The growing use of cost-effectiveness analysis (CEA) to evaluate specific interventions is dominated by studies of prospective new interventions compared with current practice. This type of analysis does not explicitly take a sectoral perspective in which the costs and effectiveness of all possible interventions are compared, in order to select the mix that maximizes health for a given set of resource constraints. WHO guidelines on generalized CEA propose the application of CEA to a wide range of interventions to provide general information on the relative costs and health benefits of different interventions in the absence of various highly local decision constraints. This general approach will contribute to judgements on whether interventions are highly cost-effective, highly cost-ineffective, or something in between. Generalized CEAs require the evaluation of a set of interventions with respect to the counterfactual of the null set of the related interventions, i.e. the natural history of disease. Such general perceptions of relative cost-effectiveness, which do not pertain to any specific decision-maker, can be a useful reference point for evaluating the directions for enhancing allocative efficiency in a variety of settings. The proposed framework allows the identification of current allocative inefficiencies as well as opportunities presented by new interventions.

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Development of WHO guidelines on generalized cost-effectiveness analysis.

A basic requirement for evaluating the cost-effectiveness of health interventions is a comprehensive assessment of the amount of ill health (premature death and disability) attributable to specific diseases and injuries. A new indicator, the number of disability-adjusted life years (DALYs), was developed to assess the burden of disease and injury in 1990 for over 100 causes by age, sex and region. The DALY concept provides an integrative, comprehensive methodology to capture the entire amount of ill health which will, on average, be incurred during one's lifetime because of new cases of disease and injury in 1990. It differs in many respects from previous attempts at global and regional health situation assessment which have typically been much less comprehensive in scope, less detailed, and limited to a handful of causes. This paper summarizes the DALY estimates for 1990 by cause, age, sex and region. For the first time, those responsible for deciding priorities in the health sector have access to a disaggregated set of estimates which, in addition to facilitating cost-effectiveness analysis, can be used to monitor global and regional health progress for over a hundred conditions. The paper also shows how the estimates depend on particular values of the parameters involved in the calculation.

The global burden of disease in 1990: summary results, sensitivity analysis and future directions.

Methods We used three life tables to examine the effect of smoking on health care costs — one for a mixed population of smokers and nonsmokers, one for a population of smokers, and one for a population of nonsmokers. We also used a dynamic method to estimate the effects of smoking cessation on health care costs over time. Results Health care costs for smokers at a given age are as much as 40 percent higher than those for nonsmokers, but in a population in which no one smoked the costs would be 7 percent higher among men and 4 percent higher among women than the costs in the current mixed population of smokers and nonsmokers. If all smokers quit, health care costs would be lower at first, but after 15 years they would become higher than at present. In the long term, complete smoking cessation would produce a net increase in health care costs, but it could still be seen as economically favorable under reasonable assumptions of discount rate and evaluation period. Conclusions If people stopped smoking, there would be a savings in health care costs, but only in the short term. Eventually, smoking cessation would lead to increased health care costs. (N Engl J Med

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The health care costs of smoking

Objective: To improve the evidence base for health policy by devising a method to measure and monitor the performance of health systems. Design: Estimation of the relation between levels of population health and the inputs used to produce health. Setting: 191 countries. Main outcome measure: Health system efficiency (performance). Results: Estimated efficiency varied from nearly fully efficient to nearly fully inefficient. Countries with a history of civil conflict or high prevalence of HIV and AIDS were less efficient. Performance increased with health expenditure per capita. Conclusions: Increasing the resources for health systems is critical to improving health in poor countries, but important gains can be made in most countries by using existing resources more efficiently. What is already known on this topic Evidence on the effectiveness of health system reforms is scarce Studies have not used a consistent framework for specifying goals or measuring outcomes What this study adds Countries with the best levels of health do not always have efficient health systems Efficiency is related to expenditure on health per capita, especially at low expenditure The methods of measuring performance provide a basis for identifying policies that improve health and for monitoring reforms

https://www.bmj.com/content/bmj/323/7308/307.full.pdf

Comparative efficiency of national health systems: cross national econometric analysis

The evidence-based approach in health policy and health care delivery.

The role of health systems infrastructure in studies of cost-effectiveness analysis and health resource allocation is discussed, and previous health sector cost-effectiveness analyses are cited. Two substantial difficulties concerning the nature of health system costs and the policy choices are presented. First, the issue of health system infrastructure can be addressed by use of computer models such as the Health Resource Allocation Model (HRAM) developed at Harvard, which integrates cost-effectiveness and burden of disease data. It was found that a model which allows for expansion in health infrastructure yields nearly 40% more total DALYs for a hypothetical sub-Saharan African country than a model which neglects infrastructure expansion. Widespread use of cost-effectiveness databases for resource allocations in the health sector will require the cost-effectiveness analyses shift from reporting costs to reporting production functions. Second, three distinct policy questions can be treated using these tools, each necessitating its own inputs and constraints: allocations when given a fixed budget and health infrastructure, or when given resources for marginal expansion, or when given a politically constrained situation of expanding resources. Confusion concerning which question is being addressed must be avoided through development of a consistent and rigorous approach to using cost-effectiveness data for informing resource allocations.

Cost-effectiveness analysis and policy choices: investing in health systems.

Se examina la funcion de la infraestructura de los sistemas de salud en los estudios analiticos de efectividad en funcion del costo y asignacion de recursos de salud, y se revisan algunos analisis de efectividad en funcion del costo en el sector salud realizados con anterioridad. Se senalan dos d(ficultades importantes relacionadas con la naturaleza de los costos del sistema de salud y la eleccion de las politicas. En primer lugal; el problema de la infraestructura del sistema de salud puede abordarse recurriendo a modelos computadorizados comn el Modelo para Asignar Recursos de Salud (MARS), desarrollado en hkroard, que integra datos sobre la efectividad en funcion del costo y de la carga de enfermeakd. Se observo que un modelo que considera la expansion de la infraestructura de salud produce casi $O% mas de anos de vida ajustados en funcion de la discapacidad totales para un hipotetico pais del Africa subsahariana que un modelo que soslaya dicha expansion. Si se desea difundir la utilizacion de las bases de datos sobre la efectividad en funcion del costo para asignar los recursos en el sector salud, sera preciso que los analisis de la efectividad en funcion akl costo pasen de aportar informacion sobre costosa notificar funciones de produccion. En segundo lugal; con estos instrumentos es posible analizar tres interrogantes concretos sobre politicas, cada uno de ellos con sus propios insumos y restricciones: la asignacion cuando el presupuesto y la infraestructura de salud son fijos, cuando hay recursos para una expansion marginal y cuando existen restricciones politicas para expandir los recursos. Para que no se confunda el interrogante que se esta abordando, es necesario desarrollar un metodo congruente y riguroso destinado a utilizar los datos de efictividad en funcion del costo para orientar la asignacion de recursos.

Jerome Kreuser

Papers

Cost-effectiveness analysis and policy choices: investing in health systems.

El análisis de la efectividad en función del costo y la elección de políticas: la inversión en los sistemas de salud