Duc Anh Ha MD., MS. DrPH Candidate Boston University School of Public Health

1. Application of WHO-CHOICE for Cost Effectiveness Analysis of Interventions to prevent Cardiovascular disease in Vietnam Duc Anh Ha MD., MS. DrPH Candidate Boston University School of Public Health Boston, February 3, 2010

2. Outline • Introduction • Epidemiology and intervention • Methods and data • Results • Discussion and policy Implications • Question and answer

3. Introduction

4. Scarcity in healthcare • Resources for healthcare are limited, especially in LMICs • G8 spent 10% GDP on healthcare in 2007 • All LMICs spent half of G8’s spending • Health spending in the poorest countries ($20-50 per capita) is 1/30 the level of that in developed countries • Burden of financing is becoming heavier • Rationale choices must be made to meet the health care needs and to deal with scarcity

5. Economic evaluation in healthcare • Definition: “The comparative analysis of alternative courses of action in terms of both their costs and consequences” (Drummond 2005). • Involves: identifying, measuring, valuing, and comparing costs and consequences • Deals with both scarcity and choices • An established tool to aid health policy makers • Be applied in a variety of healthcare areas in many developed countries, but in only few LMICs

6. Health gain Access Resources mobilization Financial risk protection Quality Pooling Equity Equity in health Purchasing/ provision Efficiency Responsiveness Economic evaluation and efficiency Heath financing functions Intermediate outcomes Health system goals Source: Adapted from Roberts at al, and WHO’s report 2000

7. CHOosing Interventions that are Cost Effective (WHO-CHOICE) • Central notion • Allocate resources across interventions and population groups to attain the highest possible level of health • Key features • Permits analysts to evaluate the costs and health benefits of a set of related interventions singly or in combination • Presents the results of CEA in a single table, in which interventions form an “expansion path” • Overcomes time, technical, data, budget constraints facing developing countries • Application of WHO-CHOICE in Vietnam • Adaptation of regional information down to the national level • Availability of national data on demographic and epidemiological parameters

8. The context of Vietnam • Recent socio-economic development • Population: 85 million, 30% of whom live in urban areas • Innovation process (Doi moi) was launched in 1986 • Economic growth: 7-8% over the last decade • Poverty rate: 18% (2007) compared to 75% in the mid 80s • Health reforms • Liberalization of the health care and pharmaceutical markets • Introduction of official user fees and health insurance • Health care financing • State budget for health care: 5% of GDP ($18 per capita) in 2006 • Out-of-pocket payment: 70% of total health expenditures • Resources are allocated on the basis of past expenditure and unscientific norms, and request-give mechanisms

9. The context of Vietnam

10. The context of Vietnam • CVD in Vietnam • Leading cause of death (one third of total deaths) • Account for 20% of total burden of DALYs • Risk factors of CVD (hypertension, smoking, obesity) are either on the rise or already at alarming levels • Among 23 countries accounting for 80% of global chronic disease deaths • Milestones of the prevention and control of CVD in Vietnam: • 2000: issue of National Tobacco Control policy • 2001: ratification of the National Strategy for People’s Health Care for the period 2001-2010 • 2002: ratification of Prevention and Control Program for certain NDCs • 2007: establishment of the NCDs program attached to the MOH

11. Objectives • Overall objective: • To inform policy makers about the costs, effects, and cost-effectiveness of prevention interventions, and how they can be combined to efficiently prevent and reduce CVD risk factors in Vietnam. • Specific objectives • To describe the burden of cardiovascular disease and its risk factors; • To estimate the costs, health effects, and cost-effectiveness of interventions to prevent cardiovascular disease in Vietnam; • To propose interventions to efficiently prevent and reduce the risk factors of CVD in Vietnam; • To share lessons learned from the contextualization of WHO-CHOICE into Vietnam’s setting.

12. Epidemiology and prevention

13. Definitions • Cardiovascular disease: • A term referring to a class of diseases involving not only conditions of the heart such as coronary artery, valvular, muscular, and congenital disease, but also hypertension and conditions of the cerebral, carotid, and peripheral circulation (Howson 1998). • Ischemic heart disease: • includes acute-myocardial infarction (AMI), angina, and congestive heart disease following AMI. • Stroke: • rapidly developing clinical signs of focal (or global) disturbance of cerebral function, with symptoms lasting 24 hours or longer or leading to death, with no apparent cause other than of vascular origin (Hatano 1976).

14. Trends in morbidity in Vietnam

15. Burden of mortality in Vietnam Source: WHO, Disease and injury country estimates

16. Burden of DALYs in Vietnam Source: Vos et al, unpublished report

17. Risk factors and economic burden • High blood pressure: • Prevalence: 16.9% among people aged 25-65 (a 51% increase since 1992), and 50% among people aged over 65 in 2002 • Obesity: • increases 2.5 times over the 1992-2002 period • Smoking • 56% males aged 16 and over smoke • Salt intake: • Predominant use of salt to preserve meat and fish, and in seasoning and sauces • Knowledge of CVD and its risk factors: • Poor perception on risk factors: correct perception 23%; wrong perception: 37% • Economic burden: • Direct costs for treatment and management • Indirect costs: lost of productivity, future earnings, and loss of care givers

18. Prevention intervention • Population-wide interventions • The majority of cases of CVD occur among persons with medium and low levels of risk • A small change in risk factors in the population at large may bring greater benefits than a large change in only a small group of high risk people • Lifestyle modification/environment changes • Individual interventions • Identify high risk susceptible persons, and offer them some protection • Based on elevated levels and absolute risks • Thrombosis prevention (aspirin), blood pressure lowering (diuretics, beta-blockers, and Angiotensin-converting enzyme (ACE) inhibitors), and cholesterol lowering (statin)

19. Methods and Data

20. Methodological framework

21. Selected interventions

22. Data collection of intervention effectiveness • Demographic data: • United Nations Population’s Division Bureau (2007) • Current epidemiology of IHD and stroke: • National Burden of Disease study • Prevalence information: • Systolic blood pressure: Vietnam National Health survey; • Smoking: the 2001 and 2008 risk factor surveys; • Salt intake profile: Intersalt project • Relative risk for IHD and stroke: • The Comparative risk assessment project (WHO) • Health state valuation/disability weight: • National Burden of Disease study • Preventive intervention effectiveness: • Systematic review, meta-analysis, and published articles • Current coverage of intervention and compliance: • Experts’ opinions

23. Summaries of effect sizes

24. Intervention costs

25. Data sources • Data on physical inputs (ingredients) and quantities • WHO-CHOICE database • Drug prices • International Drug Price Database (MSH 2007) • Personnel costs • United Nations and European Union’s salary scale and Government of Vietnam’s regulation • Media operating and IEC materials • Vietnam Television • Voice of Vietnam • Local television and radio stations • Thanh Nien publishing • Patient costs • Vietnamese costing study 2004

26. Prices/Unit costs

27. Prices/Unit costs

28. Cost analysis • CostIt (Costing Intervention Templates) was used to aggregate the cost components • Perspective: societal perspective • Choice of discount rate: 3% • Capacity utilization assumption: 80% • Program implementation horizon: 10 years • Annualization: subjected costs will be annualized over the intervention implementation horizon • Exchange rate: US$ 1= 16421 VND for the base year 2007

29. Modeling the impacts on disease outcomes • Stata modeling • Estimates population effects (expected rates of IHD and stroke incidence) with or without the implementation of the prevention measures • Undertaken by means of a simulation model based on APCSC that applies the aforementioned effect sizes to the observed risk factor profile of different age and sex groups in the Vietnamese population • PopMod modeling • Estimates the lifetime health gains experienced by the population as a result of the intervention-induced changes in disease incidence • Both IHD and stroke were explicitly modeled first without any intervention and then with the various interventions in place for 10 years • Tracks the effects over lifetime (100 years) • Quantifies population health effects to DALYs averted

30. Calculating cost-effectiveness • Both single or combined interventions were assessed • Null scenario: none of the proposed interventions was implemented • Classifications of average CER • Verycost-effective: averting each DALY at a cost less than 1 time GDP per capita; • Cost-effective: averting each DALY at a cost between one and three times GDP per capita; and • Cost-ineffective: averting each DALY at a cost over three times GDP per capita. • GDP per capita: VND13,456,000 (US$ 820) in 2007

31. Uncertainty analysis • One-way sensitivity analysis • Lower and upper limits of intervention effects • Half and double the base estimates of drug prices • Age-weight and discounting of health effectiveness • Multi-way sensitivity analysis • Best-case and worst-case scenarios • Probabilistic, multivariate sensitivity analysis • Monte Carlo League

32. Results

33. Costs

34. Typical percentage shares in program costs of population-wide interventions

35. Typical percentage shares in total costs of individual interventions

36. Health effectiveness in DALYs averted

37. Cost-effectiveness of interventions

38. Point estimated expansion path

39. Incremental cost-effectiveness ratios

40. Results of sensitivity analysis

41. Expansion path combination

42. Uncertainty around ICERs

43. Stochastic budget expansion path

44. Discussion and policy implications

45. Principal findings • Vietnam is in the second stage of the epidemiologic transition • CVD is the leading cause of death • Risk factors of CVD are either on the rise or already at alarming levels • Limited application and evidence of EE in Vietnam • Majority of population-wide and individual interventions are cost-effective according to CMH • Without budget constraint, treatment for SPB>160 and absolute risk approach should be implemented • With highly restricted resources: Mass media to reduce salt intake and cholesterol are probable interventions • Using local and context-specific information to apply WHO-CHOICE is a promising approach to improve evidence-based health policy making in developing countries

46. Study limitations • No local data on sodium consumption • Effect sizes and equations were derived from developed countries • Did not fully take into account other benefits or side effects into the models • Decrease of the risk of gastric cancer • Resistance caused by platelet-active drugs • Care must taken when interpreting results of uncertainty analyses (stochastic league table) • Not all parameters were assessed in sensitivity analyses • Hospital costs (double the base estimates) • Discount rate 10% or higher

47. Comparison with other studies • Many findings were consistent with those by Murray et al for the WPRB • Average cost-effectiveness estimates are significantly higher than the regional estimates • Different expansion path combination • Pharmaceutical interventions had similar CE results as compared with other studies in developing countries

48. Policy implications • The proposed interventions are economically sustainable measures: • target well documented behaviors and risk factors; • could lead to favorable changes in behaviors or risk factors; • be very cost effective and financially feasible in the context of Vietnam. • Utilizing the results would lead to increased efficiency in resource allocation • Contribute to reducing both economic and health burden of CVD • Go in line with WHO’s recommendations and pro-poor viewpoint of Vietnamese government • Improve health policy making based on evidence

49. Specific recommendations • Lifestyle modification education program via mass media • Affordable intervention at the current budget of VND 80billion per year • Pilot in some provinces before scaling up nationally • In the long run, should be a part of the national media strategy • Expanding individual treatment of systolic blood pressure • The budget is projected to increase • Combine follow up visit and health education • Attention should be paid to adherence to treatment • Piloting treatment based on absolute risk • Use WHO guidelines for assessment and management • Training for health workers at the primary level

50. Lessons learned • Form a good panel of expert • Present multiple disciplines • Knowledgeable of local context and data sources • Understand intervention pathways • Understand biological process of the disease and the impact of the intervention • Be focused on identifying and synthesizing evidence • As a rule of thumb, the evidence should not be identified selectively, but derived from the best designed and least biased sources.