Evaluasi Ekonomi Program Kesehatan

KMPK 31.10.11
Ari Probandari
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Referensi Utama Referensi Utama
Drummond MF, Stoddart GL, Torrance GW. Drummond MF, Stoddart GL, Torrance GW.
1998. Methods for the Economic Evaluation
of Health Care Programmes. Oxford
University Press.
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Apakah e al asi ekonomi? Apakah evaluasi ekonomi?
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The comparative analysis of alternatives courses p y
of action in terms of both cost and
consequences
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Programme A
Cost A
Consequences A
Choice
Comparator B
Cost B
Consequences B
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Partial vs Full Economic Evaluation
no yes
Are both costs (inputs) and consequences (outputs) of the alternatives examined?
no
Examines only
consequences
Examines
only cost
PARTIAL EVALUATION
PARTIAL EVALUATION
Is there
comparison
of two or
Outcome
description
Cost
description Cost-outcome description
of two or
more
alternatives
?
yes
Efficacy or
Cost minimization analysis
Cost effectiveness analysis
PARTIAL EVALUATION FULL ECONOMIC EVALUATION
effectiveness
evaluation Cost Analysis
Cost utility analysis
Cost benefit analysis
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Tipeevaluasi ekonomi (full) Tipeevaluasi ekonomi (full)
Cost effectiveness analysis (CEA)
Cost minimization analysis (CMA)
Cost utility analysis (CUA)
Cost benefit analysis (CBA)
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Mengapa evaluasi ekonomi Mengapa evaluasi ekonomi
diperlukan?
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Sumber daya terbatas dan kita tidak bisa Sumber daya terbatas dan kita tidak bisa
memproduksi semua output yang kita inginkan
dan butuhkan.
Perlu membuat keputusan rasional
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Technical andallocativeefficiency Technical and allocative efficiency
Technical efficiency Allocative efficiency Technical efficiency
Assess wether
interventions achieve
Allocative efficiency
Assess whether the
interventions meet
maximum output in a
certain level of input or
to achieve certain level of
objectives, which improve
the welfare of one person
without reducing the to achieve certain level of
output with less input.
without reducing the
welfare of another.
Source: Glossary of Frequently Encountered Terms in Health Economics.
http://www.nlm.nih.gov/nichsr/edu/healthecon/glossary.html
Type of study Cost Identification of
consequences
Consequences
Cost
minimization
analysis
Dollars Identical None
Cost
effectiveness
analysis
Dollars Single outcome, common
to both alternatives, but
achieved in different
degrees
Natural units (e.g. life
years gained, disability-
days saved, points of
blood pressure reduction degrees blood pressure reduction,
etc)
Cost utility
analysis
Dollars Single or multiple
outcome, not necessary
DALY or QALY
y , y
common to both
alternative
Cost Benefit Dollars Single or multiple Dollars
Analysis outcome, not necessary
common to both
alternative
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Perhitunganbiaya Perhitungan biaya
Biaya yang dihitung adalah opportunity cost y y g g pp y
(biaya kesempatan)
Biaya kesempatan adalah the value of
i f i l h b opportunity forgone, strictly the best
opportunity forgone, as a result of engaging
resource in an activity resource in an activity.
(http://www.nlm.nih.gov/nichsr/edu/healtheco
n/glossary.html#Cost, 2011)
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Perhitunganbiaya Perhitunganbiaya
Average costs Average costs
Incremental costs
Marginal costs Marginal costs
Fixed costs
Variable costs Variable costs
Total costs
Direct costs Direct costs
Indirect costs
A id d t Avoided costs
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Perhitunganbiaya Perhitunganbiaya
Perspektif yang dipakai menentukan cara Perspektif yang dipakai menentukan cara
perhitungan biaya: perspektif penyedia
layanan kesehatan ataukah perspektif
masyarakat?
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BiayaUPK Biaya UPK
Sensitization and mapping of
providers
DOT
Hospitalization
providers
Training
Routine interaction with/supervision
of providers
Drugs
Hospitalization
Other visits for patient monitoring
Defaulter tracing
Health education for patients
Recordingand reporting
g
Sputum smears for screening and
diagnosis
Sputum smears for monitoring
X-rays
Recording and reporting
Programme Management
Wasor
Beyond project expenditure
Coordination meetings
Other diagnostic tests
Routine interaction with PRM health
centre
Visits by detailers/TB programmers
to PPs
Coordination meetings
NTP and KNCV Staff involvement
to PPs
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Biayapasiendanpendamping Biaya pasien dan pendamping
Biaya pasien
T t ti
Biaya pendamping
T t ti Transportations
Consultations (outpatient)
Hospitalization
Investigations (laboratory, X-ray,
other e g MRI)
Transportation
Time taken to accompany patient
Wages lost
Days lost from studies (e.g.
school/college) other e.g. MRI)
Drugs
Time taken to access treatment
Wages lost by patient
Days lost fromwork by patient
school/college)
Other
Days lost from work by patient
Days lost from studies (e.g.
school/college) by patient
Interest paid on loans
Others Others
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Perhitunganefektivitas Perhitungan efektivitas
Tergantung dari jenis evaluasi ekonomi yang
akan dilakukan
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CEA CEA
An economic evaluation in which the cost
and consequences of alternative
interventions are expressed cost per unit
of health outcome of health outcome
(http://www.nlm.nih.gov/nichsr/edu/healthe
con/glossary.html, 2011)
E l i k i t b b Evaluasi ekonomi antar beberapa
alternatif dengan tingkat konsekuensi
yang berbeda tetapi dapat dibandingkan y g p p g
dengan satu ukuran keluaran.
Perbandingan dinyatakan dalam rasio
biaya efektifitas (cost effectiveness ratio)
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biaya-efektifitas (cost effectiveness ratio).
Bagaimanamemperolehdatabiaya Bagaimana memperoleh data biaya
Data primer (wawancara, observasi) Data primer (wawancara, observasi)
Data sekunder (laporan keuangan, data
bagian penunjang umum dst.) g p j g )
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Pengukuranefektifitas Pengukuran efektifitas
J umlah kasus tambahan yg terdeteksi dan J umlah kasus tambahan yg terdeteksi dan
berhasil disembuhkan melalui implementasi
PPM-DOTS di RS dan PS
Penurunan keterlambatan diagnosis dan
pengobatan melalui PPM DOTS
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ContohukuranefektivitaspadaCEA ContohukuranefektivitaspadaCEA
Study reference Clinical field Effectiveness Study reference Clinical field Effectiveness
measure
Logan et al (1981) Treatment of
hypertension
mmHg blood
pressure reduction hypertension pressure reduction
Schulman et al
(1990)
Treatment of
hypercholesterolemi
a
% serum cholesterol
reduction
a
Hull et al (1981) Diagnosis of deep-
vein thrombosis
Cases of DVT
detected
Sculpher and Buxton
(1993)
Asthma Episode-free days
Mark et al (1995) Thrombolysis Years of life gained
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Bagaimanamemperolehdataefektifitas? Bagaimana memperoleh data efektifitas?
Melakukan penelitian (menggali data primer
maupun sekunder) p )
Memakai data dari literatur yang ada (review
atau metaanalisis))
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Example of ACER and ICER ExampleofACERandICER
Cost
PPMDOTS
Cost
600,00
0
PPM DOTS
hospital referral
ACER of PPM
DOTS hospital
referral
ICER of PPM DOTS in community
health centre only = 4,000
200,00
0
referral
= 2,000
PPM DOTS in community health
centre only
0
Effectiveness
(Number of cases
200 300
ACER of PPM DOTS in community health centre only =
1,000
(Number of cases
succesfully
treated)
Handlinguncertaintyinhealth
l economicevaluation
Uncertaintyrelated
todatainput
Uncertaintyrelated
toextrapolation
Uncertaintyrelated
toanalysismethod
PresentingCIof
CER forsampled
data
Whendatais
extrapolatedor
modelled
i i i l i
Ex.presenting
resultswith
differentdiscount
Calculationof
power toadjust
adequacyof
sample size
sensitivityanalysis rate.
samplesize
Source: Drummond MF, & J efersson TO. Guidelines for authors and peer reviewers of economic
submissions to the BMJ . BMJ 1996; 313: 275.
Sensitivity Analysis SensitivityAnalysis
A technique which repeats the comparison Atechniquewhichrepeatsthecomparison
betweeninputsandconsequences,varying
the assumptions underlying the estimates In theassumptionsunderlyingtheestimates.In
sodoing,sensitivityanalysisteststhe
robustness of the conclusions by varying the robustnessoftheconclusionsbyvaryingthe
itemsaroundwhichthereisuncertainty.
(http://wwwnlm nih gov/nichsr/edu/healthec (http://www.nlm.nih.gov/nichsr/edu/healthec
on/glossary.html,2011
) )
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Cost MinimizationAnalysis Cost Minimization Analysis
M b di k 2 t l bih ilih d ti k t Membandingkan 2 atau lebih pilihan dengan tingkat
effectiveness yang sama, untuk mencari mana yang
membutuhkan paling sedikit resources.
Bentuk khusus dari CEA (CEA dengan ukuran efektivitas
yang besarnya sama)
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Cost UtilityAnalysis Cost Utility Analysis
A f f i t d d i i hi h A form of economic study design in which
interventions which produce different consequences,
in terms of both quantity and quality of life. q y q y
Pada CUA, quality of life dan morbiditas
diperhitungkan sebagai outcome dari program.
C QALY ( li dj d lif ) Cost per QALY (quality adjusted life years) atau cost
per DALY (disability adjusted life years)
QALY is units of measure of utility which combine QALY is units of measure of utility which combine
life years gained as a result of health
interventions/health care programs with a judgment
abo t the q alit of these life ears
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about the quality of these life years
Cost utilityanalysis Cost utility analysis
Ukuran effectiveness antara satu program Ukuran effectiveness antara satu program
dengan program yang lain mungkin berbeda.
Dalamsatu program mungkin ada lebih dari 1 p g g
outcome.
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Cost Benefit Analysis Cost Benefit Analysis
A method of comparing the monetary value of
all benefits of a project with all costs of that p j
project
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CBA CBA
Biaya dan benefit dinyatakan dalamnilai Biaya dan benefit dinyatakan dalam nilai
uang.
Cost-Benefit Criteria sering dinyatakan Cost-Benefit Criteria sering dinyatakan
sebagai Net Social Benefit (NSB)
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CBA CBA
Direct benefit: savings in future costs of Direct benefit: savings in future costs of
prevention/treatment/control, which would be incurred by the
health service or patient or society at large
Indirect benefit: production losses which would have occurred p
as a result of death, or incapacity or reduced productivity,
including through interrupted education, which have now been
avoided
I t ibl b fit i i i t th d ti i lit Intangible benefit, i.e. pain, anxiety or other reduction in quality
of life, either in patients or their relatives and friends, which has
now been avoided
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Metode untuk mengukur benefit dalam nilai uang
Whose
judgement?
How it is elicited Example
Policy-makers/public
figures
Explicit/stated preference e.g. court orders: how much is paid in
compensationfor injuries figures compensation for injuries
Implicit in
decisions/revealed
preference
e.g. legislationon road safety: how much is
spent on it
preference
Individuals
(patients or
general public)
Direct
survey/stated
preference
Willingness to pay (WTP)
surveys, e.g. contingent
valuation: how much would general public) preference valuation : how much would
you pay to avoid X condition?
e.g. conjoint analysis: ranking
scenarios with different scenarios with different
attributes to ascertain
preference and WTP
Implicit in e g wage premia for risky job or life insurance Implicit in
behaviour/revealed
preference
e.g. wage premia for risky job, or life insurance
payments
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Willingness-to-pay(WTP) Willingness to pay (WTP)
A technique which aims to assign a value to A technique which aims to assign a value to
health benefits by directly eliciting individual
preferences in the views of samples of the
general public who are asked how much they
would be prepared to pay to accrue a benefit
t id t i t or to avoid certain events.
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