Health and economic benefits of public financing of epilepsy treatment in India: An agent-based simulation model

Abstract

Objective: An estimated 6-10 million people in India live with active epilepsy, and less than half are treated. We analyze the health and economic benefits of three scenarios of publicly financed national epilepsy programs that provide: (1) first-line antiepilepsy drugs (AEDs), (2) first- and second-line AEDs, and (3) first- and second-line AEDs and surgery.

Methods: We model the prevalence and distribution of epilepsy in India using IndiaSim, an agent-based, simulation model of the Indian population. Agents in the model are disease-free or in one of three disease states: untreated with seizures, treated with seizures, and treated without seizures. Outcome measures include the proportion of the population that has epilepsy and is untreated, disability-adjusted life years (DALYs) averted, and cost per DALY averted. Economic benefit measures estimated include out-of-pocket (OOP) expenditure averted and money-metric value of insurance.

Results: All three scenarios represent a cost-effective use of resources and would avert 800,000-1 million DALYs per year in India relative to the current scenario. However, especially in poor regions and populations, scenario 1 (which publicly finances only first-line therapy) does not decrease the OOP expenditure or provide financial risk protection if we include care-seeking costs. The OOP expenditure averted increases from scenarios 1 through 3, and the money-metric value of insurance follows a similar trend between scenarios and typically decreases with wealth. In the first 10 years of scenarios 2 and 3, households avert on average over US$80 million per year in medical expenditure.

Significance: Expanding and publicly financing epilepsy treatment in India averts substantial disease burden. A universal public finance policy that covers only first-line AEDs may not provide significant financial risk protection. Covering costs for both first- and second-line therapy and other medical costs alleviates the financial burden from epilepsy and is cost-effective across wealth quintiles and in all Indian states.

Keywords: Agent-based model; Cost-effectiveness; Epilepsy; India; Universal public finance.

Figure 1

Epilepsy model Λ_i,j is the incidence rate for age group i of sex j; c₁ and c₂ are the effective coverage of first‐ (first‐line AEDs) and second‐line (lamotrigine or surgery along with first‐line AED) therapy; 1‐α is the treatment dropout rate due to adherence; σ_N,i,j is the natural clearance rate for age group i of gender j, and σ_t1 and σ_t2 are the clearance rates with therapy; and τ is the rate of stopping treatment when not having seizures. Those in the seizure‐free with therapy state are still medically considered to have active epilepsy. Individuals are born into the healthy and seizure‐free category. They die from exogenous causes (in any state) or epilepsy‐related causes (in states with active epilepsy) and are removed from the model.

Figure 2

Prevalence of active epilepsy over time. Results are over100 simulations. The plot includes only individuals with active epilepsy‐seizure in the last 5 years. The treated and seizure‐free group includes those that have not had recent seizures, but have had seizures in the last 5 years. Baseline effective coverage for first‐line and second‐line therapy is 36% and treatment is paid out of pocket. All policy scenarios cover the annual medical costs (consultation, diagnostics, and inpatient). In scenario 1, effective coverage for first‐line therapy is 80%, and effective coverage for second‐line therapy is 36%. Second‐line treatment and surgery are paid out of pocket. In scenario 2, effective coverage for first‐line and second‐line therapy is 80%, and only surgery is paid out of pocket. In scenario 3, effective coverage for first‐line and second‐line therapy is 80%, and no treatment is paid out of pocket. Only the top 1% of the population chooses to undergo surgery when it is covered out of pocket.

Figure 3

Cost‐effectiveness. Results are over 100 simulations. DALYs, disability‐adjusted life years. In row 1 the costs and health benefits are discounted at 3% and aggregated over the 10 years. The costs include both government expenditure and out‐of‐pocket (OOP) expenditure for diagnostics, treatments, inpatient costs, and first‐ and second‐line therapies. Row 2 represents the mean nondiscounted total costs and DALYs averted for the entire Indian population each year. All policy scenarios cover the annual medical costs (consultation, diagnostics, and inpatient). In scenario 1, effective coverage for first‐line therapy is 80%, and effective coverage for second‐line therapy is 36%. Second‐line treatment and surgery are paid out of pocket. In scenario 2, effective coverage for first‐line and second‐line therapy is 80%, and only surgery is paid out of pocket. In scenario 3, effective coverage for first‐line and second‐line therapy is 80%, and no treatment is paid out of pocket. Only the top 1% of the population chooses to undergo surgery when it is covered out of pocket. Error bars are the 95% uncertainty range.

Figure 4

Health and economic outcomes per 100,000 persons in each state. Results are over 100 simulations and 10 years; they are presented in present day values. OOP, out of pocket; DALYs, disability‐adjusted life years. States in which the standard error is large and we cannot differentiate the results from no effect are grayed out. In the OOP expenditure averted plot (row 3), two states—Assam and Odisha—have significant negative results; they were grayed out for clarity in the color scale of the maps. All policy scenarios cover the annual medical costs (consultation, diagnostics, and inpatient). In scenario 1, effective coverage for first‐line therapy is 80%, and effective coverage for second‐line therapy is 36%. Second‐line treatment and surgery are paid out of pocket. In scenario 2, effective coverage for first‐line and second‐line therapy is 80%, and only surgery is paid out of pocket. In scenario 3, effective coverage for first‐line and second‐line therapy is 80%, and no treatment is paid out of pocket. Only the top 1% of the population chooses to undergo surgery when it is covered out of pocket.