Evidence-Informed Oral Health Policy Making: Opportunities and Challenges.

Despite a clear need for improvement in oral health systems, progress in oral health systems transformation has been slow. Substantial gaps persist in leveraging evidence and stakeholder values for collective problem solving. To truly enable evidence-informed oral health policy making, substantial "know-how" and "know-do" gaps still need to be overcome. However, there is a unique opportunity for the oral health community to learn and evolve from previous successes and failures in evidence-informed health policy making. As stated by the Global Commission on Evidence to Address Societal Challenges, COVID-19 has created a once-in-a-generation focus on evidence, which has fast-tracked collaboration among decision makers, researchers, and evidence intermediaries. In addition, this has led to a growing recognition of the need to formalize and strengthen evidence-support systems. This article provides an overview of recent advancements in evidence-informed health policy making, including normative goals and a health systems taxonomy, the role of evidence-support and evidence-implementation systems to improve context-specific decision-making processes, the evolution of learning health systems, and the important role of citizen deliberations. The article also highlights opportunities for evidence-informed policy making to drive change in oral health systems. All in all, strengthening capacities for evidence-informed health policy making is critical to enable and enact improvements in oral health systems.

Considering equity in priority setting using transmission models: Recommendations and data needs.

OBJECTIVES: Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity. METHODS: We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations. RESULTS: We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration. CONCLUSIONS: Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

Development of the WHO-INTEGRATE evidence-to-decision framework: an overview of systematic reviews of decision criteria for health decision-making.

BACKGROUND: Decision-making in public health and health policy is complex and requires careful deliberation of many and sometimes conflicting normative and technical criteria. Several approaches and tools, such as multi-criteria decision analysis, health technology assessments and evidence-to-decision (EtD) frameworks, have been proposed to guide decision-makers in selecting the criteria most relevant and appropriate for a transparent decision-making process. This study forms part of the development of the WHO-INTEGRATE EtD framework, a framework rooted in global health norms and values as reflected in key documents of the World Health Organization and the United Nations system. The objective of this study was to provide a comprehensive overview of criteria used in or proposed for real-world decision-making processes, including guideline development, health technology assessment, resource allocation and others. METHODS: We conducted an overview of systematic reviews through a combination of systematic literature searches and extensive reference searches. Systematic reviews reporting criteria used for real-world health decision-making by governmental or non-governmental organization on a supranational, national, or programme level were included and their quality assessed through a bespoke critical appraisal tool. The criteria reported in the reviews were extracted, de-duplicated and sorted into first-level (i.e. criteria), second-level (i.e. sub-criteria) and third-level (i.e. decision aspects) categories. First-level categories were developed a priori using a normative approach; second- and third-level categories were developed inductively. RESULTS: We included 36 systematic reviews providing criteria, of which one met all and another eleven met at least five of the items of our critical appraisal tool. The criteria were subsumed into 8 criteria, 45 sub-criteria and 200 decision aspects. The first-level of the category system comprised the following seven substantive criteria: "Health-related balance of benefits and harms"; "Human and individual rights"; "Acceptability considerations"; "Societal considerations"; "Considerations of equity, equality and fairness"; "Cost and financial considerations"; and "Feasibility and health system considerations". In addition, we identified an eight criterion "Evidence". CONCLUSION: This overview of systematic reviews provides a comprehensive overview of criteria used or suggested for real-world health decision-making. It also discusses key challenges in the selection of the most appropriate criteria and in seeking to implement a fair decision-making process.

Progressive realisation of universal health coverage: what are the required processes and evidence?

Progressive realisation is invoked as the guiding principle for countries on their own path to universal health coverage (UHC). It refers to the governmental obligations to immediately and progressively move towards the full realisation of UHC. This paper provides procedural guidance for countries, that is, how they can best organise their processes and evidence collection to make decisions on what services to provide first under progressive realisation. We thereby use 'evidence-informed deliberative processes', a generic value assessment framework to guide decision making on the choice of health services. We apply this to the concept of progressive realisation of UHC. We reason that countries face two important choices to achieve UHC. First, they need to define which services they consider as high priority, on the basis of their social values, including cost-effectiveness, priority to the worse off and financial risk protection. Second, they need to make tough choices whether they should first include more priority services, first expand coverage of existing priority services or first reduce co-payments of existing priority services. Evidence informed deliberative processes can facilitate these choices for UHC, and are also essential to the progressive realisation of the right to health. The framework informs health authorities on how they can best organise their processes in terms of composition of an appraisal committee including stakeholders, of decision-making criteria, collection of evidence and development of recommendations, including their communication. In conclusion, this paper fills in an important gap in the literature by providing procedural guidance for countries to progressively realise UHC.

Costs and process of in-patient tuberculosis management at a central academic hospital, Cape Town, South Africa.

SETTING: South Africa reports more cases of tuberculosis (TB) than any other country, but an up-to-date, precise estimate of the costs associated with diagnosing, treating and preventing TB at the in-patient level is not available. OBJECTIVE: To determine the costs associated with TB management among in-patients and to study the use of personal protective equipment (PPE) at a central academic hospital in Cape Town. DESIGN: Retrospective and partly prospective cost analysis of TB cases diagnosed between May 2008 and October 2009. RESULTS: The average daily in-patient costs were US$238; the average length of stay was 9.7 days. Mean laboratory and medication costs per stay were respectively US$26.82 and US$8.68. PPE use per day cost US$0.99. The average total TB management costs were US$2373 per patient. PPE was not always properly used. DISCUSSION: The costs of in-patient TB management are high compared to community-based treatment; the main reason for the high costs is the high number of in-patient days. An efficiency assessment is needed to reduce costs. Cost reduction per TB case prevented was approximately US$2373 per case. PPE use accounted for the lowest costs. Training is needed to improve PPE use.

A systematic review of economic evaluation studies of tuberculosis control in high-income countries.

Tuberculosis (TB) is a leading cause of death in developing countries and an important health threat in the industrialised world. Ideally, interventions in TB control are effective, acceptable and economically attractive. This review summarises all economic evaluation studies of TB control in high-income countries over the last 20 years. We provide indications on the relative economic attractiveness of TB interventions based on the reported conclusions. A total of 118 studies using different economic evaluation methodologies on a wide range of TB interventions are included. Most studies (70%) were from North America, and about half (47%) concerned interventions among the general population. Even though the large majority of studies (85%) aimed at preventing active TB disease, 44% of these ignored the prevention of secondary infections, thereby under- estimating the benefits of the intervention. Choosing a health care instead of a societal perspective (92% vs. 8%) further underestimated the benefits. Moreover, 74 studies (62%) disregarded discounting, and for 9 of them this led to overestimated future costs. In all, 66% of the studies reported conclusions favouring the evaluated intervention, which is modest given that a publishing bias towards favourable results is to be expected. In conclusion, we demonstrate that many studies in this review have put the evaluated TB intervention at a disadvantage by the choice of methodology, i. e., underestimating benefits and overestimating costs. This may have led to an overly conservative approach to the introduction of new interventions in TB control.

Cost-effectiveness of selected interventions for hearing impairment in Africa and Asia: a mathematical modelling approach.

The purpose of this paper was to present estimates of costs and effects of selected interventions for hearing impairment in Africa and Asia. The method used mathematical simulation models on the basis of WHO burden of disease information, and WHO-CHOICE costing databases. Findings showed that in both regions, screening strategies for hearing impairment and delivery of hearing aids cost between I$1000 and I$1600 per DALY, with passive screening being the most efficient intervention. Active screening at schools and in the community are somewhat less cost-effective. In the treatment of chronic otitis media, aural toilet in combination with topical antibiotics costs is more efficient than aural toilet alone, and costs between I$11 and I$59 in both regions. The treatment of meningitis with ceftriaxone costs between I$55 and I$217 at low coverage levels, in both regions. In more absolute terms, the vast majority of all considered intervention strategies are cost-effective strategies according to international benchmarks, in both regions concerned. In conclusion, various strategies are economically attractive to reduce the disease burden of hearing impairment around the world.

Costs, health effects and cost-effectiveness of alcohol and tobacco control strategies in Estonia

OBJECTIVE: To assess the population-level costs, effects and cost-effectiveness of different alcohol and tobacco control strategies in Estonia. DESIGN: A WHO cost-effectiveness modelling framework was used to estimate the total costs and effects of interventions. Costs were assessed in Estonian Kroon (EEK) for the year 2000, while effects were expressed in disability-adjusted life years (DALYs) averted. Regional cost-effectiveness estimates for Eastern Europe, were used as baseline and were contextualised by including country-specific input data. RESULTS: Increased excise taxes are the most cost-effective intervention to reduce both hazardous alcohol consumption and smoking: 759 EEK (euro 49) and 218 EEK (euro 14) per DALY averted, respectively. Imposing additional advertising bans would cost 1331 EEK (euro 85) per DALY averted to reduce hazardous alcohol consumption and 304 EEK (euro 19) to reduce smoking. Compared to WHO-CHOICE regional estimates, interventions were less costly and thereby more cost-effective in Estonia. CONCLUSIONS: Interventions in alcohol and tobacco control are cost-effective, and broad implementation of these interventions to upgrade current situation is warranted from the economic point of view. First priority is an increase in taxation, followed by advertising bans and other interventions. The differences between WHO-CHOICE regional cost-effectiveness estimates and contextualised results underline the importance of the country level analysis. (AU)

Priority setting using multiple criteria: should a lung health programme be implemented in Nepal?

OBJECTIVES: To identify and weigh the various criteria for priority setting, and to assess whether a recently evaluated lung health programme in Nepal should be considered a priority in that country. METHODS: Through a discrete choice experiment with 66 respondents in Nepal, the relative importance of several criteria for priority setting was determined. Subsequently, a set of interventions, including the lung health programme, was rank ordered on the basis of their overall performance on those criteria. RESULTS: Priority interventions are those that target severe diseases, many beneficiaries and people of middle-age, have large individual health benefits, lead to poverty reduction and are very cost-effective. Certain interventions in tuberculosis control rank highest. The lung health programme ranks 13th out of 34 interventions. CONCLUSION: This explorative analysis suggests that the lung health programme is among the priorities in Nepal when taking into account a range of relevant criteria for priority setting. The multi-criteria approach can be an important step forward to rational priority setting in developing countries.

Management of mutual health organizations in Ghana.

OBJECTIVE: Mutual Health Organizations (MHO) emerged in Ghana in the mid-1990s. The organizational structure and financial management of private and public MHO hold important lessons for the development of national health insurance in Ghana, but there is little evidence to date on their features. This paper aims at filling this data gap, and at making recommendations to Ghanaian authorities on how to stimulate the success of MHO. METHODS: Survey among 45 private and public MHO in Ghana in 2004-2005, asking questions on their structure, financial management and financial position. RESULTS: Private MHO had more autonomy in setting premiums and benefit packages, and had higher community participation in meetings than public MHO. MHO in general had few measures in place to control moral hazard and reduce adverse selection, but more measures to control fraud and prevent cost escalation. The vast majority of schemes were managed by formally trained and paid staff. The financial results varied considerably. CONCLUSIONS: Ghanaian authorities regulate the newly established public MHO, but may do good by leaving them a certain level of autonomy in decision-making and secure community participation. The financial management of MHO is suboptimal, which indicates the need for technical assistance.

Obtaining disability weights in rural Burkina Faso using a culturally adapted visual analogue scale.

Burden of disease (BOD) estimates used to foster local health policy require disability weights which represent local preferences for different health states. The global burden of disease (GBD) study presumes that disability weights are universal and equal across countries and cultures, but this is questionable. This indicates the need to measure local disability weights across nations and/or cultures. We developed a culturally adapted version of the visual analogue scale (VAS) for a setting in rural Burkina Faso. Using an anthropologic approach, BOD-relevant health states were translated into culturally meaningful disability scenarios. The scaling procedure was adapted using a locally relevant scale. Nine hypothetical health states were evaluated by seven panels of in total 39 lay individuals and 17 health professionals. Results show that health professionals' rankings and valuations of health states matched those of lay people to a certain extent. In comparison to that of the lay people, health professionals rated seven out of nine health states as slightly to moderately less severe. The instrument scored well on inter-panel and test-retest reliability and construct validity. Our research shows the feasibility of eliciting disability weights in a rural African setting using a culturally adapted VAS. Moreover, the results of the present study suggest that it might be possible to use health professionals' preferences on disability weights as a proxy for lay people's preferences.

Perceived quality of care of primary health care services in Burkina Faso.

INTRODUCTION: Patients' views are being given more and more importance in policy-making. Understanding populations' perceptions of quality of care is critical to developing measures to increase the utilization of primary health care services. OBJECTIVE: Documentation of user's opinion on the quality of care of primary health care services. METHODS: A 20-item scale, including four sub-scales related to health personnel practices and conduct, adequacy of resources and services, health care delivery, and financial and physical accessibility, was administered to 1081 users of 11 health care centres in the health district of Nouna, in rural Burkina Faso. RESULTS: The respondents were relatively positive on items related to health personnel practices and conduct and to health care delivery, but less so on items related to adequacy of resources and services and to financial and physical accessibility. In particular, the availability of drugs for all diseases on the spot, the adequacy of rooms and equipment in the facilities, the costs of care and the access to credit were valued poorly. Overall, the urban hospital was rated poorer than the average rural health care centre. Analysis of variance showed that, overall, health system characteristics explain 29% of all variation of the responses. CONCLUSION: Improving drug availability and financial accessibility to health services have been identified as the two main priorities for health policy action. Policy-makers should respect these patient preferences to deliver effective improvement of the quality of care as a potential means to increase utilization of health care.

Stochastic league tables: communicating cost-effectiveness results to decision-makers.

The presentation of the results of uncertainty analysis in cost-effectiveness analysis (CEA) in the literature has been relatively academic with little attention paid to the question of how decision-makers should interpret the information particularly when confidence intervals overlap. This question is especially relevant to sectorial CEA providing information on the costs and effects of a wide range of interventions. This paper introduces stochastic league tables to inform decision-makers about the probability that a specific intervention would be included in the optimal mix of interventions for various levels of resource availability, taking into account the uncertainty surrounding costs and effectiveness. This information helps decision-makers decide on the relative attractiveness of different intervention mixes, and also on the implications for trading gains in efficiency for gains in other goals such as reducing health inequalities and increasing health system responsiveness.

[Vaccination of the elderly against pneumococcal disease is cost-efficient. Mass vaccination of all aged 65 and over is recommended]. / Det lönar sig att vaccinera de äldre mot pneumokocksjukdom. Generell vaccination av åldersgruppen över 65 rekommenderas.

The pneumococcal vaccine has been shown to be about 70 percent efficacious in preventing invasive pneumococcal disease in elderly persons. In a European multicenter study, pneumococcal vaccination was moderately cost-effective in preventing hospital admission due to invasive pneumococcal disease in persons 65 years of age or above. In Sweden the cost was approximately 300,000 SEK per quality adjusted life years (QALY) gained, but only about 60,000 SEK per QALY in a two-way sensitivity analysis making reasonable assumptions regarding the incidence and mortality of invasive pneumococcal disease in this age group. On the basis of these findings, pneumococcal vaccination should be recommended for all persons 65 years of age or older.

[Cost effectiveness of vaccination against pneumococcal bacteremia in the elderly: the results in Belgium]. / Kosteneffectiviteit van vaccinatie tegen pneumokokkenbacteriëmie bij bejaarden: resultaten voor België.

BACKGROUND: Several studies have shown that pneumococcal vaccination of older persons would be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection for this condition is uncertain. Given much better evidence of vaccination effectiveness against invasive disease, studies showing that vaccination is cost-effective in preventing invasive disease alone could provide strong support for public policies to vaccinate older persons. METHODS: We examined the cost-effectiveness of preventing invasive pneumococcal infection by vaccination with the 23-valent pneumococcal polysaccharide vaccine of persons > or = 65 years in age in Belgium. The direct medical costs expressed per quality adjusted life year (QALYs) of a cohort of vaccinated persons was compared with the costs per QALY in a cohort of persons who are not vaccinated. RESULTS: Preventing invasive pneumococcal infections by vaccinating elderly persons clearly benefits people's health. By vaccinating 10,000 persons over 65 years of age, approximately eight QALYs can be gained compared with no vaccination. Achieving these health benefits however requires additional costs,: 30,000 ECU per QALY gained. The cost-effectiveness ratio is slightly better (i.e. 25,000 ECU per QALY) for the age group 65-75 years, and slightly worse (i.e. 35,000 ECU per QALY) for the age group 75-84 years. It increases sharply to 77,000 ECU per QALY for the persons over 85 years of age. An extensive one-dimensional sensitivity analysis did not greatly affect these results. If vaccination is also clinically effective in preventing pneumococcal pneumonia, vaccinating all elderly persons is cost saving. CONCLUSION: Using empirical epidemiological data, pneumococcal vaccination to prevent invasive pneumococcal disease is acceptably to moderately cost-effective in Belgium. On the basis of our findings, we believe public health authorities should consider policies for encouraging pneumococcal vaccination for all persons > or = 65 years in age.

Pharmacoeconomics of influenza vaccination in the elderly: reviewing the available evidence.

Most western countries have influenza vaccination programmes for citizens aged > or = 65 years. This paper reviews the available evidence on whether elderly influenza vaccination is worthwhile from a pharmacoeconomic point of view. A search on Medline and EMBASE resulted in a primary selection of approximately 100 studies on the pharmacoeconomics of influenza vaccination in the elderly. Further selection of studies to be included in the review was based on several criteria such as original research paper, cost-benefit or cost-effectiveness analysis. influenza vaccination in the elderly, and publication between 1980 and 1999. The 10 studies included in the final selection were evaluated regarding 3 main aspects: benefit-cost ratio and cost-effectiveness ratio; vaccine effectiveness; and relative costing of the vaccine. In general, differences in benefit-cost ratios could be explained by differences in effectiveness and relative costing of the vaccine. Considering the available pharmacoeconomic evidence, influenza vaccination of the elderly in western countries is an intervention with favourable cost-effectiveness in terms of net costs per life-year gained and even has cost-saving potential. In particular, influenza vaccination among elderly people at higher risk, such as the chronically ill elderly, is generally found to be cost saving. Relatively favourable cost-effectiveness among non-high-risk elderly justifies universal influenza vaccination of the elderly from a pharmacoeconomic point of view.

Cost-effectiveness of pneumococcal vaccination of older people: a study in 5 western European countries.

Pneumococcal vaccination of older persons is thought to be cost-effective in preventing pneumococcal pneumonia, but evidence of clinical protection is uncertain. Because there is better evidence of vaccination effectiveness against invasive pneumococcal disease, we determined the cost-effectiveness of pneumococcal vaccination of persons aged > or =65 years in preventing hospital admission for both invasive pneumococcal disease and pneumococcal pneumonia in 5 western European countries. In the base case analyses, the cost-effectiveness ratios for preventing invasive disease varied from approximately 11,000 to approximately 33,000 European currency units (ecu) per quality-adjusted life year (QALY). Assuming a common incidence (50 cases per 100,000) and mortality rate (20%-40%) for invasive disease, the cost-effectiveness ratios were <12,000 ecu per QALY in all 5 countries. For preventing pneumococcal pneumonia, vaccinating all elderly persons would be highly cost-effective to cost saving. Public health authorities should consider policies for encouraging pneumococcal vaccination for all persons aged > or =65 years.

The usefulness of ratios for allocation decisions: the case of stroke.

Economic evaluation is becoming increasingly important in the field of stroke as well. The results of economic evaluation can be expressed in cost per quality-adjusted life years (QALY) gained, which enables policy makers to compare the relative efficiency of different interventions regarding different diseases. Although using the concept of QALY is preferable from a theoretical point of view, in medical practice more often cost-effectiveness analysis (CEA), and not cost-utility analysis, is applied for practical reasons. One of the main limitations of CEA is that the results may be compared only with results of other CEAs, using the same effect parameter. The calculation of cost-effectiveness ratios (CERs) in many cases is misleading for resource allocation. Effects should be expressed in interval or ratio scales in order to calculate CERs, which is rarely the case. The calculation of a CER in a CEA should only be performed if, and only if, the investigator is convinced that there is a constant relation between the specific effect parameter and the ultimate gain in health.