ABSTRACT
Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences of country contextualisation of WHO-CHOICE methods and models to a country level. Results from three contextualised cost-effectiveness analyses (CEAs) are presented, and we discuss how this evidence can inform priority setting in Ethiopia. Existing models for a range of interventions in obstetric and neonatal care, psychiatric and neurological treatment and prevention and treatment of cardiovascular diseases are contextualised to the Ethiopian setting. CEAs are defined as contextualised if they include national analysts and use country-specific input for either costs, epidemiology, demography, baseline coverage or effects. Interventions (n=61) are ranked according to incremental cost-effectiveness rates (ICERs), and expected health outcomes (Disability Adjusted Life Years (DALYs) averted) and budget impacts are presented for each intervention. Dominated interventions (n=30) were excluded. A US$2.8 increase per capita in the annual health budget is needed in Ethiopia (currently at US$28 per capita) for increasing coverage by 20%-75% for all the 22 interventions with positive net health benefits. This investment is expected to give a net benefit at around 0.5 million DALYs averted in return in total, with a willingness to pay threshold at US$2000 per DALY averted. In particular, three interventions, neonatal resuscitation, kangaroo mother care and antibiotics for newborn sepsis, stand out as best buys in an Ethiopian setting. Our method of contextualised CEAs provides important information for policy makers. Rank ordering of interventions by ICERs, together with presentations of expected budget impact and net health benefits, is a clear and policy friendly illustration of possible efficient stepwise pathways towards universal health coverage.
ABSTRACT
BACKGROUND: Setting Millennium Development Goals and Sustainable Development Goals for health has largely focused on defining specific targets of mortality and morbidity reduction over given time periods. Yet, less attention has been devoted to setting targets for the systemic determinants of health delivery, such as access and financial risk protection (FRP)-prevention of medical impoverishment. We examined candidate targets for FRP among low and middle-income countries by 2040. METHODS: We used a data set on estimates of incidence of catastrophic health expenditure (CHE)-medical expenditure exceeding 40% of household capacity to pay-among 110 countries over 1995-2007, augmented by estimates of the percentage of out-of-pocket expenditure out of total health expenditure (OOPEXP), the share of health expenditure as a percentage of gross domestic product (HEXGDP) and the gross domestic product per capita (GDPC). Using a simple model and 2040 estimates for OOPEXP, HEXGDP and GDPC from the World Bank, the International Monetary Fund and the Institute for Health Metrics and Evaluation, we projected CHE incidence by 2040 for four country income groups. RESULTS: We predicted that the 2040 incidence of CHE among households would be: 2.13% (Uncertainty interval: 0.60-6.87) among low-income countries, 1.15% (0.32-3.81) among lower-middle-income countries and 0.65% (0.18-2.21) among upper-middle-income countries. By 2040, the probability of achieving CHE <1.00% would be: 0.1 for low-income countries, 0.4 for lower-middle-income countries and 0.7 for upper-middle-income countries; for CHE <0.50%, it would be 0 for low-income countries, 0.1 for lower-middle-income countries and 0.3 for upper-middle-income countries. CONCLUSIONS: Historical trends of CHE rates can help define post-2015 targets for FRP. The projected achievements suggest that elimination of medical impoverishment will not be achieved by 2040 and that countries must urgently enact dramatic changes in policy to ensure FRP to their populations.
