Evaluasi Ekonomi Program KesehatanKMPK 31.10.11 Ari Probandari 1 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. 2 Apakah e al asi ekonomi? Apakah evaluasi ekonomi? 3 The comparative analysis of alternatives courses p y of action in terms of both cost and consequences 4 Programme A Cost A Consequences A Choice Comparator B Cost B Consequences B 5 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 6 Tipeevaluasi ekonomi (full) Tipeevaluasi ekonomi (full) Cost effectiveness analysis (CEA) Cost minimization analysis (CMA) Cost utility analysis (CUA) Cost benefit analysis (CBA) 7 Mengapa evaluasi ekonomi Mengapa evaluasi ekonomi diperlukan? 8 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 9 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 11 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) 12 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 13 Perhitunganbiaya Perhitunganbiaya Perspektif yang dipakai menentukan cara Perspektif yang dipakai menentukan cara perhitungan biaya: perspektif penyedia layanan kesehatan ataukah perspektif masyarakat? 14 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 15 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 16 Perhitunganefektivitas Perhitungan efektivitas Tergantung dari jenis evaluasi ekonomi yang akan dilakukan 17 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) 18 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 ) 19 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 20 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 21 Bagaimanamemperolehdataefektifitas? Bagaimana memperoleh data efektifitas? Melakukan penelitian (menggali data primer maupun sekunder) p ) Memakai data dari literatur yang ada (review atau metaanalisis)) 22 Example of ACER and ICER Example of ACER and ICER 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) Handling uncertainty in health l economic evaluation Uncertainty related to data input Uncertainty related to extrapolation Uncertainty related to analysis method • Presenting CI of CER – for sampled data • When data is extrapolated or modelled – i i i l i • Ex. presenting results with different discount • Calculation of power – to adjust adequacy of sample size sensitivity analysis rate . sample size Source: Drummond MF, & J efersson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ . BMJ 1996; 313: 275. Sensitivity Analysis Sensitivity Analysis • “A technique which repeats the comparison A technique which repeats the comparison between inputs and consequences, varying the assumptions underlying the estimates In the assumptions underlying the estimates. In so doing, sensitivity analysis tests the robustness of the conclusions by varying the robustness of the conclusions by varying the items around which there is uncertainty.” (http://wwwnlm nih gov/nichsr/edu/healthec (http://www.nlm.nih.gov/nichsr/edu/healthec on/glossary.html, 2011 • ) • ) 25 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) 26 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” 27 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. 28 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 29 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) 30 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 31 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 32 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.” 33
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