The Epidemiological Transition Policy and Planning Implications for Developing Countries (1993) / Chapter Skim
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HEALTH INDICES AS A GUIDE TO HEALTH SECTOR PLANNING: A DEMOGRAPHIC CRITIQUE
HEALTH INDICES AS A GUIDE TO HEALTH SECTOR PLANNING: A DEMOGRAPHIC CRITIQUE
Pages 126-144
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From page 126... ...
Problems that are revealed in using the index as a planning instrument include imprecision about the time sequence and age pattern of health program effects; inconsistency of assumptions; failure to incorporate interactions among disease processes; and failure to make explicit potentially valuable information. These problems are averted by the use of population projection to demonstrate the expected effects of health programs.
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From page 127... ...
The measure of healthy years of life saved became the numerator of a cost-effectiveness calculation that permitted comparisons across various kinds of health programs (e.g., Prost and Prescott, 1984; Barnum, 19871. These and other analyses have elaborated on this measure and considered whether to treat all healthy years lost to a disease (i.e., potentially saved through health interventions)
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From page 128... ...
These choices inevitably affect the relative value of interventions targeted at children and those targeted at adults. The decision to discount increases the relative cost-effectiveness of adult interventions, because the years of healthy life gained by children lie further in the future, on average, than those gained by adults.
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From page 129... ...
Year of healthy life added 20 10 Productive year of 20 15 healthy life addeda Discounted year of 150 49 healthy life addedb Discounted year of productive 150 190 life addeda,b SOURCE: Prost and Prescott (1984:Table 7)
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From page 130... ...
First, we focus on mortality alone. In Ghana, 70 percent of the healthy years of life added by the array of interventions studied were a product of life extension rather than of morbidity reduction (Ghana Health Assessment Project Team, 1981~.
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From page 131... ...
This formula embodies the standard procedure for calculating the total years of life added by a health program: simply estimate the number of deaths that would be averted by the program and multiply them by life expectancy at each age. Clearly, this procedure assumes that the health program operates for only one year and that those "saved" by the program revert to the average level of mortality in the population (as embodied in the set of n pa's)
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From page 132... ...
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From page 133... ...
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From page 134... ...
The bias is obviously unnecessary because population projection provides an explicit indication of the time sequence of program effects. Multiyear Health Programs Although mass immunization campaigns or campaigns to screen for cervical cancer may operate in only one year, most health programs do not.
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From page 135... ...
The fact that the benefits to younger cohorts of health improvements at older ages are not counted in the "years of life added" calculation can create a serious bias tilting calculations in favor of health interventions directed at children. It would not be a "bias" if programs lasted only one year, but few do.
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From page 136... ...
The authors report that the implicit discount rates did not vary significantly with income or education, so the figures in the table may also be reasonable approximations to values in developing countries. These results show that the saving of lives is discounted at a much higher rate than the 3 percent figure used by the World Bank in its Health Sector Priority Review.
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From page 137... ...
What if those unborn at the time of program initiation are in fact to be considered equal beneficiaries of health programs? That is to say, whatever discount rate is used, it is applied equally to all cohorts regardless of whether or not they were alive at the time program implementation decisions were made.
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From page 138... ...
The assumption that the age distribution at baseline will not change, which is built into the conventional approach, produces large biases in favor of programs targeted at young ages, even during the first decade. Relative to health interventions targeted at ages 0-4, those directed at ages 50-54 or 70-74 would produce 17-24 percent more years of life saved in 2000 than would be indicated by the index computed for 1990.
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From page 139... ...
The conventional procedure clearly overestimates years of healthy life gained. If disability rates are 20 percent at each age, then the gain in healthy years of life from the mortality reduction the bulk of the total gain in years of healthy life will be overestimated by this amount.
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From page 140... ...
The question is far from trivial because most of the years of life eventually added by most health programs will be lived by people who would not have been born in the program's absence. The huge expansion of the human population since 1940 is primarily a result of successful health programs; most of the years of life added represent births that would not otherwise have occurred, rather than longer lives for people who would have been born in any event.
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From page 141... ...
Such projections also serve as a solid and trustworthy vehicle for answering more complex questions if those are pertinent to the planning process. DISCUSSION The conventional measure of years of healthy life gained functions best as a guide to evaluating health interventions lasting one year.
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From page 142... ...
its assumption that all of those saved by the intervention will die at their life expectancy. Both of these procedures produce an upward bias in estimating years of healthy life gained; the latter bias occurs only when discounting is used.3 Most health interventions stretch over periods longer than one year.
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From page 143... ...
Creese 1990 Cost and cost-effectiveness analysis of health interventions. Health Sector Priori ties Review Paper HSPR-23.
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From page 144... ...
Rogers, and L Branch 1989 A multistate analysis of active life expectancy.
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