2015年-世界发展银行全球_Cost-Effectiveness_Analysis_of_Results-Based_Financing_Programs___A_Toolkit_70页_1mb

Cost-Effectiveness Analysis of Results-Based Financing Programs: A Toolkit Summary

Core Content

This document presents a toolkit for conducting cost-effectiveness analysis (CEA) of Results-Based Financing (RBF) programs in the context of global health, particularly focusing on maternal and child health (MCH). It is designed to assist country programs and impact evaluation teams in assessing the cost-effectiveness of RBF interventions and comparing them across different settings and program features.

Main Viewpoints

• RBF is an incentive-based approach that rewards service providers, users, or administrators upon achieving verified results. It is increasingly used in global health to improve coverage and quality of services.
• The toolkit is developed to help policy makers make informed decisions about investing in RBF programs by comparing their cost-effectiveness with alternative interventions.
• The toolkit is specifically tailored to supply-side RBF (PBF), but its principles are applicable to a wide range of health system interventions targeting MDGs 4 and 5.
• Quality of care is a key component of RBF programs and should be incorporated into the effectiveness estimation.
• The toolkit is inspired by the lack of empirical evidence on the cost-effectiveness of RBF, particularly in low and lower middle income countries.

Key Information

Purpose of the Toolkit

• To support country programs in assessing the cost-effectiveness of RBF interventions.
• To facilitate cross-country comparisons of RBF programs.
• To provide a practical approach for conducting CEA, especially when RBF is implemented or planned.

Key Steps in CEA

1. Cost Analysis: Identify and measure the costs of RBF programs.
2. Effectiveness Assessment: Translate impact evaluation results into health outcomes such as lives saved, QALYs, or DALYs.
3. Incremental Cost-Effectiveness Ratio (ICER) Calculation: Compare the cost-effectiveness of RBF programs with alternative interventions.

Types of Costs

• Direct vs. Indirect Costs: Direct costs relate to health services, lab tests, and drug therapy; indirect costs relate to productivity loss.
• Fixed vs. Variable Costs: Fixed costs remain constant regardless of service volume; variable costs change with service output.
• Financial vs. Economic Costs: Financial costs include actual expenditures, while economic costs also account for opportunity costs of resources used.

Cost Analysis Approaches

• Top-down vs. Bottom-up:
  • Top-down uses administrative records and proxies to estimate costs.
  • Bottom-up collects data on inputs from surveys and uses unit cost information.
  • The bottom-up approach is recommended due to the facility-specific data used in impact evaluations.

Effectiveness Estimation

• RBF effectiveness is measured through impact evaluations that estimate service utilization and quality of care.
• Indicators for effectiveness include maternal and child health services, institutional delivery, vaccinations, family planning, etc.
• Quality of care is converted into health outcomes using Delphi technique and quality adjustment methods.
• Lives saved can be converted into QALYs or DALYs for more comprehensive analysis.

ICER Calculation

• ICER is calculated as the difference in cost divided by the difference in outcomes.
• Thresholds for cost-effectiveness are based on GDP per capita:
  • Highly cost-effective: ICER < GDP per capita
  • Cost-effective: ICER between 1 and 3 times GDP per capita
  • Not cost-effective: ICER > 3 times GDP per capita

Sensitivity Analysis

• Used to test the robustness of CEA results.
• Includes scenario-based and parameter-based testing.
• Helps in understanding how uncertainty in data affects the ICER.

Strengths and Limitations

• Strengths:
  • Practical and concise.
  • Incorporates quality of care.
  • Provides methodological guidance for impact evaluation teams.
• Limitations:
  • Assumes RBF is an alternative to the status quo.
  • May not account for all opportunity costs.
  • Requires data collection from multiple sources.

Structure of the Toolkit

Chapters

1. General Framework for CEA
2. Cost Analysis
3. Assessing Program Effectiveness
4. Putting It Together: Generating ICERs
5. Discussion and Interpretation

Appendices

• Appendix 1: Delphi questionnaire for evaluating the impact of quality of care.
• Appendix 2: Delphi questionnaire for quantifying relative importance of generic vs. service-specific quality indicators.
• Appendix 3: Delphi questionnaire for quantifying components within service-specific quality indicators.

Tables and Figures

• Tables:
  • Effectiveness estimates and data sources.
  • Common incentivized indicators in RBF programs.
  • Impact evaluation examples.
  • Coverage under different scenarios.
  • Lives saved from improved institutional delivery.
  • Components of quality indicators.
• Figures:
  • Schema for general CEA of health programs.
  • Approaches for measuring RBF costs.
  • Schema of the LIST tool.
  • Interface of the LIST tool in Spectrum.
  • Tabs for population projection changes.
  • Parameters for baseline child health status and mortality rates.
  • Utilization of institutional delivery and other services.
  • Relationship between quality of care and its impact.

Conclusion

The toolkit provides a structured and practical guide for conducting CEA of RBF programs, emphasizing quality of care and health outcomes. It is particularly useful for impact evaluation teams and policy makers who need to make resource allocation decisions. The toolkit is grounded in real-world experience, including the Zambia RBF program, and is complementary to other tools like the Impact Evaluation Toolkit. It aims to contribute to global knowledge on the cost-effectiveness of RBF and its application in various health system contexts.