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Choosing services Integrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off Ole F. Norheim Professor in Medical Ethics and Philosophy.

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Presentation on theme: "Choosing services Integrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off Ole F. Norheim Professor in Medical Ethics and Philosophy."— Presentation transcript:

1 Choosing services Integrating Concerns for Cost-Effectiveness, Financial Protection, and the Worse Off Ole F. Norheim Professor in Medical Ethics and Philosophy of Science Dept. of Global Public Health and Primary Care University of Bergen

2 Plan •Background •Cost-effectiveness •Financial protection •Priority to the worse off •Classification of priority health services

3 Key question •Should financial protection and distributional concerns be incorporated into decision rules for publicly financed health services?

4 Priority group classification •Universal Coverage can be defined as access to key health services for all at an affordable cost 1.High-priority services 2.Normal-priority services 3.Low-priority services Key services

5 How to classify services? •Cost-effectiveness thresholds < 1 GDP per capita 1-2 GDP per capita > 3 GDP per capita (Macroeconomics and Health 2002, WHO CHOICE)

6 Example •Selected 65 health services from WHO- CHOICE database (AfrE) •Child health services •Maternal and newborn health services •Infectious disease services •Non-communicable disease services •Converted all costs to Int $ 2005 (WHO-CHOICE team BMJ series )

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9 Two problems with CEA •Ignores financial risk protection •Ignores distribution of healthy life years

10 Financial risk protection •Publicly financed health services provide –Financial risk protection –Health •Peter Smith : –If no one buys supplementary services, or –a well-functioning voluntary supplementary insurance market  service selection on the basis of standard cost-effectiveness ratios will maximize welfare (health + income) (P. Smith, Health Economics 2012) •When there is substantial out-of-pocket payment for supplementary services, this is not so.

11 •High cost services may be favored over low cost services, at least among services with similar cost-effectiveness ratios. •My interpretation: –Financial risk protection could act at least as a tiebreaker for services with identical cost- effectiveness ratios.

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13 Two problems with CEA •Ignores financial risk protection •Ignores distribution of healthy life years

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15 Integrating distributive concerns with CEA •An “Atkinson’s” social welfare function applied to health would judge: –(60, 45) as better than (80, 25) (Adler, OUP 2012) •Health prioritarianism would assign higher weights to benefits for B (Ottersen, JME 2013)

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17 11.52

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22 Opportunity cost of implementing top 5 interventions for 5 mill $ DALYs41190 DALYs = 1558 DALYs

23 Opportunity cost •Health prioritarianism •Knows the cost in terms of DALYs NOT averted •Can provide reasons for re-ranking: –some priority to the worse off

24 Priority group classification – tentative proposal

25 Ex ante / ex post prioritarianism •Distributive weights based on final – not expected – individual disease burden for various conditions

26 Imagine you can help group A or B – who would you help?

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29 Ex post: Even if we only know the outcome, but not who will be affected, we can evaluate alternative outcomes


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