[PPT] - Economic Evaluation of Multisectoral Actions for Health and PowerPoint Presentation

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A global research network in agriculture and food systems for improved nutrition and health www.ANH-Academy.org

Economic Evaluation of Multisectoral Actions for Health and Nutrition

Carol Levin, PhD University of Washington ICAE, July 30 2018

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Scope

The ANH Academy Working Group on

Economic Evaluation was established in October 2017 to advance knowledge and scientific understanding among the global research community of economic evaluation methods and metrics related to costs and benefits of multisectoral actions (agriculture, food and livelihood strategies) for nutrition and health.

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What’s the problem?

Comprehensive approaches are needed to address a

broader set of food system constraints to address undernutrition, double burden of malnutrition, emerging threat of obesity and noncommunicable diseases (NCD).

Decision makers (and modelers) need information
n the costs and benefits (or cost-effectiveness) of

multisectoral approaches.

Evidence is limited; transparency & standardization
f existing evidence is poor.

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Specific Objectives

Review current approaches for estimating costs,

benefits and cost-effectiveness of scaling up multisectoral actions to improve nutrition and health

utcomes in low and middle-income countries;
Develop principles for measuring costs, benefits and

cost-effectiveness across the range of multisectoral approaches to improve agriculture, health and nutrition, that can be adapted for use under different scenarios.

Summarize current gaps and challenges related to

these approaches, and identify opportunities for new methods and metrics for economic evaluation methods in this domain.

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Types of Economic Evaluations

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Epidemiological methods to generate evidence for impact of health & nutrition interventions

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Mixed methods for evaluating impact

f agricultural interventions

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Measuring costs of multisectoral strategies is even trickier

Limited information on costs and impacts for nutrition

sensitive interventions.

– Much of it is modeled, limited empirical evidence and challenging b/c of cross sectoral nature.

Limited published information on costs of agriculture

interventions, policies, programs.

Health and agriculture intervention impacts and costs

measured differently—

– Health: by intervention, facility or individual- derive a unit cost per beneficiary. – Agriculture: typically by crop (acre, yield, etc), by household (net income), by enterprise. – Spillover effects are harder to measure for agriculture

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New resources to improve economic evaluation in LMIC

Can we build on new resources being

developed?

Reference case approach

–iDSi Economic Evaluation for Global Health –Global Health Cost Consortium (GHCC) Reference Cases for Global Health Costing –Harvard Benefit Cost analysis guidelines– any sector (agriculture, health, education)

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iDSI reference case for economic evaluation

The Principles

Transparency
Comparators
Perspective
Measurement of Outcomes
Measurement of Costs
Time Horizon
Cost and effects outside of

health

Heterogeneity
Uncertainty
Budget impacts
Equity implications

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The GHCC Reference Case

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Guidelines for Benefit-Cost Analysis

Harvard University.
Funded by BMGF.
Developing guidelines

to encourage the conduct of high. quality benefit cost analysis.

Build on the existing

iDSI reference case.

Aligned with GHCC RC.

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What is a ‘reference case’ approach?

1. Set of ‘acceptable’ principles
2. Methodological guidance on how to achieve

those principles (theory and evidence based)

3. Standardisation for specific interventions

with additional guidance where available

4. Reporting standards

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TOWARD A FRAMEWORK AND COMMON APPROACH

Part 1: Understanding the moving parts!

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Typology of interventions

1. Supply of

nutrition foods

2. Demand

for nutrition foods

3. Enhance VC

performance & enabling environment

4. Empowering

women Figure source: de la Peña et al. IFAD 2018

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Typology of data sources

Effects

Primary

utcome
ther benefits

(in monetary value) + secondary health

utcomes

(e.g. in total DALYs)

Studies may include

nly funders’ direct

costs, or count other costs of participation and compliance Studies may measure cost per unit of one

utcome, or add up

multiple outcomes in DALYs, QALYs or dollars

The weight of evidence depends on what’s included

Direct costs Opportunity costs Direct costs

Direct costs Funders

Opportunity costs

Beneficiaries

Opportunity costs

Partners Costs

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Typology of study designs

Scope of the study

Scale, location and duration of costs and effects

Standard of evidence

Single studies

Systematic reviews

Selection bias may influence results, as evidence is available only where research is funded Studies differ in the nature of scientific evidence that is available and how it is used for cost-effectiveness analysis

Understanding of mechanisms

We see only where there’s light

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Typology of decisions to be informed

Efficacy trial (benefits only) Large scale (Incremental CEA) Pilot (incremental costs & effectiveness) Marginal (one more unit) Scaling up may reduce or increase cost per beneficiary reached, and alter effectiveness Programs can expand and create net gains until the cost of one additional unit of reach just equals the gains from that additional unit

CEA aims to inform what gets scaled up

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TOWARD A FRAMEWORK AND COMMON APPROACH

Part 2: Making sense of it all!

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Measuring costs and benefits along the Impact Pathway

Source: Gelli et al. 2015

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Identifying costs: Basic elements to consider

Direct costs for the sector (health, agriculture, WASH)

Direct costs to households Indirect or opportunity costs

Staff costs, commodities/supplies, equipment

Out of pocket expenditures

Household labor, land, lost productivity

For example

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Identify costs

Ac vi es Inputs

From

provider

Costs

To

provider, beneficiary and

ther

partners and service providers

Storage

and

processing

Physical inputs – e.g. seed, fer liser, livestock, equipment

Labour,

land, water Direct cost to provider for equipment (e.g. thresher)

Direct

cost to beneficiary for equipment maintenance and u li es (e.g. fuel), and space for storage and processing

Opportunity

cost to beneficiary for labour, space, and water use

Produc on

Equipment, e.g. thresher

Direct

costs to provider for physical inputs

Direct

costs to beneficiaries for addi onal inputs needed, such as fuel to use equipment

Opportunity

cost for beneficiary for labour, land use, and water use

Distribu on

and

transport

Vehicles, fuel

Extension

Personnel

Organisa onal

infrastructure Direct costs to provider for salaries, incen ves, volunteered me, and

ther

staff costs e.g. travel and subsistence

Ins tu onal

fixed and variable costs to provider, e.g. personnel management, training, and monitoring systems;

ffice

space and u li es; dona ons

Opportunity

cost to par cipant for me taken to engage with extension service

Direct

cost to

ther

service provider

f

any increased demand for government services Direct cost to provider for vehicles / fuel provided

Direct

cost to beneficiary for maintenance costs

Opportunity

cost to beneficiary for labour

Catering,

retail,

labelling

Supplies, equipment,

verheads

Direct costs to provider

f

supplies, equipment,

verheads
Direct

cost to beneficiary for addi onal inputs needed

Opportunity

cost to beneficiary for labour

Behaviour
change
Materials,

e.g. manuals, videos, leaflets

Pla orm,

e.g. space for mee ngs, radio air me, billboards, home visits

Personnel,

e.g. facilitators / counsellors, management

Direct

cost to provider materials, pla orm, personnel

Direct

cost to beneficiary for changing behaviour

Opportunity

cost to par cipant for uptake

f

new behaviour

Direct

cost to

ther

service provider

f

any increased demand for government services

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Health & Nutrition Agriculture Livelihoods WASH

 Height-for-age (HAZ)  Weight-for-height (WHZ)  Anemia and hemoglobin  Exclusive breastfeeding  Low birth weight  Child overweight  Breastfeeding  Wasting

Consumption of

nutrient-rich foods

Dietary diversity
Intake of

macronutrients and micronutrients Production of nutrient rich foods

Household income
Food expenditure
Food Security
Reduced diarrhea
Reduced parasites
Reduced

environmental enteropathy

Consumption of nutrient-

rich foods

Dietary diversity
Intake of macronutrients

and micronutrients

Household income Food

expenditure (total

Food Security
Increased use of maternal

health services

Higher education

participation

Measure benefits

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Applying the Framework

1. AHN Academy working paper.
2. Consensus on metrics for costs and benefits.
3. Develop a set of principles for estimating and

reporting costs and benefits across sectors.

4. Apply the framework to national

multisectoral strategy (Nepal).

5. Apply to a variety of IFPRI evaluations that

work across sectors to improve nutrition and health.

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Members of the working group

Carol Levin (University of Washington) and

Will Masters (Tufts University), co-chairs

Helen Harris-Fry (LSHTM),
Aulo Gelli (IFPRI,
Sofia Kalamatianou (LSHTM),
Jan Low (CIP),
Chloe Puett (Health Economist consultant),
Jolene Skordis-Worrall (LSHTM)
Joe Yates (LSHTM)
Steve Vosti (UC Davis)
Suneetha Kadiyala (LSHTM)

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THANK YOU!

Contact: clevin@uw.edu