Economic Evaluation of Multisectoral Actions for Health and - PowerPoint PPT Presentation

A global research network in agriculture and food systems for improved nutrition and health www.ANH-Academy.org Economic Evaluation of Multisectoral Actions for Health and Nutrition Carol Levin, PhD University of Washington ICAE, July 30 2018

Scope • The ANH Academy Working Group on Economic Evaluation was established in October 2017 to advance knowledge and scientific understanding among the global research community of economic evaluation methods and metrics related to costs and benefits of multisectoral actions (agriculture, food and livelihood strategies) for nutrition and health.

What’s the problem? • Comprehensive approaches are needed to address a broader set of food system constraints to address undernutrition, double burden of malnutrition, emerging threat of obesity and noncommunicable diseases (NCD). • Decision makers (and modelers) need information on the costs and benefits (or cost-effectiveness) of multisectoral approaches. • Evidence is limited; transparency & standardization of existing evidence is poor.

Specific Objectives  Review current approaches for estimating costs, benefits and cost-effectiveness of scaling up multisectoral actions to improve nutrition and health outcomes in low and middle-income countries;  Develop principles for measuring costs, benefits and cost-effectiveness across the range of multisectoral approaches to improve agriculture, health and nutrition, that can be adapted for use under different scenarios.  Summarize current gaps and challenges related to these approaches, and identify opportunities for new methods and metrics for economic evaluation methods in this domain.

Types of Economic Evaluations

Epidemiological methods to generate evidence for impact of health & nutrition interventions

Mixed methods for evaluating impact of agricultural interventions

Measuring costs of multisectoral strategies is even trickier • Limited information on costs and impacts for nutrition sensitive interventions. – Much of it is modeled, limited empirical evidence and challenging b/c of cross sectoral nature. • Limited published information on costs of agriculture interventions, policies, programs. • Health and agriculture intervention impacts and costs measured differently — – Health: by intervention, facility or individual- derive a unit cost per beneficiary. – Agriculture: typically by crop (acre, yield, etc), by household (net income), by enterprise. – Spillover effects are harder to measure for agriculture

New resources to improve economic evaluation in LMIC • Can we build on new resources being developed? • Reference case approach – iDSi Economic Evaluation for Global Health – Global Health Cost Consortium (GHCC) Reference Cases for Global Health Costing – Harvard Benefit Cost analysis guidelines – any sector (agriculture, health, education)

iDSI reference case for economic evaluation The Principles • Transparency • Comparators • Perspective • Measurement of Outcomes • Measurement of Costs • Time Horizon • Cost and effects outside of health • Heterogeneity • Uncertainty • Budget impacts • Equity implications

The GHCC Reference Case

Guidelines for Benefit-Cost Analysis • Harvard University. • Funded by BMGF. • Developing guidelines to encourage the conduct of high. quality benefit cost analysis. • Build on the existing iDSI reference case. • Aligned with GHCC RC.

What is a ‘ reference case ’ approach? 1. Set of ‘acceptable’ principles 2. Methodological guidance on how to achieve those principles (theory and evidence based) 3. Standardisation for specific interventions with additional guidance where available 4. Reporting standards

Part 1: Understanding the moving parts! TOWARD A FRAMEWORK AND COMMON APPROACH

Typology of interventions 1. Supply of 2. Demand nutrition for nutrition foods foods 3. Enhance VC performance & 4. Empowering enabling women environment Figure source : de la Peña et al. IFAD 2018

Typology of data sources Opportunity Effects Partners Costs costs other benefits Direct costs (in monetary value) Beneficiaries Funders Direct + secondary health Direct costs outcomes costs (e.g. in total DALYs) Opportunity costs Opportunity costs Primary outcome Studies may include Studies may measure only funders’ direct cost per unit of one costs, or count other outcome, or add up costs of participation multiple outcomes in and compliance DALYs, QALYs or dollars The weight of evidence depends on what’s included

Typology of study designs We see only where there’s light Scope of the study Standard of evidence Scale, location and duration of costs Understanding of mechanisms and effects Systematic reviews Single studies Selection bias may influence results, Studies differ in the nature of scientific as evidence is available only where evidence that is available and how it is used for cost-effectiveness analysis research is funded

Typology of decisions to be informed CEA aims to inform what gets scaled up Large scale Marginal Efficacy trial Pilot (Incremental CEA) (one more unit) (benefits only) (incremental costs & effectiveness) Scaling up may reduce or increase Programs can expand and create net gains until the cost of one additional unit of reach just cost per beneficiary reached, and equals the gains from that additional unit alter effectiveness

Part 2: Making sense of it all! TOWARD A FRAMEWORK AND COMMON APPROACH

Measuring costs and benefits along the Impact Pathway Source: Gelli et al. 2015

Identifying costs: Basic elements to consider For example Staff costs, Direct costs for the sector commodities/supplies, (health, agriculture, WASH) equipment Out of pocket Direct costs to households expenditures Indirect or opportunity Household labor, land, lost costs productivity

Identify costs Ac vi es� Inputs� � Costs� � From� provider� To� provider,� beneficiary� and� other� partners� and� service� providers� Personnel� � Direct� costs� to� provider� for� salaries,� incen ves,� � � volunteered� me,� and� other� staff� costs� e.g.� � � � Organisa onal� travel� and� subsistence� � � infrastructure� Ins tu onal� fixed� and� variable� costs� to� � � Extension� provider,� e.g.� personnel� management,� training,� and� monitoring� systems;� office� space� and� u li es;� dona ons� � Opportunity� cost� to� par cipant� for� me� taken� to� engage� with� extension� service� � Direct� cost� to� other� service� provider� of� any� increased� demand� for� government� services� � � � Physical� inputs� – � e.g.� Direct� costs� to� provider� for� physical� inputs� � seed,� fer liser,� � � Produc on� Direct� costs� to� beneficiaries� for� addi onal� livestock,� equipment� inputs� needed,� such� as� fuel� to� use� equipment� � � Opportunity� cost� for� beneficiary� for� labour,� Labour,� land,� water� land� use,� and� water� use� � � � Equipment,� e.g.� Direct� cost� to� provider� for� equipment� (e.g.� thresher� thresher)� � � Storage� and� � � Direct� cost� to� beneficiary� for� equipment� � � processing� maintenance� and� u li es� (e.g.� fuel),� and� space� for� storage� and� processing� � Opportunity� cost� to� beneficiary� for� labour,� space,� and� water� use� Vehicles,� fuel� � Direct� cost� to� provider� for� vehicles� /� fuel� provided� � � � � � Distribu on� and� Direct� cost� to� beneficiary� for� maintenance� costs� � � � transport� Opportunity� cost� to� beneficiary� for� labour� � � � Supplies,� equipment,� Direct� costs� to� provider� of� supplies,� equipment,� overheads� overheads� � � Catering,� retail,� � Direct� cost� to� beneficiary� for� addi onal� inputs� � � labelling� needed� � labour � Opportunity� cost� to� beneficiary� for� Materials,� e.g.� manuals,� Direct� cost� to� provider� materials,� pla orm,� � videos,� leaflets� personnel� � � � Pla orm,� e.g.� space� for� Direct� cost� to� beneficiary� for� changing� behaviour� � � Behaviour� � � mee ngs,� radio� air me,� Opportunity� cost� to� par cipant� for� uptake� of� new� � � change� � billboards,� home� visits� behaviour� � � � � Personnel,� e.g.� facilitators� /� Direct� cost� to� other� service� provider� of� any� counsellors,� management� increased� demand� for� government� services� � �