In this series, you learned why and how to do CEAs. You learned about DALYs and QALYs,
In this series, you learned why and how to do CEAs. You learned about DALYs and QALYs,

how to present CEA results, the role for sensitivity analyses to quantify uncertainty, and how
how to present CEA results, the role for sensitivity analyses to quantify uncertainty, and how

to deal with temporal issues.
to deal with temporal issues.

In this segment, we discuss how to organize a CEA for a research proposal. Specifically,
In this segment, we discuss how to organize a CEA for a research proposal. Specifically,

we'll show you research questions and basic methods for each.
we'll show you research questions and basic methods for each.

There are different terminologies used to present research plans. In this example, we're
There are different terminologies used to present research plans. In this example, we're

using the research questions approach.
using the research questions approach.

The topic is the cost-effectiveness of a mobile camp for adult male circumcision in rural
The topic is the cost-effectiveness of a mobile camp for adult male circumcision in rural

Zambia. Notice that we've divided the CEA inquiry into three research questions, focused
Zambia. Notice that we've divided the CEA inquiry into three research questions, focused

on: costs, health effects, and cost-effectiveness.
on: costs, health effects, and cost-effectiveness.

The first RQ is, What is the cost of delivering adult male circumcision per 100 clients circumcised
The first RQ is, What is the cost of delivering adult male circumcision per 100 clients circumcised

in this mobile camp, compared with no circumcision? The second RQ is, How many HIV infections
in this mobile camp, compared with no circumcision? The second RQ is, How many HIV infections

and disability- adjusted life years, or DALYs would be averted, per hundred individuals
and disability- adjusted life years, or DALYs would be averted, per hundred individuals

circumcised in this population over 20 years? Again, the comparison is no circumcision.
circumcised in this population over 20 years? Again, the comparison is no circumcision.

The third RQ is, What is the incremental cost per DALY averted in the population, versus
The third RQ is, What is the incremental cost per DALY averted in the population, versus

no circumcision?
no circumcision?

These are the key research questions. We start with cost, which is easiest to understand,
These are the key research questions. We start with cost, which is easiest to understand,

even for non-economists. We then proceed to health effects, which in this instance is
even for non-economists. We then proceed to health effects, which in this instance is

HIV infections and DALYs. Health effects are a little harder to understand, especially
HIV infections and DALYs. Health effects are a little harder to understand, especially

the DALYs. Finally we combine the cost and health effects to arrive at the incremental
the DALYs. Finally we combine the cost and health effects to arrive at the incremental

cost effectiveness ratio. Assembling the ICER is the most complex, and the last step in
cost effectiveness ratio. Assembling the ICER is the most complex, and the last step in

the process.
the process.

Next let's think about methods for each of these research questions. Here we have RQ
Next let's think about methods for each of these research questions. Here we have RQ

1, on the cost of delivering circumcision services, in more detail. The brief methods
1, on the cost of delivering circumcision services, in more detail. The brief methods

paragraph in blue is not standard in a grant application, instead it's for our purposes
paragraph in blue is not standard in a grant application, instead it's for our purposes

to understand broadly [1]how we might proceed.
to understand broadly [1]how we might proceed.

We would probably start by reviewing financial and service records from an operating program.
We would probably start by reviewing financial and service records from an operating program.

Typically that's done for a 12- month period, because we're in the habit of financing programs,
Typically that's done for a 12- month period, because we're in the habit of financing programs,

making reports, and so on, for fiscal years. We quantify the resources used, and the associated
making reports, and so on, for fiscal years. We quantify the resources used, and the associated

costs, as well as clients served.
costs, as well as clients served.

Let me explain the phrase resources used and associated costs. It's really important in
Let me explain the phrase resources used and associated costs. It's really important in

doing cost studies that we not just take the number that shows up at the bottom of the
doing cost studies that we not just take the number that shows up at the bottom of the

budget or expenditures page, and say, "Well, we spent 1 million dollars." We need to know
budget or expenditures page, and say, "Well, we spent 1 million dollars." We need to know

what program inputs go into that cost amount how many circumcision surgical kits, how many
what program inputs go into that cost amount how many circumcision surgical kits, how many

hours of surgeon and nurse time, how much building space, etc. This detail provides
hours of surgeon and nurse time, how much building space, etc. This detail provides

useful information and also validates the cost estimates. Thus, we always specify and
useful information and also validates the cost estimates. Thus, we always specify and

quantify the resources used.
quantify the resources used.

Another reason for this approach is that some resources may not be assigned a cost. Maybe
Another reason for this approach is that some resources may not be assigned a cost. Maybe

the surgeons were borrowed from the Ministry of Health, which paid their salaries. The
the surgeons were borrowed from the Ministry of Health, which paid their salaries. The

program budget omits these salaries. Because we're interested in societal cost what it
program budget omits these salaries. Because we're interested in societal cost what it

really costs to do this we want to include the value of all contributed resources. Similarly,
really costs to do this we want to include the value of all contributed resources. Similarly,

maybe the circumcision kit was donated by an international agency. If we use just the
maybe the circumcision kit was donated by an international agency. If we use just the

bottom line dollar number for the budget, we may overlook that. By going through a listing
bottom line dollar number for the budget, we may overlook that. By going through a listing

of personnel, supplies, equipment, and so on, we can be very clear about what resources
of personnel, supplies, equipment, and so on, we can be very clear about what resources

are required to implement this program, and make sure we're including all significant
are required to implement this program, and make sure we're including all significant

costs.
costs.

We quantify clients served because we want to understand the cost per client served,
We quantify clients served because we want to understand the cost per client served,

in this example per surgery completed. We calculate unit cost as total cost divided
in this example per surgery completed. We calculate unit cost as total cost divided

by clients served. This is the measure that best characterizes the cost of the intervention.
by clients served. This is the measure that best characterizes the cost of the intervention.

The second RQ is how many HIV infections and disability-adjusted life years will be averted.
The second RQ is how many HIV infections and disability-adjusted life years will be averted.

This assessment usually builds on empirically observed effects, such as HIV incidence in
This assessment usually builds on empirically observed effects, such as HIV incidence in

men who receive circumcisions. Studies show that male circumcision reduces HIV incidence
men who receive circumcisions. Studies show that male circumcision reduces HIV incidence

by 50% or so. However, we need to go further analytically. We can build a decision analysis
by 50% or so. However, we need to go further analytically. We can build a decision analysis

model. How many total infections are prevented depends on the HIV acquisition risk in a specific
model. How many total infections are prevented depends on the HIV acquisition risk in a specific

population 50% of a small risk is less than 50% of a large risk. This has to be specified.
population 50% of a small risk is less than 50% of a large risk. This has to be specified.

To quantify averted infections in the future requires a projection of HIV risk over time.
To quantify averted infections in the future requires a projection of HIV risk over time.

Translating into DALYs requires assigning a DALY burden to each HIV infection. This
Translating into DALYs requires assigning a DALY burden to each HIV infection. This

can be calculated, or taken from past studies.
can be calculated, or taken from past studies.

The 3rd RQ asks What is the incremental cost per DALY averted? This is the ICER. The numerator
The 3rd RQ asks What is the incremental cost per DALY averted? This is the ICER. The numerator

is net costs program costs adjusted for reductions in medical costs due to averted HIV infections.
is net costs program costs adjusted for reductions in medical costs due to averted HIV infections.

The denominator is DALYs averted.
The denominator is DALYs averted.

The cost-effectiveness ratio is the most complicated outcome conceptually, since it's a ratio of
The cost-effectiveness ratio is the most complicated outcome conceptually, since it's a ratio of

two simpler outcomes. However, it's easy to calculate once you know the net costs and
two simpler outcomes. However, it's easy to calculate once you know the net costs and

health effects. This RQ will also include the sensitivity analyses.
health effects. This RQ will also include the sensitivity analyses.

I hope this has given you a sense of how to conceptualize and approach CEA research questions.
I hope this has given you a sense of how to conceptualize and approach CEA research questions.

In the next segment, we translate this CEA topic into a decision tree that guides the
In the next segment, we translate this CEA topic into a decision tree that guides the

analysis.
analysis.

[1]I have a version that provides more detail, in Word, could include it as another slide
[1]I have a version that provides more detail, in Word, could include it as another slide

if we want to get into a little more detail.
if we want to get into a little more detail.