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With shifting disease burdens, growing populations, and rising expectations comes a greater focus on value for money. International health funders and agencies want to know how to make the most of money spent by focusing on the highest impact interventions among the most affected populations. Whether through better procurement systems for health commodities, results-based financing, or more detailed assessments of the effective ness of health technology, CGD’s work aims to make health funding go further to save, prolong and improve more lives.
Global health policy enthusiasts will be excited to see that WHO has recently published a draft Concept Note on the 2019-2023 Programme of Work under the stewardship of its new Director-General, Dr. Tedros Adhanom Ghebreyesus (or Dr. Tedros, as he is generally known). The note will doubtless stimulate much discussion within WHO and among its stakeholders and—perhaps inevitably at this stage in the DG’s tenure—much of the detail remains to be filled in. However, the note does have an important role in establishing the key themes for the Organization in the next few years, and as such, it is disappointing that it does not offer a clearer storyline of where WHO wants to go.
We see two glaring missed opportunities: 1) more centrality to universal health coverage (UHC) as an organizing principle for WHO and its work, and 2) more emphasis on enhancing the value for money of public spending on UHC and elsewhere.
Missed opportunity #1: reiterate the centrality of UHC in reaching WHO goals
The first missed opportunity is the failure to reiterate the centrality of UHC to what WHO hopes to achieve. This is surprising as much of the success the WHO has had in recent years in setting the global policy agenda stems from its presentation of the moral and economic case for UHC, particularly in the World Health Report 2010.
By contrast, the treatment of UHC in the current Concept Note is fleeting and superficial. Its opening section “What does the world need?” contains a grab bag of “global health challenges,” leading off with the threat of pandemic flu. This is a missed opportunity to lay out the appeal and power of UHC as an integrative concept. Indeed, the best chance the world has to prevent outbreaks of diseases old and new, to cope with threats to health arising from conflict and natural disasters, to secure financial protection for citizens, to manage and contain the growth in non-communicable diseases, as well as all the other things listed, is if countries move towards sustainable and equitable financing of their health systems through implementing UHC.
The note also begs the question: what exactly would WHO’s role be in supporting countries in their progress towards UHC? Had they been more specific on where WHO can add value in supporting countries to reach their UHC vision, the authors of the draft strategy could be setting out measurable indicators and attributable results of WHO’s activity, which can then be used to inform the outcomes based agenda they advocate. Would WHO be offering advice and setting global norms? Would it be involved in or even leading efforts to devise progress indicators and help collect data and report progress against those as the latest edition of GBD has done? Would it go further and set standards for minimum benefits, populating the famous WHO UHC cube? Would it help countries track expenditure or provide advice on financing and provision arrangements? Would it do even more as suggested and become more operational (and what would this look like in country settings)? And if most or all of the above, where would the capacity come from—and would an alternative not be working with others operating in this space, leveraging already committed resources and expertise in a synergistic fashion? In the spirit of setting priorities and given finite resources, WHO must surely realise that its advocacy, global coordination, and norm-setting role are its real strengths.
What makes this neglect particularly surprising is that UHC is a prominent part of the platform on which Dr. Tedros stood and was elected by the World Health Assembly. Dr. Tedros’ campaign materials prominently list Health for All as the first priority and states clearly that:
“Health for all” must be the centre of gravity for efforts to achieve all of the SDGs … WHO’s top priority must be to support national health authorities’ efforts to strengthen their core responsibilities … Achieving universal health coverage is an ambitious goal, but it is one that can and must be achieved to create a healthier and more equitable world.
No comparably strong statement appears in the present document which does not get around to discussing UHC directly until page 6, hidden between health emergencies and priority SDGs.
Missed opportunity #2: emphasize value for money in health spending and its uses
The second missed opportunity is about value for money (VfM). The UHC section of the note would be an ideal place to discuss prioritization of spending at country level, based on existing financial envelopes, while also making robust cases to countries’ treasuries for more. Instead we are given a bill: “Achieving the SDG health targets would require new investments increasing over time from an initial US$ 134 billion annually to $371 billion, or $58 per person, by 2030.” There is no mention of the need to spend better, as is clearly set out in WHO’s report on SDGs in Africa; and no mention of the lack of correlation between more spending and better outcomes.
When the note does get around to talking about VfM (on page 9), the discussion seems even more underdeveloped than the discussion of UHC. VfM should be a critical concept for WHO. But the note seems to take the narrowest possible interpretation of value for money, stressing the need for WHO to measure outcomes and operate sound financial management.
Yet as a global normative agency, WHO has a far broader duty—to guide those with the responsibility for managing the world’s health systems to adopt economic appraisal and prudent management practices. A good start would be to declare that WHO will operate on the principle of VfM in all policies, a principle which can be the responsibility of the organisation’s first Chief Economist as Glassman has argued recently.
So, WHO should adopt a reference case for economics to be incorporated into all WHO programmes and all norm setting functions, including new additions to the Essential Medicines List, especially when the new items are: expensive on-patent products; Standard Treatment Guidelines norms in high priority areas such as antenatal care; investment cases for MDG technologies which the Global Fund and UNITAID will go on to purchase at volume; diagnosis and treatment targets such as the 90-90-90 target for HIV; and treatment initiation thresholds for HIV/AIDS. All of this is necessary to ensure that money which flows into health systems is used to the greatest benefit of the target populations and to convince those who fund WHO that it is serious about the VfM agenda. Another important role that WHO could pursue is to promote VfM at the country level especially for transitioning countries—WHA2014 HITA is great starting point. As stated in the Resolution, WHO can help build local capacity for countries to select products, negotiate prices and fees, manage providers through performance contracts where possible, control for and reward quality. Without such capacity the bill for implementing UHC will be much higher and selling the costs to country Ministries of Finance will be harder. Indeed, given the focus of the note on performance indicators for WHO, building in-country capacity is something WHO could be held to account to and that could be linked to better progress towards UHC.
Dr. Tedros himself has said that “the right of every individual to basic health services will be my top priority.” Parsing “basic” as “affordable” puts UHC and VfM at the heart of the DG’s vision. Alas, this clear and compelling vision seems to have got lost in the present Concept Note, which presents a WHO trying to respond to a disparate collection of problems, but with no clear organizing concept of how to tackle the underlying systemic causes of these problems or prioritize competing demands on the Organization’s scarce resources.
Health products—including drugs, devices, diagnostics, and vector control tools—are essential for meeting the healthcare needs of any population. Right now, many low- and lower-middle-income countries (LMICs) rely on donor-managed mechanisms to procure a large share of these health commodities, often at subsidized prices or as donations—and commodity financing represents a significant proportion of external health funding in these countries. (For example, procurement and supply management of health products comprise 40 percent of Global Fund annual grant disbursements.)
But this status quo won’t stay static for long, and the global health community must prepare for sweeping changes in global health and procurement over the next 10–20 years. Here’s some of what we see happening now—and on the immediate horizon:
LMICs are becoming wealthier. . . and graduating from aid eligibility. As countries lose access to free or subsidized health commodities, they may need to develop alternative procurement arrangements to ensure a steady and affordable supply of essential health commodities.
LMIC spending on health—and health products—is rising. As countries increase domestic health spending, they will see opportunities to expand the range of health products (and services) offered to their populations.
The composition of product needs and demand in LMICs is changing. As disease burdens in LMICs continue to evolve, with noncommunicable diseases accounting for an increasing share of the total burden, patients will need access to a different mix of health interventions. At the same time, wealthier and more sophisticated urban populations will demand more complex care—from cancer treatment to kidney dialysis.
Health commodity prices paid in LMICs can be high—and highly variable. While available information is neither very recent nor complete, the literature suggests that LMICs often pay high prices for health commodities, with significant variation across countries and procurers. Looking ahead, what procurement strategies, in different contexts and for specific product classes, could help LMICs achieve more affordable prices for high-quality commodities?
The fiscal burden of health commodity costs is increasing for LMIC governments. (See the Institute for Health Metrics and Evaluation’s projections here.) As these pressures continue, countries will need to strengthen national institutions for priority-setting and procurement to achieve greater efficiency from public spending on health.
New technologies are coming online and competing for scarce LMIC funds. As new technologies—ranging from injectable antiretroviral therapy to personalized cancer vaccines—become available, countries will need to prioritize the use of scarce public funds to cover the most impactful and cost-effective products and interventions.
In this context, how can the global health community act now to ensure the medium- to-long-term efficiency, quality, affordability, and security of global health procurement? This question is the subject of a new CGD working group on the future of global health procurement, which aims to produce actionable recommendations for the global health community. The working group, launched in late July, brings together representatives from LMIC governments, global procurement agents, funders, and international agencies, as well as experts on issues such as industrial organization, contract theory, and auctions.
The final report, expected in late 2018, will outline the working group’s key findings and propose recommendations for near-term action. Throughout this process, CGD will engage key global health stakeholders—country representatives, procurement agents, funders, and industry partners—to learn from their experiences and to eventually translate recommendations into action. We know procurement and prices can be controversial issues, and we are committed to reflecting the range of views and to finding solutions that are feasible and help improve outcomes.
Stay tuned for more updates as we dive deeper into global health procurement—including what does and doesn’t work—with an eye toward informing future directions. In the meantime, if you have thoughts or ideas to share, please leave us a comment below.
At a London conference earlier this month, some donors promised generous funding for family planning services in developing countries. At the same time, however, future support from the US is in doubt, and progress towards the FP2020 family planning goals has been extremely limited. Just how much progress have we made, and how far do we have to go? What difference will the new pledges make, and how should they be used? Rachel Silverman, CGD’s assistant director of global health policy, responds to these questions in this week’s podcast.
The issue of family planning has been high on the international agenda recently. Earlier this month, London hosted a pledging conference where some donors promised generous funding for efforts to increase access to and education around family planning services in developing countries.
At the same time, however, there is increasing uncertainty about future support from the US, which has historically been one of the biggest donors. There is also growing concern about the world’s limited progress towards the family planning goals that were agreed upon in 2012, through the international framework known as FP2020.
Just how much progress have we made, and how far do we have to go? What difference will the new pledges make, and how should they be used? “There’s an opportunity to use the funds to plug some of those holes, but it will depend on how they’re managed and allocated,” Rachel Silverman, CGD’s assistant director of global health policy, tells me in this week’s podcast.
One priority, Silverman says, is to help donors “work together to make sure the funding is directed in a coordinated way towards the areas of most need, the areas where the funding can go the furthest.” Recommendations on how to do just that can be found in CGD’s recent report Aligning to 2020, and you can learn more about how to get the best health value for your money in CGD’s forthcoming book What’s In, What’s Out.
In the meantime, click below to hear more of Silverman’s thoughts on the subject and check out the full podcast at the top of this page.
This commentary was originally published on the International Journal of Health Policy and Management website, an open-access, peer-reviewed journal.
Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities.
Baltussen et al argue against an ever growing volume of one-size-fits-all cost-effectiveness data for supporting healthcare decisions en route to universal health coverage (UHC). Instead, they propose what they describe as “evidence-informed deliberative processes” which acknowledge the complex politics involved in making such decisions. Although little empirical evidence exists as to the effectiveness of deliberative processes or their impact on the quality of the decision reached, it is plausible to suppose that deliberation “as an aid to thought and judgment” and “compared with a ‘closed door’ or ad hoc process” will be “more comprehensive in the relevant issues embraced, more consistent in the way they are embraced and more engaging of the people affected by the outcome.”
Consistent with that belief, national institutions responsible for setting priorities for public spending in healthcare, which use evidence and due process, have emerged in several countries. These are mostly high-income ones – including England and Wales (National Institute for Health and Care Excellence, NICE), Canada (Canadian Agency for Drugs and Technologies in Health, CADTH) and the Republic of Korea (National Evidence-based Healthcare Collaborating Agency, NECA), as well as more recently in low- and middle-income countries (LMICs) including Thailand (Health Interventions and Technology Assessment Program, HITAP) and Brazil (National Committee for Technology Incorporation, CONITEC)., These organisations are often known as health technology assessment (HTA) agencies, with “technology” often being much broader than drugs or devices to encompass policies and delivery platforms. Moreover, their function and structure are strongly dependent upon the healthcare system within which they operate. Most explicitly consider cost-effectiveness evidence in their decision-making as well as evidence in the broadest sense, including so-called colloquial evidence on social values and service user perspectives. As interest in more systematic approaches to allocating resources grows, a global development subfield has evolved including World Health Organization (WHO) CHOICE and Disease Control Priorities (DCP), both of which produce global evidence and guidance about “globally” cost-effective health interventions. Baltussen et al claim that these global trends ignore the local political economy of priority setting and are therefore, unlikely to influence the actual allocation of scarce healthcare resources in LMICs. We agree.
Better decisions about priorities for resource allocation, based on comparative evidence of costs and benefits, and that are feasible and implementable, are becoming increasingly possible in the current move towards UHC. Many LMICs are experiencing rapid economic growth, with wealthier and more educated populations facing a growing non-communicable disease burden. In combination, these factors are leading to rising demand for quality healthcare, especially in middle-income economies. Although health budgets are increasing year on year, the lack of institutional mechanisms for prioritising services and spending makes attaining UHC all the more challenging. In response, health authorities and payers often set out to define benefits packages,, that is, the services and technologies to be covered by public budgets including social health insurance schemes and tax-funded national health services. This often happens through explicit lists, including negative lists of technologies not covered as well as positive lists (also defined as benefits catalogues by Schreyogg et al13). Designing and adjusting benefits packages is an example of priority setting, that is, deciding who receives what healthcare at what cost.,
One way in which things can go wrong is exemplified by the role of the judiciary in priority setting. At least 115 countries worldwide have the right to health enshrined in their constitutions and through legal interpretations.15,16 In the absence of corresponding legitimate, transparent and evidence-based priority setting processes, health systems become vulnerable to the country’s judiciary making ad hoc decisions on what the system ought to pay for individual patients, often overlooking overall budgetary and other constraints in making such decisions and the resulting impact on the availability of healthcare for the rest of the population. There has been, for example, a mushrooming of court decisions compelling the authorities to provide expensive, often unproven, treatments to specific individuals. A significant share of these cases have been about the delivery of services and technologies already in the benefit packages but which the system has been unable to finance and provide., However, the increasing involvement of the courts in individual treatment decisions and national policies, prioritising human rights of individual patients over affordability for the health system and patients as a whole, can undermine well-intentioned public policy and, at worst, inject further inequalities and inefficiencies into the healthcare system.
To place local values at the heart of decision-making, Baltussen et al1 launched an innovative research initiative, REVISE 2020, which openly recognises that “…that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria.” Our like-minded international Decision Support Initiative (iDSI) (http://www.idsihealth. org/) was established to strengthen in-country institutional and technical capacity together with open participative processes for evidence-informed policy-making. It takes the form of a collaboration between local policy-makers and other stakeholders for sharing experiences, methods, and knowledge.
Is the Problem Too Much Cost-Effectiveness Analysis?
Baltussen and colleagues criticise the promotion of cost-effectiveness analysis (CEA) by global players as the central or even sole criterion in decision-making for all the aforementioned political and value reasons. Yet CEA, as a means of systematically assessing the benefits against the cost of alternative investment options, is in fact not much used by countries’ health authorities in making decisions about real-life public spending in health. Moving towards a situation where economic evidence is down-valued or even deprioritised over other socially acceptable considerations, with or without deliberation, risks throwing the baby out with the bathwater.
Should Scientific Value Judgements Be Context-Free?
Global approaches to CEA can hardly be too context-sensitive. Studies done by global players that ignore local contexts but nonetheless presume to advise may undermine local priorities and distort local spending decisions. Without in-country expertise for commissioning, producing and interpreting local data on costs and outcomes, globally conducted CEA may do more harm than good,, particularly if the advice based on such analysis to countries carries weight because of the authority and standing of its authors. Standardised cost-effectiveness decision rules arbitrarily set by global experts with no consideration of local budgetary constraints and opportunity costs, and based on global generalities such as WHO’s Generalised CEA (explicitly devised to ignore the local realities of current practice through introducing null comparators), serve to promote badly applied cost-effectiveness principles.
CEA is not intrinsically centralising: whether it is depends on the politico-legal structure of the jurisdiction and the corresponding governance arrangements. Further, the “one size fits all” question applies not only at the global versus country level but also within jurisdictions, even the less federalised ones where there are ample opportunities for local priorities to clash with central ones. Countries like India and South Africa exemplify this on a grand scale. In the case of South Africa, there is a relatively small budget for the National Department of Health, and significant devolution of budgets direct to provinces, alongside a sizeable private sector which accounts for more 50% of the spent for servicing less than 20% of the population. We, therefore, agree with Baltussen et al that at national level there is a critical role for “more generic centrally-led institutionalized processes,” convening the expertise and evidence in the country to inform its priority setting in a way that is relevant. These national processes and decisions not only guide local (subnational) decisions but can be used also to define the scope of local or provincial discretion in following central guidance, providing a transparent means through which differences both of perspective and of material fact can be resolved.
The Lancet Commission on Investing in Health is another example of global advocacy. It sets out three lists of cost-effective interventions in answer to the question of “what” for UHC. But, it is not possible (let alone desirable) to determine at the global level what is cost-effective or equitable or otherwise acceptable at country or regional level. The theory may be context-free but its application is not. LMICs are especially vulnerable because they often have very limited capacity to challenge the local applicability of global advice or to conduct independent assessments that take due account of local circumstances. The first question in any respectable guidance for carrying out CEA is, rightly, something like “What is the context?” or “What is the perspective?” for this study. This is as important a question in LMICs as it is in rich countries. Even at relatively high levels of decision-making, for example, when prioritising health vis-à-vis education, the matter of resource allocation is essentially one for local judgment. After such a high level process, in a well-planned health system of an LMIC committed to UHC, the public budget for health including donor contributions and net of any substitution of donor for national funding is then available for further prioritisation within health—and will need to respect, amongst other things, the constraints of country-specific donor-set commitments to diseases like HIV and technologies like vaccines, local demographics, local disease burden, local values with respect to equity, local costs of interventions, and informed local judgments about acceptability, feasibility, manageability and speed of implementation in policy and clinical practice.
Such a more nuanced approach is not the norm even in existing international advisory agencies. WHO’s long standing process for updating its Essential Medicines List is another manifestation of limited relevance accorded to context. As a result, aspirational listing of expensive patented pharmaceuticals with little country or subnational guidance on price to ensure value for money, can often be used as a marketing tool by vested interests despite the well-meaning intentions of those access to medicines activists.,
Criteria for setting priorities are matters of political and social judgment by those who are accountable to the citizens. Technical experts do not have this accountability. We, as iDSI and like Baltussen et al, subscribe to a deliberative and locally focused approach to decision-making, that is evidence-informed, based on the principles of the iDSI Reference Case for Economic Evaluation. We support approaches that operate through transparent and independent processes that encourage trust and credibility. Our “one-size-fits-all” solutions are, therefore, set at a very high level and with the possibility of nuancing, for example of the degree of openness and participation, in keeping with such principles as those set out in the accountability for reasonableness framework. But, what we do not do is to advocate on behalf of particular types of people, categories of disease, or types of intervention or predetermined lists of services. Such matters are to be decided by countries, provinces or districts using the recommended methods and decision-making systems but embodying their own social and political values.,
Effective Deliberation Costs Money and Takes Time
Global experts should not dictate the priority that health ought to have over education or other sectors; instead, experts can help local decision-makers develop politically feasible, credible and transparent ways of making such choices. We are making some value judgments here—about decision-making processes rather than the outcome of such processes. Similarly, within health policy, it is not for external experts to decide health priorities. Experts can provide tools and evidence, and, where appropriate, broader policy frameworks. Such is the 2014 WHO resolution on “Health Intervention and Technology Assessment in support of UHC” to support local capacity strengthening and local determination of health priorities.
However, given the limited resources and capacity in many LMICs to create functioning deliberative process in the short run, one can begin with technocratic evidence generation from a small unit in a health ministry or a health insurance agency, aimed at influencing budgets and investment through providing such evidence of trade-offs to decision-makers., Those decision-makers include individuals responsible for making investment decisions at a national or provincial health insurance agency, ministries of health and social security, or ministries of finance. A deliberative process including elements of consultation, transparency, and guarding against vested interests often evolves alongside attempts to generate the needed evidence so that the evidence is more likely to influence decisions, and both elements (economic evidence and due process) are needed for paving an effective path to influencing resource allocation.
CEA matters if countries care about UHC and improving health outcomes., However, CEA that is not based on local evidence is not useful and can even be harmful., A deliberative process taking into account local values and local evidence—including but not limited to CEA evidence—is the holy grail for country empowerment and UHC sustainability and is perhaps the mechanism through which to achieve better spending outcomes in health. As countries commit to UHC and start to contribute to this commitment financially, there is an opportunity for global partners to align themselves with the principle of context-sensitive evidence as a driver for better decisions, and to support technical, institutional and informational capacity at the local level for achieving this.
It is not the role of global advocacy or technocratic institutions to pre-empt the result of local deliberative processes. The question can be globally put “who or what should get priority?” but the answer must be local. To do otherwise is to disenfranchise national policy-makers and local communities. Their answers may not be those preferred by the global advisers. Why should they be? After all, it is national policy-makers and technocrats, elected by the people or appointed by elected officials, respectively, who will be accountable for their decisions and it is probably these and other local stakeholders who can form the best judgments about what is actually feasible, sustainable and timed rightly for their particular situation. Our responsibility as advisers ought to be to facilitate governments and communities to realize their aspirations, not ours. They decide ends; we can only suggest means.
This work received funding support from the Bill & Melinda Gates Foundation, the Department for International Development (UK), and the Rockefeller Foundation. The funders played no role in the writing of the manuscript. The bulk of this work was completed while the authors KC and RL were employed by NICE International.
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In late 2015, India’s Ministry of Health affirmed its commitment to universal health coverage (UHC) in a public letter: “We are… committed to ensuring Universal Health Coverage with first priority accorded to the health needs of those who require it the most. UHC with equity is thus our goal.”
Fast forward to this year’s budget when the Indian government announced its intention to provide dialysis in every district hospital in the country. Kidney failure in India has doubled over the past 15 years; there are about 220,000 new patients with end-stage renal disease (ESRD) each year and the majority are poor.
But if India actually funded and provided dialysis to the population in need, the entire Central government’s public spend on health might be consumed (see Figure). Dialysis, particularly hemodialysis or HD, is expensive. In India, one HD session costs about Rs 2,000 (USD$30), which adds up to more than Rs 300,000 per patient per year (USD$4,465). Of course, there might be economies of scale that could drive down prices and marginal costs over time, but the point is that little thought seems to have been given to the expenditure requirements and trade-offs that a dialysis coverage decision might generate for a health system committed to “UHC with equity”.
Figure: Projected national annual costs of dialysis –if fully implemented- could surpass National Health Mission budget for FY16-17
Calculated using UN population projection data and Veerappan and Abraham (forthcoming) for prevalence rate of 785 per million population for three years. Multiplied projected prevalence by average cost of dialysis per patient (Rs 300,000). Projection is if all patients received average amount and frequency of dialysis treatments. Compared with amount Rs allocated in National Health Mission budget FY16-17.
As in many other countries, politicians have decided what will be subsidized in an ad hoc way. With no clear criteria or explicit process for deciding what health services will be covered with public monies, the measure was simply announced in the Union budget, complete with a tax break for importation of dialysis equipment and a note that the initiative could be implemented through a public-private partnership.
The possible result: implicit and unfair rationing of care—with spending consumed on a first-come, first-served basis, likely in urban areas. As former Health Minister of Maharashtra Suresh Shetty has highlighted, it is difficult to get qualified doctors and technicians to perform dialysis in rural areas. Further, while there is certainly need and demand for dialysis services, many Indian citizens still lack access to the most basic kinds of cost-effective health care: things like oral rehydration salts for diarrhea, vitamin A supplementation, treatment of depression or smoking cessation support, among many others, not least programs that could help prevent ESRD and its precursors (diabetes, hypertension) in the first place.
Now that the decision has been made, authorities in India—and those in Indonesia, Pakistan and Nigeria who are moving ahead with similar initiatives—need to ensure that the dialysis program implemented does not consume the entire budget or crowd out other important uses of public spending on health, thereby working for and not against UHC aspirations.
We suggest three strategies based on other countries’ experiences: (1) more systematic evaluation of options to inform coverage decisions; (2) more systematic attention to the ethical aspects of selecting patients who will receive dialysis in the context of a limited budget and supply constraints; and (3) more attention to cost-effective prevention and management of ESRD pre-cursors such as diabetes and hypertension.
First, policymakers need to evaluate the cost-effectiveness of different kinds of dialysis to choose the most effective and least costly option for coverage. Thailand’s health system provides some insight: in the early 2000s, ESRD incidence increased and there was a push for inclusion of dialysis in the country’s Universal Coverage Scheme (UCS) benefits package. The National Health Security Office (NHSO), Thailand’s payer agency, subsequently commissioned nephrologists and policy researchers to evaluate the cost-effectiveness of different kinds of dialysis. Although their study found that neither hemodialysis (HD) nor peritoneal dialysis (PD) was cost-effective according to their standards, they determined that PD was more cost-effective than HD because PD had a home treatment option, whereas additional infrastructure and human resources were needed to treat patients with HD and HD can be costly for households (even if the service is free) because patients and/or caregivers still need to pay a lot for transport between home and a dialysis center 2-3 times a week. Based on this evidence, the NHSO opted for a PD first policy in Thailand’s UCS benefits package. This kind of analysis and decision is crucial for UHC given—as in Thailand—many nephrologists will own private HD clinics, and will likely advocate for extension of this model, in spite of the untenable costs that may have implications for equity. Attention should also be paid to how a government announcement to cover dialysis in whatever form can affect the price of related products; in Indonesia, for example, PD consumable manufacturers were considering price hikes once an official policy was announced, suggesting that government may wish to negotiate prices ahead of any decision-making.
Second, the government should consider the equity, ethics, and social and legal implications in making decisions about who will benefit from the dialysis program. The approach in one hospital in South Africa is interesting. In 2010, after learning that white patients were almost four times more likely to be accepted for dialysis treatment than nonwhites at Tygerberg Hospital, provincial officials and medical professionals in South Africa created an official, transparent and accountable system to decide which patients would receive dialysis treatment on a priority basis, given the limited budget and capacity. This idea has been around for some time in the framework of Accountability for Reasonableness, but is receiving increasing attention in operational settings as in the South African example, among others. As India plans its dialysis program, it is important that guidelines are explicit for every step of dialysis selection and treatment, and that the ethical implications of such decisions are addressed and managed.
Finally, to combat the staggering increase of ESRD, prevention is key. Rather than spending all of the funding allocated to kidney disease on tertiary care options, the Indian government must consider prevention efforts as an equally important, if not more important, priority. Dialysis is only a Band-Aid to the problem; risk factor prevention, diabetes management and screening programs and other prevention measures need to be implemented to stop the disease at its root, as the Prime Minister himself has pointed out.
And tracking and discussing what countries actually do—as in this blog post- is also important, and follows on our continued work on priority-setting, since the way in which health systems cope in balancing these demands has major implications for global health’s UHC dreams.
Thanks to Anit Mukherjee and Yot Teerawattananon for their input on this blog post.
 HD uses a man-made membrane to filter wastes and extra fluid from the blood, while PD uses the lining of the abdominal cavity and dialysate solution to remove wastes and extra fluid from the body.
At the World Bank’s Annual Universal Health Coverage (UHC) Financing Forum this year, I took part in a mock competition to help determine the topic of next year’s forum. I was up against Larry Gostin, who argued that the 2017 forum should focus on equity and human rights, and Sara Bennett, who made the case for it to be the political economy. My pitch was for the forum to focus on efficiency—or value for money—in UHC reforms, and here’s why:
There are two core reasons why thinking about and ensuring value for money in health is so important right now. First, the health sector needs to ensure that limited resources go as far as possible. In 2010, the World Health Report estimated that 20-40 percent of all health sector resources are wasted and therefore not put toward achieving health goals. Second, across sectors, competition for resources and the attention of policymakers and donors is heating up as the global economic slowdown constrains domestic resources, and as development assistance for health has flat-lined in recent years. A good way to make sure that health stays on top of the agenda is to show citizens and decision-makers that the health sector can provide value for money.
So what is value for money? It is getting the most benefits out of a set of resources by allocating more efficiently, generating more impact, or lowering costs. It is not recklessly cutting health budgets or irresponsibly pivoting to a priority-of-the-moment issue. That can have serious consequences, such as the resurgence of diseases like yellow fever and malaria.
To mobilize resources more efficiently, countries can reduce distortions in existing tax systems (for example, at the intersection of formal and informal sectors) and donors can streamline programs and lending. Combining pooling arrangements can improve risk protection and lower administrative costs. It can also help avoid unsavory incentives that can otherwise only be contained with extensive (and expensive) regulation. And finally, we can also spend more efficiently. For instance, evidence from countries like Rwanda and Argentina suggests that results-based-financing (RBF) can help align incentives to encourage performance and to send money to the frontlines. But even within RBF programs there is room for improving efficiency, such as by lowering the costs of routine performance verification.
Value for money can also be applied to data collection in health. Universal health coverage programs generate large amounts of administrative data that could be used to inform policies and programs, but are often messy and difficult to access. As a result, existing data are not used to their full potential—including their potential to help identify and tackle inefficiencies. On the flip side, too much and unnecessary data are collected, often at substantial cost.
To convince countries and donors in the current economic climate to put up the funds needed to address the health equity gap, an estimated $70 billion per year until 2035, the global health community has to prove that it can make good use of funds and get results. Doing so will foster resilience and help maintain the impressive health gains and systems reforms of the last decades. To make next year’s Universal Health Coverage Financing Forum a success, we should start now to focus on strengthening the evidence base and political support for value for money. And of course, value for money shouldn’t only be on the agenda of next year’s forum, it should also be on the minds of researchers and decision-makers worldwide.
You can watch the entire session, including Gostin and Bennett’s pitches, here.