Calculating a real example: reducing vehicular crashes and their health consequences (analyzed in Kenya, Tanzania and Ug

3. Calculatinga real example: reducing vehicular crashes and their health consequences (analyzed in Kenya, Tanzania and Uganda: DCP2 p. 749b) Can intervene at any or all of three stages Can intervene on any or all of three factors Look for simple, self-enforcing interventions, if system capacity limited (speed bumps vs. more police trained and deployed against speeding)

9. Is CEA worth doing? Criticisms (and Answers to them)— (1) Conclusions are obvious, already recommended (save newborns, immunize children, improve obstetric care, distribute bednets, kill mosquitoes, treat STDs, use DOTs against tuberculosis, etc.) Best practice and are cost often unknown; CEA helps with scaling up, choices among interventions (HIV, malaria, injuries), coping with new threats (CVD, diabetes)

10. Is CEA worth doing? Criticisms (and Answers to them)— (2) Countries are already trying most of these interventions, but facing financial constraints Often at too small scale; very often with poor quality, organization, results; CEA can show quality improvements, cost-savings vs. status quo or (nearly) cost-free gains in outcomes; money is not always the problem; a little extra rationality can’t hurt, even if moves only to 2nd- or 3rd-best solution

11. Is CEA worth doing? Criticisms (and Answers to them)— (3) Too much of “would be good if--” advice that country’s health systems are too dysfunctional to follow; the ideal is the enemy of the not-so-bad Use CEA to set standards for cost and outcome, or find better ones; emphasize systemic interventions, not only medical ones; find out why systems are so dysfunctional; combine CE advice with own knowledge and views about equity, poverty, needs

12. Is CEA worth doing? Criticisms (and Answers to them)— (4) Far too little data, too much guesswork for results to be persuasive, conclusive Ignore small differences in CERs, look at orders-of-magnitude; supply local data to fill holes or improve on imputed values; use concept of CE even when numbers have errors or wide confidence intervals; value is conceptual as well as quantitative, especially where there is little tradition of any economic analysis

13. Uses of cost-effectiveness analysis Obvious use for comparing different interventions for the sameoutcome (just equivalent to cost-minimizing) Especially useful for different outcomes of the same kind(deaths, life years, DALYs) Cannot compare outcomes of differentkinds (health vs. education vs. roads)

14. What CEA does and doesn’t tell Does tell whether an intervention is worth undertaking (relatively, not absolutely)—does it provide value for money--but Does not say who should undertake it (government, NGOs, private providers) Does not say how to pay for it (patient fees, taxes, insurers, donors, charities, etc.)

15. CEA is not a general solution to development problems; it allows choices only in one sector, and it does not maximize overall welfare Amen: but a portable, accurate, reliable, inter-person comparable utilometer is not invented yet; all choices among goods, people, sectors, intervals, generations, values are difficult; CEA and DCPP results in general are a partial but real help that can be crucial to development

16. Crucial things to remember about CEA • Estimates of cost and effect assume a particular set of inputs in appropriate proportions; if these are not supplied and used, the cost will be higher or the effect less, or both (e.g., an operating theater without a surgeon, clinics without drugs) • Cost-effectiveness ratios (CERs) show what is possible, not guaranteed. (Take DCPP estimates as a goal or norm for actual results, not as the answer)

17. What other considerations matter? At least eight other criteria may be considered to affect priority: Vertical equity, Horizontal equity, Poverty, Catastrophic cost, Public goods, Externalities, Rule of Rescue, and Public demands Any of these may be inconsistent with cost-effectiveness; need to judge the balance

18. Crucial things to remember about CEA • Once “effects” are defined, distributional assumptions are built in: e.g., all deaths or all life-years are treated as equal; distant years are worth less than current ones; 10 years for one person = one year each for 10 people • Cost-effectiveness is an efficiency measure; it may be in conflict with either horizontal or vertical equity, or both

20. Cost-Effectiveness vs. Vertical Equity Disease 1 2 3 4 Intervention Cost Intervention Effectiveness Disease Severity

21. DCP2 also offers suggestions about health systems and their relation to interventions • Ensure that focused disease-specific efforts (such as vertical programs) contribute to system strengthening, not detract from it • Reforms affecting organizational structures and human resource management are more likely to be successful if they are incremental and gradual and adjusted as needed • One should keep the health of the system in mind whenever major new programs are introduced

22. More general systemic messages • Different interventions compete for the use of inputs; assure that inputs are actually made available for each intervention as needed • Monitor input uses and intervention outcomes; see whether potential cost-effectiveness is realized

23. Money will always matter, but— fortunately— A country, a population, or an individual need not be rich to be healthy, if priorities are well chosen and implemented. The history of progress in health is a history of making money ever less important compared to knowledge and its wise use

24. For more information, visit www.dcp2.orgAll the DCPP publications can be downloaded for free; interpretation and advice are available from the editors and authors