Equitable Prioritization of Health Interventions by Incorporating Financial Risk Protection Weights Into Economic Evaluations

Published:December 07, 2022DOI:



      Financial risk protection (FRP), or the prevention of medical impoverishment, is a major objective of health systems, particularly in low- and middle-income countries where the extent of out-of-pocket (OOP) health expenditures can be substantial. We sought to develop a method that allows decision makers to explicitly integrate FRP outcomes into their priority-setting activities.


      We used literature review to identify 31 interventions in low- and middle-income countries, each of which provided measures of health outcomes, costs, OOP health expenditures averted, and FRP (proxied by OOP health expenditures averted as a percentage of income), all disaggregated by income quintile. We developed weights drawn from the Z-score of each quintile-intervention pair based on the distribution of FRP of all quintile-intervention pairs. We next ranked the interventions by unweighted and weighted health outcomes for each income quintile. We also evaluated how pro-poor they were by, first, ordering the interventions by cost-effectiveness for each quintile and, next, calculating the proportion of interventions each income quintile would be targeted for a given random budget. A ranking was said to be pro-poor if each quintile received the same or higher proportion of interventions than richer quintiles.


      Using FRP weights produced a more pro-poor priority setting than unweighted outcomes. Most of the reordering produced by the inclusion of FRP weights occurred in interventions of moderate cost-effectiveness, suggesting that these weights would be most useful as a way of distinguishing moderately cost-effective interventions with relatively high potential FRP.


      This preliminary method of integrating FRP into priority-setting would likely be most suitable to deciding between health interventions with intermediate cost-effectiveness.


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        • Mirelman A.
        • Mentzakis E.
        • Kinter E.
        • et al.
        Decision-making criteria among national policymakers in five countries: a discrete choice experiment eliciting relative preferences for equity and efficiency.
        Value Health. 2012; 15: 534-539
        • Cookson R.
        • Mirelman A.J.
        • Griffin S.
        • et al.
        Using cost-effectiveness analysis to address health equity concerns.
        Value Health. 2017; 20: 206-212
        • Ottersen T.
        • Millum J.
        • Ruger J.P.
        • et al.
        The future of priority-setting in global health.
        in: Norheim O.F. Emanuel E.J. Millum J. Global Health Priority-Setting. Oxford University Press, Oxford, England2019: 317-326
        • Bleichrodt H.
        • Diecidue E.
        • Quiggin J.
        Equity weights in the allocation of health care: the rank-dependent QALY model.
        J Health Econ. 2004; 23: 157-171
        • Baltussen R.
        • Niessen L.
        Priority setting of health interventions: the need for multi-criteria decision analysis.
        Cost Eff Resour Alloc. 2006; 4: 14
        • Verguet S.
        • Laxminarayan R.
        • Jamison D.T.
        Universal public finance of tuberculosis treatment in India: an extended cost-effectiveness analysis.
        Health Econ. 2015; 24: 318-332
        • Asaria M.
        • Griffin S.
        • Cookson R.
        Distributional cost-effectiveness analysis: a tutorial.
        Med Decis Making. 2016; 36: 8-19
        • Verguet S.
        • Kim J.J.
        • Jamison D.T.
        Extended cost-effectiveness analysis for health policy assessment: a tutorial.
        Pharmacoeconomics. 2016; 34: 913-923
        • Round J.
        • Paulden M.
        Incorporating equity in economic evaluations: a multi-attribute equity state approach.
        Eur J Health Econ. 2018; 19: 489-498
        • Baltussen R.
        • Marsh K.
        • Thokala P.
        • et al.
        Multicriteria decision analysis to support health technology assessment agencies: benefits, limitations, and the way forward.
        Value Health. 2019; 22: 1283-1288
        • Cookson R.
        • Griffin S.
        • Norheim O.F.
        • Culyer A.J.
        Distributional cost-effectiveness analysis: quantifying health equity impacts and trade-offs. Oxford University Press, Oxford, England2020
        • Krol M.
        • Brouwer W.
        • Sendi P.
        Productivity costs in health-state valuations : does explicit instruction matter?.
        Pharmacoeconomics. 2006; 24: 401-414
        • Murray C.J.
        • Frenk J.
        A framework for assessing the performance of health systems.
        Bull World Health Organ. 2000; 78: 717-731
      1. Roberts M. Hsiao W. Berman P. Reich M. Getting Health Reform Right: A Guide to Improving Performance and Equity. Oxford University Press, Oxford, England2008
        • World Health Organization
        Making fair choices on the path to universal health coverage: final report of the consultative committee on equity and universal health coverage.
        Geneva: World Health Organization. 2014;
        • World Health Organization
        Tracking Universal Health Coverage: 2017 Global Monitoring Report.
        World Health Organization, Geneva, Switzerland2017
        • Wagstaff A.
        Measuring financial protection in health.
        in: Smith P.C. Mossialos E. Papanicolas I. Performance Measurement for Health System Improvement: Experiences, Challenges and Prospects. Cambridge University Press, Cambridge, England2010: 114-137
        • Saksena P.
        • Hsu J.
        • Evans D.B.
        Financial risk protection and universal health coverage: evidence and measurement challenges.
        PLoS Med. 2014; 11e1001701
        • Murray C.J.L.
        • Salomon J.A.
        • Mathers C.D.
        • et al.
        Summary Measures of Population Health: Concepts, Ethics, Measurement and Applications.
        World Health Organization, Geneva, Switzerland2002
        • Smith P.C.
        Incorporating financial protection into decision rules for publicly financed healthcare treatments.
        Health Econ. 2013; 22: 180-193
        • Essue B.M.
        • Laba T.L.
        • Knaul F.
        • et al.
        Economic burden of chronic ill health and injuries for households in low- and middle-income countries.
        in: Disease Control Priorities. Third Edition. Volume 9. The World Bank, Washington, DC2017: 121-143 (Improving Health and Reducing Poverty)
        • Jan S.
        • Laba T.L.
        • Essue B.M.
        • et al.
        Action to address the household economic burden of non-communicable diseases.
        Lancet. 2018; 391: 2047-2058
        • Haakenstad A.
        • Coates M.
        • Marx A.
        • Bukhman G.
        • Verguet S.
        Disaggregating catastrophic health expenditure by disease area: cross-country estimates based on the World Health Surveys.
        BMC Med. 2019; 17: 36
        • Haakenstad A.
        • Coates M.
        • Buhkman G.
        • McConnell M.
        • Verguet S.
        Comparative health systems analysis of differences in the catastrophic health expenditure associated with non-communicable versus communicable diseases among adults in six countries.
        Health Policy Plan. 2022;
      2. Tracking universal health coverage. World Health Organization. The World Bank.
        • Wagstaff A.
        • Flores G.
        • Smitz M.F.
        • Hsu J.
        • Chepynoga K.
        • Eozenou P.
        Progress on impoverishing health spending in 122 countries: a retrospective observational study.
        Lancet Glob Health. 2018; 6: e180-e192
        • Wagstaff A.
        • Flores G.
        • Hsu J.
        • et al.
        Progress on catastrophic health spending in 133 countries: a retrospective observational study.
        Lancet Glob Health. 2018; 6: e169-e179
      3. Glassman A. Giedion U. Smith P.C. What’s in, What’s Out: Designing Benefits for Universal Health Coverage. Center for Global Development, Washington, DC2017
        • Verguet S.
        • Hailu A.
        • Eregata G.T.
        • Memirie S.T.
        • Johansson K.A.
        • Norheim O.F.
        Toward universal health coverage in the post-COVID-19 era.
        Nat Med. 2021; 27: 380-387
      4. Resource pack: extended cost-effectiveness analysis. Center for Health Decision Science, Harvard TH Chan School of Public Health.
        • Pratt J.W.
        Risk aversion in the small and in the large.
        in: Foundations of Insurance Economics. Springer, Dordrecht, The Netherlands1992: 83-98
        • McClellan M.
        • Skinner J.
        The incidence of medicare.
        J Public Econ. 2006; 90: 257-276
        • Brown J.R.
        • Finkelstein A.
        The interaction of public and private insurance: Medicaid and the long-term care insurance market.
        Am Econ Rev. 2008; 98: 1083-1102
        • Pillarisetti A.
        • Jamison D.T.
        • Smith K.R.
        Household energy interventions and health and finances in Haryana, India: an extended cost-effectiveness analysis.
        in: Injury Prevention and Environmental Health. Third Edition. Volume 7. The World Bank, Washington, DC2017: 223-237 (Disease Control Priorities)
      5. DataBank. The World Bank.
        Date accessed: October 12, 2020
        • Norheim O.F.
        Ethical priority setting for universal health coverage: challenges in deciding upon fair distribution of health services.
        BMC Med. 2016; 14: 75
        • Thokala P.
        • Devlin N.
        • Marsh K.
        • et al.
        Multiple criteria decision analysis for health care decision making—an introduction: report 1 of the ISPOR MCDA Emerging Good Practices Task Force.
        Value Health. 2016; 19: 1-13
        • Baeten S.A.
        • Baltussen R.M.
        • Uyl-de Groot C.A.
        • Bridges J.
        • Niessen L.W.
        Incorporating equity-efficiency interactions in cost-effectiveness analysis-three approaches applied to breast cancer control.
        Value Health. 2010; 13: 573-579
        • Oliveira M.D.
        • Mataloto I.
        • Kanavos P.
        Multi-criteria decision analysis for health technology assessment: addressing methodological challenges to improve the state of the art.
        Eur J Health Econ. 2019; 20: 891-918
        • Hurley J.
        • Mentzakis E.
        • Walli-Attaei M.
        Inequality aversion in income, health, and income-related health.
        J Health Econ. 2020; 70102276
        • Pirttilã J.
        • Uusitalo R.
        A “leaky bucket” in the real world: Estimating inequality aversion using survey data.
        Economica. 2010; 77: 60-76
      6. Adler MD. Measuring social welfare: an introduction. New York: Oxford University Press, 2019.

        • Fleurbaey M.
        • Luchini S.
        • Muller C.
        • Schokkaert E.
        Equivalent income and fair evaluation of health care.
        Health Econ. 2013; 22: 711-729
        • Brouwer W.B.F.
        • Culyer A.J.
        • van Exel N.J.A.
        • Rutten F.F.H.
        Welfarism vs. extra-welfarism.
        JHealth Econ. 2008; 27: 325-338
        • Thorpe J.
        • Viney K.
        • Hensing G.
        • Lönnroth K.
        Income security during periods of ill health: a scoping review of policies, practice and coverage in low-income and middle-income countries.
        BMJ Glob Health. 2020; 5e002425