value for money. OBJECTIVE: The aim of this paper was to estimate the marginal productivity of the Indonesian healthcare system using subnational data, and to use this to inform health opportunity costs in the country. METHODS: We define a dynamic health production function to model the stream of effects of current and prior public health spending decisions on population under-five mortality. To estimate the model, we use data from the 33 Indonesian provinces for the 2004-2012 period. The estimated elasticity is then translated into gains in terms of cost per DALY (disability-adjusted life-year) averted. We use dynamic panel data methods to address potential endogeneity issues in the model. RESULTS: Our base-case estimates suggest that a 1% expansion in the level of health spending reduces under-five mortality by 0.38% (95% CI 0.00-0.76), which translates into a cost of averting one DALY of $235 (2019 US$). CONCLUSION: With Indonesia aiming for universal health coverage, our results support these efforts by highlighting the associated benefits resulting from increases in public health expenditure and have the potential to inform the decision-making process about a suitable locally relevant cost-effectiveness threshold.
Assuntos
Atenção à Saúde , Gastos em Saúde , Humanos , Anos de Vida Ajustados por Qualidade de Vida , Indonésia , Análise Custo-BenefícioRESUMO
OBJECTIVES: The implementation of COVID-19 vaccination globally poses unprecedented stress to health systems particularly for countries with persisting health workforce shortages prior the pandemic. The present paper estimates the workforce requirement to reach 70% COVID-19 vaccination coverage in all countries by mid-2022 using service target-based estimation. METHODS: Health workforce data from National Health Workforce Accounts and vaccination coverage reported to WHO as of January 2022 were used. Workload parameters were used to estimate the number of health workers needed with a service target-based approach, the gap and the scale-up required partially accounting for countries' challenges, as well as the associated costs in human resources. RESULTS: As of 1 January 2022, only 34 countries achieved 70% COVID-19 vaccination coverage and 61 countries covered less than a quarter of their population. This analysis showed that 1 831 000 health workers working full time would be needed to reach a global coverage of 70% COVID-19 vaccination by mid-2022. To avoid severe disruptions to health system, 744 000 additional health workers should be added to domestic resources mostly (77%) in low-income countries. In a sensitivity analysis, allowing for vaccination over 12 months instead of 6 months would decrease the scale-up to 476 000 health workers. The costing for the employment of these 744 000 additional health workers is estimated to be US$2.5 billion. In addition to such a massive scale-up, it is estimated that 29 countries would have needed to redeploy more than 20% of their domestic workforce, placing them at serious risk of not achieving the mid-year target. CONCLUSION: Reaching 70% global coverage with COVID-19 vaccination by mid-2022 requires extraordinary efforts not before witnessed in the history of immunisation programmes. COVID-19 vaccination programmes should receive rapid and sustainable investment in health workforce.