How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations

K Hauck,A Morton,K Chalkidou,Y-Ling Chi,A Culyer,C Levin,R Meacock,M Over,R Thomas,A Vassall,S Verguet,P.C Smith

doi:10.1016/j.socscimed.2018.10.030

Abstract

Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.

Highlights

Health system strengthening (HSS) is a critical component of global public health and international development (Frenk, 2010; Kutzin & Sparkes, 2016; Naimoli et al, 2018).There is consensus that, alongside spending on specific healthcare and public health interventions, there is a need to invest in the complex health system infrastructure of human and capital resources on which delivery of these interventions is dependent
Much of the HSS literature is implicitly concerned with the need to address opportunities and constraints presented by service delivery platforms
Platforms provide the opportunity to exploit economies of scope, i.e. increases in cost-effectiveness of interventions arising from their joint delivery

Summary

Introduction

Health system strengthening (HSS) is a critical component of global public health and international development (Frenk, 2010; Kutzin & Sparkes, 2016; Naimoli et al, 2018). Despite an extensive literature on HSS, there is very little evidence on exactly what proportion of funds should be spent on HSS to maximize outcomes from constrained health budgets, or how they should be spent It was estimated in 2014 that around $274 billion spending on health is needed per year to reach the ambitious Sustainable Development Goals 3 targets on Women’s and Children’s health by 2030, of which around 75% of costs are for health system strengthening, with health workforce and infrastructure (including medical equipment) as the main cost drivers (Stenberg et al, 2014). This paper differs from standard approaches towards CEA by relaxing the requirement that the costs and benefits of interventions are independent of each other, as a result of the common dependency on the platform. More realistic operational models can be developed for specific decision problems using the general principles outlined in this paper

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