Day 1 :
Keynote Forum
Anver Hamdani
Ministry of Health, Sri Lanka
Keynote: Improving service quality and sustainability in management of COVID 19 patients in low resourced country
Biography:
Anver Hamdani is a highly dedicated healthcare specialist with over 17 years of experience in public health administration and medical care. He is experienced in various healthcare settings, including pandemic preparedness and response, emergency resilience and response, medical technological services and tertiary and patient care.
Abstract:
During COVID-19 pandemic, quality of healthcare provision, health systems and patient satisfaction have been greatly affected. Low-resourced countries such as Sri Lanka, delivers free health services, faced severe shortages in financing, human resource, medicine and supplies. The health system was not prepared to encounter COVID-19 challenges. The negative impact of COVID on national economy aggravated this situation. Further, the health system was overburdened by a policy of admitting all tested positive patients for institutionalized care. Therefore, it was pivotal to evaluate the quality and sustainability of the care provided.
Above challenges faced by the health system were identified through participatory observation. The patient centered care was assessed with regards to four domains; food, sanitation, patient care and management. Data collected using an interviewer-administered questionnaire via distant communication mode, 206 participants in 55 treatment centers across Sri Lanka during March-May 2021. The level of satisfaction regarding patient care and management recorded highest compared to other domains (71%). High-risk and complicated patients were referred to specialized tertiary care. However, this process of admitting all positively tested and providing care at different levels was very resource intensive.
The isolation process and the illness led to severe stress for patients, especially among asymptomatic or mildly symptomatic. Even though overall satisfaction was high, the impact of satisfaction regarding food (64%), sanitation (63%) and patient care (71%), nevertheless overall satisfaction was less due to economic and logistical constraints. Based on the above findings, it was proposed to introduce a home-based management system for those who are asymptomatic to mild symptomatic and triage for early identification of high-risk patients. A telemedicine system was proposed for triaging and home-based management. These proposals were immediately implemented and played a major role in reducing the economic and resource burden on health system and drastically reducing morbidity and mortality during subsequent COVID waves.
- Public Health Economics
Location: SYDNEY 1-2
Session Introduction
Ayesha Samankula
Ministry of Health, Sri Lanka
Title: An integrated patient management system during COVID-19 pandemic in a low middle income country-Sri Lanka
Biography:
Ayesha Dimali Samankula did her post graduate studies in Health Sector Disaster Management in Sri Lanka in 2019-2020. She was a National COVID Coordinator in the Ministry of Health Sri Lanka from 2020-2022. She actively engaged in COVID-19 management and prevention tasks during this period. She currently works as a Vitreo Retinal Medical Officer in National Eye Hospital, Colombo, Sri Lanka. She Plans to do more studies on diabetes prevention and diabetes retinopathy prevention around the world in future.
Abstract:
Sri Lanka is a lower-middle income country in the South Asian region. Sri Lanka’s COVID-19 response is characterized by a strong preventive approach with rational utilization of available resources. All patients who tested positive were managed at healthcare institutions initially. Asymptomatic or mildly symptomatic patients were admitted to Intermediate Care Centres for monitoring, management and discharged in 14 days. The patients with critical symptoms, uncontrolled comorbidities and other complications were admitted to hospitals for closer monitoring and specialized management.
Increase in number of cases and deaths were unprecedented. The number of healthcare workers available for the functioning of the system too declined with a significant proportion acquiring the infection and the remaining workforce on the verge of physical and mental exhaustion. The priority shifted towards triaging and identifying those who need immediate medical intervention at the earliest stage of the disease to reduce severe disease and death.
A virtual triaging system for the identification and evacuation of those who needed hospitalization and to facilitate home management for mild and asymptomatic patients was proposed. Telemedicine system was introduced and an integrated patient management system was established via Short Message Services (SMSs) and telephone helplines. Four key stakeholders, the National Operation Centre for Prevention of COVID-19 Outbreak (NOCPCO), Sri Lanka Medical Association (SLMA), the Ministry of Health and National Ambulance Service were brought together with the cooperation and support of national telecommunication service providers.
This system had a major impact on the management the pandemic in the country. Within two weeks of commencement, an increase the number of available beds in both the government and private sector was observed reduction in hospital admissions, oxygen dependency, comorbidities and death counts were noted. It also reduced the unnecessary exposure of healthcare workers to infected individuals.
This innovative initiative from Sri Lanka utilized the volunteerism in a resource-constrained scenario during COVID-19 pandemic and harnessed the support from all stakeholders including underutilized sectors in the provision of healthcare, including information and communication systems.
Biography:
Vladyslav Kulikov is a PhD student at Bangor University. The studentship was devised by Professor Rhiannon Tudor Edwards, co-director at CHEME, Bangor University and Huw Thomas, Finance Director at Hywel Dda University Health Board in response to the Russian invasion of Ukraine in February of 2022. His PhD project focuses on co-production in Hywel Dda University Health Board. He looks at the public opinion of the healthcare system and explores the preferences of the public and the economic rationale for prevention and co-production in the planning, organization and delivery of health and social care.
Abstract:
Background: Co-production is described in healthcare as a process of users and providers working together to improve health. It is seen as one of the ways to address a post-pandemic imbalance between supply and demand in the National Health Service (NHS). In line with the national policy, Hywel Dda University Health Board (HDUHB) is shifting from hospital-based care to a community-based model and from curative to preventive care. Little is known about the public preferences for preventive public health measures and the co-production of health in rural communities of Mid&West Wales.
Objective: To explore the preventive nature of co-production in HDUHB, map the preferences of the public in rural communities and inform effective co-creation in health and social care delivery.
Methods: Mixed methods are used to answer the research questions. A systematic review is underway to evaluate the existing literature on co-production and prevention in the UK and Wales focusing on rural communities. Quantitative (Discrete Choice Experiments (DCE)) and qualitative methods (surveys, interviews) are being used to elicit the preferences of the public in the HDUHB area.
Expected findings: To map public preferences for the prevention of illness and co-creation of health and collect feedback from the communities and key HDUHB stakeholders about the existing care delivery model. To measure the impact of co-production in addressing current economic challenges in the NHS and evaluate public health measures in HDUHB as a tool of co-production.  
Expected contribution: To synthesize what has already been done and further debate the effectiveness of co-production in addressing the imbalance between supply and demand in the NHS. The findings may contribute to policy change and promote understanding between the decision-makers and the public.
Conclusion: This work will contribute to the growing literature on the importance of co-production and prevention in healthcare research and delivery
Biography:
Bertrand has a PhD in Epidemiology/Biostatistics and a degree from the Institute of Statistics and the University of Paris. He has 20 years of experience in epidemiological studies and health economic evaluations with a university (INSERM), institutional (INCa) and pharmaceutical industry background. He has participated in many efficiency dossiers submitted to the CEESP and is teaching student of Master degree of Market Access and Health Economic Evaluation in Chatenay-Malabry. He has an expertise in model development in oncology.
Abstract:
In France, the main objective of economic evaluation of health technologies is to estimate an Incremental Cost-Outcome Ratio (ICER). The CEESP (Economic & Public Health Assessment Commission) provides an economic opinion on its credibility. The ICER is considered credible in the absence of a major reservation or major uncertainty. A validated ICER is expected to provide economically relevant information for the price negotiation with CEPS (French Pricing Committee).
Using Vyoo Agency efficiency database, all available validated Health Economic appraisal published between January 1 and until December 31, 2022, were reviewed to analyze the levels of ICERs.
In 2022, the CEESP validated the results of 12 health economic assessments out of 27 disclosed opinions. Nine of these opinions concern cancer treatments and 3 onco-hematology. For one assessment, the evaluated treatment is dominated. It is cost-effective compared to all others with an average ICER of €189,543.17/QALY. The levels of ICER vary widely: 2 ICERs are below €50,000/QALY, 3 between €50,000 and €15000/QALY, 3 between €150,000 and €250,000 and 2 above €250,000/QALY. ICERs range is wider in onco-hematology with ICERs between €7,392/QALY and €545,599/QALY as compared to that reported in oncology with ICERs between €49,572 and €250,086/QALY.
These levels of ICER are high compared to those accepted abroad, notably the UK. This is partly explained by the methodological requirements. The CEESP’s commitment to explore and control uncertainty leads to select conservative hypotheses to prevent any risk of underestimating the ICER. This trend does not fit well with the threshold of €0/QALY (which corresponds to the dominance); currently the only official one accepted by the CEPS to influence and speed up the price negotiations. Defining a reference value for qualifying the estimated ICER appears to be necessary to provide concrete information that can be used in price negotiations between Pharma Companies and the CEPS.
- Health Economics and Hospital Services
Location: SYDNEY 1-2
Session Introduction
Ashoke Bose
M. L. Bose Memorial Health Foundation, Inc., USA
Title: Economics of P2P healthcare payment strategy: An analysis of annual reports of a member of trinity health systems
Biography:
Ashoke Bose is involved in many diverse areas; spanning from heat transfer, turbulence to storage technology to market research. He found they are all connected as our global economy. At present, He is working on Near Zero Carbon (NZC) technology at SEAT, LLC, which is an extension of his Thesis on Natural Convection Heat Transfer in Phase Change Materials at McGill University, Montreal Canada Also; he is working on Elastic Coupon-Data Distribution Database technology.
Abstract:
An innovative algorithm for finding pairing members in a P2P healthcare payment network was proposed by the author in 2020. It has been claimed that the proposed P2P payment platform could eliminate the high administrative cost of the commercial health insurance system in USA. This could be accomplished by allowing the Patients without Insurance (PwI) to have access to a Primary Care Provider (PCP) in an early stage of their illness. By having access to a PCP at an early stage would prevent the PwI population from revisiting Emergency Room (ER) services in a community hospital. Further, this P2P strategy, if adopted by the community health systems, would reduce the economic stress on the health systems by lowering the cost of ER services due to reduction in ER visits by PwI population.
In 2021-2022, the author had the opportunity to work at St. Joseph’s Health (SJH) in Syracuse, NY, a wholly owned member of Trinity Health. An investigation was carried out by analyzing the publicly available Annual Reports of SJH before and during COVID to determine the feasibility of spending part of the Annual Expense budget, which is commonly known as “charity care”, for the proposed P2P healthcare payment strategy. A preliminary report on this investigation is presented in the paper.
Rafia Rahman
University of Dhaka, Bangladesh
Title: Explore the issues to achieve value-based healthcare services: A method of way out
Biography:
Rafia Rahma works as an assistant professor at the Institute of Health Economics, University of Dhaka. She has published several articles and attended various conferences centered on Health Economics.
Abstract:
Considering health as a regular consumer product, people are careless regarding health. The pandemic era discovers, to cure disease we need value-based healthcare service instead of value-money for health. In the pandemic era 2020 breaks healthcare service delivery systems across the world.
Aim of the study was to explore a method of way-out to achieve value-based healthcare services. Here, the term “value” is defined as either cure from diseases or reduced suffering from diseases. Likewise, “value-based healthcare services” is defined as providing appropriate services to either cure diseases or reduce the suffering of diseases. It was a piloting, cross sectional and mix method type of study. It was conducted to see the feasibility. Objectives of the study were;
- To explore the current status of value-based health service.
- To discover the factors influencing value-based health services.
- To determine client perception and suggestions for improvement of value-based services.
- To determine management perception and suggestions for improvement of value-based services.
A conceptual framework is prepared and followed during research [Figure 1]. One hundred and five (105) outdoor patients of a district hospital (Madaripur) at Dhaka division in Bangladesh was the study place, sample size and respondent. Regarding supply-side, four managers of four district hospitals (designated as civil surgeons) in Bangladesh were interviewed. The convenience sampling technique was used here. A total of sixty-six (66) dependable variables were addressed twenty-three (23) independent variables. To fulfill the objectives and aim of the study a total of forty-six (46) questions for demand-side (patient) and sixty-seven (67) questions for supply-side (healthcare manager) was asked. Primary data was collected from the survey.
To collect data a face-to-face interview from respondents was conducted asking both open and closed ended structured questionnaires. For water, sanitary, hand wash hygiene (WASH) at facility observation techniques was used. Participants were informed regarding confidentiality as well as the option of withdrawing from participation if they felt uncomfortable and those data were used in this research. 73.3% male and 26.7% female with age limit from 18 to 100 completing primary (47%) and secondary (45%) level of education engage with business (52%) and housekeeping (21%) earn thirty-five to one lac per month living mostly brick made house (97%) with facility of sanitation (100%) and water (97%) supply at home is the socio-demographic status of respondents. Regarding perception of disease development, they know disease does not develop naturally (92%), they believe (97%) food habit, no exercise and tobacco consumption is responsible for developing disease. About 97% of respondents were sick for less than seven days and were not under treatment (93%) and came for consultation by their own choice (67%) and near to home (17%). About 95% of respondents visited this HCF before and 99% came to receive HC services whenever required. According to their (95%) statement HC providers inform them about the outcome of disease and they (97%) are happy with the services. Health was valued by QALY (EQ5D) and visual analogue scale. Sample populations gave values ranging from 50 to 100 and the median is 90 in visual analogue scale. EQ5D found some problem; in mobility (11.4%), taking self-care (7%), doing usual activity (10%), moderate pain (26.7%) and anxiety (11.5%). Therefore, health is valued in this HCF. According to respondents, the friendly behaviour (64%) of HC providers assists to improve their health state, for further improvement to value health they (52%) suggest improving privacy. About 92% of respondents feel the presence of a third party locally called DALAL is good to get healthcare services. Through them they (79%) receive healthcare from a private chamber of HC provider and this third party did not take any money from them. About 92% of respondents understood value-based healthcare services and according to them (95%) HC providers provide them adequate service (in terms of cure from disease). Study population (97%) agreed that they got adequate services against money they spent on HC services.
The study concludes with the recommendations that the result of pilot study is feasible but cannot be generalised. To give a recommendation at policy level further study with a good number of facilities and sample size will be required. To serve this a further research in eight district hospitals on thirty-two hundred sample sizes (following 95% Confidence level sample size [385] and Taro Yamane’s formula [397] sample size) is in planning.
Dmytro Babelyuk
Bangor University, United Kingdom
Title: A health economics approach to medical workforce planning in rural health board in the North Wales: Towards a community-based model
Biography:
Dmytro Babelyuk is a PhD student at Bangor University. He has attended several conferences and workshops in the field of Health Economics all around the globe.
Abstract:
Background: Post pandemic challenges exacerbated and created more demands for smart visionary health economics decisions regarding modern medical workforce planning, especially in rural regions in Wales. The NHS currently has a shortage of around 100,000 full-time medical staff in the United Kingdom (UK). Only 36% of consultant physician posts in Wales were filled in 2021. The reason for 71% of unsuccessful appointments was the absence of applicants.
Objective: The objective of this doctoral research is to identify approaches to training and recruiting medical professionals within the framework of the current model which is moving to a more community-based model. The aim of this reform strategy is to assist Hywel Dda University Health Board (HDUHB) to recruit the qualified and well-trained medical professionals in a cost-effective way.
Methods: During this doctoral research different methods will be used. The key one is PBMA, which will be supplied by systematic literature review, targeted surveys and personal interviews. Programme Budgeting and Marginal Analysis (PBMA) is an approach that assists decision-makers optimise the influence of healthcare resources on the health demands of a local population by analysing the current financial allocations and thinking for improvements.
Expected results: Using the health economics toolbox, this doctoral thesis will provide economic evidence regarding the cost-benefits and cost-effectiveness of operationalising HDUHBs strategy of training future medical professionals from the local community. Current training and recruitment practices will be described in detail along with costs to the NHS in Wales. Findings from this thesis will be disseminated to the other Health Boards in Wales as well as internationally.
Discussion: The results of this doctoral thesis will benefit decision-makers and policymakers with future workforce planning by gaining a deeper understanding of a staffing issue in terms of local education and retaining medical professionals in rural areas in the UK and internationally.
- Health Economics Modelling
Location: SYDNEY 1-2
Session Introduction
Esperanca Lourenco Guimaraes
National Institute of Health, Mozambique
Title: Cost-effectiveness of human papillomavirus vaccines for preadolescent girls in Mozambique: A static cohort model
Biography:
Esperança is Veterinarian by training, Master in Animal Science (focus in Epidemiology) and PhD candidate in Tropical Diseases and Global Health. She works at National Institute of Health (INS) as Project Assistant of a capacity building project, Researcher in the fields of Enteric Infections, Immunization and Health Economics and as member of the Institutional Review Board.
Abstract:
Statement of the problem: Mozambique has one of the highest rates of cervical cancer in the world. Human papillomavirus vaccination was introduced for pre-adolescent girls in November 2021. This study evaluated the health and economic impact of the current HPV vaccine (GARDASIL-4) and two other vaccines (CECOLIN and CERVARIX) that could be used in the future.
Methodology & theoretical orientation: A proportionate outcomes static cohort model was used to estimate the lifetime costs and benefits of vaccination with CECOLIN, CERVARIX and GARDASIL-4 in 10 cohorts of girls aged 9 years (2022-2031) and 5 cohorts of girls aged 10-14 years in the year 2022. The primary outcome measure was the incremental cost per Disability-Adjusted Life-Year (DALY) averted from a government perspective. Each vaccine was compared to no vaccination and to each other. We assessed uncertainty through deterministic and probabilistic sensitivity analyses.
Findings: Without cross-protection all three vaccines had similar health benefits (48% reduction in cervical cancer cases and deaths). With cross-protection CERVARIX could have substantially more health benefits than the other two products (62% versus 48% reduction). Without Gavi donor support, discounted vaccine program costs were $43 m for CECOLIN, $61 m for GARDASIL-4 and $69 m for CERVARIX. With Gavi donor support all vaccines had similar discounted vaccine program costs (US $27 million). In scenarios without cross-protection CECOLIN was dominant; CECOLIN was cost saving with Gavi support and still very cost-effective without Gavi support. In scenarios with cross-protection and Gavi support CERVARIX was dominant and cost-saving. With cross-protection and no Gavi support, CECOLIN had the most favorable cost-effectiveness
Conclusion: At a threshold of US 175 (35% of the national GDP per capita), HPV vaccination is cost-effective for preadolescent girls in Mozambique. The optimal choice of vaccine depends on influential cross-protection assumptions. CERVARIX is worth consideration, particularly while its cost is heavily subsidized by Gavi.
Bertrand Tehard
Vyoo Agency, France
Title: Overview of the economic opinions published by the HAS in 2022
Biography:
Bertrand has a PhD in Epidemiology/Biostatistics and a degree from the Institute of Statistics and the University of Paris. He has 20 years of experience in epidemiological studies and health economic evaluations with a university (INSERM), institutional (INCa) and pharmaceutical industry background. He has participated in many efficiency dossiers submitted to the CEESP and is teaching student of Master degree of Market Access and Health Economic Evaluation in Chatenay-Malabry. He has an expertise in model development in oncology.
Abstract:
In France, the CEESP (Economic & Public Health Assessment Commission) oversees health economic appraisal of medical technologies when requested concomitantly with a reimbursement demand. This appraisal establishes the methodological acceptability of the health economic dossier submitted. Methodological acceptability is defined through methodological reservations qualified as minor, important or major. A major reservation invalidates the dossier and the economic value that it defends.
An appraisal also specifies the level of uncertainty surrounding the results. A major uncertainty invalidates the results and the dossier per se. Uncertainty could be driven by the difficulty to estimate key parameters, by a lack of credibility of hypotheses or interpretability of the results.
Using Vyoo Agency efficiency database, the objective is to analyze the main reasons retained by the CEESP to invalidate the economic information among health economic appraisals published in 2022.
All available Health Economic appraisals published between January 1 and until December 31, 2022, were reviewed. In 2022, 27 appraisals were disclosed, 14 of which were invalidated. Thirteen major methodological reservations were stated, invalidating 9 dossiers. The major reservations relate to relative effectiveness modelling (6), utility estimation (5) and sensitivity analyses (2). Relating to the modelling of the treatment effect, 3 reservations concern indirect comparisons and 3 hypotheses used to model the relative effect regarding available data. In addition, 4 dossiers were invalidated due to major uncertainty mainly supported by the evolving context (2), statistical variability of the parameters (1) or immaturity of the data (1). One evaluation was not assessable.
In 2022, less than 50% of dossiers are likely to provide valuable economic information in the decision-making process in France. Reducing the number of invaluable assessments is a key issue to ensure economic information can be fully used in price negotiations.
- Pharmaceutical Economics
Location: SYDNEY 1-2
Session Introduction
Yossef Lomnicky
Maccabi Healthcare Services, Israel
Title: Increasing drug availability while implementing cost containment policies: 13 years experience of Maccabi Health Services (MHS)
Biography:
Yossef Lomnicky is the head of the Pharmacy Department at Maccabi Health Services (MHS) which is a large health maintenance organization in Israel. He has attended several conferences around the globe.
Abstract:
Background: Drug expenditure has been growing at an accelerated rate in developed countries at an annual increase of 2-10%. The Maccabi Health Services (MHS), the second largest health maintenance organization in Israel has implemented a “smart policy” that includes a wide range of steps aimed to reduce non-essential drug costs while maintaining maximum quality of health services.
Methods: We evaluated the contribution of the implemented methods on the annual drug expenditure values from 2007 to 2019. The expenditures were evaluated and standardized to the "Israeli Health value index" of 2019 and calculated per insured per MHS member. The main steps were implemented in three levels, physicians, drugs companies and the patients.
The policy was implemented using "preferred drugs" which the physicians were directed to prescribe in most therapeutic groups (example: Statins, Ace I, ARBs, Steroids for inhalation etc.). Start to use generics as soon as they are marketed. Renewing drug purchasing contracts, Restricting the use of expensive drug via preauthorization, setting higher co-payments for "non-preferred drugs" and revising contracts with pharmacies that provide service for the MHS members in order to achieve better terms for the MHS.
Results: Figure 1 displays the MHS’s drug expenditures from 2007 through 2019. It can be seen that drug expenditures were elevated by a total of 5% that presents an average of 0.4% per year. The overall outcomes of implementing the drugs cost containment steps, demonstrated an average increase rate of 0.4% in annual drugs expenditures (in the period 2007 to 2020) per standardized MHS member. This increase rate is relatively low compared to most developed countries, despite the fact that Israel is among the early adapter of new pharmaceutical technologies.