The Lancet Commission on Investing in Health Report Launch: December 3

Graphic

Pneumococcal disease is a leading cause of death for children under 5, particularly in developing countries. Using data from a 2000 WHO study, this graph shows the number of deaths per 100,000 children under 5 attributable to invasive pneumococcal disease, across six countries.

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. 



Health and Development

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.

Health Economics
February 2014

Research Area: Health and Development
Type: Article | Hot Topic(s): Health Valuation
The Question

Universal public finance (UPF) for health interventions entail consequences in a number of domains. UPF increases intervention uptake and consequent health gains; generates financial consequences; and provides insurance either through coverage or prevention. How can the consequences of UPF in each of these domains be evaluated? How can this be applied to UPF for tuberculosis treatment in India?

What We Found

We developed a method for the economic evaluation of UPF and other health policy instruments, which we call "extended cost-effectiveness analysis" (ECEAs).When applied to evaluating UPF in TB treatment in India, our ECEA example concluded that replacing private finance for TB treatment with UPF could bring substantial health gains and financial risk protection benefits. These benefits would have the most effect on poorer populations.

Why It Matters

ECEA builds on standard cost-effectiveness analysis (CEA) in three dimensions, all of which enhance the ability of stakeholders to evaluate policy: first, some health policy instruments (in particular UPF) will provide insurance against financial risks; second, policies have direct financial implications because private expenditures may be crowded out; last, health policy instruments have distributional consequences across wealth strata of a population. The methods we developed and employed in this study can therefore be a useful application in further analyzing health policy across a wide range of policy instruments and places. 

 

Homepage image via Yale Rosen/Flickr.


31 Jan 2014

By Anup Malani and Phoebe Holtzman

Health and Development

27 Nov 2013
Elyse Franko

We invite our readers to join us on December 3 for the launch of The Lancet Commission on Investing in Health (CIH) report “Global Health 2035: A World Converging Within a Generation”, which will take place in London, Johannesburg and Tunis.

Health and Development

The Question

The Rashtriya Swasthya Bima Yojana (RSBY), which was introduced in 2008 in India, is a social health insurance scheme that aims to improve healthcare access and provide financial risk protection to the poor. In this study, we analyse the determinants of participation and enrolment in the scheme at the level of districts. We used official data on RSBY enrolment, socioeconomic data from the District Level Household Survey 2007–2008, and additional state-level information on fiscal health, political affiliation, and quality of governance.

What We Found

Results from multivariate probit and OLS analyses suggest that political and institutional factors are among the strongest determinants explaining the variation in participation and enrolment in RSBY. In particular, districts in state governments that are politically affiliated with the opposition or neutral parties at the centre are more likely to participate in RSBY, and have higher levels of enrolment. Districts in states with a lower quality of governance, a pre-existing state-level health insurance scheme, or with a lower level of fiscal deficit as compared to GDP, are significantly less likely to participate, or have lower enrolment rates. Among socioeconomic factors, we find some evidence of weak or imprecise targeting. Districts with a higher share of socioeconomically backward castes are less likely to participate, and their enrolment rates are also lower. Finally, districts with more non-poor households may be more likely to participate, although with lower enrolment rates.

Why It Matters

The findings from this study can be used by governments to strengthen RSBY targeting systems and serve as an example for future studies evaluating the efficacy and impact of RSBY.


The Question

Institutional care is a growing component of health care costs in low- and middle-income countries, but local health planners in these countries have inadequate knowledge of the costs of different medical services. In India, greater utilisation of hospital services is driven both by rising incomes and by government insurance programmes that cover the cost of inpatient services; however, there is still a paucity of unit cost information from Indian hospitals. In this study, we estimated operating costs and cost per outpatient visit, cost per inpatient stay, cost per emergency room visit, and cost per surgery for five hospitals of different types across India: a 57-bed charitable hospital, a 200-bed private hospital, a 400-bed government district hospital, a 655-bed private teaching hospital, and a 778-bed government tertiary care hospital for the financial year 2010–11.

What We Found

The major cost component varied among human resources, capital costs, and material costs, by hospital type. The outpatient visit cost ranged from Rs. 94 (district hospital) to Rs. 2,213 (private hospital) (USD 1 = INR 52). The inpatient stay cost was Rs. 345 in the private teaching hospital, Rs. 394 in the district hospital, Rs. 614 in the tertiary care hospital, Rs. 1,959 in the charitable hospital, and Rs. 6,996 in the private hospital.

Why It Matters

Our study results can help hospital administrators understand their cost structures and run their facilities more efficiently, and we identify areas where improvements in efficiency might significantly lower unit costs. The study also demonstrates that detailed costing of Indian hospital operations is both feasible and essential, given the significant variation in the country’s hospital types. Because of the size and diversity of the country and variations across hospitals, a large-scale study should be undertaken to refine hospital costing for different types of hospitals so that the results can be used for policy purposes, such as revising payment rates under government-sponsored insurance schemes.


BMJ Open
June 2013

Research Area: Health and Development | Region: South Asia
Type: Article
The Question

Despite a growing volume of surgical procedures in low-income and middle-income countries, the costs of these procedures are not well understood. We estimated the costs of 12 surgical procedures commonly conducted in five different types of hospitals in India from the provider perspective, using a microcosting method.

What We Found

Costs of conducting lower section caesarean section ranged from rupees 2469 to 41 087; hysterectomy rupees 4124 to 57 622 and appendectomy rupees 2421 to 3616 (US$1=rupees 52). We computed the costs of conducting lap and open cholecystectomy (rupees 27 732 and 44 142, respectively); hernia repair (rupees 13 204); external fixation (rupees 8406); intestinal obstruction (rupees 6406); amputation (rupees 5158); coronary artery bypass graft (rupees 177 141); craniotomy (rupees 75 982) and functional endoscopic sinus surgery (rupees 53 398).

Why It Matters

Estimated costs are roughly comparable with rates of reimbursement provided by the Rashtriya Swasthya Bima Yojana (RSBY)—India's government-financed health insurance scheme that covers 32.4 million poor families. Results from this type of study can be used to set and revise the reimbursement rates.