For Discussion and Consultation: Our Ideas for “Health Impact Accounts”

Dr. Armin H. FidlerLead Adviser, Health Policy and Strategy

The World Bank GroupBrussels, February 7, 2012

Outline

BackgroundRationaleChallenges to current approachThe need for Health Impact AccountsPrinciples for estimatesNext steps

Significant increase in DHA but challenges to sustain

• Recent scale-up of funding for health from domestic and donor sources

• Several reasons behind expansion of donor interest in health

• Following 2008 global fiscal crisis, donor countries are increasingly demanding clear evidence on the impact of their investment

Demand from donors and tax-payers for funding organizations to demonstrate results

Multilaterals, in the past, have had two options to respond to demand for evidence:

1. Ex-ante analyses of global costs and health benefits – Although ex-ante analyses of global costs and health benefits

have figured prominently in advocacy for global health programs7 these efforts are often based on the limited evidence-base available prior to major program scale-up.

2. Ex-post evaluations of investments. – These results are often delivered long after project is

completed and methods are not applicable to on-going review

A recent effort to communicate results: “Lives Saved”

3. Calculation of ‘lives saved’ to provide rapid estimates based on likely benefits from expenditures– Provide a timely, compelling, and perceived as meaningful

metrics for impact of investments in the health sector – While current Lives Saved approach should be applauded, it

does not take into account the entire health system when measuring outcomes

– Additionally, these results, while faster, face significant methodological and data challenges

• Due to current challenges, the World Bank has decided to revise (“upgrade”) its Lives saved methodology.

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World Bank – IHME Collaboration on next Generation of Lives Saved

The World Bank has partnered with IHME to:• Preserve the benefits of initial Lives Saved approach with

timely, meaningful and compelling information with comprehensible estimates on the likely impact of health investments

• Create a framework for the next generation of investment impact accountability methodology

• Improve metrics that take into account all key components of the health system that contribute to success

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Rationale

• Demand for metrics that convey the impact of DAH in a compelling, digestible and timely manner

• While current Lives Saved approach should be applauded, it does not take into account the entire health system when measuring outcomes

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Lives Saved Approach: Key Challenges

• Current Lives Saved approach diminishes the importance of the role of Health System Investments–Most approaches attribute lives saved to

consumables or commodities– They neglect to take into account that the

effectiveness of such consumables and commodities depends upon their reaching patients and users

–Many components of the delivery-value-chain may be involved in this

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Child Treated

Efficient Warehousing and wholesale

distribution

Currently, Impact linked mostly with commodity

Purchased Malaria Drug

Malaria treatment

Child Treated

Global R & D; country level quality control and licensing

Robust and Efficient Procurement

Efficient Warehousing and wholesale

distribution

Clinic, and trained health worker

Information and HH demand side mechanisms

But, effectiveness of treatment requires a well functioning malaria treatment value chain

Purchased Malaria Drug

Motivated and efficient Health

Worker, diagnosis and treatment

Malaria treatment

Key priority disease value chains share same critical components. Need for System approach to strengthen them

Interventions

Child Treated

Malaria Prevention through Bed-Net

Global R & D; country level quality control and licensing

Robust and Efficient Procurement

Efficient Warehousing and wholesale

distribution

Clinic, and trained health worker

Information and HH demand side mechanisms

Purchased Malaria Drug

Motivated and efficient Health

Worker, diagnosis and treatment

Mother Treated

Vertical HIV Transmission Prevention

Global R & D; country level quality control and licensing

Robust and Efficient Procurement

Efficient Warehousing and wholesale

distribution

Clinic, Laboratory and trained health worker

Information and HH demand side mechanisms

Purchased ARV

Motivated and efficient Health

Worker, diagnosis and treatment

Mother Consuming MN

Micro Nutrients Supplement During Pregnancy (Vit A)

Global R & D; country level quality control and licensing

Robust and Efficient Procurement

Efficient Warehousing and wholesale

distribution

Clinic, and trained health worker

Information and HH demand side mechanisms

Purchased Micro Nutrient

Motivated and efficient Health Worker, prescription and

provision

Regulatory Capacity (Stewardship)

Procurement Capacity

Consumable or commodity

Syst. Component

Logistics and Distribution

Communications; CCTs, Health

InsuranceWorker training,

hiring and retention;

Infrastructure

Provider Payment Mechanisms

Lives Saved Approach: Key Challenges

• Health Impact from Investments in Other Sectors are underestimated– For example, the impact of programs on

environmental pollution, transportation, and indoor air pollution are not yet assessed

– Currently included: education for young girls, road safety, water and sanitation

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Methodological Limitations

• Potential for double-counting– Current Live Saved methodologies have the potential for the

same life saved to be counted multiple times by different donor organizations

• Heterogeneity in the timing of benefits– Deaths prevented through one intervention can be nearly

instantaneous while for others it may be in years to come• Efficacy versus effectiveness

– Most information currently used comes from randomized clinical trials, but an extensive literature demonstrates that due to enhanced provider effort and exclusion criteria used in RCTs, the likely benefits in most scaled-up programs will be smaller

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Moving Forward

•To sustain investments in global health– critical to quantify the likely health benefits of the current investment portfolios –communicate that impact in a timely and compelling manner.

• One way: “Health Impact Accounts”HIAs are a systematic assessment of the health impact of an investment portfolio compared to the counterfactual

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1. Assess all investments in terms of critical value chains

•Improved health from investment comes through the delivery of interventions to improve health •First step to understanding investment impact is identifying the critical value chains involved in the implementation

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2. Assess national changes in inputs and effective coverage for a value-chain

•HIA must take into account all actors influencing a value chain in a country•This requires the most information possible on NHAs, but in their absence, the projection of a secular trend in coverage that would have occurred without donor investments would suffice

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Bednets Example

Hypothetical case of the trend in investment and coverage for a value-chain 17

GOV

ITN

Cov

erag

e

YEARstart year

secular

DAH

3. Allocate national changes in effective coverage to components and by investors in value-chain

•If one organization is investing in cold chains and health information and the other in financing vaccines, the overall changes in immunization coverage should be allocated accordingly

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3. Allocate national changes in effective coverage to components and by investors in value-chain

• If there is clear evidence about the pay-off from different types of investments this should be taken into account

• If there is clear evidence that one donor is more efficient that others in investing DAH on value chain components, this should be taken into account

• Otherwise, all donors should be considered equally efficient

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4. Estimate health impact from changes in coverage with evidence including national trends in health outcomes

•The strongest possible effort should be made to map the path for intervention to health gain•Take into account both demand and supply side factors to identify gap between efficacy and effectiveness

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5. Health impact should be disaggregated into time periods and different metrics

•Different users of the HIA may want to understand when benefits should occur and what the magnitude of the gain is for the affected population

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Deaths averted YLLs DALYs

Have accrued

Should accrue

Next Steps

• Demonstrate feasibility of proposed approach at a global scale for selected value chain both in and out of the health sector

• Develop strategic messaging of new health impact accounting to explain, justify and enhance credibility

• Expand analysis beyond World Bank

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