April 9, 2021

Developing a distributional population health metric that incorporates health inequalities and illness-related poverty | Final Takeaways from 2019 Burke Fellowship

Stéphane Verguet, MPP, MS, PhD, was awarded a Burke Global Health Fellowship in 2019 for a project entitled “The eDALY: Developing a distributional population health metric that incorporates health inequalities and illness-related poverty.” Protecting from the financial risks of illness and improving the distribution of population health are major health system objectives integral to achieving universal health coverage (UHC). Health priority setting must therefore include the impact of interventions per population subgroup (socioeconomic status) and their financial risk protection benefits – avoiding impoverishment from illness-related out-of-pocket expenditures. This will permit identifying “best buys” in terms of equity and poverty reduction gains when investing in health interventions. Stéphane proposed to create an eDALY, that is a metric that extends the DALY (disability adjusted life years) to quantify health disparity and FRP dimensions into priority setting. The work encompassed both modeling investigations and empirical data collections.

Thanks to the Burke Fellowship, Stéphane was able to allocate significant time to focus on shaping these ideas: “I could really dedicate efforts to fully concentrate on the eDALY investigations and to strategize on how to effectively advance this research further; and the Burke Fellowship provided me with this unique opportunity.” While the data collections initially planned have been partially postponed due to COVID-19, his team was still able to pilot an online survey in the US; and hope to refine, tailor and expand this online platform to carry out research in South Africa and Ethiopia in the near future. “The Burke Fellowship ideally granted me time to reflect on where I would like to take my research over the next few years, and, simultaneously, to concentrate on drafting a few important manuscripts over the time of the project”. 

Before the Burke Fellowship, Stéphane had started with developing extended cost-effectiveness analysis (ECEA) to evaluate the consequences of policies in four domains: health gains; out-of-pocket costs averted and financial protection benefits for individuals; impact per income group; and total implementation costs. ECEA has made important contributions so far. Yet, its results are disaggregated, presenting health and financial protection benefits across income groups; and the next step is to develop a systematic way to assess and weigh these dashboards of outcomes. The Burke Fellowship exactly allowed him to pursue this with achieving two important milestones:

1. To test metrics for incorporating health equity into economic evaluations

2. To pilot an online survey on potentially desirable features of such health equity metrics

First, his team reviewed the mathematical construct of disability-adjusted life years (DALYs) that aggregate mortality and morbidity outcomes of diseases and that estimate both Years of Life Lost (YLL) and Years of Life lived with Disability (YLDs). For a majority of diseases, DALYs seem greatly driven by YLLs; hence, we started to focus our research on disease-specific mortality outcomes.

Second, due to lack of available data on systematic disease-specific outcomes across income and wealth groups in many countries, his team examined the population-level distributions in age at death using demographic data: that enabled us to characterize disparities in lifespan and to point to worse-off populations (e.g. those with reduced longevity). For that purpose, they analyzed life table data from 30+ countries and constructed indicators that can summarize features of age-at-death distributions. This can be a stepping stone toward further studying health disparities across income groups, including how these overall disparities are related to disease-specific inequalities and the social determinants of health in various low- and middle-income country contexts.

Third, they studied the financial protection dimension that includes the magnitude of illness-related out-of-pocket costs related to disease treatment (e.g. cost of drugs, hospitalizations). Specifically, they designed analytical tools to jointly aggregate the distributions in both financial protection and health outcomes into economic evaluations, so to yield an aggregated dashboard of health and financial outcomes (per income quintile) resulting from the impact of interventions. This enables them to report on the value for money, in terms of joint equity and financial protection, of health interventions to set fair health priorities.

In order to calibrate their mathematical aggregation and “equity” weights, they designed an online survey. The survey explored how people value equity and financial protection by posing ethical dilemmas. Practically, survey participants face a series of illness situations where they have to choose, as individuals around the world do, between two different options. The dilemmas include issues of disease severity, mortality, out-of-pocket costs and medical impoverishment (corresponding to “catastrophic” expenditures, i.e. substantial lack of financial protection). Subsequent analysis of participant responses can help derive relative weights to shape eDALY subcomponents. Next, they intend to launch it in South Africa as soon as possible.

In summary, national health systems must fulfill multiple objectives including maximizing equity and financial protection, in addition to maximizing health, with limited financial resources. Ultimately, the eDALY project which the Burke Fellowship enabled, has helped develop quantitative methods toward selecting the health interventions to prioritize based on criteria of equity and financial protection, for implementing equitable policies toward UHC. This is a stepping stone toward fair priority setting and reducing health disparities and poverty. 

Stéphane Verguet, MPP, MS, PhD, is Assistant Professor of Global Health at the Harvard T.H. Chan School of Public Health and a core faculty member of the Center for Health Decision Science. He has two mains areas of research, both related to health systems, health economics, and priority setting: (1) the incorporation of the dimensions of equity and financial risk protection into the economic evaluation of health policies with the development and application of the extended cost-effectiveness analysis methodology; (2) health system analysis and performance, including the study of the interaction and integration of health services delivery platforms and health system modeling. He co-leads the Disease Control Priorities – Ethiopia project, which in close collaboration with Ethiopia’s Ministry of Health intends to strengthen health economics and priority-setting capacity in Ethiopia.