Health Impact Metrics Dr. Nirali Chakraborty Population Services International Social Franchise Metrics Working Group +

+ Outline Rationale for modeling health impact Description of metrics Input and output Interpreting the data Using the data Impact Calculator Page 2

+ Comparing impact Page 3

+ Equivalent comparisons Page 4

+ Health Impact: What Any metric which measures the population level effect of the intervention(s) – Reduction in Maternal/Child/Neonatal Mortality – Reduction in unmet need for FP – Couple Years of Protection (CYPs) provided – DALYs averted Page 5

+ Health Impact: What Any metric which measures the population level effect of the intervention(s) – Reduction in Maternal/Child/Neonatal Mortality – Reduction in unmet need for FP – Couple Years of Protection (CYPs) provided – DALYs averted Page 6

+ Health Impact: Why? From your perspective, why is it – Important – Relevant – Interesting – Necessary To calculate health impact? Pair and share! Page 7

+ Franchise decision making Page 8

History – How did we arrive at the DALY averted? Page 9

What is a DALY? A year of healthy life lost to death or illness Disability-Adjusted Life Year 10

The DALY allows us make comparisons across populations and health conditions. When we sum up all the DALYs for a given country, that’s their burden of disease. When we sum up all the countries, that’s the Global Burden of Disease. DALYs from X disease DALYs from Y disease DALYs from X disease DALYs from Y disease DALYs from X disease DALYs from Y disease DALYs in Country A Global Burden of Disease DALYs in Country B DALYs in Country C

+ Evolution of PSI’s metrics Couple Years of Protection (CYPs): allows comparison across FP interventions of different duration Person-Years of Protection (PYPs): converts sales figures into a single metric to aggregate interventions for different health areas and different durations (does not estimate health impact) DALYs Averted: summary measure of population health which captures morbidity and mortality – allows aggregation and comparison across health area and country Page 12 CYPsPYPs DALYs Averted

ACTs distributed IUDs inserted Projected Impact Condoms sold PSI uses modeled projections of health impact to target and track progress Page 13 We measure outputs, like the number of IUDs inserted or ACTs distributed We use mathematical models to project impact based on those outputs

To calculate the contribution of years lived with disability to the total DALYs, the time spent with a particular illness or condition is multiplied by a disability weight. We have adopted the disability weights used by GBD Disability weights

Inputs Outputs Products and services DALYs averted

+ Calculation and Data Needs Most programs maintain records of how many health services and commodities are provided in a given year. These statistics can be multiplied by a country-specific coefficient for each item. Each coefficient is based on assumptions of the health benefits provided by a particular health service or commodity within a given country.

2 million antibiotics distributed x.5 DALYs averted coefficient for pneumonia treatment in that country = 1 million DALYs averted by pneumonia treatment Calculating DALYs averted

+ What do DALYs averted tell us? One DALY averted means that the services provided by a franchise resulted in a year of healthy life saved. Unlike Couple Years of Protection (CYPs), DALYs averted take into account the wide range of services that are now offered by social franchise programs.

Inputs Outputs Products and services DALYs averted

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Estimated Family Planning Users Pregnancies averted Births averted Maternal deaths averted DALYs averted (maternal morbidity & mortality, child mortality) Child deaths averted (Due to improved birth spacing) Family planning services/products provided Apply continuation and mortality rates to past LAPM clients Count backwards Products provided Units needed per year Long acting & Permanent methods Short-term methods PAGE 21

+ Calculating DALYs averted Children at risk of malaria

+ Calculating DALYs averted Children at risk of malaria Children who will get malaria without a preventive intervention (LLINs)

+ Calculating DALYs averted Children at risk of malaria Children who will get malaria after LLIN scale up Children who will get malaria without a preventive intervention (LLINs)

+ Calculating DALYs averted Children at risk of malaria Children who will get malaria without a preventive intervention (LLINs) Children who will get malaria after LLIN scale up Malaria averted

+ Calculating DALYs averted Children at risk of malaria Children who will get malaria without a preventive intervention (LLINs) Children who will get malaria after LLIN scale up Malaria averted = Impact per net Number of nets Malaria averted

So what? Page 27

+ Uses of DALYs Averted at PSI Primary internal performance indicator – focuses attention on health impact Used for setting targets at project and country level Can be used to inform decisions about trade- offs between interventions Page 28

+ page 29

PSI Impact Calculator Project impact by country Learn about PSI’s models Prepare bid proposals Inform targets Share your analysisSee 2013 impact Impactcalculator.psi.org 30

PSI Impact Calculator Project impact by country Learn about PSI’s models Prepare bid proposals Inform targets Share your analysisSee 2013 impact Impactcalculator.psi.org 31

Project impact by country Impactcalculator.psi.org To start, type impactcalculator.psi.org directly into your browser. This will take you to the landing page Questions? From the landing page, simply click “Project Impact by Country” And choose your country of interest from the drop down menu to get started 32

Project impact by country Impactcalculator.psi.org Questions? To start, click the box next to the intervention(s) you are interested in. You can also activate or deactivate ALL of the interventions in a health area Once activated, simply enter your future sales or distribution numbers. 33

Project impact by country Impactcalculator.psi.org Questions? Let’s take an example… If PSI inserted 20,000 contraceptive implants (3-year) in the Dominican Republic in 2014… We would avert 3,681 DALYs 46 deaths, and 9,298 unintended pregnancies We would also provide 50,000 CYPs 34

Project impact by country Impactcalculator.psi.org Questions? A note on projecting impact for condoms: Condoms have impact across two health areas: HIV & TB, and Reproductive Health. Projected impact is displayed in both health areas Within each health area the additional impact figures from the alternate heath area are also displayed. The aggregate impact from both health areas is displayed in the right margin. Other impact indicators, such as new infections averted, are displayed in the Excel export. 35

Project impact by country Impactcalculator.psi.org Questions? So, if PSI distributed 20,000,000 condoms in the Dominican Republic in 2014… We would avert41,874 DALYs 146 deaths 584 new HIV infections and 29,443 unintended pregnancies We would also provide 166,667 CYPs 36

Project impact by country Impactcalculator.psi.org Questions? ‘In Country interventions’ and ‘Additional PSI interventions’ The interventions that display automatically are ‘In Country Interventions’. These are all interventions reported by the country for 2013 or ‘Additional PSI Interventions’ can be displayed and will appear below. These are all interventions for which we have a DALY coefficient in this country. Simply click the ‘plus sign’ to expand and scroll down. 37

PSI Impact Calculator Project impact by country Learn about PSI’s models Prepare bid proposals Inform targets Share your analysisSee 2013 impact Impactcalculator.psi.org 38

See 2013 Impact Impactcalculator.psi.org Questions? Using our previous example, you can access 2013 data in two ways 1. Click 2013 impact under any intervention. Last year’s data will display automatically. 2. Click Total 2013 data in the right margin to download an excel file with last year’s data. 39

PSI Impact Calculator Project impact by country Learn about PSI’s models Prepare bid proposals Inform targets Share your analysisSee 2013 impact Impactcalculator.psi.org 40

Learn about PSI’s models Impactcalculator.psi.org Questions? Intervention specific model overviews provide a quick glance at how PSI models impact. Access them in one of two ways. 1. Click ‘Learn about PSI’s models’ from the landing page and select your intervention of interest 2. Click the name of any intervention from inside the calculator and the model overview will display 41

Learn about PSI’s models Impactcalculator.psi.org Questions? Here’s one example of a model overview Scroll down for more details 42

Learn about PSI’s models Impactcalculator.psi.org Questions? Include impact estimates confidently in new business proposals. Each model overview contains an example ‘Statement of Modeled Results’. Use this to tailor your message based on your own impact projections. 43

PSI Impact Calculator Project impact by country Learn about PSI’s models Prepare bid proposals Inform targets Share your analysisSee 2013 impact Impactcalculator.psi.org 44

Share your analysis Impactcalculator.psi.org Questions? Sharing is easy Display only the interventions you are interested in. Share by exporting your analysis to excel or simply hitting print 45

Calculating DALYs averted Children who will get malaria without a preventive intervention (LLINs) 46

Calculating DALYs averted Children who will get malaria after LLIN scale up Malaria averted Children who will get malaria without a preventive intervention (LLINs) 47

Calculating DALYs averted Children who will get malaria after LLIN scale up Malaria averted = Impact per net Number of nets Malaria averted Children who will get malaria without a preventive intervention (LLINs) 48

+ Couple Years of Protection USAID championed measurement method Recently revised to reflect new methods and updates to research Based on efficacy and effectiveness of each contraceptive method Each method has a coefficent, indicating how long a couple is protected per use/package of method.

+ Page 50 MethodCYP per unit Copper-T 380-A IUD 5 year IUD e.g. LNG-IUS 4.6 CYP per IUD inserted 3.3 CYP 3 year implant (e.g. Implanon)2.5 CYP per implant 4 year implant (e.g. Sino-Implant)3.2 CYP per implant 5 year implant (e.g. Jadelle)3.8 CYP per implant Emergency Contraception20 doses per CYP Fertility Awareness Methods1.5 CYP per trained adopter Standard Days Method1.5 CYP per trained adopter LAM4 active users per CYP Sterilization10 (Global) 13 (India, Nepal, Bangladesh) Oral Contraceptives15 cycles per CYP Condoms (Male and Female)120 units per CYP Vaginal Foaming Tablets120 units per CYP Depo Provera (DMPA) Injectable4 doses per CYP Noristerat (NET-En) Injectable6 doses per CYP Cyclofem Monthly Injectable13 doses per CYP Monthly Vaginal Ring/Patch15 units per CYP

Questions?