Improving the use of economic evaluation data for priority setting in a multi-donor environment in resource-limited countries: The case of tuberculosis and other poverty-related diseases among children in Zambia, Mozambique and Côte d'Ivoire

Background and rationale

Every country, regardless of its economic level, faces challenges in meeting the needs of its health systems to satisfy its populations, regardless of its level of resources (Pichon-Riviere et al. 2023). The situation becomes increasingly difficult as nations strive to ensure access to health care for all, whether in terms of who is covered, what type of treatment is given, or how much it costs the population, which poses the difficult task of making trade-offs between costs and benefits (which requires efficiency), as well as between equity and other social values. Health systems are primarily designed to improve health and efficiency, that is, the amount of health achieved relative to the amount of resources spent. The use of cost-effectiveness estimates for policymaking faces a number of barriers in the majority of low- and middle-income countries that require careful attention (Shillcutt et al. 2009). These include the lack of information on the costs and effects of interventions, the very small number of cost-effectiveness analyses conducted, the lack of evidence on the costs and effects of packages of measures, and the difficulty of generalizing or comparing studies from specific settings using different methodologies and outcome measures. Setting priorities in public health and health policy is important but complex (Stratil et al. 2020). Systematic assessment of evidence and other factors requires careful evaluation of many, often conflicting, normative and technical requirements. The choice of which factors to use as standards has a significant influence on the outcome of the decision-making process. Cost and effectiveness have been the primary considerations in many decision-making processes that directly impact health. This contrasts with the complexity of real-world decision-making, where normative and practical factors can play a major role in guiding choices. Establishing a systematic process to inform priority setting and decision-making can help optimize resources and minimize opportunity costs associated with lower-impact investments.

Objective

1. Develop a methodological framework to better support health planners in financial planning and priority setting for TB in resource-limited settings with a high TB burden.
2. Propose a new direction for resource allocation using program budgeting and marginal analysis for the national TB control program in Zambia.
3. Explore the cross-cutting application of the new methods developed in Objectives 1 and 2 to other poverty-related diseases through the IPORA consortium and the Young Team Associated with IRD platform in Zambia, Mozambique and Côte d’Ivoire.

Main methods

Objective 1: Developing a methodological framework

Phase 1: Identifying evidence to inform the methodological framework: First, identifying previous frameworks or guidance that inform the new methodological framework. Second, identifying new evidence to help develop the methodological framework. A variety of methods will be used to identify new evidence, including scoping studies, desk reviews, and key informant interviews from national TB programmes, ministries and departments responsible for planning, resource mobilization and allocation, and all partners funding TB activities in Zambia and Mozambique.

Phase 2: Developing the methodological framework: The new methodological framework will be developed during this phase by adapting the frameworks or guidelines obtained during Phase 1 and combining them with additional guidance.

Phase 3: Evaluate and refine: This last phase will consist of evaluating and improving the proposed methodological framework. The methodological framework will be driven by case studies and Delphi panels will be used as evaluation methodologies. If necessary, the methodological framework will be improved based on the evaluation results. The IPORA Inter-PM Methodological Working Group on Actor Network Analysis, led by Tanguy Bernard and Kaleab Baye (Food System), will be regularly involved in each phase in order to provide inputs at different stages of the framework development (through our regular meetings already in place). The aim will be to obtain expert advice from this working group on our alternative approach to social network analysis, and to facilitate the application of our work to other development sectors, as presented in Objective 3.

Objective 2: Programme budgeting and marginal analysis

Programme budgeting and marginal analysis involves seven steps and allows an organisation to take a more systematic approach to setting priorities and allocating resources.
Determine the objective and scope of the priority-setting exercise
Develop a budget for the programme
Establish a marginal analysis advisory group Determine locally relevant decision criteria with the help of decision-makers and stakeholders Identify options for (a) increasing services (b) freeing up resources through operational efficiencies (c) freeing up resources through reducing or eliminating some services Evaluate investments and disinvestments Validate results and reallocate resources

Objective 3: Apply the new methodology developed in Objectives 1 and 3 to other poverty-related diseases through the IPORA consortium

The activities under Objective 3 will build on the results of Objectives 1 and 2 and will be carried out within IPORA through existing working groups with which I am already formally engaged. Through the IPORA Inter-PM Methodological Working Group on Stakeholder Network Analysis, we will disseminate the results of our methodological framework and our marginal analysis tool for program budgeting. I am also involved in the IRD collaboration tool (Young Team Associated with IRD) supported by the University of Bordeaux (GHiGS) and the University of Zambia, involving other partners including the Bordeaux School of Economics on poverty-related diseases issues, with a strong capacity building dimension (PhD and Masters training), and which will also support other collaborations. We are particularly looking to present the new methods developed to IPORA partners in Côte d’Ivoire, and potentially in Ethiopia.

Expected results

Objective 1: This study will inform financial planning and priority setting for TB control and develop a methodological framework for decision-making processes, both within and across countries, in the multinational environment of resource-limited settings where TB is prevalent. •
Objective 2: we will propose a new direction for resource allocation for the TB control programme in Zambia using marginal analysis for programme budgeting.
Objective 3: Dissemination of the tools through the IPORA network and the Young team associated with IRD in Zambia.