InaHEA HUTUBESSY2 final
Economics of Vaccines
The Role of Economic Evaluations for
Universal Health Coverage
Raymond Hutubessy PhD MSc
(hutubessyr@who.int)
Initiative for Vaccine Research
World Health Organization
Geneva, Switzerland
Plenary III Session: Preventive Health Programs in Social Health Insurance
3rd InaHEA Congress, 28-30 July 2016, Yokyakarta, Indonesia
Outline of presentation
- Challenges in Indonesia with regard to vaccine uptake
- Vaccine related policy questions in Indonesia to reach UHC and how
Economic Evaluations can help
- How Economic Evaluations can contribute to shape an Effective Health
Ministry Strategic Plan
- Illustrations
- Traditional economic evaluations – Human Papilloma Virus (HPV) vaccines
- Broader economic value of child immunization in Indonesia
- Concluding remarks
Traditional EPI and “new generation” vaccines
WHO recommendations routine
immunization
Vaccines introduced with Gavi*
support in LICs
Inactivated
2013 Oral Cholera
Polio
2014
BCG, Hep B, IPV, DTP, measles,
rubella, Hib, RV, PCV, HPV
* www.gavi.org
Indonesia’s immunization schedule
• WHO recommended
routine vaccines
–
–
–
–
–
–
BCG
Hep B
IPV
DTP
Hib
Measles
• Not covered
– Routine vaccines
•
•
•
•
Rubella
Pneumoccocal (planned)
HPV (Gavi demo planned)
Rotavirus
– Non-routine
•
•
•
•
Hep A
Infuenza
JE
Meningococal
Indonesia’s challenges
• Sustain coverage current vaccines
• Uptake of new vaccines
• Health is a low priority in terms of public
health spending & Gavi Transition Situation
DTP coverage versus health spending
Tandon et al. Health Financing System Assessment: Indonesia. Word Bank
DTP3 coverage change 2013 - 2014 and size of
under and unvaccinated children in 2014
Viet Nam
Philippines
Indonesia
Central African Republic
Liberia
Guinea
Haiti
South Sudan
Equatorial Guinea
Source: WHO/UNICEF coverage estimates 2014 revision. July 2015
.Immunization Vaccines and Biologicals, (IVB), World Health Organization
. WHO Member States 194
7
Inequitable access to vaccines
• Geography poses challenges to
distribution/access to vaccines
Vaccine affordability and sustainability issues
with new generation vaccines
Routine
vaccines
Cents
Infants
Through EPI
delivery
Vaccine affordability and sustainability issues
with new generation vaccines
EPI vaccines
Cents
New vaccines
Dollars
Infants
Life course
Through EPI
delivery
Outside EPI and
integrated
Total and Public Health Expenditure in
Indonesia one of the lowest in the World
Tandon et al. Health Financing System Assessment: Indonesia. Word Bank
Increasing share of vaccine costs as Indonesia
economy grows
Gavi transition to Fully Self-Financing
Currently Gavi
funding
contributes 6%
of all public
expenditure in
health
Reasons for un- and undervaccination
Provider &
community
demand
• Lack of knowledge and awareness
• Reactogenicity of vaccines not addressed
adequately
• Vaccine hesitancy
System
weaknesses
•
•
•
•
Access to services
Inadequate human resources
Inadequate financing
Weak procurement and distribution
Poor quality and use of data
• Remote, underserved areas
• Migrant and nomadic populations
• Displaced populations and those affected by
conflicts and crisis
13
Main policy questions for Indonesia
• How to sustain programmatically?
– Current standard EPI program?
– Adding new vaccines more expensive such as RV,
PCV and HPV?
• How to sustain financially?
– Indonesia gears towards UHC and prepares for
UMIC status (Gavi graduation)
Ten attributes for an Effective Health Ministry Investment
Plan to Ministry of Finance
1. Demonstrates how health programmes contribute to broader national
development objectives
2. Explains and quantifies how well-designed and well-targeted health expenditure
is an investment not merely a cost
3. Demonstrates good use of existing financial and other resources by the health
sector
4. Demonstrates effective allocation of existing health sector resources, with a focus
on results
5. Shows how health expenditure is cost–effective and even cost-saving to
government, development partners and households
6. Identifies and explains market failures in health provision that require public
expenditure
7. Identifies and quantifies mutual benefits for the public health and finance sectors:
improving health while raising additional government revenue
8. Presents a clear and accountable plan for downstream implementation,
management, evaluation and lesson-learning from health programmes
9. Presents a strong evidence base for health policy and programming
decision-making
derson et al. Bull World Health Organ 2016;94:468–474
10.
Avoids earmarking of funds to the health sector, but shows how investment in
the health sector complements investments in other sectors such as education
Economic Evaluations for UHC
• Increasing pressure for health systems to
adopt strategic purchasing strategies that
explicitly assess interventions for inclusion in
benefit or entitlement policies
– Role for economic evaluations to play in services
to cover
Types of economic evaluations, question addressed
and analytical tools
Type of economic
evaluation
Question to be
addressed
Economic tool
available
Economic burden
What is the VPD burden
in economic terms?
Cost-of-Illness study
Affordability
How much money needs
to be secured to deploy
vaccines?
Costing study
Value for money
What is the cost per
immunized child, case,
death or DALY?
Cost-effectiveness study
Broader economic
impact
What is the
macroeconomic impact
of VPDs?
General equilibrium
models
“New generation” vaccines issues
illustrated with Human Papilloma Virus (HPV)
vaccines
• Equity
– Vaccine uptake
– Global distribution of economic gains
• Market Distortions
– Vaccine price and limited manufacturers
• New Delivery Strategies and Costs
• Cost-Effectiveness Analysis (CEA)
– Evidence globally and SEA/Indonesia
– Cost-effectiveness thresholds
WHO Position Paper on HPV
Vaccines
(WER October, 2014)
(www.who.int/immunization/documents/positionpapers/en/)
•
Target Pop: girls 9-13 years
•
2 doses (6 months apart)
•
No max interval (suggested not more
than 12-15 months)
•
If interval < 5 months, give another
dose 6 months after 1st dose
•
Part of Comprehensive Cervical
Burden of Disease
CERVICAL CANCER
MORTALITY RATES
AGE STANDARDIZED –
BY CONTINENT/SUB-REGION
Eastern Africa
Western Afr
Middle Africa
Melanesia
Southern Africa
Southern Asia
South America
Caribbean
SE Asia
AFRICA
LAC
Caribbean and South
America are relatively
higher than neighbors
to the north.
EUROPE
Western and Northern
Europe lower than
Eastern
Europe
NORTH
AMERICA
PACIFIC
Melanesia rivals Africa, while
Polynesia and Micronesia are in
the middle of the pack.
ASIA
Southern, Southeast and
Central higher than
West Asia.
Central Asia
Eastern Europe
Polynesia
N. Africa
Eastern Asia
Micronesia
S Europe
N Europe
W Asia
AUS/NZ
W Europe
N America
Australia/NZ
0
5
10
15
20
25
30
Equity
Countries with HPV vaccine in the national immunization
programme, Gavi demo projects and planned introductions in 2015
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
WHO 2013. All rights reserved
Global economic surplus of HPV vaccines*
Vaccine benefits
Consumer surplus
(less) Vaccine
costs
Global
economic
surplus
Cervical cancer
treatment cost
savings
DALYs due to
cervical cancer
prevented
Procurement
costs
Administration
costs
Discovery costs
Revenues from
vaccine sales
Producer surplus
Clinical trials
(less) Vaccine
costs
* Herily et al. Health Affairs 2016
Manufacturing
costs
Marketing costs
Unequal global economic surplus distribution of
HPV vaccines*
* Herily et al. Health Affairs 2016
Vaccine Pricing
HPV VACCINE PRICES CAN
VARY WIDELY, AFFECTING
AFFORDABILITY.
HIGH
INCOME
COUNTRIES
$US
130200 /dose
?
MIDDLE
INCOME
COUNTRIES
GAVI
ELIGIBLE
COUNTRIES
?
$US
4 -5 /dose
Affordability
HICs
UMICs
LMICs
HPV vaccine, price per dose (US$)
Service delivery costs
SERVICE
more
DELIVERY COSTS
outreach
REQUIRED
SCHOOLS AND/OR PULSED
CAMPAIGNS .
More (2)
contacts
REQUIRED TO
ACHIEVE FULL
IMMUNITY
more
TARGET people
(adolescents)
requires new services
*Levin et al. Vaccine 2014
more
iec /
social
mobilisation
needed to
address
sensitivities and
rumors
Cost/FIG
1.50-19,00 US$*
SOME UNIQUE
CHARACTERISTI
CS OF HPV
VACCINE
SERVICE
DELIVERY
INCREASE
SERVICE
DELIVERY COSTS
COMPARED WITH
OTHER VACCINES
Global HPV Delivery Cost analysis using WHO C4P cost
tool
Vaccine cost
Botwright et al.
Work in Porgress
Functions NIP in Indonesia
• Centralized functions
–
–
–
–
–
–
Vaccine selection
Procurement of vaccines
Technical assistance
M&E
Quality control
Training
• Sub-national function
– Service delivery
– Support operation costs
for health centers and
village health posts
Detailed costing for planning purposes,
scaling up and uptake of vaccines are
needed
Cost-effectiveness analysis
Burden of CxXa
(cost and human
suffering)
Reduced burden
of CxCa
No HPV
vaccination
HPV
vaccination
Cost of intervention
Cost-effectiveness analysis of HPV vaccines in LMICs
EXISTING RESEARCH LIMITATIONS
Local capacity to
perform own analysis
is lacking in most
LMICs
Evidence from
LMICs is still
scarce
Most LMIC studies
are across any
Insufficientusing
data
countries
for cost-effectiveness study
same 1-2 models
COST-EFFECTIVENESS:
EXAMPLE
Cost-effectiveness
Fesenfeld et al. Vaccine. 2013 Jul 3
in developing countries
Cost-Utility Analysis on HPV vaccination and
screening in Indonesia
The main purpose
To model the costs, clinical
benefits, and cost-utility of
both visual inspection with
VIA screening alone and HPV
vaccination in addition to
VIA screening in Indonesia
Setiawan et al. Value in Health, 2016
Cost-Utility Analysis on HPV vaccination and
screening in Indonesia
Study Conclusion
The addition of HPV vaccination on top of VIA screening
could be a cost-effective strategy in Indonesia even if
relatively conservative assumptions are applied
Note: Cost-effectiveness defined as 1x GDP/capita
Is HPV vaccine at i$15/dose cost-effective in Indonesia?
Setiawan et al. Value in Health, 2016
How to define “value for money”?
•
Widely used CMH CET*:
–
–
•
3x GDP per capita “cost-effective”
1x GDP per capita “very cost-effective”
Not always useful from a country perspective
1xGDP/capita
*CMH: Commission on Macroeconomics and Health.
CET: Cost-Effectiveness Thresholds
3xGDP/capita
Newall et al.Pharmacoeconomics, 2014, May 3
New WHO recommendation on use of CETs
• Benchmark CE results against the least cost-effective health
interventions already funded by relevant jurisdictions
• Use CET not in isolation but in context specific process for decision
making supported by issues like:
– Broader benefit package of interventions
– Legislation
– Stakeholder buy-in
– Fairness
• Focus on budget impact
* CET: Cost-Effectiveness Thresholds
Broader Economic Impact of Vaccines (BEIV)
•
Traditional CEAs (eg cost per QALY/DALY) are well-established tools for decision making in
many countries.
•
Issue #1 (raised by external stakeholders like NGOs): the scope of traditional CEAs is too
narrow. What about:
– Labor productivity
– Cognitive development
– Educational attainment
– Savings
– Direct foreign investment
– Fertility
– Population health
•
Issue #2 (raised by Ministers of Finance, Planning etc): the outcomes of traditional CEAs
are not useful for decision making and financial planning. What about:
– Public sector budget impact
– Return on investment
– Impact on GDP and tax revenues
Ten attributes for an Effective Health Ministry
Investment Plan to Ministry of Finance
1. Demonstrates how health programmes contribute to broader national
development objectives
2. Explains and quantifies how well-designed and well-targeted health expenditure
is an investment not merely a cost
3. Demonstrates good use of existing financial and other resources by the health
sector
4. Demonstrates effective allocation of existing health sector resources, with a focus
on results
5. Shows how health expenditure is cost–effective and even cost-saving to
government, development partners and households
6. Identifies and explains market failures in health provision that require public
expenditure
7. Identifies and quantifies mutual benefits for the public health and finance sectors:
improving health while raising additional government revenue
8. Presents a clear and accountable plan for downstream implementation,
management, evaluation and lesson-learning from health programmes
9. Presents a strong evidence base for health policy and programming
decision-making
derson et al. Bull World Health Organ 2016;94:468–474
10. Avoids earmarking of funds to the health sector, but shows how investment in
A framework for BEIV impact and grading the
evidence
Jit et al. BMC Med
2015
Investments in vaccination and cognitive
development of children in Indonesia
•
RAND Family Life Survey (IFLS) data set for Indonesia
– Longitudinal data set of children initially 5 years of age, 1993/1994 - 2007/2008
– Representative sample of 83% population, over 30K individuals from 13 out of 27
provinces
– For the final analysis, we restricted the sample to children reporting birth years
between 1992-1994 and age of 3-5 years in IFLS2 with nonmissing data and still living
in 2007 (subsample size varies by outcome)
•
Purpose : to estimate differences in factors below and vaccination status
– Height, body-mass-index, IQ, school attainment and EBTANAS assessments
•
Main results
– Childhood vaccination leads to gains in human capital that manifest relatively
early and may result in greater adult productivity.
erbooy et al. Work in Progress
Conclusions
• As countries experience different levels of economic development they
have different policy questions hence require different economic and
financing tools to sustain programs or introduce new vaccines
• WHO provides technical assistance through guidance documents and
decision making tools for vaccine introduction and broader sector wide
planning and priority setting
• In MICs/countries in transition there is insufficient political will to
prioritize new vaccines and health in general
• Vaccine prices that give “value for money” are crucial for making
vaccination programs sustainable particularly in MICs/UMICs
Ways forward for Indonesia
• More economic evaluations are needed in Indonesia to reach JKN
• More human capacity needed to conduct local analysis
• Guidelines on standardising CEA for Indonesia as part of HTA and
integrated into decision making processes
– Indonesia specific CET threshold?
• More data needed
– Large scale costing studies, analysis of cost functions to inform asessment of
scaling up interventions and generalize unit costs across a diverse country like
Indonesia are needed
WHO Guidance documents on economic
evaluations
• WHO-CHOICE
– Making Choices in Health: WHO guide
to cost-effectivenes analysis (2003)
– Sector-wide priority setting
• WHO IVB Guides
– Guidelines for estimating costs of
introducing new vaccines into the
national immunization system (2002)
– WHO guide for standardization of
economic evaluations of
immunization programmes (2009)
• Health Systems Financing
– Broader economic impact
Acknowledgements
- Mark Jit
London School of Hygiene and Tropical Medicine, London UK. Health Protection Agency, London, UK
- Ann Levin and Win Morgan
- LevinMorgan Inc. Washington DC. USA
- Dwi Endarti
- Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- Didik Setiawan
- Department of Pharmacy, University of Groningen, The Netherlands; Faculty of Pharmacy, University of
Padjadjaran, Bandung, Indonesia
- Siobhan Botwright
- Gavi, Geneva, Switzerland
The Role of Economic Evaluations for
Universal Health Coverage
Raymond Hutubessy PhD MSc
(hutubessyr@who.int)
Initiative for Vaccine Research
World Health Organization
Geneva, Switzerland
Plenary III Session: Preventive Health Programs in Social Health Insurance
3rd InaHEA Congress, 28-30 July 2016, Yokyakarta, Indonesia
Outline of presentation
- Challenges in Indonesia with regard to vaccine uptake
- Vaccine related policy questions in Indonesia to reach UHC and how
Economic Evaluations can help
- How Economic Evaluations can contribute to shape an Effective Health
Ministry Strategic Plan
- Illustrations
- Traditional economic evaluations – Human Papilloma Virus (HPV) vaccines
- Broader economic value of child immunization in Indonesia
- Concluding remarks
Traditional EPI and “new generation” vaccines
WHO recommendations routine
immunization
Vaccines introduced with Gavi*
support in LICs
Inactivated
2013 Oral Cholera
Polio
2014
BCG, Hep B, IPV, DTP, measles,
rubella, Hib, RV, PCV, HPV
* www.gavi.org
Indonesia’s immunization schedule
• WHO recommended
routine vaccines
–
–
–
–
–
–
BCG
Hep B
IPV
DTP
Hib
Measles
• Not covered
– Routine vaccines
•
•
•
•
Rubella
Pneumoccocal (planned)
HPV (Gavi demo planned)
Rotavirus
– Non-routine
•
•
•
•
Hep A
Infuenza
JE
Meningococal
Indonesia’s challenges
• Sustain coverage current vaccines
• Uptake of new vaccines
• Health is a low priority in terms of public
health spending & Gavi Transition Situation
DTP coverage versus health spending
Tandon et al. Health Financing System Assessment: Indonesia. Word Bank
DTP3 coverage change 2013 - 2014 and size of
under and unvaccinated children in 2014
Viet Nam
Philippines
Indonesia
Central African Republic
Liberia
Guinea
Haiti
South Sudan
Equatorial Guinea
Source: WHO/UNICEF coverage estimates 2014 revision. July 2015
.Immunization Vaccines and Biologicals, (IVB), World Health Organization
. WHO Member States 194
7
Inequitable access to vaccines
• Geography poses challenges to
distribution/access to vaccines
Vaccine affordability and sustainability issues
with new generation vaccines
Routine
vaccines
Cents
Infants
Through EPI
delivery
Vaccine affordability and sustainability issues
with new generation vaccines
EPI vaccines
Cents
New vaccines
Dollars
Infants
Life course
Through EPI
delivery
Outside EPI and
integrated
Total and Public Health Expenditure in
Indonesia one of the lowest in the World
Tandon et al. Health Financing System Assessment: Indonesia. Word Bank
Increasing share of vaccine costs as Indonesia
economy grows
Gavi transition to Fully Self-Financing
Currently Gavi
funding
contributes 6%
of all public
expenditure in
health
Reasons for un- and undervaccination
Provider &
community
demand
• Lack of knowledge and awareness
• Reactogenicity of vaccines not addressed
adequately
• Vaccine hesitancy
System
weaknesses
•
•
•
•
Access to services
Inadequate human resources
Inadequate financing
Weak procurement and distribution
Poor quality and use of data
• Remote, underserved areas
• Migrant and nomadic populations
• Displaced populations and those affected by
conflicts and crisis
13
Main policy questions for Indonesia
• How to sustain programmatically?
– Current standard EPI program?
– Adding new vaccines more expensive such as RV,
PCV and HPV?
• How to sustain financially?
– Indonesia gears towards UHC and prepares for
UMIC status (Gavi graduation)
Ten attributes for an Effective Health Ministry Investment
Plan to Ministry of Finance
1. Demonstrates how health programmes contribute to broader national
development objectives
2. Explains and quantifies how well-designed and well-targeted health expenditure
is an investment not merely a cost
3. Demonstrates good use of existing financial and other resources by the health
sector
4. Demonstrates effective allocation of existing health sector resources, with a focus
on results
5. Shows how health expenditure is cost–effective and even cost-saving to
government, development partners and households
6. Identifies and explains market failures in health provision that require public
expenditure
7. Identifies and quantifies mutual benefits for the public health and finance sectors:
improving health while raising additional government revenue
8. Presents a clear and accountable plan for downstream implementation,
management, evaluation and lesson-learning from health programmes
9. Presents a strong evidence base for health policy and programming
decision-making
derson et al. Bull World Health Organ 2016;94:468–474
10.
Avoids earmarking of funds to the health sector, but shows how investment in
the health sector complements investments in other sectors such as education
Economic Evaluations for UHC
• Increasing pressure for health systems to
adopt strategic purchasing strategies that
explicitly assess interventions for inclusion in
benefit or entitlement policies
– Role for economic evaluations to play in services
to cover
Types of economic evaluations, question addressed
and analytical tools
Type of economic
evaluation
Question to be
addressed
Economic tool
available
Economic burden
What is the VPD burden
in economic terms?
Cost-of-Illness study
Affordability
How much money needs
to be secured to deploy
vaccines?
Costing study
Value for money
What is the cost per
immunized child, case,
death or DALY?
Cost-effectiveness study
Broader economic
impact
What is the
macroeconomic impact
of VPDs?
General equilibrium
models
“New generation” vaccines issues
illustrated with Human Papilloma Virus (HPV)
vaccines
• Equity
– Vaccine uptake
– Global distribution of economic gains
• Market Distortions
– Vaccine price and limited manufacturers
• New Delivery Strategies and Costs
• Cost-Effectiveness Analysis (CEA)
– Evidence globally and SEA/Indonesia
– Cost-effectiveness thresholds
WHO Position Paper on HPV
Vaccines
(WER October, 2014)
(www.who.int/immunization/documents/positionpapers/en/)
•
Target Pop: girls 9-13 years
•
2 doses (6 months apart)
•
No max interval (suggested not more
than 12-15 months)
•
If interval < 5 months, give another
dose 6 months after 1st dose
•
Part of Comprehensive Cervical
Burden of Disease
CERVICAL CANCER
MORTALITY RATES
AGE STANDARDIZED –
BY CONTINENT/SUB-REGION
Eastern Africa
Western Afr
Middle Africa
Melanesia
Southern Africa
Southern Asia
South America
Caribbean
SE Asia
AFRICA
LAC
Caribbean and South
America are relatively
higher than neighbors
to the north.
EUROPE
Western and Northern
Europe lower than
Eastern
Europe
NORTH
AMERICA
PACIFIC
Melanesia rivals Africa, while
Polynesia and Micronesia are in
the middle of the pack.
ASIA
Southern, Southeast and
Central higher than
West Asia.
Central Asia
Eastern Europe
Polynesia
N. Africa
Eastern Asia
Micronesia
S Europe
N Europe
W Asia
AUS/NZ
W Europe
N America
Australia/NZ
0
5
10
15
20
25
30
Equity
Countries with HPV vaccine in the national immunization
programme, Gavi demo projects and planned introductions in 2015
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
WHO 2013. All rights reserved
Global economic surplus of HPV vaccines*
Vaccine benefits
Consumer surplus
(less) Vaccine
costs
Global
economic
surplus
Cervical cancer
treatment cost
savings
DALYs due to
cervical cancer
prevented
Procurement
costs
Administration
costs
Discovery costs
Revenues from
vaccine sales
Producer surplus
Clinical trials
(less) Vaccine
costs
* Herily et al. Health Affairs 2016
Manufacturing
costs
Marketing costs
Unequal global economic surplus distribution of
HPV vaccines*
* Herily et al. Health Affairs 2016
Vaccine Pricing
HPV VACCINE PRICES CAN
VARY WIDELY, AFFECTING
AFFORDABILITY.
HIGH
INCOME
COUNTRIES
$US
130200 /dose
?
MIDDLE
INCOME
COUNTRIES
GAVI
ELIGIBLE
COUNTRIES
?
$US
4 -5 /dose
Affordability
HICs
UMICs
LMICs
HPV vaccine, price per dose (US$)
Service delivery costs
SERVICE
more
DELIVERY COSTS
outreach
REQUIRED
SCHOOLS AND/OR PULSED
CAMPAIGNS .
More (2)
contacts
REQUIRED TO
ACHIEVE FULL
IMMUNITY
more
TARGET people
(adolescents)
requires new services
*Levin et al. Vaccine 2014
more
iec /
social
mobilisation
needed to
address
sensitivities and
rumors
Cost/FIG
1.50-19,00 US$*
SOME UNIQUE
CHARACTERISTI
CS OF HPV
VACCINE
SERVICE
DELIVERY
INCREASE
SERVICE
DELIVERY COSTS
COMPARED WITH
OTHER VACCINES
Global HPV Delivery Cost analysis using WHO C4P cost
tool
Vaccine cost
Botwright et al.
Work in Porgress
Functions NIP in Indonesia
• Centralized functions
–
–
–
–
–
–
Vaccine selection
Procurement of vaccines
Technical assistance
M&E
Quality control
Training
• Sub-national function
– Service delivery
– Support operation costs
for health centers and
village health posts
Detailed costing for planning purposes,
scaling up and uptake of vaccines are
needed
Cost-effectiveness analysis
Burden of CxXa
(cost and human
suffering)
Reduced burden
of CxCa
No HPV
vaccination
HPV
vaccination
Cost of intervention
Cost-effectiveness analysis of HPV vaccines in LMICs
EXISTING RESEARCH LIMITATIONS
Local capacity to
perform own analysis
is lacking in most
LMICs
Evidence from
LMICs is still
scarce
Most LMIC studies
are across any
Insufficientusing
data
countries
for cost-effectiveness study
same 1-2 models
COST-EFFECTIVENESS:
EXAMPLE
Cost-effectiveness
Fesenfeld et al. Vaccine. 2013 Jul 3
in developing countries
Cost-Utility Analysis on HPV vaccination and
screening in Indonesia
The main purpose
To model the costs, clinical
benefits, and cost-utility of
both visual inspection with
VIA screening alone and HPV
vaccination in addition to
VIA screening in Indonesia
Setiawan et al. Value in Health, 2016
Cost-Utility Analysis on HPV vaccination and
screening in Indonesia
Study Conclusion
The addition of HPV vaccination on top of VIA screening
could be a cost-effective strategy in Indonesia even if
relatively conservative assumptions are applied
Note: Cost-effectiveness defined as 1x GDP/capita
Is HPV vaccine at i$15/dose cost-effective in Indonesia?
Setiawan et al. Value in Health, 2016
How to define “value for money”?
•
Widely used CMH CET*:
–
–
•
3x GDP per capita “cost-effective”
1x GDP per capita “very cost-effective”
Not always useful from a country perspective
1xGDP/capita
*CMH: Commission on Macroeconomics and Health.
CET: Cost-Effectiveness Thresholds
3xGDP/capita
Newall et al.Pharmacoeconomics, 2014, May 3
New WHO recommendation on use of CETs
• Benchmark CE results against the least cost-effective health
interventions already funded by relevant jurisdictions
• Use CET not in isolation but in context specific process for decision
making supported by issues like:
– Broader benefit package of interventions
– Legislation
– Stakeholder buy-in
– Fairness
• Focus on budget impact
* CET: Cost-Effectiveness Thresholds
Broader Economic Impact of Vaccines (BEIV)
•
Traditional CEAs (eg cost per QALY/DALY) are well-established tools for decision making in
many countries.
•
Issue #1 (raised by external stakeholders like NGOs): the scope of traditional CEAs is too
narrow. What about:
– Labor productivity
– Cognitive development
– Educational attainment
– Savings
– Direct foreign investment
– Fertility
– Population health
•
Issue #2 (raised by Ministers of Finance, Planning etc): the outcomes of traditional CEAs
are not useful for decision making and financial planning. What about:
– Public sector budget impact
– Return on investment
– Impact on GDP and tax revenues
Ten attributes for an Effective Health Ministry
Investment Plan to Ministry of Finance
1. Demonstrates how health programmes contribute to broader national
development objectives
2. Explains and quantifies how well-designed and well-targeted health expenditure
is an investment not merely a cost
3. Demonstrates good use of existing financial and other resources by the health
sector
4. Demonstrates effective allocation of existing health sector resources, with a focus
on results
5. Shows how health expenditure is cost–effective and even cost-saving to
government, development partners and households
6. Identifies and explains market failures in health provision that require public
expenditure
7. Identifies and quantifies mutual benefits for the public health and finance sectors:
improving health while raising additional government revenue
8. Presents a clear and accountable plan for downstream implementation,
management, evaluation and lesson-learning from health programmes
9. Presents a strong evidence base for health policy and programming
decision-making
derson et al. Bull World Health Organ 2016;94:468–474
10. Avoids earmarking of funds to the health sector, but shows how investment in
A framework for BEIV impact and grading the
evidence
Jit et al. BMC Med
2015
Investments in vaccination and cognitive
development of children in Indonesia
•
RAND Family Life Survey (IFLS) data set for Indonesia
– Longitudinal data set of children initially 5 years of age, 1993/1994 - 2007/2008
– Representative sample of 83% population, over 30K individuals from 13 out of 27
provinces
– For the final analysis, we restricted the sample to children reporting birth years
between 1992-1994 and age of 3-5 years in IFLS2 with nonmissing data and still living
in 2007 (subsample size varies by outcome)
•
Purpose : to estimate differences in factors below and vaccination status
– Height, body-mass-index, IQ, school attainment and EBTANAS assessments
•
Main results
– Childhood vaccination leads to gains in human capital that manifest relatively
early and may result in greater adult productivity.
erbooy et al. Work in Progress
Conclusions
• As countries experience different levels of economic development they
have different policy questions hence require different economic and
financing tools to sustain programs or introduce new vaccines
• WHO provides technical assistance through guidance documents and
decision making tools for vaccine introduction and broader sector wide
planning and priority setting
• In MICs/countries in transition there is insufficient political will to
prioritize new vaccines and health in general
• Vaccine prices that give “value for money” are crucial for making
vaccination programs sustainable particularly in MICs/UMICs
Ways forward for Indonesia
• More economic evaluations are needed in Indonesia to reach JKN
• More human capacity needed to conduct local analysis
• Guidelines on standardising CEA for Indonesia as part of HTA and
integrated into decision making processes
– Indonesia specific CET threshold?
• More data needed
– Large scale costing studies, analysis of cost functions to inform asessment of
scaling up interventions and generalize unit costs across a diverse country like
Indonesia are needed
WHO Guidance documents on economic
evaluations
• WHO-CHOICE
– Making Choices in Health: WHO guide
to cost-effectivenes analysis (2003)
– Sector-wide priority setting
• WHO IVB Guides
– Guidelines for estimating costs of
introducing new vaccines into the
national immunization system (2002)
– WHO guide for standardization of
economic evaluations of
immunization programmes (2009)
• Health Systems Financing
– Broader economic impact
Acknowledgements
- Mark Jit
London School of Hygiene and Tropical Medicine, London UK. Health Protection Agency, London, UK
- Ann Levin and Win Morgan
- LevinMorgan Inc. Washington DC. USA
- Dwi Endarti
- Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
- Didik Setiawan
- Department of Pharmacy, University of Groningen, The Netherlands; Faculty of Pharmacy, University of
Padjadjaran, Bandung, Indonesia
- Siobhan Botwright
- Gavi, Geneva, Switzerland