GHME 2013 Conference Session: New directions in cost-effectiveness analysis Date: June 18 2013 Presenter: Josh Salomon Institute: Harvard School of Public Health

2. Salomon – Cost-effectiveness - 2
An observation
• Hundreds of cost-
effectiveness analyses
are published each year
• Relatively few examples
of these analyses being
used in formulation or
modification of policies
in global health
Source: Tufts CEA Registry
0
50
100
150
200
250
300
350
400
1990 1995 2000 2005 2010
Numberofstudies
Year

3. Salomon – Cost-effectiveness - 3

4. Salomon – Cost-effectiveness - 4
June 2011

5. Salomon – Cost-effectiveness - 5
Secretary Clinton, November 8, 2011:
“…our efforts have helped set the stage for a
historic opportunity, one that the world has
today: to change the course of this pandemic
and usher in an AIDS-free generation.”
President Obama, December 1, 2011:
“…Today, we come together as a global
community … to renew our commitment to
ending the AIDS pandemic once and for all.”
Global Fund for world health halts new programs
By JOHN HEILPRIN, Associated Press – Nov 24, 2011
GENEVA (AP) — The world's biggest financier in the fight against three killer diseases
says it has run out of money to pay for new grant programs for the next two years — a
situation likely to hit poor AIDS patients around the world.
November - December 2011

6. Salomon – Cost-effectiveness - 6
HPTN 052: Preventing transmission with early ART
Cohen et al. NEJM, July 2011

7. Salomon – Cost-effectiveness - 7
Treatment as prevention: ‘breakthrough of the year’
Science, December 2011

8. Salomon – Cost-effectiveness - 8
Fifteen years earlier…
WHO Press Release, March 1997

9. Salomon – Cost-effectiveness - 9
March 1997

10. Salomon – Cost-effectiveness - 10
Boehme et al. NEJM, September 2010 Small & Pai NEJM, September 2010
Game change for TB diagnosis? (September 2010)

11. Salomon – Cost-effectiveness - 11
Sputum smear microscopy Xpert MTB/RIF

12. Salomon – Cost-effectiveness - 12
Xpert MTB/RIF
• Automated, cartridge-based PCR
• Simplified procedures, rapid turn-
around (<2 hours)
• Specificity: 98%
• Sensitivity: 92% (sm+), 73% (sm–)
• WHO, Dec 2010: “the foundation
for a revolution in the diagnosis
of TB and drug-resistant TB”
• Vassall et al. 2011 (PLoS Med):
Xpert appears highly cost-
effective in South Africa
Game changer?

13. Salomon – Cost-effectiveness - 13
An observation
• Hundreds of cost-
effectiveness analyses
are published each year
• Relatively few examples
of these analyses being
used in formulation or
modification of policies
in global health
Why?
Source: Tufts CEA Registry
0
50
100
150
200
250
300
350
400
1990 1995 2000 2005 2010
Numberofstudies
Year

14. Salomon – Cost-effectiveness - 14
An agenda for cost-effectiveness analysis in global health
Intervention $ / DALY averted
Condoms + treatment of STI
for sex workers
1
Blood safety 1 – 43
Peer education for sex
workers
4 – 7
Voluntary counseling and
testing
18 – 22
Prevention of mother-to-
child transmission
1 – 730
Treatment of other STIs 12
Antiretroviral therapy 1,000 – 2,000
Source: Creese et al. Lancet 2002
Example: Estimated cost-effectiveness of HIV/AIDS
interventions in Africa
• Published evidence on
cost-effectiveness often
seems too good to be
true
• Agenda item #1: More
ex-post analysis of cost-
effectiveness
• Not only impact but
also efficiency should
be submitted to
rigorous evaluation in
real-world programs

15. Salomon – Cost-effectiveness - 15
• CEA often fails to focus
on actionable decisions in
real-world contexts
• Need information on
cost-effectiveness of
strategies, which are
more than just
technologies.
Strategy = technology +
specific implementation
plan
An agenda for cost-effectiveness analysis in global health

16. Salomon – Cost-effectiveness - 16
• CEA often fails to focus
on actionable decisions in
real-world contexts
An agenda for cost-effectiveness analysis in global health
1980 2000 2020 2040
Year
Granich et al. Lancet 2009Granich et al. PLoS ONE 2012
Costs for different ART eligibility scenarios,
compared to status quo

17. Salomon – Cost-effectiveness - 17
Source: Menzies et al. (in preparation)
• CEA often fails to focus
on actionable decisions in
real-world contexts
An agenda for cost-effectiveness analysis in global health
0
5
10
15
20
25
30
35
40
45
2012 2016 2020 2024 2028
TBmortality(per100,000)
Projected TB mortality in Kenya
Reductions in mortality if Xpert
is implemented:
• Where culture is available
• Where only smear is
available
• Where neither smear and
culture currently reach
Example: Xpert test for TB being adopted rapidly
based on strong evidence of effectiveness and
preliminary analysis of CE

18. Salomon – Cost-effectiveness - 18
Source: Menzies et al. 2012
• CEA often fails to focus
on actionable decisions in
real-world contexts
• Agenda item #2:
Emphasize analysis of
adoptable strategies
through a health systems
lens, with explicit and
credible accounting for all
relevant costs, outcomes
and constraints relevant
to a specific implemen-
tation approach
An agenda for cost-effectiveness analysis in global health
Example: Xpert test for TB being adopted rapidly
based on strong evidence of effectiveness and
preliminary analysis of CE
…but most CE analyses to date have ignored the
single biggest associated cost because it is not borne
by the TB program

19. Salomon – Cost-effectiveness - 19
Source: Salomon et al, PLoS Med 2006
Example: New, shorter TB drug regimens could avert
millions of TB deaths
 Decision analysis may be
missing key opportunities
to address problems
most amenable to the
approach
e.g. investment choices on
R&D toward new health
technologies
0
0.2
0.4
0.6
0.8
1
1.2
2000 2005 2010 2015 2020 2025 2030
Time (years)
An agenda for cost-effectiveness analysis in global health
TBdeaths(millions)

20. Salomon – Cost-effectiveness - 20
Source: Salomon et al, PLoS Med 2006
Example: New, shorter TB drug regimens could avert
millions of TB deaths
…but delay in investment has been costly
 Decision analysis may be
missing key opportunities
to address problems
most amenable to the
approach
e.g. investment choices on
R&D toward new health
technologies
0
0.2
0.4
0.6
0.8
1
1.2
2000 2005 2010 2015 2020 2025 2030
Time (years)
An agenda for cost-effectiveness analysis in global health
TBdeaths(millions)

21. Salomon – Cost-effectiveness - 21
Source: Salomon et al, PLoS Med 2006
Example: New, shorter TB drug regimens could avert
millions of TB deaths
…but delay in investment has been costly
…and further delay will continue to erode potential
benefits
 Decision analysis may be
missing key opportunities
to address problems
most amenable to the
approach
e.g. investment choices on
R&D toward new health
technologies
• Agenda item #3: Define a
“global health technology
portfolio” by assessing
potential health returns
on R&D investments
0
0.2
0.4
0.6
0.8
1
1.2
2000 2005 2010 2015 2020 2025 2030
Time (years)
An agenda for cost-effectiveness analysis in global health
TBdeaths(millions)

22. Salomon – Cost-effectiveness - 22
Summary and final thoughts
• In the US, resistance to cost-effectiveness analysis in
healthcare is strong
• In resource-poor countries, the need is greater, and resistance
may be weaker
• To be truly useful for global health policy, we need to re-
evaluate the way we go about decision analysis:
 Establish more credible evidence based on ex post evaluation
 Move from identifying what can work under optimal
circumstances to evaluating how we can maximize delivery of
promising interventions within real-world systems
 Take a long-term portfolio view on prioritizing investments in
future health technologies