CDDEP Director Featured in New York Times

In collaboration with the University of Washington, The Center for Global Health Research, and the Public Health Foundation of India, the Disease Control Priorities Network (DCPN) aims to improve the efficacy of health resource spending in various contexts around the globe.

15 Aug 2014

“It’s complicated.“ That was one conclusion of a randomized trial of amoxicillin for children with uncomplicated severe acute malnutrition (SAM) in Niger. The trial was conducted by Epicentre, the research affiliate of Doctors Without Borders (Medicins sans Frontieres; MSF) to test the World Health Organization (WHO) recommendation that all kids with SAM be given an antibiotic—amoxicillin—along with “ready-to-use therapeutic food,” whether or not they have specific signs of infection.

The Question

How would increasing immunization coverage and introducing a rotavirus vaccine affect the disease and financial burden of vaccine-preventable illnesses in India?

What We Found

Using IndiaSim, a simulated agent-based model (ABM) of the Indian population (including socio-economic characteristics and immunization status) and the health system, we modeled three interventions: the introduction of a rotavirus vaccine is introduced at the current DPT3 immunization coverage level; the increase in coverage of three doses of rotavirus and DPT and one dose of the measles vaccine to 90% randomly across the population; and the targeted increase of these vaccines to 90% in rural and urban regions (across all states) that are below that level at baseline. For each intervention, we evaluate the disease and financial burden alleviated, costs incurred, and the cost per disability-adjusted life-year (DALY) averted.

Baseline  immunization coverage is low and has a large variance across population segments and regions. We determined that targeting specific regions can approximately equate the rural and urban immunization rates. Introducing a rotavirus vaccine at the current DPT3 level (intervention one) averts 34.7 (95% uncertainty range [UR], 31.7–37.7) deaths and $215,569 (95% UR, $207,846–$223,292) out-of-pocket (OOP) expenditure per 100,000 under-five children. Increasing all immunization rates to 90% (intervention two) averts an additional 22.1 (95% UR, 18.6–25.7) deaths and $45,914 (95% UR, $37,909–$53,920) OOP expenditure. Scaling up immunization by targeting regions with low coverage (intervention three) averts a slightly higher number of deaths and OOP expenditure. The reduced burden of rotavirus diarrhea is the primary driver of the estimated health and economic benefits in all intervention scenarios. All three interventions are cost saving.

Why It Matters

Improving immunization coverage and the introduction of a rotavirus vaccine significantly alleviates disease and financial burden in Indian households. We have determined that population subgroups or regions with low existing immunization coverage benefit the most from the intervention. This study could therefore inform future interventions by encouraging targeting those subgroups to alleviate the burden rather than simply increasing coverage in the population at large.

16 Jun 2014

Meet Saima Arshad. When she tested positive for tuberculosis, she was quarantined in her in-laws’ house, forced to wear a protective mask, and separated from the entire family – including her husband. 

The Question

Objectives: To estimate the epidemiological and financial benefits and the distributional consequences of policy interventions for coronary heart disease (CHD) and secondary Acute Myocardial Infarction (AMI) prevention in India.

Population:  Nationally representative sample population of one million.

Interventions: Policies of Universal Public Provision (UPP) and Universal Public Finance (UPF) for scaling up availability of four drug therapies: aspirin only; aspirin with beta blocker; aspirin with beta blocker and angiotensin-converting-enzyme inhibitor (ACEI); and aspirin with beta blocker, ACEI, and statin.

Main outcome measures: Incremental health (deaths averted) and financial (out-of-pocket medical expenditure averted, impoverishment averted, and value of financial risk protection) outcomes by wealth quintile, compared to baseline.

What We Found

Scaling up the four interventions can potentially avert between 25.4 (24.4–26.4) and 119.1 (118.2–120.0) deaths per year per 100,000 persons aged 30 or older. Under UPF, out-of-pocket (OOP) medical expenditures increase by $1,283 ($1,085–$1,481) per 100,000 persons in the aspirin-only case, but decreases by $14,641 ($14,466–$14,816) per 100,000 when all four drugs are scaled up. The UPP lower bound scenario, which assumes no change in people’s provider choice, increases OOP expenditure by up to $105,587 ($105,369–$105,806) per 100,000 persons. The UPP upper bound case, in which people change their health care provider after the policy, averts OOP costs by up to $14,289 ($14,100–$­14,468) per 100,000. The burden averted relative to income is typically highest for the first and fourth income quintiles. The policies also provide a very high and progressive-with-income value of insurance, barring a few exceptions. Finally, UPF and UPP upper bound policies prevent as many as 131 patients per 100,000 people from falling into poverty due to OOP expenditure. 

Why It Matters

Conditional upon provider choice behavior, the UPP and UPF policies may lead to a significant drop in both disease and financial burdens. The degree of averted burden varies across income groups, with higher relative benefits accruing to the poor. 

IndiaSim: An Agent-based Model for Estimating the Health and Economic Benefits of Secondary Preventionof Coronary Heart Diseases in India [ABSTRACT]


Research Analyst

Contact »

Devra joins CDDEP from Boston Medical Center's Epidemiology and Outcomes Research Unit, where she worked on disease modeling and researched the cost-effectiveness of different screening and treatment methods for people co-infected with HIV and Hepatitis C. She has a Master's of Science in Global Health and Population from Harvard School of Public Health with a concentration in Infectious Disease Epidemiology. Devra's research interests include: infectious disease dynamics, disease modeling, social determinants of health, and economic impact of diseases.

March 2014 | pg.

Research Area: Disease Control Priorities
Type: Article
The Question

How do incentives affect countries' decisions to report infectious disesase outbreaks?

What We Found

We compiled data on reports of meningococcal meningitis to the World Health Organization (WHO) from 54 African countries between 1966 and 2002. This period is marked by two events: first, a large outbreak reported from many countries in 1987 associated with the Hajj that resulted in more stringent requirements for meningitis vaccination among pilgrims; and second, another large outbreak in Sub-Saharan Africa in 1996 that led to a new international mechanism to supply vaccines to countries reporting a meningitis outbreak. 

We found that the Hajj vaccination requirements that were instituted in 1988 were associated with reduced reporting, especially among countries with relatively fewer cases reported between 1966 and 1979. After the vaccine provision mechanism was in place in 1996, reporting among countries that had previously not reported meningitis outbreaks increased.

Why It Matters

This shows that incentives, rather than just financial assistance to build surveillance networks, have the potential to alter reporting decisions for infectious disease outbreaks, especially when the burden of disease is low. In our study, policies that changed the benefits of reporting had little effect on reporting by countries with a large burden of meningococcal meningitis, but significantly altered reporting by countries with fewer cases.

15 Jan 2014
Elyse Franko

Click here for a live webcast of the event: January 16, 2014, 1:15pm-2:30pm EST

31 Dec 2013
Elyse Franko

CDDEP Director Ramanan Laxminarayan was a featured contributor this week in a New York Times "Room for Debate" discussion on antibiotic resistance.

What We Found

As the results of the Lancet Commission on Investing in Health and the Global Investment Framework for Women's and Children's Health have shown, the full impact of health investments goes beyond GDP to the value of being alive and healthy. When this fact is recognized, the return on investments in health is magnified several times over. The authors, a group of health policy leaders from around the world – including CDDEP Director Ramanan Laxminarayan – argue that the benefits of investing in health are clear, with substantial long-term economic returns; that the required investments are substantial, but not insurmountable, that the required investments for health in low-income countries should come from multiple complementary sources; that countries should be supported to develop sustainable financing mechanisms; and that ministries of finance, as well as private sector players, should be engaged to ensure investments are effective. 


Image via EU Humanitarian Aid and Civil Protection/Flickr