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Choosing services. The case for cost-effectiveness. Toby Ord Research Fellow, Oxford University President, Giving What We Can. Key services. Universal coverage is defined in terms of access to key services

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choosing services

Choosing services

The case for cost-effectiveness

Toby Ord

Research Fellow, Oxford University

President, Giving What We Can

key services
Key services
  • Universal coverage is defined in terms of access to key services
  • Countries moving towards universal coverage must therefore identify what services are key
  • Also need to prioritize among these key services when expanding the range of services accessible at an affordable cost
examples
Examples
  • Typically targets the whole population or the part which is least likely to obtain affordable access to a comprehensive package
  • Package of minimum, basic, or essential services or benefits
    • Ghana, Nigeria, Rwanda, Vietnam, Mexico
  • Typically emphasize:
    • Vaccination, child health, maternal care
cost effectiveness
Cost-effectiveness
  • Sounds boring, but it is the core of what health systems are about
  • Effectiveness = health benefit
  • Cost-effectiveness = providing the most health benefit for a given budget
  • We typically measure health benefit in DALYs
    • A measure of the years of life saved and morbidity prevented
cost effectiveness1
Cost-effectiveness
  • Some interventions deliver much more health benefit for a given budget
  • It is not a matter of 10% better or 50% better
    • but hundreds or thousands of times better
  • It isn’t the only important thing, but it is the core
what does a daly cost
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

£20,000 / DALY barrier

what does a daly cost1
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

what does a daly cost2
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

what does a daly cost3
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

Distribution of condoms

what does a daly cost4
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

Distribution of condoms

what does a daly cost5
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

Distribution of condoms

Distribution of bed nets

what does a daly cost6
What does a DALY cost?

Treatment of Kaposi’s Sarcoma

Antiretroviral therapy

Prevention of transmissionduring pregnancy

Distribution of condoms

Distribution of bed nets

facts about the ce distribution
Facts about the CE distribution
  • If you funded them equally, the top 20% would produce 80% of the value
  • The best intervention is 10,000 times better than the worst
  • The best intervention is 100 times better than the median
  • If you choose two at random, on average one is 100 times better
how important is cost effectiveness
How important is cost-effectiveness?
  • Prioritizing on cost-effectiveness is:
    • The difference between saving a life and saving 100 lives
  • Failure to prioritize on cost-effectiveness is:
    • Letting 100 die to save 1
    • ‘Not seeing the forest for the trees’
    • Squandering 99% of the value we could produce
    • Wasting public funds
    • Unfairly privileging the few at the expense of the many
    • Helping the rich or powerful at the expense of the poor
  • Example: spending $1m on dialysis instead of on DOTS
    • Buying 20 years of life for some at the expense of 20,000 years for others
the biggest moral issue in global health
The biggest moral issue in global health
  • Not the most exciting
  • Not the most philosophically interesting
  • Not the most technically interesting or challenging
  • But the core of the issue
  • (Actually securing large amounts of good health for the public)
  • It should be the starting point for priority setting
other concerns gps health
Other concerns (GPS Health)
  • Severity of health condition
  • Realization of potential
  • Past health loss
  • Rarity of health condition
  • Socio-economic status
  • Area of residence
  • Sex and gender
  • Race, ethnicity, religion
  • Productivity
  • Care for others
  • Catastrophic health expenditure
quantitative combinations of criteria
Quantitative combinations of criteria

Basic approach

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Cost per DALY (multiples of GNI / capita)

quantitative combinations of criteria1
Quantitative combinations of criteria

Basic approach

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7

9

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Cost per DALY (multiples of GNI / capita)

UK approach (NICE)

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4

7

9

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quantitative combinations of criteria2
Quantitative combinations of criteria

Basic approach

0

4

7

9

2

1

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8

Cost per DALY (multiples of GNI / capita)

Overlap Approach

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7

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