Impact case study database

Our research has been geared towards impact at various levels: 1. National, especially in Malawi; 2. Regional adoption of the HBP work in Malawi as best practice; and 3. Global policymaking. The thread that brings these impact areas together is that the outcome of decisions made at higher levels can only be fully understood by determining impacts on those countries ultimately intended to be the beneficiaries of international health decisions.

(1) Designing the Essential Health Package (EHP) of interventions to be prioritized for funding in Malawi (national level)

Like many countries, Malawi has chosen to prioritize spending by developing a health benefits package (which in Malawi is referred to as an Essential Health Package; the EHP). York methods and applications have been incorporated into Malawi’s plans for healthcare provision through sustained engagement between the Ministry of Health (MOH) and York researchers, including an initial health economics workshop with the MOH and other Government departments held in June 2016 [5.1a] and annual meetings since 2016. In July 2017, Malawi published its medium-term strategic health plan for 2017-2022 with a chapter on EHP that is underpinned by York research [5.1b]. As the Deputy Director - Planning Department in the MOH puts it: “CHE’s research has impacted on Malawian policy development in two ways: by providing an analytic framework which enables robust determination of the EHP around which the health budget is formulated; and by providing new estimates of Cost-Effectiveness Thresholds which allow us to prioritize those interventions which deliver health gains at lower costs” [5.1c; A, B]. The strategic health plan notes that previous EHPs could not be implemented partly because “the cost-effectiveness threshold that was used for determining whether an intervention would be included in the EHP did not reflect the opportunity cost of health spending in Malawi” [5.1b, p. 33]. Instead, the plan cites York research (including earlier work that was subsequently published as **[A]**) as providing more appropriate benchmarks [5.1b, pp. 33-5]. As a result, the revised EHP costs 31% less than the cost of providing its predecessor package, and less per DALY averted: “while implementing the previous package would have cost USD7.91 per DALY averted, with the revised EHP it only costs USD5.97 per DALY averted” [5.1b, p. 40] . York research has thus contributed significantly to a revised EHP which “provides better value for money than the previous package” [5.1b, p. 40] .

As well as informing the allocation of Malawi’s USD247million revised EHP, York’s analytic framework and cost-effectiveness thresholds are also used by the Foreign, Commonwealth and Development Office (FCDO, formerly DFID) to guide allocation of funds in FCDO’s Umoyo-Wathu Health Systems Strengthening Programme, which provides GBP130,000,000 funding for health assistance in Malawi. The FCDO Team Leader of the Human Capital Team describes the Umoyo-Wathu programme as “firmly grounded on the EHP’ and explains that the programme ‘focuses on scaling up access and impact of the EHP, and makes use of York’s research to inform and guide investments in cost-effective health services” [5.1d].

(2) Regional adoption of the HBP work in Malawi as best practice

York’s analytic framework and cost effectiveness benchmarks developed for Malawi [A, B] subsequently influenced health policy regionally in the East, Central and Southern Africa Health Community (ECSA-HC) - the regional intergovernmental organization representing all Ministries of Health in its 9 member states (Kenya, Lesotho, Malawi, Mauritius, eSwatini, Tanzania, Uganda, Zambia, Zimbabwe). As confirmed by the Director of Programmes, ECSA-HC formally recognises the Malawian EHP as best practice [5.1e]. As he writes: “ The revised benchmarks on cost-effectiveness developed by York’s Centre for Health Economics enable more focused and effective spending, providing better value for money and improved health outcomes ” [5.1e]. In 2018, at their annual meeting, the 9 ECSA-region Ministers of Health wrote a regional Ministerial Resolution on Priority Setting and Health Benefits Package Design (HMC67/R2) [5.1f]. The resolution reflects the principles of the York research by proposing methods that reflect the realities of resource constraints, particularly the need to consider the supply side constraints to HBP implementation, and is now adopted as policy throughout the region. Following this, training on HBP design was provided by York researchers to MOH representatives and academic partners from 9 ECSA states (4-6 February, 2019, Lilongwe, Malawi). As a result, other countries in the region, including Uganda, Zambia and Kenya, have embarked upon efforts to revise their health benefits packages [5.1e]. York’s approach to HBP design has also influenced health planning in Ghana, a country of 29,000,000 people and annual health insurance expenditure of ~USD250,000,000. In 2018, the MOH commissioned an economic evaluation of the national health insurance scheme. That evaluation notes that “the research methods were inspired by research in which an EHP was developed for Malawi)” [5.2, p.14; A].

The York approach to EHP design has also been adopted as an example of best practice by the UK FCDO. As the Team Leader in the Human Capital Team at FCDO Malawi explains: “the Malawi example of the EHP is part of the FCDO Best Buys guidance to country offices, for helping develop effective health services” [5.1d]. This document is provided to all FCDO in-country health leads.

(3) Global health policy-making and prioritization

In June 2015, the WHO announced that it would stop recommending the use of 1-3 times the GDP per capita benchmark in its guidance [5.3a]. Through sustained engagement with the WHO [5.3b], research from York on the most appropriate benchmarks to use to evaluate the cost-effectiveness of health interventions in LMICs influenced this decision (earlier work, subsequently published as **[B]*). A WHO Economist at this time notes the York research was: “instrumental in shifting thinking about economic evaluation at WHO’ and ‘directly influenced a series of decisions at WHO to clarify its position about cost-effectiveness thresholds for LMICs...and enabled in turn the increased prioritization and scale-up of interventions that could deliver higher health gains for lower cost” [5.3c].

York methods research has also influenced recommendations by WHO clinical departments, especially in HIV. Our research (with the HIV Modelling Consortium, for which we lead economic analyses), has been incorporated into the last 3 HIV Treatment Guidelines and major updates [5.4a-c, 5.5a]. One study [C] argued for the adoption of a differentiated care approach to monitoring patients on HIV treatment and this was incorporated into the 2016 WHO HIV Treatment Guidelines [5.4a], leading to the approach now being available for the majority of the 17,000,000 people receiving HIV treatment worldwide. The Director of the HIV Modelling Consortium states: “The policy changes have reduced the frequency of visits required by patients to see healthcare providers, and led to increased health gains at a lower overall cost than previous treatment models used” [5.5b]. Differentiated treatment approaches have also been emphasised in the new UNAIDS HIV targets which will guide global HIV responses between 2020 and 2025 [5.6]. Additional research [D][E] has informed the 2017 WHO Advanced HIV Disease Guidelines recommendation for an enhanced package of care to those living with HIV and presenting at clinics with advanced disease [5.4b]. An independent review of the Joint Global Health Trials Scheme, funded to GBP138,800,000 in rounds 1-9, included the REALITY trial study [D] as its first example of impact and policy influence [5.7].

The Portfolio Holder for Advanced HIV Disease at WHO summarises: “The 2013 Consolidated HIV Guidelines included for the first time extensive disease modelling, cost-effectiveness analysis and emphasised a public health approach to providing care to people living with HIV...UoY researchers (had) a major input to (the) policy shift towards providing ART for all people living with HIV in 2016...UoY has continued to provide important inputs into HIV guidelines processes (including) differentiated care, enhanced prophylaxis for advanced HIV disease, and changes in drug regimens” [5.5a]. Since then, there has been a major shift in the emphasis placed on economic analysis: “ Economic analysis is now recognized as being a critical component for Guidelines development. The work of the Centre for Global Development and the international working group convened by (CGD) and co-chaired by Paul Revill ...provided WHO and other international health agencies with recommendations for the use of economic analysis in health policy formulation” [5.5a].

The approaches that York has developed to economic analysis have additionally informed investments in health technologies of the future, especially by the BMGF who fund development of many products tailored for LMICs. York researchers have assessed the likely impacts of new HIV diagnostics, in particular. One example is the research on the potential of HIV self-testing [F], if it were to come to market and become widely available. This led to investment in continued product development by the BMGF [5.5b]. The research also acted as a catalyst for further research. Most notably, research on feasibility and implementation was conducted through the HIV Self Testing in Africa (STAR) initiative, funded by UNITAID with support from the BMGF and others [5.8a]. York researchers’ work on self-testing also led to a positive recommendation in the 2016 WHO Guidelines on HIV Self Testing Supplement [5.8b], in which [F] was cited, and its availability was subsequently scaled-up [5.5b]. By July 2018, HIV self-testing was used by an estimated 4,700,000 people, with the global market expected to reach 20,000,000 annually by the end of 2020 [5.8c].