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Health Economics

We have a dynamic group of over 50 health economists working on a diverse portfolio, ranging across methods development, empirical research and policy impact.  Over the past 50 years we have developed strong national and international partnerships.  LSHTM economists have a wealth of experience in advising UK and other national governments, international agencies and organisations.

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Research

Our research spans the field of health economics, including: economic evaluation and priority setting and evaluation of complex policy interventions.

Teaching

We have a flourishing research degree programme in health economics, with around 30 students, working across low, middle and high income countries.

Research
Research IHEA

Our research spans the field of health economics, including:

  • Economic evaluation and priority setting
  • Evaluation of complex policy interventions
  • Health system financing and organization
  • Preferences and behaviour

We work on empirical and methodological developments, with particular interests in the following methods:

  • Causal inference approaches to provide accurate, relevant estimates of the effectiveness and cost-effectiveness of new health care interventions.
  • Novel preference elicitation methods and Discrete Choice Experiments (DCEs).
  • Methods for studying health care markets
  • Incorporating constraints in economic evaluation
  • Equity analyses using dynamic demographic and transmission modelling
  • Willingness to pay thresholds for multi-sectoral interventions
  • Cost functions in data scarce environments
  • Standards in global health costing
  • Use of behavioural economics and demand analysis to inform intervention and trial design & parameterise uptake in economic evaluation models
  • Methods for tracking global and domestic resource flows for health

Read more about the wide range of health economics research we conduct in this brochure.

Teaching
Teaching Health Economics

Masters programmes  

Health Economics courses are a core part of our Masters teaching in public health, featuring prominently in the following face-to-face courses in London:

And the following distance-learning courses:

Economics MSc modules include “Introduction to Health Economics”, “Economic Analysis for Health Policy”, “Economic Evaluation”, and “The Economics of Global Health Policy”. Key to our teaching is the use of our research and policy experience within our teaching materials.

Further details including the application process is available, for the face-to-face programme and for the distance learning programmes, as well as advice on scholarship funding.

Research degrees  

We have a flourishing research degree programme in health economics, with around 30 students, working across low, middle and high income countries.

Further information is available on the research degree programme and on scholarship funding.

 

Examples of current and recently completed thesis topics include:

 

Manuel Gomes - Statistical methods for cost-effectiveness analysis that use cluster randomised trials

Noemi Kreif - Methods to address selection bias in health economic evaluations that use patient-level observational data

Adam Steventon - Methods to increase the internal and external validity of evaluations of preventive community-based interventions in health and social care

Melisa Martinez Alverez – Development financing in Tanzania

Carol Dayo Obure – Exploring the efficiency of Sexual and Reprodictive Health/HIV integration

Kate Mandeville – Train to retain:  The role of specialty training in stemming Malawi’s medical brain drain

Laura Anselmi – Equity and efficiency in the geographic allocation of public health resources in Mozambique

Marie Sanderson - The impact of incentives for competition and cooperation on the behaviour of health care organisations: a case study of the planning and provision of diabetes services in the English NHS

Stefanie Tan - The impact of financial incentives on non profit organisations: a case study of social investment bonds in England

Luke Harman - Agricultural and health input subsidies In development: Inter-sectoral lessons from theory and practice,

Antonia Dingle -  Equity of access to reproductive and maternal health services in Cambodia:  Status, measures, determinants and interventions     

Sonalini Khetrapal - Public-private partnerships in India: the case of a national health insurance scheme

Rym Ghouma - Determinants of doctors’ behaviour and quality of care in Tunisia

Pitchaya Indravudh - Introducing and scaling up HIV self testing in Malawi, Zimbabwe and Zambia   

Theodora Ogharanduku - Effects of user fee removal on quality of care.

Deborah Pedrazzoli. The economic burden of TB and the mitigation effect of social protection: a population-based study in Ghana.

Rishma Maini. Health workers in the Democratic Republic of Congo: an exploration of their motivation, incentives, and the effects of an intervention to improve their remuneration by government.

Ahmed Salehi.- An Economic Evaluation of Results-Based Financing Intervention within the Basic Package of Health Services in Afghanistan.

Peter Binyaruka - Effect of Pay for Performance on supply side inequity in Tanzania.

Inthira Yamabhai -  Heath and economic implications of patent protection for pharmaceuticals: A case-study of Thailand

Gillian Stynes - The role of professional education in pharmacist migration from sub-saharan Africa

Suriwan Thaiprayoon -  Health and trade negotiations: a case study of the Thai Ministry of Public Health

Thinakorn Noree - The impact of medical tourism on the domestic economy and health system: a case study of Thailand

Judith Kabujuluzi - Macroeconomic implications of health sector reforms: a computable general equilibrium analysis of Uganda

Noemia Teixeira-Filha -  Cost-effectiveness of a protocol for TB diagnosis in people living with HIV: An economic study alongside a pragmatic trial in Brazil.

Li Sun – Economics of breast cancer in China

LSHTM @ IHEA
LSHTM @ IHEA

The 12th World Congress in Health Economics (iHEA 2017) will be held in Boston from 8-11 July 2017.

The theme this year is Revolutions in the Economics of Health Systems.

Many health economists from the London School of Hygiene & Tropical Medicine will present cutting edge research at iHEA2017. Our presentations will span a wide range of topics including a new approach to economic evaluation, an investigation into the impact of soda taxes and stated preferences for preventing HIV, we are excited to share lessons for policy makers and new methodological techniques.

Meet the dynamic team of health economists working at LSHTM and learn more about the area of work they will present at the conference. View our video playlist.

Playlist iHEA

IHEA conference blogs

Pre-conference meeting of the international academy of health preference research (IAHPR) - Matthew Quaife

The IAHPR (international academy of health preference research) is a relatively new network of preference researchers working in health, formed in 2014. It is mostly made up of people using discrete choice experiments (DCEs) to answer health questions, and meets twice a year – often coinciding with IHEA, EuHEA or health services conferences.

Meetings are normally fairly techy, and often have heavyweights in the DCE world presenting their work. I found the meeting in Boston particularly interesting because of the range of topics presented – from the feasibility of eliciting preferences from participants with dementia in the USA, to preferences for HIV testing in China – alongside a range of methodological validity and health state valuation studies which are the more traditional domain of DCE researchers in health.

One of my favourite papers was presented by John Bridges of Johns Hopkins University, who carried out a choice experiment about choice experiments (!) to understand who cares about taking part in surveys, and who just does it for the money. His results are reassuring or worrying – depending on your priors about DCEs – finding that three quarters of people report that they care about studies which are valid, relevant and unbiased. The other quarter of respondents are in it for the money – caring only about the financial incentive given for taking part, and the time it takes to complete.

There was a lot of discussion about what this means – should we just ignore people whose answers that we don’t like (or that don’t fit with our models of behaviour), or include them and account for this variation in different ways (latent class models for example). Fern Terris-Prestholt of LSHTM noted that people make bad decisions in real life, so why wouldn’t they in a DCE!? It was generally noted that we have been looking at the validity of stated preference exercises for the last ten years, and haven’t made a great deal of progress, but it seems like conversations are starting again and it will be an important area to focus on in the future.

If you have a poster accepted to the programme, as I did, you are asked to give an “elevator talk” for three minutes to summarise your study. This was really useful for getting people to come and have a look at your poster afterwards, and although the 3 minute limit was a challenge it really makes you think about what is important (and interesting!) from your findings. 

The IAHPR is still a growing organisation, and is really good at encouraging student/early-career researchers. It is quite techy, but good exposure for us at LSHTM who are working on fairly applied choice modelling projects to make sure that our methods are good enough.

Reference Case for Global Health Costing – Sedona Sweeney

I went to a session in the morning concerning the Reference Case for Global Health Costing, developed by the Global Health Cost Consortium (GHCC).  GHCC members presented the current quality of reporting for costing studies and the current situation on availability of guidance for costing.  They then presented the reference case, including some of the challenges they had encountered in its development. The discussion surrounding the reference case was very interesting, and brought forward ideas about how the reference case can be used, what some of its limitations might be, and what some of the next steps are in terms of realising the potential that the Reference Case holds. 

Charles Burungi from UNAIDS acknowledged that whilst costing studies are the bedrock on which most economic evaluations sit, the guidance to ensure that costing studies are high quality is still really lacking.  He told a story of a recent review they undertook as part of a financial planning exercise within UNAIDS, and said that for most of the 53 studies they ‘weren’t sure what to believe’ in terms of methods, and as a result their costing effort ended up ‘mixing apples and oranges’, with much of the data they were attempting to use completely incomparable.  His hope, he said, was that if people start using the Reference Case, users of cost data such as UNAIDS will end up with data that is much more comparable, applicable, and therefore useful for global health planning.

Bruce Larson also congratulated the effort, but expressed a concern about the audience of the reference case.  He acknowledged that the process of developing the reference case must have been “like herding cats”, to strike the balance between economists and non-economists, and between people with ample experience and people with no experience in collecting cost data.  He noted that the current wording of the reference case may be either too inaccessible or too basic depending on the audience, where “those who understand it don’t need it, and those who need it don’t understand it”. 

GHCC members acknowledged that pitching the reference case properly to all potential users is a challenge, and stressed that this is a ‘living document’.  They invited audience members to contribute to the process by feeding back to GHCC or engaging on the discussion board provided on the GHCC website.  They also discussed potential dissemination avenues – noting that important audiences include not only current producers of cost data but also funders, journal editors, and users of cost data.

Reproductive health, sexually transmitted infections and HIV – Jason Ong

What an amazing smorgasbord of topics today!  Frankly speaking, I was overwhelmed by the range of talks available and trying to summarize the day is quite an impossible task.  There were talks from the spectrum of the theoretical (e.g. accurately defining country specific DALY thresholds) to a whole range of practicalities of economic evaluations influencing health policies (dental care, cancer screening, etc…).  I chose to walk the route of identifying presentations related to reproductive health/sexually transmitted infections/HIV as that is my special interest.  Here are some highlights:

  • A session by Elaine Hill from the University of Rochester looked at the impact of Catholic owned hospitals in the US and showed that tubal ligation rates dropped by 29% when changing to Catholic ownership (as the Catholic directive is that tubal ligation is not permitted) within a year of transfer of ownership.  Her work demonstrated how quickly the range of health services may change depending on the ownership of health providers.  This is particularly pertinent for privatized health systems. 
  • An important presentation from Laura Di Giorgio (PATH, USA) was in examining the cost-effectiveness of subcutaneous DMPA (depo-medroxyprogesterone acetate, a long acting reversible contraceptive) compared to intramuscular DMPA in Uganda. This research is important because 214 million women in low and middle income countries still have an unmet need for modern contraceptives.  Key barriers may be long and costly travel distances and shortages of trained healthcare staff.  In Uganda, intramuscular DMPA is the most commonly used contraceptive method but discontinuation rates are high.  Laura reported her preliminary analysis which showed the unit costs of subcutaneous DMPA was of similar price to intramuscular DMPA, but the effectiveness was higher, thereby making subcutaneous DMPA more cost-effective.  The main advantage of subcutaneous DMPA is that it can be self-administered by patients at home (i.e. no need for 3 monthly visits to a health professional). 
  • HIV modelling work from Robyn Stuart (University of Copenhagen) and Gesine Meyer-Rath (University of the Witwatersrand, South Africa) demonstrated how models can be used to help governments optimize their HIV budgets to the suite of available HIV prevention programs. Whilst the models ‘under the hood’ are impressive, there remains many parameters that are assumed rather than based on robust research.  Therefore, caution must be exercised in the interpretation of these model results.  It highlighted for me the important work at LSHTM where researchers are spending enormous efforts to accurately estimate cost functions for various intervention programs.  These are difficult to calculate but are so critical for informing these epidemiological models.  As they say, rubbish in, rubbish out.  More information on the Optima model can be found at http://www.optimamodel.com/

Whilst my last highlight of the day is not to do with sexual health, I was particularly intrigued by the presentation by Scott Rozelle (Stanford University USA) on the use of mystery patients to evaluate the quality of primary care in China.  Much work in health economics have emphasized how important establishing a strong primary health care system is.  And yet, primary care doctors in China still suffer from low social status, patient mistrust, and violent conflicts with patients are not uncommon.

Prof Rozelle and his team sent standardized patients to 439 randomized facilities in China with case scripts i.e. ‘fake’ patients who pretended to have diarrhea, tuberculosis, etc… to evaluate the quality of these primary care doctors.  In short, the quality is not great and his conclusion was that ‘your probability of being hurt is higher than being helped if you get sick in rural China’.  A damning but sobering report card.

The challenge now is to work with Chinese authorities in strengthening their primary care system, particularly in the rural areas. 

What do policy-makers want to know? Lessons learned on the use of economic evaluation evidence for priority-setting and programming in low and middle-income countries - Michelle Remme

In global health, there is a growing demand for evidence-based planning and value-for-money, both among global and national decision-makers, as well as a growing body of economic evaluations. However, there is overall less of an institutional approach for the consideration of this evidence in decisions around designing essential health benefit packages, or investing in new interventions with health impact. This is not to say that economic evaluation is not being used as a tool to guide decisions in these settings. Rather, economic evaluation data is feeding into national policies and programming, but answering different questions. This LSHTM organised session at iHEA 2017, chaired by Virginia Wiseman, aimed to highlight the needs and use of economic evaluation by policy-makers in LMICs and provide insights from Tanzania and Colombia into how analysts are adapting to these needs and questions.

Key messages:

Lesson 1
Although economists and donors tend to focus on cost-effectiveness, policy-makers may want to use cost data to understand unintended programme effects and provide practice guidance for programme optimisation. This was the case in Jo Borghi’s presentation on the evaluation of a pay-for-performance (P4P) scheme in Tanzania, which revealed a high burden of P4P administration on staff time that in turn reduced outpatient visits, particularly at the lower level facilities. Based on this evidence, the national roll-out of the scheme included outpatient visits as an output indicator and integrated verification within routine supportive supervision.

Lesson 2
Once there is evidence that a health technology or intervention is effective, policy-makers will often want to know whether they can afford to roll it out and what its budget impact will be. Leonardo Arregoces showed how health decision-makers in Colombia require budget impact analysis for decisions around coverage, and he presented a novel approach to dealing and reporting uncertainty in these analyses, with the example of parameterising predicted uptake of cancer drugs.

Lesson 3
There are different types of policy-makers who make decisions on health or health-producing investments, each with a different set of objectives and constraints. In my presentation I discussed the case of cross-sectoral co-financing for HIV in Tanzania, and brought in the perspectives of policy-makers across sectors on their resource allocation processes and criteria. This highlighted a disconnect between the conventional decision frames used in economic evaluation and the reality of decision-making, whereby government payers and donors are often constrained by additional institutional boundaries and not only their budgets.

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During a lively discussion, inputs were also solicited from the audience about other innovative work in this area. Several participants reflected on existing cross-sectoral planning and coordination processes and the areas with more potential for co-financing, such as nutrition and antimicrobial resistance. Summing up the discussion, Tommy Wilkinson (from iDSI) highlighted the need for different economic arguments to be made for different payers and levels of government. While analysts are constantly required to present short messages to policy-makers (preferably in the form of single summary measures) with limited room to consider uncertainty, they will need to find innovative ways to tailor arguments that acknowledge complexity and uncertainty.

In the absence of HTA bodies and limited country-specific cost and effectiveness data, it is likely that the decision space and evidence needs in many low and middle-income countries will be different from those seen in high-income countries. With severely constrained health budgets, significant non-budget constraints, multiple payers, and limited room for incremental investment, decisions that stand to benefit from economic evaluation may be more centred around optimal programme design, and budget impact, among others. It may be important to rethink how health economic evaluation can best meet these needs, while still ensuring that the concept of opportunity costs of investments is central to the priority-setting dialogue, and that the link between investment and disinvestment is explicit during the priority-setting process.

How do fiscal (and other) policies affect nutrition and nutrition-related health? - Laura Cornelsen

With Boston meeting behind, I am impressed with how much interesting work is being done across the globe on understanding how fiscal (and other) policies are affecting nutrition and nutrition-related health. In particular as taxes on sugary drinks are gaining a lot of traction, new evidence on how these might work is crucial for proper evaluation of such policies.

Some of the highlights of the included work presented by Eleanora Fischera (University of Bath) on analysing associations between front-of-pack labelling and supply/demand of retailers own-branded foods. Her findings indicated that nutritional quality of foods may improve when FOP labels are introduced and raises questions on what are the mechanisms (reformulation?). Andrew Mirelman (University of York) presented work showing that an excise tax on sugary drinks in Chile was associated with a reduction in the consumption of these products.

Larissa Cardoso (Universidade Federal de Goias) and Andres I Vecino-Ortiz (Universidad Javersiana; Johns Hopkins University) presented on analyses of demand for sugary drinks in Brazil and Colombia, respectively. Though neither of the countries currently have specific taxes on sugary drinks, the presentations showed the likely effects on the demand as well as estimates on overweight and obesity prevalence in Columbia.

Our own session “Do, and how do soda taxes work”, also focused on the fiscal policies. Richard Smith (LSHTM) presented an analysis of associations between rising sugary drinks prices and alcohol demand, highlighting the need for fiscal policies to consider such spillover effects.  I presented preliminary findings on a discrete choice experiment we are conducting to disentangle the effect of framing and signalling from price effects when taxes are introduced. Judit Val Castello (Universidad Pompeu Fabra) showed preliminary findings from an impact evaluation of a tax on sugary drinks in Catalonia, Spain that was implemented only May 2017. These were quite fascinating as it’s a first country where pass-through of the tax is mandatory. Finally, John Cawley (Cornell University) showed interesting results on studies of pass-through rates of localised soda taxes in the US (Berkeley and Philadelphia). The session finished with a discussion on how do we measure the success of soda taxes and the need for broadening the scope of evaluations to not only understand consumption and health effects but also effects on the wider economy from different and quite complex consumption and spillover effects.