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MINISTRY OF HEALTH

REF

İ

K SAYDAM HYGIENE CENTER PRESIDENCY

SCHOOL OF PUBLIC HEALTH

BA

Ş

KENT UNIVERSITY

NATIONAL BURDEN OF DISEASE AND

COST EFFECTIVENESS PROJECT

COST EFFECTIVENESS

FINAL REPORT

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© Refik Saydam Hygiene Center Presidency Refik Saydam School of Public Health Directorate

This report has been written by Başkent University, Ankara for its use, publication and distribution by the Ministry of Health (RSHMB- Refik Saydam Hygiene Center Presidency, the School of Public Health). No other individuals or agencies except for the Ministry of Health (RSHMB- the School of Public Health) can claim for any rights based on this report nor can utilize it.

No individuals who have utilized this report can claim for any losses due to its content. The publishing of this report does not undertake any responsibilities for its content.

Neither Başkent University and the Ministry of Health ( RSHMB- the School of Public Health) nor any personnel, managers or representatives who are positioned in either of these agencies can be held responsible for any information or statement included in this report and no claims can be made that these two agencies and their above mentioned personnel have undertaken any kind of commitment, given any kind of warranty or will make any kind of written and verbal statements in the future.

All rights are reserved. In compliance with the Law no 4110 and FSEK no 5846, a written authorization in compliance with the Article no 52 must be received from the right owner of this report before its use. Otherwise, no use of this report through different kinds of processing, copying, distributing, selling, hiring, lending, representing, presenting and delivering by means of any radio or wireless, technical, digital and / or electronical communication methods is permitted.

For Further Information, Please Contact

Refik Saydam Hygiene Center Presidency

Refik Saydam School of Public Health Directorate

Address:İbrahim Müteferrika Sokak, No:5, 06030, Rüzgarlı/ Ulus/ Ankara, Turkey

Phone : 00-90--312-3091224

e-mail : mektep@hm.saglik.gov.tr

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ACKNOWLEDGMENTS

This study was conducted in order to estimate the National Burden of Disease and financed by Republic of Turkey, Ministry of Health. We thank first of all, the Ministry of Health for all kinds of support in the completion of the study, especially the Health Project General Coordinators Mehmet Fettahoğlu;MD and Haydar Mezarcı; the School of Public Health’s Director Salih Mollahaliloğlu,MD; Nazan Yardım, MD (Public Health Specialist); Berrak B. Başara, MD, Ömer Varol,MD; Vural Dirimeşe, MD (Family Physician); Mehtap Kartal,MD (Family Physician) ; Halil E. Erişti, MD and to all the others involved at the Refik Saydam Hygiene Center Presidency School of Public Health, for working closely with us since the planning phases in all aspects of the Study; and to the members of the steering and scientific committee of the National Burden of Disease and Cost Effectiveness Project for their valuable contributions.

In addition to that we also want to thank to the staff of School of Public Health’s, Public Health Department; Engin Özkan,MD; Demet Aksoy, Esin Şener, MD; Zekiye Çelebi, MD; İlhan Öztürk, MD, Serap Taşkaya and Belgin Özhan,MD for their valuable contributions.

We also wish to acknowledge in support and encouragement of Başkent University President Prof. Mehmet Haberal, who believed in the importance of this project for the country and provided all his possibilities for us since the beginning of the project in order to run this very important study.

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NBD-CE PROJECT MONITORING COMMITTEE MEMBERS

MINISTRY OF HEALTH

General Directorate of Primary Health Care Systems

Dr. İ. Ercan BAL, Dr. Hülya ALTINYOLLAR, Dr. Nihal BABALIOĞLU

General Directorate of Maternal Child Health and Family Planning Dr. Levent EKER, Dr. Arzu KÖSELİ

General Directorate of Treatment Services

Dr. Ertan KAVASOĞLU, Hakime ZAL, Dr.Filiz BOZKURT, Hüseyin BÜYÜKKAYIKÇI

Agency Directorate of Fight Against Tuberculosis

Dr. Binnaz KAYA DURUNAY, Dr. Ayşen Melek AYTUĞ KOŞAN

Agency Directorate of Fight Against Malaria, Dr.Ömer YEDİKARDEŞLER

General Directorate of Medication and Pharmacology, Ecz. Eda CİNDOĞLU

Agency Directorate of Information Systems,

Dr. Songül DOĞAN, Dr. Özlem YİĞİTBAŞIOĞLU

Agency Directorate of Fight Against Cancer,

Professor Dr. Murat TUNCER, Dr. Funda TEKİN, Dr. Emire ÖZEN

Ministry of Health,Research

İnciser KAYA, İlknur GÜNEY, Rasim CEYHAN

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Ankara Hospital

Dr. Mehmet FETTAHOĞLU

Refik Saydam Hygiene Center Presidency School Of Public Health

Dr. Nazan YARDIM, Dr. Berrak BORA BAŞARA, Dr. Mehtap KARTAL, Dr. Halil Erkan ERİŞTİ, Dr. Ömer VAROL, Dr. Vural DİRİMEŞE.

NBD-CE PROJECT STEERING COMMITTEE MEMBERS

MINISTRY OF HEALTH

Undersecretary, Prof. Dr. Necdet ÜNÜVAR

Refik Saydam Hygiene Center Presidency School Of Public Health, Dr. Salih MOLLAHALILOĞLU

REPUBLIC OF TURKEY, MINISTRY OF INTERNAL AFFAIRS General Directorate of Population and Citizenship Affairs,

Orhan AKKAYA, Döner TETİK

REPUBLIC OF TURKEY, HEADQUARTERS TURKISH GENERAL STAFF Turkish Armed Forces Health Command,

Muharrem UÇAR

REPUBLIC OF TURKEY, PRIME MINISTRY, UNDERSECRETARIAT OF TREASURY Public Economic Ventures, General Directorate, A. Tuncay TEKSÖZ

Foreign Economic Relations, General Directorate Ayşe AKKİRAZ

REPUBLIC OF TURKEY, PRIME MINISTRY STATE PLANNING ORGANIZATION, General Directorate of Social Sectors and Coordination

Muharrem VARLIK, Nihan KIRCALIALİ

REPUBLIC OF TURKEY, PRIME MINISTRY CHAIRMANSHIP OF STATE STATISTIC INSTITUTE

Agency Directorate of National Calculations;

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Directorate of Social Sectors and Coordination;

Şengül ARSLAN, Nevin UYSAL

Agency Directorate of Research, Investigation and Statistics Techniques Yılmaz ERŞAHİN, Muharrem GÜR

REPUBLIC OF TURKEY , MINISTRY OF FINANCE General Directorate of Budget and Financial Control, Abdurrahman VARGÜN,

REPUBLIC OF TURKEY, GENERAL DIRECTORATE OF SOCIAL SECURITY

ORGANIZATION FOR ARTISANS, CRAFTSMAN, TRADESMAN AND THE OTHER SELF-EMPLOYED, Chairmanship of Health Affaires,

Merih DİZİCİ

REPUBLIC OF TURKEY, GENERAL DIRECTORATE OF RETIREMENT FUND, Agency Directorate of Health Care Services

Tarık KANGAL

REPUBLIC OF TURKEY, MINISTRY OF LABOR AND SOCIAL SECURITY

Chairmanship of Social Security Institution, General Directorate of Health Affaires Hüseyin BÜYÜKKKAYIKÇI, Nuri ŞAŞMAZ

NBD-CE PROJECT SCIENTIFIC COMMITTEE MEMBERS

HACETTEPE UNIVERSITY PRESIDENCY Faculty of Medicine, Department of Public Health

Associate Professor Dr. Nesrin ÇİLİNGİROĞLU, Associate Professor Dr. Bahar GÜÇİZ DOĞAN, Dr. Banu ÇAKIR, Dr. Sarp ÜNER, Associate Professor Dr. Hilal ÖZCEBE

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Institution of Population Studies,

Professor Dr. Sabahat TEZCAN, Research Assistant Elif KURTULUŞ YİĞİT,

Faculty of Economic and Administrative Science, Economy Department Research Assistant, Zafer ÇALIŞKAN

ANKARA UNIVERSITY PRESIDENCY

Directory of Health Education Faculty

Assistant Professor Dr. İsmail AĞIRBAŞ, Associate Professor Dr.Efsun Ezel ESATOĞLU

School of Political Sciences,

Assistant Professor Dr. Hasan ŞAHİN

GAZİ UNIVERSITY PRESIDENCY

Faculty of Medicine, Department of Public Health, Associate Professor Dr.Işıl MARAL

Directorate of Investigation and Prevention of Accidents Institution Dr. Elif DURUKAN

Faculty of Economic and Administrative Science, Professor Dr. Metin Kamil ERCAN

MARMARA UNIVERSITY PRESIDENCY Directory of Health Education Faculty, Assistant Professor Dr. Metin ATEŞ

DOKUZ EYLÜL UNIVERSITY PRESIDENCY

Directory of Faculty of Economic and Administrative Science Assistant Professor Dr. Yasemin YEĞİNBOY

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KARADENİZ TEKNİK UNIVERSITY PRESIDENCY Faculty of Medicine, Department of Public Health, Assistant Professor Dr. Murat TOPBAŞ

ERCİYES UNIVERSITY PRESIDENCY

Faculty of Medicine, Department of Public Health, Professor Dr. Osman GÜNAY

KOCAELİ UNIVERSITY PRESIDENCY

Faculty of Medicine, Department of Public Health, Assistant Professor Dr. Nilay ETİLER

ASSOCIATIONS

Association of Thorax, Dr. Osman ÖRSEL

Association of Public Health Experts, Associate Professor Dr. Hilal ÖZCEBE

Association of Clinical Microbiology and Infection Diseases Professor Dr. Halil KURT

Association of Internal Diseases Experts, Dr. Gülay SAHİN GÜVEN

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NBD-CE PROJECT BASKENT UNIVERSITY PROJECT TEAM

PROJECT ADMINISTRATION

Professor Dr. Korkut Ersoy, Project Coordinator

Associate Professor Dr. Adnan Kısa, Associate Coordinator Professor Dr. Şahin Kavuncubaşı, Associate Coordinator

COST EFFECTIVENESS GROUP

Professor Dr. Mahmud Khan, Director, Tulane University Professor Dr. Şahin Kavuncubaşı, Baskent University Associate Professor Dr. Adnan Kısa, Baskent University Assistant Professor Dr. Nermin Özgülbaş, Baskent University Assistant Professor Dr. Simten Malhan, Baskent University Dr. Ergün Öksüz, Baskent University

Beyhan Aksoy, MBA, Baskent University Cenk Sözen, MBA, Baskent University

TRANSLATIONS

Gregory Hammond, MSci Elif Şengül

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CONTENTS

ACKNOWLEDGMENTS...Hata! Yer işareti tanımlanmamış.

NBD-CE PROJECT BASKENT UNIVERSITY PROJECT TEAM...iii

NBD-CE PROJECT MONITORING COMMITTEE MEMBERS ... iv

NBD-CE PROJECT STEERING COMMITTEE MEMBERS... v

NBD-CE PROJECT SCIENTIFIC COMMITTEE MEMBERS ... vi

CONTENTS ... ix

LIST OF FIGURES... xx

INTRODUCTION... 1

1.1. Objectives of the Cost Effectiveness Study ... 1

1.2. Cost Effectiveness Analysis ... 2

1.3. Cost-effectiveness Approach... 4

1.3.1. The General Approach of Cost-effectiveness ... 4

1.3.2. Approach Proposed by Cowley et al. (1994) ... 6

1.4. Essential Service Packages (ESP) ... 10

1.4.1. Content and Design of Essential Service Packages... 12

1.4.2. Policy Implementation of Essential Service Package ... 13

COST EFFECTIVENESS ANALYSIS METHODOLOGY ... 15

2.1. Coverage and Sample Size of Costing Surveys ... 15

2.1.1. Selection of Cities for Cost Analysis ... 18

2.1.2 Use of ‘Human Development Index’ in Sample Selection ... 19

2.1.3. Regional General Capacity Utilization Rate – Occupancy Rate... 20

2.1.4. Selection of Cities ... 21

2.1.4.1. West Region ... 21

2.1.4.2. Central Region... 23

2.1.4.3 East Region... 24

2.2. Selection of Hospitals for Cost Analysis... 25

2.2.1. Selection of the Ministry of Health Hospitals ... 25

2.2.2. Selection of University Hospitals... 26

2.2.3. Selection of Social Insurance Organization (SIO) Hospitals ... 26

2.2.4. Selection of Private Hospital... 26

2.3. Selection of Primary Health Care Facilities ... 27

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2.3. 3. Selection of Tuberculosis (TB) and Malaria Dispensaries... 27

2.4. Organization of Cost Analysis Study ... 28

2.5. Cost Analysis Methodology for Hospitals ... 30

2.6. Step-Down Allocation Methodology ... 31

2.6.1. Determination of Outputs (Services)... 31

2.6.2. Identification of Cost Centers... 36

2.6.3. Determination of Cost Items ... 37

2.6.3.1. Direct and Indirect Personnel Expenditures... 38

2.6.3.2. Material Expenditures ... 38

2.6.3.3. General Production Expenditures... 38

2.6.3.4. Hospital Building Depreciation... 39

2.6.3.5. Fixed Asset Depreciation ... 39

2.6.4. Distribution of Expenditures to Service Centers (Primary Distribution) ... 39

2.6.5. Allocation of Resources used in Secondary Cost Centers to Principal Cost Centers ... 40

2.6.6. Calculation of Unit Cost and Allocation of General Administrative Expenditures ... 41

2.7. Cost Analysis Methodology in Primary Health Care Facilities ... 43

2.7.1. Data Source Information Related to Primary Health Care Facilities ... 43

2.7.2. Determination of Cost Centers ... 45

2.7.3. Identification of Expenditure Items... 47

2.7.4. Allocation of Costs by Service Centers and Data Sources... 48

2.7.4.1. Medical Supply Expenditures ... 48

2.7.4.2. Drug Expenditures... 48

2.7.4.3. Direct Personnel Expenditures ... 48

2.7.4.4. Indirect Personnel Expenditures... 48

2.7.4.5. Electricity Expenses ... 49

2.7.4.6. Water Expenses ... 49

2.7.4.7. Fuel Expenses... 49

2.7.4.8. Communication Expenses ... 49

2.7.4.9. General Supply Expenses... 50

2.7.4.10. Fixed Asset Depreciation Expenditures ... 50

2.7.4.11. Building Depreciation Expenditures ... 50

2.7.5. Allocation of Auxiliary Expenditure Centers’ Costs to Cost Centers (2nd. Allocation) 50 2.7.6. Calculation of Unit Cost and Allocation of General Administrative Expenditures ... 50

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2.8.1. Procedure For Determining Costs Of Laboratory Tests... 53

2.8.1.1. First Step: Determining The Distribution of Lab Test Types ... 54

2.8.1.2. Second Step: Estimating Unknown Distribution From Reference Distribution ... 54

2.8.1.3. Third Step: Test Weight Determination ... 55

2.8.1.4. Fourth Step: Calculating The Number Of Weighted Tests ... 55

2.8.1.5. Fifth Step: Calculating The Unit Cost Of Weighted Tests... 56

2.8.1.6. Sixth Step. Calculating The Unit Cost by Type of Test... 56

RESULTS OF THE PRIMARY HEALTH CENTER COSTING STUDIES ... 57

3.1. Primary Health Centers Unit Service Costs ... 57

3.1.1. Total costs... 57

3.1.2. Unit Costs ... 59

3.1.2.1. Laboratory Services... 70

3.1.2.2. Unit Costs of Outpatient Clinic Services ... 74

3.1.2.3. Child Health Services Unit Costs... 77

3.1.2.4. Unit Costs of Family Planning ... 80

3.1.2.5. Unit Costs of Dental Care Outpatient Clinic Services ... 86

3.1.2.6. Unit Costs of Environmental Health Services... 88

3.1.2.7. Unit Costs of Vaccination Services... 90

3.1.2.8. Emergency Service Unit Costs... 93

3.1.2.9. Wound and Injury Dressing Services and Unit Costs ... 94

3.1.2.10. Unit Costs of Monitoring ... 96

3.1.2.11. Unit Costs of Home Visits... 97

3.1.2.12. Unit Costs of Birth Services... 98

3.1.2.13. Unit Costs of Observation Services... 98

3.2. Unit Costs of Services Provided In Other Primary Health Care Facilities ... 99

3.2.1. Service Unit Costs of Diyarbakir Malaria Dispensary... 99

3.2.2. Unit Costs of Istanbul 70. Yıl Okmeydanı MCHFP Center... 99

3.2.3. Unit Costs of Ankara Tuberculosis Dispensary No 3 ... 100

RESULTS OF HOSPITAL COSTING STUDIES ... 103

4.1. Input Prices and Amounts of Inputs ... 103

4.2. Amounts of Outputs ... 103

4.3. Managerial and Environmental Factors ... 104

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4.4.1.1. Patient Day Costs ... 106

4.4.1.2. Clinic-Level Costs... 109

4.4.1.3. Outpatient Clinic Costs ... 111

4.4.2. University Hospitals ... 115

4.4.2.1. Service Costs ... 115

4.4.2.2. Clinic-Level Costs... 115

4.4.2.3. Outpatient Clinic Services... 116

4.4.2.4. Outpatient Clinic Based Costs in University Hospitals... 117

4.4.3. SIO Hospitals ... 118

4.4.3.1. Outpatient Clinic Costs ... 120

4.4.4. Private Hospital ... 122

4.4.4.1. Outpatient Clinic Costs ... 122

COSTS OF SOME SELECTED HEALTH INTERVENTIONS... 127

5.1.1. Costing of Health Interventions ... 127

5.1.2. Calculating the Effectiveness of Interventions... 131

5.1.3. Calculation of Cost Effectiveness Ratios and The Essential Health Care Package ... 134

5.2. Cost of Some Selected Public Health Interventions... 134

5.2.1. Mass Media Encouraging Seat Belt Usage ... 135

5.2.2. Mass Media Anti-Smoking Campaign ... 137

5.2.3. Condom Use for Prevention of STDs (Total Costs Including Cost of Condoms) ... 139

5.2.4. Expanded Program on Immunization Plus (Vitamin A distribution included) ... 141

5.2.5. Mass Media Alcohol Campaign ... 146

5.2.6. Home Based Treatment of Diarrhea in <5 Year Olds (Including Education Costs).... 149

5.2.7. Malaria Prevention via Environmental Spraying ... 151

5.2.8. Malaria Prevention via Bed-Nets ... 152

5.2.9. General Screening Of Adults For Hypertension And Diabetes ... 152

5.2.9.1. Screening And Treatment For Hypertension... 152

5.2.9.2. Screening And Treatment For Diabetes ... 154

5.3. Cost Effectiveness of Some Selected Health Interventions ... 155

5.3.1. Costing of Clinical Interventions ... 156

5.3.2. Method Followed in the Costing of Interventions... 157

5.3.3. The following information is needed for the Cost Effectiveness calculations:... 162

ESSENTIAL SERVICE PACKAGES FOR TURKEY... 210

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6.2. Package 2: Child Health Cluster ... 211

6.3. Package 3: Maternal Health Cluster... 211

6.4. Package 4: STD service package... 212

6.5. Package 5: Service Package for Cancer ... 212

6.6. Package 6: Diabetes And Hypertension Related Cluster ... 213

6.7. Package 7: Oral and Dental Health Package ... 213

6.8. Package 8: Mental Health Package ... 213

6.9. Package 9: Interventions with CE ratio of Less Than $500 ... 214

6.10. Package 10: Comprehensive Package ... 216

6.11. Package 11. COPD and ARIs Package (Health Center) ... 218

6.12. Package 12. Osteoarthritis and Osteoporosis Package... 218

6.13. Package 13. Selected Top 20 DALYs causing diseases... 219

CALCULATING THE MEDICAL CARE PRICE INDEX ... 220

7.1. Methodology ... 220

7.2. SIS Weights for Calculating the Price Index... 221

7.3. Price Indices for the Two Survey Periods ... 222

7.4. Correcting the Survey Expenditure Numbers for Inflation ... 223

CONCLUSIONS AND POLICY IMPLICATIONS... 225

8.1. Hospital Costing Study... 225

8.2. Primary Health Care Center Cost Analysis... 229

8.3. Cost Effectiveness Analysis ... 232

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TABLE OF CONTENTS

Table 1. Decision Rules in Cost-Effectiveness Analysis ... 6

Table 2. Sample Size Stated in Terms of Reference (TOR) ... 16

Table 3. Plan Approved During the Study Design Meeting... 16

Table 4. Approved Sample Size (Hospitals and Primary Health Care Facilities )... 18

Table 5. HDI and CUR Values for West Region Cities... 22

Table 6. HDI and CUR Values for Cities in the Central Region ... 23

Table 7. HDI and CUR Values for Cities in the East Region ... 24

Table 8. Names of Hospitals Selected from West Region ... 25

Table 9. Names of Hospitals Selected from East Region... 25

Table 10. Names of Hospitals Selected from Central Region... 26

Table 11. Primary Health Care Facilities ... 28

Table 12. Cost Items in Hospital Services ... 37

Table 13. Criteria for Direct Cost Allocation... 40

Table 14. Allocation Criteria of Hospital Expenditures by Auxiliary Cost Centers... 41

Table 15. Total Costs of Primary Health Care Facilities and Their Allocation ... 58

Table 16. Izmir Bornova Health Care Center... 61

Table 17. Izmir Kemalpaşa Health Care Center... 62

Table 18. Izmir Koyundere Health Care Center... 63

Table 19. Elazig Baskil Health Care Center... 64

Table 20. Elazig Mollakendi Health Care Center ... 65

Table 21. Elazig Yenimahalle Health Care Center ... 66

Table 22. Diyarbakır Malaria Dispensary ... 67

Table 23. Istanbul 70. Yıl Okmeydanı Maternal Care and Family Planning Center ... 68

Table 24. Ankara No 3 Pulmonary Tuberculosis Dispensary ... 69

Table 25. Unit costs of laboratory services ... 71

Table 26. Average costs of laboratory services (Including drug and medical supplies)... 73

Table 27. Average costs of laboratory services (Excluding drug and medical supplies)... 73

Table 28. Unit Costs of Outpatient Clinic Services ... 75

Table 29. Average Cost Of Outpatient Services (Including Drug And Medical Supplies) ... 76

Table 30. Average Cost Of Outpatient Services (Excluding Drug And Medical Supplies) ... 76 Table 31. Unit Costs of Phenylketonuria Services (Including Drugs and Medical Supplies) . 77 Table 32. Unit Costs of Phenylketonuria Services (Excluding Drugs and Medical Supplies) 78

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Table 34. Unit Costs of ORT Services (Excluding Drugs and Medical Supplies) ... 79

Table 35. Unit Costs of Pneumonia Treatment (Including Drugs and Medical Supplies)... 79

Table 36. Unit Costs of Pneumonia Treatment (Excluding Drugs and Medical Supplies)... 80

Table 37. Unit Costs of Pill Service (Including Drug and Medical Supply Expenditures) ... 80

Table 38. Unit Costs of Pill Service (Excluding Drug and Medical Suply Expenditures) ... 81

Table 39. Unit Costs of Condom Service (Including Drug and Medical Expenditures)... 82

Table 40. Unit Costs of Condom Service (Excluding Drug and Medical Expenditures) ... 82

Table 41. Unit Costs of IUD Services (Including Drugs and Medical Supplies) ... 83

Table 42. Unit Costs of IUD Services (Excluding Drugs and Medical Supplies) ... 84

Table 43. Unit Cost of Injection Services (Drugs and Medical Supplies Included) ... 84

Table 44. Unit Cost of Injection Services (Drugs and Medical Supplies Excluded) ... 85

Table 45. Unit Costs of Other Methods of Family Planning Services ... 85

Table 46. Unit Costs of Other Methods of Family Planning Services ... 86

Table 47. Unit Costs of Dental Care Outpatient Clinic... 87

Table 48. Average Cost Of Dental Outpatient (Including Drug And Medical Supplies) ... 87

Table 49. Average Cost Of Dental Outpatient (Excluding Drug And Medical Supplies) ... 88

Table 50. Unit Costs of Environmental Health Services... 88

Table 51. Average Cost Of Environmental Services (Incl. Drugs And Medic. Supplies)... 89

Table 52. Average Cost Of Environmental Services (Excl. Drugs And Medic. Supplies)... 89

Table 53. Unit Costs of Vaccination Services... 91

Table 54. Average Cost Of Vaccination Services (Including Drug And Medical Supplies)... 92

Table 55. Average Cost Of Vaccination Services (Excluding Drug And Medical Supplies).. 92

Table 56. Emergency Service Unit Costs... 93

Table 57. Emergency Service Average Costs (Including drug and medical supplies) ... 94

Table 58. Emergency Service Average Costs (Excluding drug and medical supplies) ... 94

Table 59. Unit Costs of Wound and Injury Dressing Services ... 95

Table 60. Average cost of wound dressing (Including drug and medical supplies) ... 95

Table 61. Average cost of wound dressing (Excluding drug and medical supplies) ... 96

Table 62. Monitoring Costs (Including Drugs and Medical Supplies) ... 96

Table 63. Monitoring Costs (Excluding Drugs and Medical Supplies) ... 97

Table 64. Average Costs of Home Visits (Including Drugs and medical Supplies) ... 98

Table 65. Unit Costs of Birth and Observation Services ... 98

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Table 68. Unit Costs of Ankara Tuberculosis Dispensary No 3 ... 100

Table 69. Weighted Average Cost of the Tuberculosis Dispensary Services .Hata! Yer işareti tanımlanmamış. Table 70. Weighted Average Cost of the Tuberculosis Dispensary Services .Hata! Yer işareti tanımlanmamış. Table 71. Patient Day Costs In MOH Hospitals (Median)... 107

Table 72. Correlations of Capacity Usage Rates, Patients Per Staff, and Costs ... 108

Table 73. Average Patient Day Costs in Clinics of the Ministry of Health Hospitals ... 110

Table 74. Outpatient Clinic Costs by MOH Hospitals... 111

Table 75. Outpatient Clinic Costs Of MOH Hospitals (median) ... 113

Table 76. Costs of Emergency Service ... 114

Table 77. Patient Day Cost in University Hospitals... 115

Table 78. Clinic Patient Day Costs of University Hospitals ... 116

Table 79. Average Outpatient Costs Of University Hospitals ... 117

Table 80. Outpatient Clinic Costs of University Hospitals ... 118

Table 81. Average Patient Day Costs of SIO Hospitals... 119

Table 82. Average Patient Day Costs of SIO Hospitals by Clinics ... 119

Table 83. Average Outpatient Costs of SIO Hospitals... 120

Table 84. Average Outpatient Costs of SIO Hospitals... 121

Table 85. Emergency Service Costs of the SIO Hospitals ... 121

Table 86. Clinic Costs of Patient Days... 122

Table 87. Outpatient Clinic Costs of Private Hospital ... 123

Table 88. Hospital Costing Study: Actual and Adjusted General Departmental Costs (Median) ... 124

Table 89. Hospital Costing Study: Actual and Adjusted Outpatient Service Costs (Median)125 Table 90. Hospital Costing Study: Actual and Adjusted Special Room Costs (Median) ... 126

Table 91. Hospital Costing Study: Actual and Adjusted Laboratory Tests’ Costs (Median) 126 Table 92. DALYs Attributable to Smoking and Cost per DALYs Saved by Media Campaign Against Smoking, Turkey 2000... 138

Table 93. Doses Delivered In A Year In Turkey (year 2000)... 142

Table 94. Calculation of SavedDALYs for TT2 ... 144

Table 95. Calculation of Saved DALYs for Pertussis... 145

Table 96. Calculation of Saved DALYs for Measles... 146

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Table 98. DALYs Attributable to Alcohol Consumption in Turkey, 2000 and

Cost-effectiveness of Alcohol Control and Education Program for Males. ... 147

Table 99. DALYs Attributable To Alcohol Consumption In Turkey, 2000 And Cost-Effectiveness Of Alcohol Control And Education Program For Females. ... 148

Table 100. DALYs Attributable To Alcohol Consumption In Turkey, 2000 And Cost-Effectiveness Of Alcohol Control And Education Program. ... 149

Table 101. Health Center Based Treatment Of Diarrhea Of Adults ... 167

Table 102. Health Center Based Treatment Of Diarrhea in Age <5 Patients ... 168

Table 103. Hospital Based Treatment Of Diarrhoea Of <5 Year... 169

Table 104. Health Center Based Treatment Of ARIs In <5 Year Olds (Pneumonia) ... 170

Table 105. Health Center Based Treatment Of Pharyngitis In <5 Year Olds ... 171

Table 106. Hospital-Based Treatment Of ARIs In <5 Year Olds (Pneumonia)... 172

Table 107. Hospital Based Treatment Of Pharyngitis In <5 Year Olds... 173

Table 108. Health-Center Based Chemotherapy For Tuberculosis... 174

Table 109. Hospital-Based Chemotherapy For Tuberculosis ... 175

Table 110. Antenatal Care At Health Center/Delivery At Home... 176

Table 111. Antenatal Care At Health Center/Delivery At Health Center ... 177

Table 112. Antenatal Care At Health Center/Delivery At Hospital... 178

Table 113. Motor Traffic Accident Treatment At The Hospital ... 179

Table 114. COPD Treatment At The Hospital (Inc. Asthma)... 181

Table 115. COPD (Inc. Asthma) Treatment At The Health Center ... 182

Table 116. Health Center Based Hepatitis Treatment... 183

Table 117. Hepatitis Treatment At Hospital ... 184

Table 118. Health Center Based Diagnosis And Treatment of Malaria... 185

Table 119. Pap Smear At Health Center, And Treatment Of Cervical Cancer At Hospital .. 186

Table 120. Simple Health Center Based Treatment Of Hypertension ... 187

Table 121. Hospital based treatment of malignant hypertension ... 188

Table 122. Health Center Based Treatment Of STD... 189

Table 123. Hospital-Based Treatment For Kidney Dialysis ... 190

Table 125. Diabetes Treatment ... 192

Table 126. Hospital Based Treatment Of Oral Health ... 193

Table 127. Hospital Based Treatment Of Schizo-Affective Disorders ... 194

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Table 129. Health Center And Hospital Based Diagnosis And Treatment Of Pneumonia In < 5

Years... 196

Table 130. Health Center And Hospital Based Diagnosis And Treatment Of Acute Otitis .. 197

Table 131. Health Center And Hospital Based Diagnosis And Treatment Of Depression.... 198

Table 132. Health Center And Hospital Based Diagnosis And Treatment Of Osteoarthritis 199 Table 133. Health Center And Hospital Based Diagnosis And Treatment Of Osteoarthritis 200 Table 134. Health Center And Hospital Based Diagnosis And Treatment Of Peptic Ulcer.. 201

Table 135. Health Center And Hospital Based Diagnosis And Treatment Of Osteoporosis 202 Table 136. Health Center And Hospital Based Diagnosis And Treatment Of Parasitic Disease of GIS ... 203

Table 137. Hospital Based Diagnosis And Treatment For Cancers... 204

Table 138. Hospital Based Diagnosis And Treatment For Cancers... 205

Table 139. Hospital Based Diagnosis And Treatment For Cancers... 206

Table 140. Hospital Based Diagnosis And Treatment For Cancers... 207

Table 141. Health Center and Hospital Based Diagnosis And Treatment For Pertussis ... 208

Table 142. Health Center and Hospital Based Diagnosis And Treatment For Measles ... 209

Table 143. Public Health Package... 210

Table 144. Child Health Cluster... 211

Table 145. Maternal Health Cluster ... 211

Table 146. STD Service Package ... 212

Table 147. Service Package for Cancer... 212

Table 148. Diabetes And Hypertension Related Cluster... 213

Table 149. Oral and Dental Health Package ... 213

Table 150. Mental Health Package... 214

Table 151. Interventions with CE ratio of less than $500 ... 214

Table 152. Comprehensive Package ... 216

Table 153. COPD and ARIs Package (Health Center)... 218

Table 154. Osteoarthritis and Osteoporosis Package ... 218

Table 155. Selected Top 20 DALYs causing diseases... 219

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LIST OF FIGURES

Figure 1. Steps in Cost Effectiveness Analysis... 5

Figure 2. Approach Proposed by Cowley et al. (1994) ... 7

Figure 3. Methodology for clinical interventions... 9

Figure 4. Methodology for public health interventions... 10

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ABBREVIATIONS

A1 Province Type Health Center ABD United States of America

MCHFP Maternal and Child Health and Family Planning ARI Acute Respiratory Infections

BCG Bacille Calmette Guerin Vaccine C Cost per Health Service

STD Sexually Transmitted Diseases D1 District Type Health Center DALY Disability Adjusted Life Years SIS State Institute of Statistics DMhg Variable Cost per Patient Day DMp Variable Cost per Outpatient Clinic DPT Diphtheria, Pertussis, Tetanus WHO World Health Organization

EPI Expanded Programme on Immunization GCUR General Capacity Usage Rate

GDP Gross Domestic Product HYE Healthy Year Equivalent

IMCI Integrated Management of Childhood Illnesses HDI Human Development Index

CUR Capacity Usage Rate

CEA Cost Effectiveness Analysis Mhg Unit Patient Day Cost Mky Control Cost

Mp Unit Outpatient Cost Mp Outpatient Cost

Mpy Examination cost of disease y Myh Patient Day Cost

ORS Oral Rehydration Therapy ALS Average Length of Stay PEM Protein Energy Malnutrition PPP Purchasing Power Parity QALY Quality Adjusted Life Years

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MOH-RPC Ministry of Health Research, Planning and Coordination Unit MOH Ministry of Health

MOH-PCU Ministry of Health, Health Project General Coordination Unit SMhg Constant Cost per Patient Day

SMp Constant Cost per Outpatient

PCU Health Project General Coordination Unit SIO Social Insurance Organization

TPI Total Price Index TP Total Patient Day TMp Total Outpatient Cost TMs Total Clinic Cost

DHS Demographic Health Survey TOR Terms of Reference

TOs Number of Outpatient

TT Tetanus Toxoid

NBD-CE National Burden of Disease and Cost Effectiveness USD United States Dollar

V Number of Visits Necessary of Health Service WHO World Health Organization

IP Number of Inpatients

YLD Years of Life Lost due to Disability YLL Years of Life Lost

NB Number of Beds

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INTRODUCTION

1.1. Objectives of the Cost Effectiveness Study

The 2002 World Bank Health Sector Report on Turkey states that despite considerable progress achieved in the recent past, Turkey continues to rank far behind most middle-income countries of the world in terms of the health status of its people. According to the same report, life expectancy of the population in Turkey is nearly ten years below the OECD average, and infant and maternal mortality rates are among the highest among middle-income countries. By most accounts, the overall performance of the health sector of Turkey has remained relatively poor in terms of health attainment indicators. Therefore, given the current situation in the health sector, substantial and sustained efforts will have to be made in the coming years if Turkey is to meet the health targets of the Millennium Development Goals by the year 2015 (1).

Many factors affect the low levels of health outcomes in Turkey. On the financing side, in addition to the fact that resources may not be adequate for efficient delivery of health care services, the available resources are not allocated efficiently and equitably. Public provision of health is characterized by poor incentives for managers and providers alike, leaving them open and vulnerable to alternative sources of income to augment their meager salaries. The delivery of health care is also fragmented, and the practice of integrated health service delivery is rare. The potential of the private sector has not been fully exploited and its role and responsibilities are not adequately defined. Access to clean water, satisfactory sanitation and education - all known to be powerful determinants of good health – is uneven, and large populations in rural areas and in the Eastern regions of the country lack even the basic amenities. The present situation, therefore, is one in which reported health expenditures are low for a country at this level of economic development, where the poor have erratic access to health services and the overall health status of the population is well below that of countries at comparable income (1).

Efforts have been made in recent years to identify the root causes of problems in the Turkish healthcare system, but the assessments have frequently been inadequate and incomplete. Thus the Ministry of Health decided to implement the National Burden of Disease and Cost Effectiveness Study (NBD-CE) to provide explicit and objective criteria to guide Turkey's health sector reforms, policies and strategies into the next century. The results of this study

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will suggest ways to improve access to health services, enhance equity in utilization, increase cost-effectiveness, enhance quality of care and improve health outcomes overall.

The Ministry of Health (MOH) is also keen to ensure that the NBD-CE Study will help development of local capacity to undertake routine monitoring of the burden of disease and to analyze the cost-effectiveness of health interventions.

Under the NBD-CE study, the following specific objectives will be achieved:

• To conduct costing studies to estimate the cost of providing services through hospitals and primary health care centers in Turkey.

• To estimate the unit cost of broad service types with the improvements in the capacity utilization of the facilities.

• To estimate the cost of providing the interventions listed in the NBD-CE Terms of Reference.

• To estimate the potential health impacts of the interventions, if the interventions are provided with adequate quality.

• To suggest a number of packages of essential health services which have the potential to significantly reduce the burden of disease and the estimated resource cost of the packages.

• To indicate a number of factors likely to be important in improving the effectiveness and efficiency of the health system

• To provide key policy makers with health intervention package options and the implications of those options for health sector performance and affordability

• To establish in Turkey the technical and institutional capacity to carry out future NBD and cost-effectiveness studies.

1.2. Cost Effectiveness Analysis

Resources for the delivery of health services are limited in every country, so choices always have to be made as to which health services should be financed by the government, irrespective of the method of actual delivery of services. Resource allocation decisions imply tradeoffs between funding one type of health program versus another. For example, choosing

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cost, health planners can use the methodology of cost-effectiveness analysis. Because health effects are measured in common units across interventions, cost-effectiveness ratios can be compared. Cost-effectiveness Analysis (CEA) is a technique for identifying the most effective use of limited resources (2). In cost-effectiveness analysis, an estimate of the health effects of the interventions is divided by the economic cost of those interventions. The interventions with the largest effect per unit cost are considered to be the most cost-effective. By this approach, health interventions can be ranked according to their cost-effectiveness ratios, and the most cost-effective programs can be selected as health priorities for funding by governments.

Cost effectiveness provides a common language to debate resource allocation for health policies. Decision-making based on improper interpretations of cost effectiveness – or based on no cost-effectiveness information at all – can result in economically costly, wasteful policies and missed opportunities to improve health. Cost effectiveness does not replace other criteria for selecting policies, but it does provide additional information to weigh the relative value of different policies (3).

Cost-effectiveness analysispresents the cost of a policy with the effects in a single ratio: Cost-effectiveness ratio = (net cost of implementing a policy)/ (health improvement achieved by the policy. Thus, cost effectiveness does not simply refer to the cost of an intervention, but to the cost of the intervention compared to the health outcomes achieved by the intervention. In the literature, all studies accept this general formula of cost-effectiveness to calculate the ratios of various health interventions. For example, Cowley et al., define the cost-effectiveness as(4): “Dividing the cost of a health service by the number of DALYs gained from that health service”. All the studies compiled in the World Bank publication Disease Control Priorities in Developing Countries (5) used this approach of calculating cost-effectiveness ratios. Recently, the WHO (44) has published a new approach of estimating cost-effectiveness but the general formula to determine cost-effectiveness of health interventions remains dividing cost of the intervention by the health outcomes (change in healthy life years in this case).

For legislators, public officials, and corporate executives, cost effectiveness is one consideration when making decisions about health policies. Other compelling reasons may exist for adopting a particular policy, even if it is not the most cost-effective alternative. For

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example, policymakers may want to target populations who are uninsured or have a high occurrence of chronic disease. Sometimes the most cost-effective policy may not be politically or socially acceptable or even feasible to implement. In any case, policymakers should at least consider any available evidence of an intervention’s cost-effectiveness.

Calculating the cost-effectiveness of health interventions requires a common currency for measuring costs and a unit for measuring health impact. For example, different interventions can be compared in terms of what each of them costs to achieve one additional year of healthy life. Outcomes are measured in Disability-Adjusted-Life Years (DALYs), a measure that combines healthy life years lost because of premature mortality with those lost from disability (4). Disability Adjusted Life Years (DALYs), Healthy Year Equivalents (HYEs), or Quality Adjusted Life Years (QALYs) are all standardized time-based measures of health that include the impact of interventions on years of life lost due to premature mortality and years of life lived with a non-fatal health outcome, weighted by the severity of the outcome. The World Health Organization (WHO) employs DALYs in its Cost Effectiveness Analyses.

1.3. Cost-effectiveness Approach

1.3.1. The General Approach of Cost-effectiveness

Figure 1 shows the general steps of CEA. In this analysis, we use a very similar strategy as presented in figure 1, except that no attempt has been made to compute monetary savings of the interventions or wide range of sensitivity analyses (as it is not required by the TOR). We are interested to find out the health consequences of the interventions rather than monetary savings.

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Figure 1. Steps in Cost Effectiveness Analysis (Source: Designing a Benefits Package, 1999)

Step l. Define the program to be analyzed: its focus, processes, and limits: Seemingly minor differences in the definition of the program, such as targeting efficiency in term of reaching high-risk persons, can have a large impact on costs and effects. For these reasons, a precise definition of the program is critical.

Step 2. Compute the net monetary cost for the prevention and treatment of illness under the proposed program compared with the cost of the status quo. Generally, costs are computed from a societal perspective. However, in this report costs are calculated from the providers’ perspective as well. That is, the values of all societal resources used in the program are counted as costs, regardless of who pays for them. It is often convenient to compute costs on a per participant basis. In our analysis, we are concerned about the cost of interventions from the perspective of the health sector. Therefore, all health sector activities will be costed.

Step 3. Compute the health effects or benefits. Cost-benefit analysis requires that benefits be expressed in monetary terms, but cost-effectiveness analysis permits the use of any commensurate measure of benefits. Lives saved, complications averted, or cases of illness prevented are examples of possible benefit or effectiveness units. In this analysis, we will be using DALYs saved as the effectiveness measure.

1. Define the program

- Develop alternative approaches to the problem

- Define precisely problems to be analyzed (who, what, where, why, when and how)

2. Compute net costs

- Compute gross program costs

- Compute monetary savings.

- Discount costs and savings to present value

- Compute net costs (gross costs less savings)

5. Perform sensitivity analysis

- Vary certain parameters and recomputed costs and health effects.

- Examine effects on decision.

4. Apply decision rules

- Identify case based on net costs and net effects - Apply rule for appropriate case

3. Compute net health effects (in terms of additional years of healthy life)

Add

- Additional years with full health

- Additional years of disease - Improvement in health (no extension of life)

-Negative effects

(inconveniences and morbidity) * Modify by time preference factors

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Step 4. Apply a decision rule based on the net costs and net health effects. The rule must be selected in terms of the four logically possible alternative situations involved in an intervention, as described in Table 1.

Step 5. The final step in a cost-effectiveness analysis is to perform a sensitivity analysis.

Many of the procedures required for estimating costs and benefits require estimates of data and preferences that are not known with certainty. For example, it is not possible to predict exactly the future discount rate. Opinions can differ about the value of a year with impaired health relative to a year of perfect health (3).

Table 1. Decision Rules in Cost-Effectiveness Analysis Decision Rules in Cost Effectiveness Analysis

Net Effects Net Costs Positive Net Costs Zero or Negative

Positive Case 1 Cost-Effectiveness = Net Costs-

Net Health Effects Selects most efficient programs for improving health.

Case 2 Program economically valuable. Should generally be implemented.

Zero or Negative Case 3 Program Benefits offset by morbidity and inconvenience. Program generally should not be implemented.

Case 4 Cost-Effectiveness = Net Costs-Net Health Effects Selects most efficient programs for containing costs.

1.3.2. Approach Proposed by Cowley et al. (1994)

The cost-effectiveness approach used in this study is basically the method proposed and implemented by the WB and the WHO in conjunction with the GBD study of early 1990s. The method was also the basis for calculating cost-effectiveness of disease specific interventions reported in the book “Disease Control Priorities”(5). In the following paragraphs, the method used by WHO has been summarized.

(i). Estimating the cost of interventions

The figure below (Figure 2) summarizes the method followed by Cowley et al. in estimating the cost of intervention (4). The figure is directly taken from Cowley et al report. (4) Note that

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guideline for dealing with the health condition addressed by the intervention in question. All the interventions we want to cost are listed in the TOR. Excepting the selected public health interventions, all interventions listed in the TOR are basically “single intervention” type (i.e., the intervention consists of just one specific management strategy). In Cowley et al (4)., they have considered a number of interventions which are multiple intervention type (sick child module, for example). However, one can combine a number of interventions together to derive a multiple intervention strategy.

Figure 2. Approach Proposed by Cowley et al. (1994)

EXPENDITURE AND CLINICAL

GUIDELINES CLINICAL GUIDELINES

DISEASE & DEMOGRAPHIC PROFILE

NUMBER OF HOSPITAL OUTPATIENT VISITS PER INTERVENTION NUMBER OF HOSPITAL OUTPATIENT PARTICIPANTS COST PER HOSPITAL OUTPATIENT VISIT CASES TO TREAT HOSPITAL HEALTH CENTER X X X COST / INTERVENTION INTERVENTIONS TECHNICAL EFFICIENCY SYSTEM EFFICIENCY PROVIDER EFFICIENCY COST/INTERVENTION OR CLUSTER TARGET COVERAGE TOTAL COST OF THE PACKAGE PROGRAM OR PACKAGE Program Efficiency Adjustment to Cost EXPENDITURE AND CLINICAL GUIDELINES CLINICAL GUIDELINES

DISEASE & DEMOGRAPHIC PROFILE

NUMBER OF HOSPITAL OUTPATIENT VISITS PER INTERVENTION NUMBER OF HOSPITAL OUTPATIENT PARTICIPANTS COST PER HOSPITAL OUTPATIENT VISIT CASES TO TREAT HOSPITAL HEALTH CENTER X X X COST / INTERVENTION INTERVENTIONS TECHNICAL EFFICIENCY SYSTEM EFFICIENCY PROVIDER EFFICIENCY COST/INTERVENTION OR CLUSTER TARGET COVERAGE TOTAL COST OF THE PACKAGE PROGRAM OR PACKAGE Program Efficiency Adjustment to Cost

Unlike the Cowley paper (4), in this study two levels of health facilities, health centers and hospitals were used. In the TOR, health facilities are defined as either health center or hospital.

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The clinical guideline (treatment guideline) will provide the information on number of visits needed to health centers and hospitals per case of illness and the days of stay in hospital if hospitalization is required. The guideline will also provide the amount of different types of drugs and other medical commodities needed per case treated or managed. Let us assume that the quantities of different types of resources needed for one unit of intervention j are given by the vector Xj =

[

X1j X2j...Xmj

]

. If the cost vector of the resources used is c=

[

c1c2...cm

]

,

the cost per unit of intervention will be Cj = c.Xj/

Clearly, the parameters we need for calculating the cost of intervention is not only the resource requirements per unit of intervention but also the unit cost parameters. The cost of various services and supplies are obtained from the actual costs collected from hospitals and health centers or from relevant market prices of the commodities. One problem in the estimation of costs is to determine which cost parameter to use. When multiple health centers and hospitals are surveyed, the unit costs vary considerably across the health facilities even after controlling for rural-urban or geographical location. For national level cost-effectiveness analysis, it is important to use a relevant unit value. One option is to use the weighted average of the costs. Another option is to project the unit costs for the health centers if the utilization level (capacity utilization) is no less than 80%. In fact, if the MOH wants to find out the cost savings to be achieved through better capacity utilization, it can conduct sensitivity analysis using 60 to 90% capacity utilization levels. The study did not conduct the sensitivity analysis but the excel files of the report can easily be used to find the cost if a different capacity utilization assumption is used.

The unit cost of intervention only provides the cost per case of the illness managed. However, the policy makers would also like to know the total amount of resources needed for the intervention in the country. As seen in Figure 2, to estimate the total cost of the intervention in the country, the number of cases to be treated in a particular year needs to be calculated. Number of cases to treat is not simply the incidence of the disease (for short-term acute conditions, it will be equal to incident cases). All the individuals with the medical condition in that specific year will be the target population. Given the coverage of the intervention, one can find the number of cases likely to be treated or managed. Multiplying the number of cases managed with the unit cost of intervention, total cost can be derived. Details of costing the intervention will be discussed below. Also, given that unit costs may occur as distributions,

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(ii). Estimating the Effectiveness of Interventions

The effectiveness of interventions were estimated by Cowley et al. (4) by estimating the DALYs lost with and without treatment. The difference between these two DALY numbers represents the effectiveness of the intervention. In the figures below, the methodology is shown in a schematic manner for clinical interventions. The figure 3 shows that disease or injury creates disability (both level and duration) or death. The disability associated with the disease or illness can also lead to death. Therefore, the disease or injury ultimately lead to three possible health states: complete recovery, permanent disability or death. The health states can be expressed in terms of DALYs lost. Therefore, in the first figure on clinical intervention, the health status measure provides DALYs lost when a specific clinical intervention (or set of interventions) is implemented. In other words, DALYc is the amount of DALYs lost from the health condition with the clinical intervention. Similarly, in the second figure, the outcome measure DALYni shows the DALYs lost without the presence of the intervention. The difference between these two, i.e., DALYNI – DALYc, is the effect of the intervention per unit of intervention.

Figure 3. Methodology for clinical interventions.

In Figure 4 the effectiveness calculations for public health interventions are shown. Unlike the clinical interventions, public health interventions provide preventive services or behavior change communication interventions. These interventions actually modify the risk of the disease or injury. Once the risk factors are affected, the outcome can also be observed in

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DALY terms with and without the presence of the intervention. Therefore, in this case, the effectiveness of the intervention should be equal to DALYNPH-DALYPH.

Figure 4. Methodology for public health interventions.

1.4. Essential Service Packages (ESP)

The World Bank’s 1993 World Development Report suggests the collection of various health services into a “package” for governments to deliver essential health services for their people (6). Today, governments can and often do proceed in other ways to provide health services for their citizens. They can simply agree to pay for or guarantee to provide any of a list of health services, without considering possible relations between one intervention and another. Or they could choose not to specify goals at all, and agree to pay for, or provide, a collection of inputs: medical professionals would than decide which services were actually provided, whether by delivering services they thought were justified or by responding to demand for services. The principal argument for a collection of services to be provided jointly is to minimize the total cost of the essential service package by exploiting the shared use of health inputs such as physicians and hospitals that make up the healthcare infrastructure (4).

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A basic package of health services has three main distinguishing features:

Limited scope: A package typically contains a limited subset of all health care interventions made possible by today’s medical technology. By definition, it cannot and will not include everything.

Prioritized contents: Interventions are not randomly assigned to the package; rather, they result from a prioritization process to achieve specific technical and/or social objectives. This process can be used by the policy makers, medical professionals, or society as a whole.

Synergy among contents: A package of health services is more than a simple list of interventions. In principle, the package should be constructed in such a way that individual inputs can complement each other, and the whole will be greater than the sum of its parts. In practical terms, this means that the package is not just a one-by-one enumeration of services that can be provided(2).

A major benefit of packaging is that it allows for thorough considerations of intervention inputs in terms of cost-effectiveness. As an example, a certain intervention input may be costly (and possibly cost-ineffective), such as a microscope used solely for examining urine at a health center. However, if the microscope could be used for other medical interventions as well, such as for sputum examinations for tuberculosis, the cost of the microscope is then shared. In essential service packages, intervention input costs are closely clustered or associated in the sense that if one is available, another can be provided at little or no extra cost. Packaging also outlines a more complete cost-effectiveness consideration of interventions when they are “clustered” together. For instance, the addition of mineral/vitamin distribution to the expanded program of immunization adds little to the cost of the program and provides a feasible method of delivery, reducing the cost of both programs compared to what they would cost individually. Clustering or grouping can also provide increased intervention effectiveness when one intervention is substantially enhanced by the presence of another (4).

Grouping together health services in a package has the following benefits: • Links between preventive and therapeutic services

• Multiple outputs from inputs • Elucidation of all required inputs • Coordination of resources

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A package can link treatment and prevention activities, rather than viewing them in isolation of one another. It therefore recognizes that treatment activities, and costs, could be eliminated with adequate attention paid to prevention.

A package forces one to identify all inputs that may be required to promote a particular intervention. Providing immunizations to children will not be effective if promotional or educational programs do not accompany them.

Packaging can help to identify and coordinate the required technical, administrative, and educational resources that are required. At the same time, this approach can help to improve the use of specialized resources by screening patients at different levels of care, ensuring that referrals to higher-level facilities are made only when appropriate (2).

1.4.1. Content and Design of Essential Service Packages

A health package can be designed purely to deal with a country’s principle health problems; services would then be included to treat problems in descending order of importance as measured by the loss in disability-adjusted life years (DALYs). In practice, the solutions for such problems may yield very small health gains or have very high costs, or both. An alternative is to design the package on the basis of interventions, according to their cost-effectiveness. This is the ratio of the health gain (in DALYs) to the cost of providing the interventions once (where that is appropriate) --- or during a year (where treatment must be repeated). The greater gain obtained per unit cost, the more cost-effective the intervention is (4).

A basic package of health services should include a combination of both public health and clinical interventions. Again, all interventions, regardless of type, should be evaluated according to the same criteria. A common assumption is often made that public health interventions, particularly preventive services, are preferable to clinical or curative ones. However, this must be measured in clear terms; in the case of the decision-making process to assemble the basic package of health services recommended by the World Bank, that process involved assessing the burden of disease and measuring the cost-effectiveness of particular treatments.

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Public Health Interventions: These fall into three primary categories, and any of these can be included within a basic package of health services:

• Services that foster changes in personal behavior, such as smoking cessation classes to discourage the use of tobacco; or information, education and communication programs to increase the use of condoms.

• Services that control environmental hazards, such as spraying programs to kill mosquitoes and prevent malaria; or the development or regulation of safety products such as seat belts to decrease the toll of traffic accidents and injuries.

• Services that deliver specific health care to the population, such as the provision of vaccines and immunizations to both children and adults; or food supplementation for malnourished children and/or pregnant women.

Clinical Health Interventions: It is often suggested that the consumption of preventive and public health services can reduce the need for curative services. While this may be true to some extent, it is unlikely to be practical in all cases. As such, it is both desirable and necessary to include clinical interventions in a basic package of health services, provided that those meet the established criteria for inclusion.

1.4.2. Policy Implementation of Essential Service Package

A government wishing to adopt an essential national health care package faces a number of requirements and choices. These involve the need for information, choices about how to deliver and pay for services, and questions as to how to influence decisions in the private sector or in sub-national levels of government.

Data Needs For Design Of The Package: The analytical requirements for a rigorously designed national package are substantial. But countries can design provisional packages quickly while the analytical database is built up. They can develop a national essential package by using proxies for the data, or alternatively, by adopting the minimum package described above (perhaps with some adjustments) as the preliminary national package. Over the longer term, the package is best designed from results of a national burden of disease estimation and the local level of analysis of the cost-effectiveness of the interventions. The national burden of disease can be calculated over a period of months if data on morbidity and mortality are available. If these data are missing indirect estimation can be used, or as an interim proxy, regional disease burden estimates can be adjusted for a particular country.

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Local estimates of intervention costs should also be developed, at least for the most important health interventions. This can also take months, depending on the cost data available.

Implementation of The Package: Once a national package is designed, the challenge is how to implement it. Government budgets are not organized by disease intervention. Allocations are made across organizations (ministries of health, affiliated foundations, governmental research institutions, third-party insurers), across facilities (hospitals, and health clinics) and across input categories (personnel, supplies, drugs, maintenance, training, transport and the like) (4).

How to Finance The Package Of Services: Along with estimating the cost of the package of health services, it will be necessary to determine how the package will be paid for. The primary issues here are:

• What portion of public resources should be directed toward the package of services vs. toward other health care services?

• To what extent should private resources be required to pay for the package?

Public Resources: There are clear reasons why the public sector should be involved in the financing and/or provision of services. These include the appropriate promotion or encouragement of health services with public-good characteristics, the role of the government in providing information to consumers, and the government’s frequent objective of promoting equity and ameliorating poverty. Thus, there are clear efficiency and equity reasons to utilize public financing to cover the cost of the package. What is less clear, however, is how to determine what level of public resources should be made available to finance the package. Should the government reallocate all of its available resources for the health sector to cover the cost of the package? Or should it allocate only a portion of them, saving some resources for services provided through more traditional methods?

Private Resources: There are also justifications for including private financing of a basic package of health services, at least as part of the overall financing picture. A certain amount of cost sharing or co-payments could be required, to help cover some of the costs of the package, for example, drug costs. While this would help generate additional resources (which may be critically important given the tight budgetary constraints in some countries), care must be taken that those who are truly needy are exempted from financial requirements (2).

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COST EFFECTIVENESS ANALYSIS METHODOLOGY

For the cost-effectiveness analysis of interventions, two numbers or values need to be calculated: the cost of the intervention (for all interventions stated in Appendix B of Terms of Reference, see Appendix 1) and “burden of disease” associated with the interventions. The burden of disease associated with different health conditions will be obtained by using the results of burden of disease study. Costs of intervention are derived by using the unit-cost data obtained from health facilities (hospital, primary health care facilities) as well as price data obtained from the market for selected health commodities and services. A number of essential health care packages will also be defined by considering intervention cost effectiveness ratios.

In this analysis cost information was collected for the year 2001. To plan the health facility surveys, it is important to define the time frame for the costing exercise. At a study design meeting held during 1-6 July 2002, it was decided that the reference year for costing would be 2001 (see Inception Report of the Project). The market price data were also collected for the year. The selection of the year created one problem for the cost-effectiveness exercise, namely, the Burden of Disease component of the project estimated the DALYs lost due to various health conditions, diseases or injuries for the year 2000. Since the DALYs lost from health conditions are estimated over the life time of the individuals suffering from the illnesses and as the “expected” prevalence and incidence of illnesses are unlikely to change drastically over a period of one year, considering DALYs derived from 2000 data as the basis for effectiveness calculation should not affect the ranking of the interventions.

For the Cost Effectiveness study, there are four objectives in the TOR, defined as follows: OBJECTIVE 1. Determining the costs of interventions stated in TOR,

OBJECTIVE 2. Identifying effectiveness of interventions stated in TOR,

OBJECTIVE 3. Calculating cost effectiveness levels of interventions stated in TOR,

OBJECTIVE 4. Combining NBD-CE study outcomes so as to create a minimum of 10 packages consisting of essential interventions.

2.1. Coverage and Sample Size of Costing Surveys

The cost analysis studies of primary health care institutions and hospitals were conducted in two steps. The first step was the Pilot study and the second step was the main study. Included in the sampling plan of the Pilot study were Kazan Hamdi Eriş State Hospital, Ankara Numune Education and Research Hospital and Ankara No. 3 Tuberculosis Dispensary, while

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the main study was conducted on selected health institutions in Turkey’s East and West regions. The objective of the Pilot study was to determine potential problems in the main study and to make a test application of the data collection instrument. Sample sizes are given in Table 2.

Table 2. Sample Size Stated in Terms of Reference (TOR)

PILOT MAIN STUDY

CENTRAL WEST EAST

MOH City State Hospital 1 1 1

MOH District State Hospital 1 1 1

SIO Hospital 1 1 1

University Hospital 1 1 1

Private Hospital 1 1 1

Urban Primary Health Center* 1 1 1

Rural Primary Health Center* 1 1 1

TOTAL 7 7 7

*The term “health centre” used herein shall be construed as to cover primary health care facilities including but not limited to Tuberculosis Dispensary, Mother and Child Care Centers, and Malaria Centers

The above-mentioned sampling plan was discussed and re-designed during the Study Design meeting held 1-6 July 2002. In Table 3, the sampling plan approved by the scientific committee during the Study Design meeting is presented.

Table 3. Plan Approved During the Study Design Meeting REGIONS

HEALTH FACILITIES

CENTRAL WEST EAST

MOH < SH (State Hospital) with 50 beds 1 1 1

MOH 51- SH 100 beds 1 1 1

MOH 101- SH 200 beds 1 1 1

MOH 201- SH 400 beds 1 1 1

MOH SH with 401+ beds 1 1 1

SIO Hospital 2

University Hospital 2

Private Hospital 1

Urban HC (Health Center) 1 1 1

Rural HC 1 1 1

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According to the sampling plan stated in the Terms of Reference, 15 hospitals and 6 health centers should have been used in the costing study. The new sampling plan of the costing study, which was revised in the July 2002 study design meeting, called for the inclusion of 20 hospitals and 6 health centers. There are two principal reasons for this difference:

1. The sampling plan in TOR is based on hospital ownerships, whereas the new sampling plan emphasizes the size of the facility as one of the important variables of health facility costs. Thus it will be possible to see if cost differences exist due to the scale economy. Presence of significant economies of scale may encourage policy planners to establish hospitals of optimal size.

2. In Turkey, approximately half of the health care services are provided by the Ministry of Health. Since more than half of the hospitals in Turkey are Ministry of Health hospitals, it was suggested that the emphasis should be to cost hospital services for MOH hospitals by hospital size. During the study design meeting, the methodology was designed and accepted, with MOH hospitals to be classified in 5 categories.

The sampling design developed by foreign and national consultants suggested that costing of primary health care facilities in urban and rural areas would be inadequate, and in the interest of the study’s usefulness a recommendation was made to include district type health centers in the study sample.

During the first three-month Progress Meeting all the suggestions were discussed and it was decided to include maternal child health and family planning centers, Tuberculosis Dispensary and Malaria Dispensaries in the study. Table 4 lists the final sample size agreed upon during the progress meeting.

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Table 4. Approved Sample Size (Hospitals and Primary Health Care Facilities ) REGIONS

HEALTH FACILITIES

CENTRAL WEST EAST

MOH < SH with 50 beds 1 1 1

MOH SH with 51-100 beds 1 1 1

MOH SH with 101-200 beds 1 1 1

MOH SH with 201-400 beds 1 1 1

MOH SH with 401+ beds 1 1 1

SIO Hospital 2

University Hospital 2

Private Hospital 1

City Type Health Center 1 1

District Type Health Center 1 1

Village Type Health Center 1 1

Maternal Child Health and Family

Planning Center 1

Tuberculosis Dispensary 1

Malaria Dispensary 1

TOTAL 11 9 9

According to the finalized sampling plan, 20 hospitals, 6 primary health centers, 1 Maternal Child Health and Family Planning Center (MCH/FP Center), 1 “ Tuberculosis” Center, and 1 “Malaria” Center were included for a total of 29 health facilities. To select the hospitals and health centers for the costing study, a two-stage approach to selection was followed. At the first stage, cities were selected and then at the second stage the health facilities were selected within each of the cities.

2.1.1. Selection of Cities for Cost Analysis

In the first stage, cities in East (Eastern Anatolia and South Eastern Anatolia), West (Aegean and Marmara Regions) and Central (Central Anatolia) regions as stated in TOR were decided.. As for the identification of cities in regions, a number of selection criteria were defined in the progress meeting. These criteria were the level of Human Development Index

Figure

Figure 1. Steps in Cost Effectiveness Analysis    (Source: Designing a Benefits Package, 1999)
Figure 2. Approach Proposed by Cowley et al. (1994)
Figure 3.  Methodology for clinical interventions.
Figure 4.  Methodology for public health interventions.
+7

References

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