Antares
Health Priorities Matrix
Harnessing Private Enterprise
for Public Health
Briefing Note
August 2011
Antares is a collaboration between the
Harvard School of Public Health and Harvard Business School
For more information, please contact:
David Bloom [email protected]
Michael Chu
[email protected]
Alix Smullin [email protected]
Copyright © 2012 The President and Fellows of Harvard College
Overview
The Antares Health Priorities Matrix is a novel and practical approach to illuminating and
improving priority setting in global health.
When making choices regarding how to direct resources, health decisionmakers face an array of considerations that often are complicated and confusing. Two primary questions emerge.
• What are the most important health issues?
• How do we choose among alternative interventions that address those issues?
The Antares Matrix is a rational, transparent, evidence-based method for ranking health problems in different
settings in terms of their importance. Its purpose is to support strategic decision making with respect to the
determination of health priorities.
Antares Health Priorities Matrix
Financial
E ects
Scale
Health condition
Equity
Antares
Matrix Users
Spillover
E ects
Health Preference
Selection Tool
Malaria
2
HIV/AIDS
3
Tuberculosis
AMRO
4
Diabetes
EMRO
5
IHD
EURO
6
Road
Tra
SEARO
7
COPD
WPRO
8
MAT/PER
9
CER/VAS
AFRO
weighting
CostE ectiveness
1
Custom Health
Preference Profiles
Ranking Matrix
c
Ranked Health
Conditions
The Antares Matrix is driven by:
• Customized health preference profiles that reflect the relative importance users attach to key aspects
and implications of different health conditions: Scale of Disease, Household Financial Effects, Social
Equity, the Cost-Effectiveness of Available Interventions, and Spillover Effects (both health and social).
• A robust database of health metrics and information, aggregated from trusted institutions and
publications.
Global health professionals can employ the Antares methodology during strategic planning to save time,
eliminate confusion, and facilitate meaningful discussion and negotiation.
This note explains the Antares Matrix, our vision for its use, and a plan for realizing that vision.
2
Background and Priority Setting
The field of global health is in the midst of an exciting period of development. Measuring and reporting basic
facts about the deficits and disparities in global health have been important to the field since its inception.
Research emphasis shifted in the past decade to analysis of why deficits and disparities matter – ethically and
morally, politically, socially, economically, and from the standpoint of international law and human rights.
It is well established today that global population health could be much better. One central issue is how to
define the best approaches to making progress in this crucial arena. What actions should governments, nongovernmental organizations (NGOs), and others take to improve the health and overall well being of billions of
people around the world?
Priority setting, explicit and implicit, is a key task that arises constantly in the realm of intervention. When
faced with limited resources and huge demands, how should we decide which problems deserve the most
attention? And once we decide which problems to focus on, which options for intervention deserve the most
resources?
Historically, this question has been answered in a haphazard manner in many settings. Data on which to base
decisions often are absent or ignored. Similarly, up-to-date literature often is overlooked or unavailable to
those who could make use of it. Policymakers may not know how to interpret data and literature, even when
they are available, or how apply them to the situation at hand. Finally, of course, decisions often are made on
the basis of local and short-term political considerations and may be distorted by factors such as corruption
and interest group politics.
Similarly, there is no standard approach to priority setting among global health experts. Ethicists have one
way of setting priorities (principles of right conduct), international law specialists have another (human rights
treaties), and economists (benefit-cost analysis) and political scientists (voting and polling) have yet others.
Each approach has strengths and weaknesses, but there is no dominant method and no recognized “best
practice” for priority setting across the field of global health.
An ideal priority setting framework distinguishes health issues on the basis of their importance. Among the
important issues, those that have readily-available cost-effective interventions are good candidates for
implementation. Those that do not have such interventions are candidates for additional research and
development aimed at devising a conceptual solution or improving the economics of its delivery. The Antares
Matrix was created to help decisionmakers organize and augment their health data and knowledge, and to
shape a coherent strategic plan.
Potential impact of intervention
Large
Cost-effectiveness
of intervention
High
Implement
Low
Research &
Development
Small
Skip...
The strategic opportunity space for global health interventions
3
The Antares Approach to Priority Setting
An effective approach to priority setting must provide decisionmakers with a flexible and
consistent means for making difficult choices while taking into account a range of complex
data, literature, and contextual information.
We created the Antares Health Priorities Matrix to facilitate priority setting in global health. The Antares
Matrix identifies key objectives and takes quantitative account of them in light of available data and research
literature to deliver a ranked set of focal health areas. It offers decisionmakers an evidence-based, contextspecific, and transparent algorithm for distinguishing health problems in terms of their importance.
The first version of the algorithm uses the World Health Organization’s (WHO) six regions of the world as
the objects of analysis. WHO supplies descriptive statistical summaries on health, illness and death for each
region.
Phase One
Which problems
should I focus on?
Phase Two
Which interventions should I choose to address the prioritized problems?
The Antares Matrix
The starting point for the Antares Matrix is a list of health conditions that one might potentially want to
address. Each condition is scored on the basis of data on the size of the problem and literature on its social
and economic consequences. Scores are assigned in relation to each of the following factors:
1. Scale of Disease: how much disability and death is caused by the health condition?
2. Household Financial Effects: to what extent does the condition adversely affect earnings and savings in
low-income households?
3. Social Equity: how disproportionate is the effect of the condition on vulnerable groups like women
and children?
4. Cost-Effectiveness: are relatively cost-effective solutions available? and
5. Spillover Effects: to what extent does the condition trigger other health conditions (e.g., diabetes and
cardiovascular disease) or health or social problems among other people (e.g., infectious disease or
social stigma)?
Users can assign their own weights to each of the aforementioned criteria and to the common health
conditions or they can rely on expert opinion, as we did with the initial version of the Antares Matrix.
(See Appendix A for details of the criteria.)
4
Details: How the Antares Matrix Works
Running the Antares Matrix requires specification of a geographic focus and preference weights (that sum to
100%) associated with the five factors noted above. Health and economic data are also required as input. The
Antares Matrix delivers a geography-specific list of health conditions and diseases as output. The conditions
are ranked in order of their importance, where importance is defined with respect to the five factors and their
corresponding weights.
All that a user must do is to create a health preference profile and select a geographic focus area because the
remaining data is pre-aggregated in the system. They may choose either to use health condition scores
assigned by our panel of experts or to assign their own scores, should they feel strongly about the status of a
health condition in their geographic focus area. The pre-aggregated data in the system is based on a thorough
review of professional literature and health data from reliable sources.
Antares Matrix
Inputs and Output
Professional
Literature
Global Health and
Development Data
Health condition
AFRO
AMRO
Ranking Matrix
EMRO
EURO
SEARO
WPRO
Create or select a Health
Preference
Profile
Choose an Area for
Geographic Focus
Score Health Conditions
(or Use Expert Opinions)
1
Malaria
2
HIV/AIDS
3
Tuberculosis
4
Diabetes
5
Heart Disease
Antares Matrix
Algorithm
Ranked Health
Conditions
Processing
Output
Inputs
Case Study: An employee of a ministry of health, recently assigned as chief of health services for a particular region of
the country, develops a health preference profile that aligns with the priorities of the current minister of health. She uses
the Antares Matrix to support development of a strategic plan for realigning health services in her region to the overall
goals of the ministry.
We used the following expert-derived weights for the five criteria in our initial prototype version of the
Antares Matrix:
Category
Weight
Scale
34
Household Financial Effects
24
Equity
20
Cost-effectiveness
6
Spillover
16
Total
100
5
Details: How the Antares Matrix Works
The Antares Matrix can be applied to different geographies (e.g., from community health departments to
states, countries, regions, and the world). To illustrate its workings, we created the following example. It uses
the weights associated with each of the five factors (and of their subcategories, which appear below), in
conjunction with data from each WHO region, to identify the set of health conditions that deserve the most
attention in each region. This matrix gives an overall view of the criteria and their subcategories, showing
their potential application to WHO’s six regions and to the world as a whole.
Scale
Region
DALYs
Mortality
Household financial
effects
Income
Spending
Equity
SES
(access to
care)
Spillovers
SES
(burden of
disease)
Gender
(burden of
disease)
Costeffective
ness
Medical
Social and
economic
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
GLOBAL
The resulting output is a list of the 10 highest-priority health conditions for each region of the world, and for
the world as a whole. These “Antares Top 10” are the conditions for which effective solutions can have a
major, large-scale impact on health in a given geographic area. We found in the first version that the following
sets of diseases were the priority focal areas for the regions specified:
Rank
AFRO
AMRO
EMRO
EURO
SEARO
WPRO
GLOBAL
1
HIV/AIDS
Diabetes
HIV/AIDS
CER/VAS
HIV/AIDS
HIV/AIDS
HIV/AIDS
2
Malaria
HIV/AIDS
MAT/PER
IHD
MAT/PER
CER/VAS
MAT/PER
3
MAT/PER
CER/VAS
IHD
HIV/AIDS
IHD
Diabetes
Diabetes
4
LRI
U/DEPR
Road traffic
U/DEPR
CER/VAS
U/DEPR
CER/VAS
5
Diabetes
IHD
Diabetes
Diabetes
Diabetes
IHD
IHD
6
CER/VAS
MAT/PER
TB
TB
LRI
Road traffic
U/DEPR
7
TB
Road traffic
CER/VAS
Road Traffic
U/DEPR
COPD
LRI
8
CHD
COPD
U/DEPR
MAT/PER
TB
MAT/PER
TB
9
Diarrhea
TB
COPD
COPD
Road traffic
TB
Malaria
10
Road traffic
Cataracts
Diarrhea
STIs
Cataracts
Vision
Road Traffic
CER/VAS = Cerebrovascular
CHD = Childhood cluster diseases
COPD = Chronic obstructive pulmonary disease
IHD = Ischaemic heart disease
LRI = Lower respiratory infections
MAT/PER = Maternal & perinatal conditions
STIs = Sexually transmitted diseases
TB = Tuberculosis
U/DEPR = Unipolar depression
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Vision for the Future: Version 2.0 and Beyond
The core Antares Matrix concept draws heavily on rich data sources and literature to provide insight into
setting health priorities in a manner that reflects individual preferences. With accessibility as a primary goal of
the project, we currently are developing an interactive version of the Antares Matrix that we hope will enable
us to bring it to a wider audience.
We have four goals for further development of the Antares Matrix:
1. Update the Antares Matrix algorithm with country-specific data
Recent years have seen a marked increase in the amount of country-level data pertaining to health
conditions. The WHO, the World Bank, and a number of other organizations release data on a regular
basis. We plan to incorporate up-to-date country data into the Antares Matrix, so that it provides more
relevant and accurate output.
2. Update the literature and background information
The current focus on global health research has led to important and reputable developments in the
measurement of health conditions and program evaluation methodologies. We are reviewing recent
literature for developments relevant to our goals and will include them, where possible, in the
methodology underlying the algorithm.
3. Develop an interactive web-based version and user manual
The Antares Matrix relies on dynamic and accessible data. We plan to develop a web-based interactive
version of it that permits users to work individually or collaboratively and to publish Antares reports to
external sites. The interactive version will include visual preference graphs, a simple and visually rich
way to identify the differences between preference rankings that drive Antares Matrix output.
4. Demonstrate the use of the Antares Matrix in choosing among particular health interventions
Cost-effectiveness is a well-established tool for ranking health interventions from lowest to highest in
terms of the improvement realized per dollar spent. One limitation of cost-effectiveness analysis is that it
is limited to a single measure of health improvement (e.g., cases averted, deaths averted, DALYs gained).
Interventions that affect multiple measures of health improvement and their spillover effects are ill-suited
to cost-effective analysis. Since health interventions affect the impact score the Antares Matrix associates
with each condition, the Antares Matrix can serve as a multidimensional way to assess cost-effectiveness.
7
Vision for the Future: Engaging Users
One of our goals is to turn the Antares Matrix into an interactive website that is accessible and relevant to
decisionmakers. Users will be able to customize their criteria weighting and make decisions based on countryspecific considerations. Our approach makes that possible and relatively easy.
Users will determine their own weighting for the health preferences criteria. The interactive tool will suggest
health priorities by combining these weights with data from recognized sources such as (but not limited to)
WHO, the World Bank, and health ministries. In the absence of national data, external sources will be used by
default. The website eventually will allow users to input data, too.
Possible users of the website include:
• Ministries of Health
Ministries can weight the criteria according to national or subnational conditions and derive an ordered
“top-10” list of diseases to tackle. This list then can be compared to the diseases on which funds currently
are spent. We aspire to the Antares Matrix becoming a widely-used tool for strategic planning.
• Media and Opposition Parties
The Antares Matrix will help promote healthy and informed public dialogue by facilitating the analysis of
health priorities.
• Philanthropists and Foundations
Philanthropic decisionmakers can use the Antares Matrix to determine the diseases on which they
potentially can have the largest impact. Such users also could rank health conditions that interest them,
along with their social preferences, to receive suggestions of geographic areas that match their mission.
• Graduate and Undergraduate Courses
Interest in global health is growing rapidly throughout the world, as evidenced by the rising number of
global health programs, concentrations, and courses in graduate schools of public health, public policy,
and business, schools of medicine, and in undergraduate programs. The Antares Matrix can be an extremely
useful pedagogical tool to support study of health intervention priority-setting in these curricula.
Case Study: A Board of Directors member at a non-profit foundation that supports schoolgirls in India creates a preference
profile to fit the mission of the organization. She uses the output of the Antares Matrix to improve her understanding of
which health problems could be addressed in schools to improve the health, attendance, and performance of vulnerable
girls. She presents her findings to the Board and uses them to guide a discussion of programmatic development.
8
Version 2.0: Developing Visual Preference Profiles
We are developing a prototype system for visual preference profiles, loosely based on the shape of a star –
Antares is in fact the name of the 15th brightest star in the nighttime sky.
Our goal is the creation of a system that is easy to use, easy to recognize, and accepted as a
standard for health preference mapping.
Each arm of the Antares star represents one of the five criteria represented in preferences selection. The sum
total of all points assigned during weighting must equal 100. The arms of the star, therefore, represent the
relative number of points assigned to each criterion.
5
5
4
4
3
3
2
2
1
1
Early iterations of the visual health preference profiles
In the series of images below, if a user gives equal weight to all five criteria, we would have the image on the
left. If a user weights the criteria differently, using the weights in the table, we would see an image such as
the one on the right, with the arms of the star displayed in lengths proportional to the criterion weight.
Category
Even Weighting
(the Antares logo)
Weight
Scale
34
Household Financial Effects
24
Equity
20
Cost-effectiveness
6
Spillover
16
Total
100
Ranked Weighting
The goal is that users, with time, will learn to glance at a preference profile and quickly understand the
weighting. All other input being equal -- the same geographic focus and health/economic data -- the user
preferences will be the sole differentiating factor between users with varying Antares Matrix output. The
visual preference profile system remains under development and will change as we refine our approach and
receive feedback from users. Below are more examples of how ranked preference profiles might appear.
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Appendix A: Weighting Criteria Details
1. Scale of Disease
Available data give us a picture of the overall impact of each disease, accounting for both disease
prevalence and severity. Data on mortality and Disability-Adjusted Life Years (DALYs) for each disease are
available by region, thus allowing for cross-regional comparisons. To assess the overall impact of each
disease, a weighted average was calculated using a 3:1 ratio of the DALY score to the mortality score to
emphasize the burden of disease.
2. Household Financial Effects
The household financial effects category reflects our interest in measuring the extent to which specific
diseases impoverish people. The data used include both diminished household earnings due to a given
disease as well as income spent to prevent or cure the disease.
3. Social Equity
In many societies, women and children have little control over resources and limited decisionmaking
power. Similarly, across societies, the poor have the fewest resources with which to avert or treat health
problems. The equity criterion seeks to capture the impact of disease on women, children, and the poor,
and more broadly, any vulnerable groups with low socioeconomic status. This criterion also takes access
to care into account.
4. Cost-Effectiveness of Available Interventions
This criterion takes into account the availability of cost-effective interventions to address a given disease.
We assigned Cost-Effectiveness a relatively low weight when using the first version of the tool so as not to
limit the results to conditions for which cost-effective strategies currently are available. It is important not
to rule out the possibility of innovation that would boost cost-effectiveness in some circumstances. It is
also important to consider that there are some diseases (e.g., pancreatic cancer) for which there is little
effective treatment, either currently or in prospect. Including the Cost-Effectiveness criterion helps steer
resources away from unproductive uses.
5. Spillover Effects
The tool takes into account two specific types of situations in which addressing a disease has significant
implications beyond the disease itself. (A) Medical spillovers that occur when one disease affects another
(e.g., HIV infection increases susceptibility to tuberculosis; it also puts others at risk of tuberculosis); and
(B) social and economic spillovers occur when a disease has an effect on social or human capital (e.g.,
when high HIV rates affect a significant portion of a population’s ability to be economically productive due
to communicability and the associated social stigma).
10