Summary:
Economic evaluation is the comparative analysis of alternative course of action in terms of both their cost and their consequences. In health sector, where a lot of budget is needed, economic evaluation becomes an important aspect to look upon; the alternatives of any investment, interventions, decisions etc. should be carefully analyzed and proper choice to be made, so the consequences and benefits is accountable and worth the cost. According to the demand of the economic investment in health sector; the type, steps and reporting of the evaluation should be carefully monitored for better and expected outcome. In the context of Nepal, we lack independent body in government level for proper economic evaluation in health sector which should be a concern. Hence, dedicated and trained human resources in decision making for quality and optimized investment in health services are a must.
Brief Background:
The Master of ceremony, Dr. Baidehi Upadhyay initiated the webinar with the introduction of the speaker Dr. Reshu Agrawal Sagtani and the moderator Dr. Smirti Pant.
Dr. Agrawal Sagtani is the Assistant Professor in School of Public Health at Patan Academy of Health Sciences (PAHS), Kathmandu, Nepal. She received her Post Graduate Diploma in Health Economics, Health Care Financing and Policy from Public Health Foundation of India. She also has a Diploma in Biostatistics and Research Methodology from Global Institute of Medical Sciences, India. She completed her BDS from College of Dental Surgery, and Masters in Public Health (MPH) from School of Public Health & Community Medicine, B.P Koirala Institute of Health Sciences (BPKIHS), Dharan, Nepal. She is also resource faculty of Biostatistics for MBBS students and Epidemiology of NCDs for MPH students and health economics for Master’s program at PAHS and Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. She also contributes as Editorial board member of PLoS One journal and Journal of Patan Academy of Health Sciences (JPAHS). With her outstanding performance with researches, she is a recipient of national and international research grants and also National Level Consultant for projects related to costing of health care interventions. Her research interests include economic evaluation and policy research with primary focus on prevention and control of Non- Communicable Diseases (NCDs).
Dr. Pant is Assistant Professor in Department of Community Medicine, Maharajgunj Medical Campus and Institute of Medicine, Kathmandu, Nepal. She did her MBBS and MD in Community Medicine from Kathmandu Medical College, Kathmandu, Nepal. She is a life member of Nepalese Society of Community Medicine (NESCOM). She is a recipient of Best Paper (Poster) at 4th National Summit of Health and Population Scientists of Nepal and also recipient of University Grant Commission, research grant for Master’s Thesis. Her research interest and publications include papers on COVID-19, Nutrition, Air pollution, G6PD etc.
Dr. Pant started the session with the introduction of economic evaluation, understanding and use of economic evidence in decision making; by individuals, companies and in government levels. She focused on the importance of understanding of economic evidence in public health interventions which is an integral part of evidence based public health. Then, the speaker of the session, Dr. Agrawal gave a clear view of the concept of economic evaluation and its importance in health sector. She discussed the fundamental job of any economic evaluation and rationale of using it in public health. The types, steps of economic evaluation and the importance of reporting were discussed with an example of a systematic review done on economic evaluation guidelines in low- and middle-income countries. Then she further reiterated about the scenario of economic evaluation in health sector in Nepal, talking about the existing Monitoring and Evaluation guideline and also some evidences of studies done on economics of health sector. She then talked about the debates surrounding economic evaluation, the opportunities and challenges in present scenario of our country.
The presentation was wrapped up with few questions raised by the participants whom the speaker answered with very much clarity and precision. Five zoom poll questions were put forward in regard to the presentation and understanding about the society NESCOM. The webinar lasted for about 1 and half hours with about 100 participants and ended with the announcement of an upcoming webinar on “Grant Writing in Academia”.
Objective of the Webinar:
1.To know the concept of economic evaluation
2.To know the rationale of using it in public health
3.To know the types, steps and reporting of economic evaluation
4.To know the guidelines, evidence, debate, opportunities and challenges around economic evaluation in Nepal
Key points that came out during the discussion:
- Health budget of Government of Nepal 2079/80 has decided to increase the list of free essential drugs from 70 to 98, increase the capital and infrastructure development, focus more on digital technology, screening at least once for NCDs in people over 40 years and others. But the pertinent question is whether the investments are up to the mark? The economic evaluation thus focuses in the betterment of these investments and the expected outcome
- Economic evaluation is related to costs and consequences. Based on cost and consequences we need to make the decision regarding a choice. Thus, economic evaluation is the comparative analysis of alternative courses of action in terms of both their costs and their consequences
- The fundamental jobs of any economic evaluation are to recognize, measure, value and compare the costs and consequences of the alternatives being considered. It makes explicit the total resources consumed and the benefits generated by a specific intervention or program
- The rationale for doing economic evaluation is: Health is our Constitutional right; the state should take care of all our health. But practically it is not possible to cater to all our health care needs and demands because of scarce resources – human, time, facilities, equipment, knowledge, etc. Also, there is competing claims, and alternative choices for the investment to be done. Systematic analysis for relevant alternatives is thus important measurement to ensure efficiency
- Types of Economic Evaluation:
Cost minimization analysis- Choose to reduce the amount of cost
- Cost effectiveness analysis – Choose to improve the morbidity and mortality outcome.
- Cost utility analysis- Cost to avoid 1 DALY or gaining 1 QALY, choose the one with less cost.
- Cost consequence analysis – Consequences scenarios is made before and investment done accordingly.
- Costs benefit analysis – Used to transfer budgets from one sector to other in government levels.
- Social/Return of Investment – Benefits also in terms of social changes, cultural adaptation along with monetary benefit.
- Steps in conducting an economic evaluation
- Framing the problem: The study question, perspective, time frame and analytic horizon.
- Choosing the baseline comparator and alternative intervention: Comparator, target population.
- Identifying the outcome measures: Intermediate/final outcomes, source of effectiveness data.
- Identify the intervention and outcome costs: Direct/indirect costs, discounting.
- Construct the decision model: Decision tree or decision analytical modeling.
- Analyze and interpret the results.
- Perform sensitivity analyses: Addressing uncertainty.
- Presentation of results: Reporting guidelines.
- Some studies were reviewed to see if economic evaluation guidelines are being used which showed some countries use mandatory guidelines; whether systemic analysis is done or not, decision analysis, analytic horizon kept into consideration or not
- There is no mandatory guideline for economic evaluation in Nepal, though Monitoring and Evaluation Guideline exists. This guideline is an important aspect of our health care system which clearly states that we need to analyze efficiency and cost effectiveness and compare it to make sure the input comes with effective outcome. The pharmacoeconomics in Nepal also discusses and designs the free drugs lists in Nepal. Many but not enough studies are being done for the importance of economic evaluation in public health sector in Nepal
- Health care should not only focus in efficient use of resources, it has to be thought from equity perspective as well, which may not be practically true. So, assessment of distributional inequalities is important, there may be a tradeoff between equity and efficiency
- Economic evaluation may be complex in certain scenario like in social determinants of health where determinants cannot be easily quantified and also in genetics where it cannot be measured.
Points for the policy brief:
Since there are no mandatory guidelines for economic evaluation in health care system in Nepal, the government should focus more in these aspects. There is a need of independent body in the Governmental sector for Health Technology Assessment and Economic Evaluation for effectiveness. The changing political scenario gives hope that accountability holds in the health care system, the federalization of health system with autonomy to local levels can be a opportunity which needs to be grabbed.
Points to be discussed in the executive committee:
1.Role of Nepalese Society of Community Medicine (NESCOM) to discuss the possibility for more extensive courses and workshop related to economic evaluation in health care in Nepal
2.To perform more research and study to explore the cost benefit analysis of preventive medicine over the curative medicine; the expense over the curative medicine could definitely be reduced focusing and advocating the use of preventive medicine
Conclusion:
Economic evaluation in health care is important as it is necessary to make proper decisions of investments for better effectiveness and benefits of the outcome. There are many challenges to make the health system better in our context, however, opportunities that are arising should be utilized and proper economic evaluation prior to any health-related decisions should be done with an effective mandatory guideline.