Title: NIHR Global Health Research Group on Global Health Econometrics and Economics (GHE2), University of York
Funder: Department of Health and Social Care

Abstract: A - C The proposed programme of work aligns both with the University of York’s (UoY) strategy 2015-2020 ‘to be a world leader in research’ and the specific ambition to encourage international research activity - and builds on two of its themes: ‘Health and Wellbeing’ and ‘Justice and Equality’. UoY has entered into an ambitious engagement with ODA-compliant research, aiming to leave a legacy for the University, research in the UK and our partners in the global South. CHE has a team of 50 health economists representing the full breadth of the discipline. Its joint submission with related health groups at UoY to the REF 2014 was ranked top in the country for research environment. While CHE is regarded as one of the leading health economics institutions worldwide [1], most of its research has focussed on high-income health systems (esp. the UK NHS). This proposal is part of CHE’s aim to use health economics to inform policies in LMICs. CHE has an excellent track record in the core domains of GHE2 (econometric analysis and economic evaluation) with demonstrable impact for over 30 years. The UoY is committed to ensuring the success of the proposed Group and has agreed to support it with funding a 3-year full-time Grade 6 research fellow position. The UoY has been investing in supporting International Development research; the International Development Network provides a vehicle to access extended networks of expertise in research programmes in partnership with ODA-recipient countries. Early successes include GCRF funding on leishmaniasis and MRC funding on tobacco control. CHE itself has existing successful international projects in disease modelling/economic evaluation and is seeking to build upon these with GCRF funding (e.g. Thanzi la Onse [TLO] proposal to RCUK), targeting South and East Africa, but these do not have GHE2’s focus on impact evaluation using secondary data. Together, TLO and GHE2 represent the breadth of CHE’s research in global health covering major thematic areas in health economics and building a solid basis on which to sustain further growth. D RCTs are the gold standard of evaluative techniques but randomisation is seldom feasible for evaluating larger-scale interventions that go beyond patient-level, disease-specific interventions [2-4]. This has left a major evidence gap around types of interventions that could have large population health impacts: (1) Health system-level e.g. universal health insurance, and (2) Population-level interventions e.g. taxes on unhealthy foods (See Additional Information). The key objective of GHE2 is to contribute to filling the evidence gap on ‘what works, for whom and at what cost’ in terms of system- and population-level interventions in LMICs. We will do this by conducting country-specific case studies led by researchers in partner countries (Brazil, Indonesia, South Africa) on a set of system- and population-level interventions selected on the basis of pressing national policy needs, their relevance for policymaking beyond the country itself, and the availability of suitable data for evaluation. The case studies focus on quasi-experimental research designs [5] relevant to situations where RCTs are less feasible and that address key limitations of RCTs (e.g. external validity) [4]. Combining existing, under-exploited data with rigorous empirical impact evaluation methods provides evidence to inform policymaking at comparatively low cost. State-of-the-art approaches, e.g. panel instrumental variables and synthetic control methods, will be adopted to assess average population health impacts and distributional impacts, capturing effects across different socioeconomic groups. An integral part of this work will be theory-based logic models of the key causal pathways; identifying the key active ingredients and contextual factors of the intervention [6-7]. There is also a major gap in assessing the value-for-money of the above policies [8-9]. While economic evaluation methods are well developed for medical treatments, often based on evidence from RCTs, this is not the case for population- and system-level interventions. Economic evaluation is a crucial link between impact evaluation-based evidence and making resource-constrained decisions [8,10]; providing information on whether an intervention that ‘works’ can also deliver benefits (which may include equity concerns) given available resources. Country-specific work will be accompanied by a set of conceptual and methodological projects (see add. info and supporting diagram), which together lay the ground for future evaluative work in global health and for developing material for short courses and potential future distance learning courses. South Africa (SA): We will evaluate 2 health system interventions (1) a community health worker programme introduced by the National Department of Health to improve access to healthcare for disadvantaged populations; and (2) the introduction of dedicated obstetric emergency ambulances in the Free State Province, to improve care during obstetric emergencies. We will use previously under-exploited, routinely collected health care data to evaluate the effectiveness and cost-effectiveness of the programmes, considering average and equity impacts. We also evaluate a population-level intervention, the tax on sugar sweetened beverages (SSB), anticipated to be implemented in 2017. This builds on initial collaborations on the SSB tax impact evaluation by the SA team and CHE, which we will extend by assessing the equity impacts and exploring the feasibility of conducting an economic evaluation, accounting for equity effects (‘distributional cost-effectiveness analysis’ [11]). Brazil: We will evaluate a system-level intervention, the Family Health Programme (PSF). PSF is based on multi-professional Family Health Teams, which visit people’s homes regularly and perform health promotion and prevention activities. Despite the PSF being the broadest health programme ever launched in Brazil, there is little evidence of the effects of its coverage on population health. We develop and apply methodologies to investigate 3 key research questions, using available data sources: (1) What has been the quantitative impact of PSF expansions on broad indicators of individual health status, including non-communicable diseases? (2) How do PSF health impacts vary according to different levels of population coverage across areas? (3) What is the relative cost-effectiveness of different levels of PSF coverage? Indonesia: In 2014, the Indonesian Government implemented a National Health Insurance (Jaminan Kesehatan Nasional (JKN)) comprising a wide range of policies, including a unified benefit package, premium subsidies for the poor, a national formulary, and a provider contracting and payment system. We will contribute, first, to the evaluation of JKN’s impact on the performance of the health system, and ultimately on population health, using information from available household survey data gathered before and after the JKN intervention. We will assess the impact of JKN on access to formal care, equity in access to care, protection from catastrophic health payments, and poverty. Our second focus is on evaluating the adoption of a DRG based payment system for hospital services as a part of JKN. Utilising our extensive experience with evaluating such systems in the UK and Europe we will focus on unintended consequences of hospital payment such as up-coding by hospitals and unnecessary relocation of patients. This research will lay the foundations for policy proposals to improve the hospital payment system. Cross-cutting conceptual and methodological projects: we anticipate a set of activities focusing on methodological challenges of impact evaluations to emerge from the country work. A tentative list of activities is detailed in Additional Information. GHE2’s 6-month delivery targets include: (1) full protocols for empirical analyses of all country-specific evaluations; (2) first draft of at least one cross-cutting methods paper; (3) preliminary list of cross-cutting methods and concepts papers (incl. elaborated outlines); (4) country-specific capacity building plans developed; (5) GHE2 inception and first International Steering Group meetings completed. Precise long-term aims are subject to completion of these targets, but the basic aim is for all country-specific analytical work to start in year 1 and produce initial results by the end of year 2. Finalisation will be in year 3, except for potential distinct sub-analyses of evaluations that we may consider completing as self-contained pieces beforehand. The cross-cutting work will be informed by the case studies and as such most of this is likely to be carried out in year 2 and 3, except for the first paper that likely will be on issues around the intersection of impact evaluation and economic evaluation in year 1. Capacity building material will be developed in year 2 and short course will be held in year 3. For a full description of our activities to establish strong partnerships and strengthen capacity, please see sections on Research Capacity and Pathways to Impact. E - F In light of the major evidence gap in terms of population- and system-level interventions, the proposed work is but the beginning of a long term programme of work, for which we see multiple extensions e.g. (1) GHE2 will pave the way for developing impact and economic evaluation designs ex ante, in collaboration with policy-makers; (2) there is a need for impact/economic evaluations (and capacity building) in low-income countries, where data quality allows; and (3) exploring work on randomised impact evaluations. Given the growing amount of funding available for development work (incl. via the GCRF), we are confident that on the basis of the collaborations within and outside of GHE2, we will be able to sustain the funding over the longer term.

Lay abstract: There is a pressing need to establish “what works” in global health. The dominance of randomised controlled trials (RCTs) leaves major gaps in evidence on interventions that could have large impacts on population health but are hard to evaluate with RCTs. These include: (1) Health system-level interventions (such as introducing universal health insurance schemes and strategies to improve provider performance), and (2) Population-level interventions (regional and national policies to address health risks by changing underlying social, economic and environmental conditions, such as taxes on sugar-sweetened beverages or restrictions on advertisements of alcohol). The Global Health Econometrics and Economics Group (GHE2) will address this evidence gap by applying and developing methods to: (1) estimate the impact of population- and system-level interventions; and (2) assess the value-for-money of these interventions. We will employ state-of-the-art empirical methods applied to existing but under-exploited data sources to assess average population health impact and distributional effects, thereby establishing both whether interventions work overall and whether health outcomes of the poorest and most vulnerable improve more than those of the rich. Assessing impact alone, however, is insufficient to inform decision-making at country level or by international organisations, since with budget constraints governments are forced to make difficult choices among many effective interventions. We will, therefore, complement the evaluation of the effectiveness of interventions with an assessment of the value-for-money they offer (economic evaluation), which constitutes a critical, and currently underdeveloped, link between evidence and decision-making in the context of budget constrained choices. GHE2’s work to link the areas of impact evaluation and value-for-money assessment will contribute to the knowledge base of “what works” in global health. This will have a profound effect on the efficient use of resources and improved population health in low- and middle income countries. Research in York will be implemented in close collaboration with leading research institutions in three partner countries across three different continents, Brazil, Indonesia and South Africa, with significant opportunities for mutual learning. The partners’ projects have been prioritised according to their national and international policy relevance, and include the evaluation of the main national primary care programme in Brazil; evaluations of a major community-health worker programme and the national sugar-sweetened beverage tax policy in South Africa; and the evaluation of a major health insurance reform in Indonesia. These individual projects will be enhanced by cross-cutting methodological research and practical policy guidance. We will engage closely with policymakers throughout the development and communication of the research to ensure that our findings inform key areas of policy and have direct benefits for population health.

Research activity codes: 8.5 RESOURCES AND INFRASTRUCTURE (HEALTH SERVICES)
Health categories: GENERIC HEALTH RELEVANCE