Eastern Mediterranean Regional Office, World Health Organization Dr. Hossein Salehi May 20-24, 2007 Alexandria, Egypt

1. CAPACITY DEVELOPMENT WORKSHOP ON HEALTH SYSTEM DEVELOPMENT FOR REGIONAL COUNTRY OFFICE STAFFTools for Policy Analysis: Cost Effectiveness Analysis Eastern Mediterranean Regional Office, World Health Organization Dr. Hossein Salehi May 20-24, 2007 Alexandria, Egypt

2. Introduction; Concept of cost • Cost: • Accounting cost • Economic cost (value of foregone resources)

3. Project A; MRI • Annual cost $1,000,000 • Annual Benefit 1,000 DALY averted • Project B; Immunization for HB • Annual cost $1,000.000 • Annual Benefit 1,600 DALY averted • Project C;(best alternative) • Annual cost $1,000,000 • Annual Benefit 1,800 DALY averted

4. Introduction; Concept of cost; cont Opportunity cost “opportunity cost is the value of the best forgone alternative”

5. Introduction; Concept of cost, cont • Who bear(s) the cost? • Individual (private) cost • Implementing agency cost (public cost) • Society (Social Cost) vs. Private cost

6. Why costing? • Budgeting • Provider payment • Fee-for-Services • Capitation • Efficiency • Providers • Interventions

7. Intervention cost • Intervention cost • Cost-Benefit Analysis (CBA) • Cost-Effectiveness Analysis (CEA) • Generalized Cost-Effectiveness Analysis (GCEA)

8. WHO-GCEA • Attention to current inefficiencies in the allocation of resources • Context-specific CEA is too demanding for most countries • There are no international guideline for CEA

9. CEA; Cost-Benefit ratio Cost a1 c h O Health benefits (DALYs averted)

10. Cost a1 C1 a2 C2 h O Health benefits (DALYs averted) `

11. a4 c4 a3 b3 a2 a1 c3 b2 b1 c2 c1

12. a4 c4 a3 b3 a2 a1 c3 b2 b1 c2 c1

13. League Table League Table

14. League Table

15. League Table

16. WHO CHOICE Project • Prepared for 14 sub-regions: WHO political groupings and mortality strata • All results on www.who.int/choice • Country contextualization tool currently being finalized after tests in Thailand, Estonia, Sri Lanka (mental health), Ghana, Mexico

17. Maternal and neonatal • Referral care level • Treatment of severe pre-eclampsia/eclampsia* • Antibiotics for pre-term prelabour rupture of membranes (pPROM)* • Antenatal steroids for pre-term births* • Management of obstructed labour, breech & fetal distress (OL)* • Management of severe post-partum haemorrhage (PPH)* • Management of maternal sepsis* • Emergency neonatal care (ENC) combination of 15-18 • Management of very low birth weight babies (vLBW)* • Management of severe neonatal infections* • Management of severe neonatal asphyxia* • Management of neonatal jaundice* Primary-level care including outreach Selected antenatal care interventions (ANC) combination of 1-4 • Tetanus toxoid (TT) • Screening for pre-eclampsia • Screening & treatment of asymptomatic bacteruria • Screening & treatment of syphilis Skilled maternal and immediate newborn care (SMNC) combination of 5 -8 • Normal delivery by skilled attendant • Active management of the third stage of labour • Initial management of post-partum haemorrhage (PPH) • Neonatal resuscitation • Community-based interventions • Community newborn care package combination of 19-20 • Support for breastfeeding mothers • Support for low birth weight babies • Community-based case management for neonatal pneumonia

18. Mgmt of Post partum haemorrhage and shock 95% Antibiotics for pPROM 95% Mgmt of maternal sepsis 95% Antenatal steroids Mgmt of obstructed labour 95% Emergency newborn care 95% Pre-eclampsia/ eclampsia 95% SMNC 95% Other ANC 95% Tetanus 95% Breastfeeding and care for LBW 95% Results for Afr-E region Community-based Mgmt of pneumonia (95%) Community mgmt of pneumonia 95%

19. Antenatal steroids95% Antibiotics for pPROM 95% Mgmt of obstructed labour 95% Screening for syphilis 95% ENC 95% Maternal sepsis 95% Resuscitation and referral care for eclampsia 95% Mgmt of PPH 95% Community mgmt of pneumonia 95% Eclampsia and screening for bacteruria 95% Normal delivery by skilled attendant 95% LBW95% Breastfeeding 95% Tetanus 95% Tetanus 80% Breastfeeding 80% Breastfeeding 50% Results for Sear-D region Results for Sear-D region

22. Issues in GCEA • Estimating cost • Estimating health benefits • Discounting • Uncertainty • Ethical issues • Equity

23. Ethical Issues in CEA • How should states of health and disability be evaluated? • Whose valuation? • Is value of a year of life depends on one’s age? • socioeconomic status,…? • Should health benefits be discounted? • How distribution of benefits be considered? • What priority should be given to sickest or worst off? • Large benefits to a few vs. small benefits to a large group. Which one? (Rule of rescue) • Fair chance or best outcome?

24. Which ?

25. CAPACITY DEVELOPMENT WORKSHOP ON HEALTH SYSTEM DEVELOPMENT FOR REGIONAL COUNTRY OFFICE STAFFTools for Policy Analysis: Cost Effectiveness Analysis Eastern Mediterranean Regional Office, World Health Organization Dr. Hossein Salehi May 20-24, 2007 Alexandria, Egypt

26. Cost-EffectivenessThe case:You have $10,000,000. What project(s) will you select for implementation. Please consider cost-effectiveness, health conditions, ethical issue, equity,…