Cost effectiveness analysis of CSS -preliminary results · ... Preventive antibiotics for mothers with high risk of infection and Use of antibiotic for preterm birth ... umbilical

国家卫生计生委卫生发展研究中心China National Health Development Research Center

http://www.nhdrc.cn

Cost effectiveness analysis of CSS

-preliminary results

Kun Zhao

China National Health Development Research Center

Center for Health Policy Evaluation and Technology Assessment

October 2015，Beijing

2. Methods

Content

3. Results

4. Preliminary recommendations

1. Background

Infant mortality rate: 8.9 / 1,000

Under-5 mortality rate: 11.7 /1,000

Maternal mortality: 21.7 / 100,000

Challenge：• Large population

• Imbalanced urban and

rural development

• Limited resources

Lead：NHFPC and UNICEF

Aim：Reduce children’s mortality, improve

children's health

Intervention：106 items

Based on international evidence, combined with

real situation in China

Infant mortality rate :8 / 1,000

Under-5 mortality rate :10 /1,000

Maternal mortality : 18/100,000

Developer：WHO, Futures institute

Usage：Support health programs in low-income

countries

Feature：Evidence-based effect estimation, health

budget estimation, priority identification

1. Background

Priority input areas

Effectiveness？Funding？

Cost-effectiveness？

Eliminate newborn and under-5

preventable deaths

During 12th Five-Year Plan

13th Five-Year Plan

Preliminary objectives

UN SDGs

China Child Survival Strategy (CSS) OneHealth Tool（OHT）

2. Method

2.1 Research framework

• Develop effective intervention package based on CSS

Prioritize intervention

• Background parameters

• Intervention parameters

• Cost data

Parameter identification

and data collection • Based on OHT

• Cost analysis

• Effect analysis

• Cost-effectiveness analysis

Data analysis

• Provide suggestion for the next 5-year plan

Policy suggestion

Determining standard：（1）with evidence-based effectiveness in OHT（2）WHO

suggestion（3）Expert suggestion

2.2 Effective intervention package development

Expert group (5 rounds of consultation, 43 person-times): Health policy formulation and planning experts,

maternal and child specialists, clinical experts, health economists

CSS

(106 items) 44 items

Expert opinion

24

items

Deleted：62 items

not suggested by

WHO

33

items

Deleted：16 items without

determined evidence

3 items not suitable for China

situation

Combined：4 items to 2 items

Expanded：4 items to 12 items

expert opinion

Combined：4 items to 2

items

Deleted：7 items

already full coverage or

effects not measurable


Effective

intervention

package

(33 items)

Effective

intervention

package

(44 items)

1. Collapse same interventions. Safe termination of pregnancy and Safe termination of

pregnancy for unintended pregnancy; Preventive antibiotics for mothers with high risk of

infection and Use of antibiotic for preterm birth with premature rupture of membranes

2. Deleted irrelevant items. Safe childbirth, promote vaginal delivery, Post-natal nutrition: iron,

folic acid, VD, calcium, iodine, etc., Management of severe acute malnutrition

3. Deleted items excluded from LiST. Unintended pregnancy prevention, Early screening of

HIV, syphilis, and hepatitis B., Intervention, treatment, visiting and management of HIV, syphilis

and hepatitis B patients, Labor induction for full-term baby with premature rupture of

membranes, Timely detection of HIV, syphilis and hepatitis B status, special treatment and aid on

delivery, Treatment for postpartum hemorrhage, Prevention of post-natal bleeding, Antiretroviral

drugs for newborns of HIV-infected mother; promote breast feeding, eliminate mixed feeding;

Antiretroviral drugs for both mother and child, Neonatal jaundice (pathological and breast milk)

and other critical illness identification and referral, Preventive antiretroviral therapy for newborn

exposed to HIV, Preventive antibiotic treatment for newborn with high risk of viral infection, Use

of Continuous Positive Airway Pressure (CPAP) for respiratory distress syndrome in premature

newborn, Treatment of neonatal jaundice (pathological), Treatment of anemia in post-natal

mother, Visit and monitor of children born to HIV or syphilis-infected mother, Timely treatment

and integrated care if infected

4. Broken items. Prevention of pregnancy complications broken

into“hypertension”and“gestational diabetes”;“Newborn: breast feeding, umbilical cord and

skin care, keep warm, VD supplement” into“breastfeeding counseling”,“keep

warm”;“Routine vaccination”into“DPT”,“BCG”,“Polio vaccine”,“HepB

vaccine”and“Measles vaccine”；“Secondary vaccination”into“Hib

vaccine”,“PCV”and“rotavirus vaccine”


Effective

intervention

package

(33 items)

1. Further collapsed items.“breastfeeding

counseling”with“Breast feeding within six month”;“keep

warm”and“Kangaroo Mother Care”2. Deleted items excluded from LiST.“treatment of local

infections（newborn）”“Management of low birth weight

and preterm birth”3. Deleted items with 100% coverage or without clear and

calculable effectiveness.“Polio vaccine”,“BCG”,“HepB

vaccine”,“gestational diabetes”,“Induction of labor for

pregnancies lasting 41+ weeks”

Effective

intervention

package

(24 items)

Maternal Interventions

Monitoring and treatment of syphilis

Safe termination of pregnancy

Folic acid, iron, calcium and nutrient supplement

Oral folic acid and other nutrients supplements

Prevention of pregnancy-induced hypertension

Prevention of complications of abortion

Prevention and management of postpartum hemorrhage

Caesarean section on indication

Newborn interventions

Use of antibiotics for premature rupture of membranes (PROM)

Neonatal resuscitation

Kangaroo Mother Care

Neonatal sepsis (fully supportive care)

Neonatal sepsis (antibiotic injections)

Child Interventions

Exclusive breastfeeding for six months

Continued breastfeeding from 6 months onwards with appropriate complementary feeding

DPT vaccine

Measles vaccine

Haemophilus influenzae vaccine

Pneumococcal vaccine

Rotavirus vaccine

Pneumonia management (antibiotics)

Diarrhea management (ORS)

Diarrhea management (zinc)

Antibiotic treatment of dysentery

Effective intervention package

Treatment

intervention,

14

Preventive

intervention,

10

Public health

project/Basic

medical insurance, 15

OOP, 9

Pregnant

woman, 8

Newborn, 5

Children under

5, 11

Grouping of (cost) effective intervention packages

By target population By intervention type By funding source

高效包及需要人群、覆盖率详见附件一：高效包明细及需要人群、覆盖率.xlsx

%E9%99%84%E4%BB%B6%E4%B8%80%EF%BC%9A%E9%AB%98%E6%95%88%E5%8C%85%E6%98%8E%E7%BB%86%E5%8F%8A%E9%9C%80%E8%A6%81%E4%BA%BA%E7%BE%A4%E3%80%81%E8%A6%86%E7%9B%96%E7%8E%87.xlsx

Analytical tool：OneHealth Tool

Time：2015-2020

Costing range: National

Costing perspective: Government

Costing estimation methods: Standard costing method

Costing items: medicines, supplies and test programs

Performance indicators: Child / maternal mortality

Cause of

death

Intervention population：Demographic characteristics

Population health status

（Epidemiology）

Effect：Prevention of

child and

maternal deaths

Effective intervention package

Need to invest (drugs,

supplies and test)

2.3 Analytical tool

Baselinecoverage rate (2015)

Target coveragerate (2020)

Cost Effect

Intervention 1

# # # #

Intervention 2

# # # #

Intervention 3

# # # #

………. # # # #

2.4 CSS Model building

Main parameters Source Note

Background data

Demographic characteristics Sixth census

Population health status OHT system default dataChange IMR,U5M,MMR based on China

data

Intervention coverage5 times expert meetings, 43 person times

consultations

Target population Expert consultation

Proportion of need intervention among

the target populationExpert consultation

Baseline coverage (2015)Literature review, report and Expert

consultationAverage of urban and rural coverage rate

Target coverage (2020) Expert consultation

Target value will be up to 90% for

interventions with baseline coverage of

90% or less

Target value will be 100% for

interventions with baseline coverage more

than 90%

Intervention cost data

drugs / supplies / tests required OHT system default and Expert

consultationActivity Based Costing

Drug / test / Supplies price

National Drug bidding information

platform, Guangdong / Guizhou /

Qinghai pilot data

Based on the information platform, pilot

data as a supplement, and take the lowest

price

Intervention effect OHT system default data RR of various causes of death

2.5 Data collection

2.5 Data collection

序号干预措施

实施渠道

目标人群

药品/耗材医务人员门诊人次和住院天数

药物/耗材/检验

接受这一治疗百分比

标注单位数

每日次数

所需天数

所需总量

单位成本

平均每例病人花费

人员类型

接受治疗的比例

分钟天/访问数

总分钟数

类型接受百分比

备注单位次数

总访问量

1

梅毒的监测与治疗

乡级/县级及以上

孕妇

采血包（采血针，采血管，棉拭子，隔离垫，一次性手套，输液贴）

100 1 1 1 护士 100 15 1门诊人次

100 1

Intervention coverage rate increases consistently annually

- Cost Estimation

Intervention funds required annually = intervention unit cost * number * intervention

coverage

Intervention unit cost = Drugs / Supplies / test * Number * Price

Number of people requiring intervention =

Number of whole population *proportion of the target population *proportion of need

intervention among the target population

- Effect Estimation

Child and maternal deaths averted= baseline deaths – deaths averted by year

- Cost-effectiveness analysis

Average cost-effectiveness ratio = cost / averted deaths

2.6 Data analysis

3. Preliminary results

7.70

5.39

8.98

6.28

12.00

8.47

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

2015 2016 2017 2018 2019 2020

M

o

r

t

a

l

i

t

y（

‰）

Newborn mortality

Infant mortality

Under-5 mortality

2020 target（under-5 mortality）

2020 target (infant mortality）

RR=30.0%

RR=30.1%

RR=29.4%

Figure 1 2015-2020 Effect of implementation of intervention package

on children mortality rate

3.1 Effect estimate (24 intervention items)

2015-2020 accumulation：

120,000 newborn deaths prevented

263,000 under-5 deaths prevented

23.2

14.61

0.00

5.00

10.00

15.00

20.00

25.00

2015 2016 2017 2018 2019 2020

De

ath

pe

r 1

00

,00

0 p

regn

ant

po

pu

lati

on

Maternal mortality

2020 target

3.1 Effect estimate (24 intervention items)

2015-2020:

4243maternal death averted

Figure 2 2015-2020 Effect of implementation of intervention package

to maternal mortality rate

RR=37.0%

7.06

7.7

5.73

4

5

6

7

8

9

10

2015 2016 2017 2018 2019 2020

M

o

r

t

a

l

i

t

y

（

‰）

Newborn mortality rate

8.08

8.98

7.2

4

5

6

7

8

9

10

2015 2016 2017 2018 2019 2020

M

o

r

t

a

l

i

t

y

（

‰）

Infant mortality rate

10.64

12

9.62

8

9

10

11

12

13

14

2015 2016 2017 2018 2019 2020

M

o

r

t

a

l

i

t

y

（

‰）

Under-5 mortality rate

22.93

23.2

14.92

10

12

14

16

18

20

22

24

26

28

30

2015 2016 2017 2018 2019 2020

Maternal mortality rate Death

per 1

00

,00

0 p

regnan

t p

op

ulatio

n

3.1 Effect Estimation(Public health/basic medical insurance VS. OOP)

OOP Public health/BMI

5.39

8.4714.61

24 items

RR=25.6%

RR=8.3%

RR=30.0%

RR=10.0%

6.28

RR=19.8%

RR=30.1%

RR=11.3%

RR=19.8%

RR=29.4%

RR=1.2%

RR=35.7%

RR=37.0%

3.1 Effect Estimation

(Public health/basic medical insurance VS. OOP)

InterventionAverted total deaths

Averted under-5 deaths

Averted 1-59month child deaths

Averted <1month child deaths

Avertedmaternal deaths

OOP（9 items） 100655 50281 29247 21034 93

Public health/Medical insurance（15items）

175046 86092 35592 50499 2863

Intervention package 24items

275701 136373 64839 71533 2956

0% 20% 40% 60% 80% 100%

Prevented maternal deaths

Prevented <1month child deaths

Prevented 1-59 month child deaths

Prevented under-5 deaths

Prevented total deaths

OOP

Public health/ medical insurance

2151

3228

7250

7558

8734

9422

9846

12101

14054

35690

0 5000 10000 15000 20000 25000 30000 35000 40000

列1

2015-2020 averted child and maternal deaths


Child Pneumonia management (antibiotics)





Diarrhea management (ORS)


Pregnant women Folic acid, iron, calcium and nutrient supplement


Continued breastfeeding from 6 months onwards with appropriatecomplementary feedingRotavirus vaccine

Oral folic acid and other nutrients supplements for woman aroundpregnancyUse of antibiotics for premature rupture of membranes (PROM)



DPT vaccine



Measles vaccine





90.4% of total averted deaths

3.1 Effect estimation （24items）

3.2 Cost estimation（24 items）

2015-2020, total cost was 123.921 billion yuan

94.52

145.92

191.23

232.54

270.03

304.95

0.00

50.00

100.00

150.00

200.00

250.00

300.00

350.00

2015 2016 2017 2018 2019 2020

Co

st (0.1

billio

n)

Treatment

intervention,

53.09

Preventive

intervention

（Pneumococca

l vaccin…

Preventive

intervention

(others),

417.18

Public health

project/Basic medical insurance,

90.86

OOP

（Pneumococc

al vaccine）, 768.94

OOP (others), 379.41

Maternal, 347.91

New born,

7.8Children under 5, 883.49

3.2 Cost structure（24 items）

By target population

(0.1billion)

By intervention type

(0.1billion)

By funding source

(0.1billion)

81801.33

80365.74

78276.05

40551.29

37664.29

18913.50

10649.35

6477.04

4903.87

534.19

0.00 2000000.00 4000000.00 6000000.00 8000000.00 10000000.00 12000000.00

成本-

效果

Cost effectiveness ratio （RMB/ one death prevented）










Continued breastfeeding from 6 months onwards withappropriate complementary feedingDiarrhea management (ORS)


Use of antibiotics for premature rupture of membranes(PROM)Haemophilus influenzae vaccine


Oral folic acid and other nutrients supplements for womanaround pregnancyRotavirus vaccine

Measles vaccine



DPT vaccine



Pregnant women Folic acid, iron, calcium and nutrientsupplement

3.4 Cost-effective analysis（24 items）

Treatment,

7

Preventive ,

3

Medical

insurance

covered, 7

OOP, 3

Maternal, 3

Newborn, 4

Children

under 5, 3

3.4 Cost-effective analysis

Top 10 most cost-effective interventions are categorized as below:

By target population By intervention type By funding source

治疗

性措

施, 6.47

预防

性措

施, 3.3

Medical insurance covered,

6.47

OOP, 3.30

3.4 Cost-effectiveness analysis

Investment cost for top 10 most cost-effective interventions

maternal

2.88

newborn,

4.12

Children

under 5, 2.78

Treatment, 6.47

preventive,

3.3

By target population

(0.1billion)

By intervention type

(0.1billion)

By funding source

(0.1billion)

Top 10 cost-effective interventions

Childhood pneumonia management (use of antibiotics)


Indication of cesarean section



Neonatal sepsis - antibiotic injection



Neonatal sepsis - fully supportive care

Continued breastfeeding from 6 monthsonwards with appropriate complementary feeding

Top 10 effective interventions

Cesarean section on indication

Child pneumonia management (use of antibiotics)


six months exclusive breastfeeding



Diarrhea Management (ORS)


Maternal nutrition package


3.5 Scenario Analysis

Overlapping intervention:

Child pneumonia management (antibiotics)






Top10 effective remaining

items：• Pneumococcal

vaccination

• Haemophilus influenzae

vaccination

• ORS

• Maternal nutritional

supplements (iron, folic

acid, calcium, iodine)

Top10 cost-effective

remaining items ：Neonatal sepsis –(antibiotic i)

Management of abortion

complications

Prevention of postpartum

hemorrhage

Continued breastfeeding from

6 months onwards with

appropriate complementary

feeding

6 items 4 items4 items

Overlapping 6 interventions:

Child pneumonia management

(antibiotics)





Neonatal sepsis –(fully supportive care)

6 items 10

ite

ms

14

ite

ms

Top10 effective remaining 4

items：

• Pneumococcal vaccination


vaccination

• ORS


supplements (iron, folic acid,

calcium, iodine)

Top10 cost-effective remaining 4

items ：Neonatal sepsis - antibiotic

injection


complications


hemorrhage

Continued breastfeeding from 6

months onwards with appropriate

complementary feeding

other 10

items

24 items

Intervention

Cost (0.1billion)

Ratio of cost（%）

Averted deaths（10,000）

Ratio of effectiveness（%）

6 items 7.13 0.57 9.15 75.60

10 items 9.77 0.78 9.38 77.51

14 items 1141.56 92.12 11.63 96.11

24 Items 1239.21 100.00 12.10 100.00


6 items 10 items 14 items 24 items

Total cost（0.1 billion） 7.13 9.77 1141.56 1239.21

Effect（2020）

Maternal mortality rate（per 100,000 Live Births）

17.62 15.9 15.81 14.61

Newborn mortality rate（‰ LB） 5.86 5.83 5.73 5.39

Infant mortality rate（‰ LB） 6.89 6.86 6.64 6.28

Under-5 mortality rate（‰ LB） 9.48 9.44 8.87 8.47

2015-2020 Cost and effectiveness estimation of difference intervention packages



1239

493

0

200

400

600

800

1000

1200

1400

Current price Lowest price

5 y

ear total co

st

（0.1

billio

n

）

Reduce 60%

5 years’ total cost for effective intervention package with 24 items


Current price in China：￥777/shot

International lowest price：￥22.5/shot

81801.33

80365.74

78276.05

40551.29

37664.29

18913.50

10649.35

6477.04

4903.87

534.19

0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000

成本-

效果

成本效果比（元/避免1例死亡）










Continued breastfeeding from 6 months onwards withappropriate complementary feedingDiarrhea management (ORS)



Use of antibiotics for premature rupture of membranes(PROM)Haemophilus influenzae vaccine


Oral folic acid and other nutrients supplements for womanaround pregnancyRotavirus vaccine

Measles vaccine



DPT vaccine


Pregnant women Folic acid, iron, calcium and nutrientsupplement

Cost-effectiveness ratio increase from

ranking 23 to 13

Cost-effectiveness analysis on

effective intervention package with 24 items

6 items 10

items

14

items

Other 10

items

24

items

Intervention Cost (0.1billion)

Ratio of cost（%）

Averted deaths（10,000）

Ratio of effectiveness（%）

6 items 7.13 0.57 9.15 75.60

10 items 9.77 0.78 9.38 77.51

14 items（International）

395.52 31.92 11.63 96.11

14 items（China）

1141.56 92.12 11.63 96.11

24 items（International）

493.17 39.80 12.10 100.00

24 items（China）

1239.21 100.00 12.10 100.00

3.5 Scenario AnalysisCoincide 6 interventions:

Childhood pneumonia management (use

of antibiotics)

Cesarean section

Implementation of Kangaroo Mother Care

six months of exclusive breastfeeding



Top10 effective remaining 4

items：

• Pneumococcal


• ORS


supplements (iron, folic acid,

calcium, iodine)

Top10 cost-effective remaining 4

items ：Neonatal sepsis - antibiotic

injection


complications


hemorrhage

6 months to 2 years breastfeeding

and complementary feeding

6 items 10 items14 items

（China）14 items

（International）24 items

（China）24 items

（International）

Total cost（0.1 billion） 7.13 9.77 395.52 1141.56 493.17 1239.21

Effect（2020）

Maternal mortality

（per 100,000 maternal

population）17.62 15.9 15.81 15.81 14.61 14.61

Newborn mortality（‰） 5.86 5.83 5.73 5.73 5.39 5.39

Infant mortality（‰） 6.89 6.86 6.64 6.64 6.28 6.28

Under-5 mortality（‰） 9.48 9.44 8.87 8.87 8.47 8.47

2015-2020 Cost and effectiveness estimation for difference intervention packages, if

pneumococcal vaccine price at International lowest market price


Conclusions

• Many more child deaths can be averted at a cost that China can afford

• Out of pocket expenditure (OOP) for child health (for both prevention and

care) can be reduced significantly

• Three key internationally recommended interventions (low osmolarity oral

rehydration salts (LOORS), pneumococcal conjugate vaccine (PCV) and

Haemophilus influenza type b (Hib)) are vastly overpriced in China

compared to international market prices:

• 1 sachet ORS China USD 4 vs UNICEF USD 0.05 [80x]

• 1 dose PCV China USD 125 vs UNICEF/GAVI USD 3.54 [35x]

• 1 dose Hib China USD 12.90-24.19 vs UNICEF/GAVI pentavalent

vaccine USD 1.19 [11-20x]

Preliminary Recommendations

Maximize impact and efficiency for child survival, while minimizing cost:

• Define a national essential package of child survival interventions, based on

maximizing # death averted and cost effectiveness ratios;

• Ensure nation-wide implementation of such an essential package;

• Pool finances from various sources to support nation-wide implementation;

• In the next five years, Ensure to include in the essential package for children, in

accordance with the priority sequence of the effectiveness and cost-effectiveness

– Tier 1: C-section on indication, newborn resuscitation, newborn sepsis

management, pneumonia management with antibiotics, exclusive breastfeeding,


– Tier 2: management of abortion complications, prevention of post partum

haemorrrhage, newborn sepsis management (with injectable antibiotics),

continued breastfeeding with appropriate complementary feeding

– Tier 3: diarrhoea management with ORS, pneumococcal vaccine, Hib vaccine,

maternal micronutrient supplementation “YYB” (Fe, Fo, Ca, etc)

Thank you！

Documents

Cost effectiveness analysis of CSS -preliminary results · ... Preventive antibiotics for mothers with high risk of infection and Use of antibiotic for preterm birth ... umbilical