Economic evaluation and decision making for quality improvement in complex community health systems

Kumar, Meghan Bruce ORCID: 0000-0002-4713-8328 (2020) Economic evaluation and decision making for quality improvement in complex community health systems. PhD thesis, University of Liverpool.

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Abstract

Community health is a fundamental part of many healthcare systems and is widely advocated as a means to increase access to and coverage of health services, yet the quality of care in large-scale community health programmes is mixed. Quality improvement (QI) approaches are now being tested in community settings and there is limited evidence that integrating QI approaches can underpin success of community programmes. However, how best to measure that success and the cost and value thereof to the different decision makers in complex community health systems is not yet known. This thesis provides the first economic evaluation of QI in community health systems, linking this to an exploration of decision making that includes an assessment of how economic evidence like this is used. Using an interdisciplinary mixed methods approach, I worked across several countries (Ethiopia, Kenya, Indonesia, Malawi, and Mozambique) to provide evidence to inform policy decisions. I first examined the costs of a QI intervention in all five countries and then used those data as the foundation of a cost-effectiveness decision tree model for the intervention in Kenya. Through interviews with national and global decision makers, I qualitatively examined the use and value of evidence in community health programmes. I present the results in a series of three related publications, linking them together with a literature review and discussion that show how these studies build upon each other and what they add to the existing evidence base. This thesis shows that QI for community health is a good investment contingent on an existing cadre of community health workers. The budget impact of the QI intervention is low (less than 0.53% of general government health expenditure) and the modelled cost-effectiveness yields an incremental cost-effectiveness ratio of US$249.43 per disability-adjusted life year. The absolute costs are highly dependent on context and the intensity of the intervention. Qualitative findings indicate that decision makers are not satisfied with existing evidence and have limited capacity to assess its relevance for their settings and perspectives. As a result, power and politics fill this evidence gap. Evidence must be at the heart of decisions in funding universal health coverage for them to be sustainable. To achieve this, the global community must strengthen the relevance of evidence and build the capacity of decision makers to understand and apply it. For a complex system, useful evaluation should describe context and mechanism of an intervention, estimate the effect size on both programmatic and health impacts and accurately reflect the opportunity costs.

Item Type:	Thesis (PhD)
Uncontrolled Keywords:	Community Health, Economic evaluation, Priority setting, Quality improvement
Divisions:	Faculty of Health and Life Sciences
Depositing User:	Symplectic Admin
Date Deposited:	15 Jan 2021 16:49
Last Modified:	18 Jan 2023 23:34
DOI:	10.17638/03100599
Supervisors:	Taegtmeyer, Miriam Madan, Jason Barasa, Edwine
URI:	https://livrepository.liverpool.ac.uk/id/eprint/3100599