Methods of cost-effectiveness analysis (CEA) have largely been developed for application in Western country settings. Little attention has been paid to the methodological issues in cost valuation in resource-poor settings, where failing exchange rates and severe market distortions require further clarifications of appropriate valuation methods. This paper links insights from social cost-benefit analysis with the current CEA guidelines to develop a more apt approach to cost valuation in resource-poor settings.
Resource allocation and health financing
Cost valuation in resource-poor settings
Health Policy and Planning 2005
Cost-effectiveness analysis for priority-setting in South Africa: What are the possibilities?
Doherty J: South African Medical Journal 100(12):816–821, December 2010
This study explores the role of cost-effectiveness analysis (CEA) in supporting decision-making around health care priorities in South Africa by referring to South African studies that have provided clinical and policy guidance at the levels of the patient, the service and the population. In her analysis, the author positions cost-effectiveness evidence in relation to other concerns such as equity and the overall performance of the health system. At the level of the patient, CEA helps to decide which of several alternative interventions is the most cost-effective in addressing a specific problem. CEA can also assist in identifying interventions that need to be introduced to respond to emerging conditions, as well as help policy makers adjudicate between different modes of service delivery, for example by assessing costs of different types of service integration.
Cost-effectiveness analysis of HIV chemoprophylaxis
Grant R, Lama J, Goicochea P, et al: The Sixteenth International AIDS Conference, August 2006
Ethical guidelines require that research on effectiveness of HIV chemoprophylaxis be performed in populations where the intervention would be feasible if the trials demonstrate efficacy with acceptable safety. Population effects and cost effectiveness were simulated using a mathematical model that considers heterosexual and homosexual transmission, higher infectiousness in early and late infection, age and sex effects on susceptibility, risk behavior variation, condom replacement, known age-sex partner preferences, and primary and secondary drug resistance. The article describes the findings and relevant conclusions drawn.
COST-EFFECTIVENESS OF HIV/AIDS INTERVENTIONS IN AFRICA
This Lancet article assesses the existing cost-effectiveness data for HIV/AIDS interventions and its implications for value-for-money strategies to combat HIV/AIDS in Africa. The researchers found that cost-effectiveness varied greatly between interventions. They argue that a strong economic case exists for prioritisation of preventive interventions and tuberculosis treatment. Where potentially exclusive alternatives exist, cost-effectiveness analysis points to an intervention that offers the best value for money. The article concludes that cost-effectiveness analysis is an essential component of informed debate about priority setting for HIV/AIDS.
Cost-effectiveness of improving the quality of care of children admitted in district hospitals in Kenya
Health Economics Unit, University of Cape Town, Policy Brief: October 2011
The district hospital has been considered a critical avenue for the delivery of child-saving interventions. It has been suggested that improving the performance of district hospitals would reduce child mortality by 3-30% in the areas they serve. It has however been
shown that the quality of care delivered in these hospitals in Kenya is inadequate. To improve the quality of care of children admitted in district hospitals in Kenya, the study developed clinical guidelines
in selected district hospitals. The guidelines were linked with health
worker training, job aids, follow-up and supervision and performance feedback termed the 'Emergency Triage and Treatment Plus (ETAT+) strategy. The strategy improved the quality of care of children admitted in hospitals by 25%. The total cost of scaling up the intervention was calculated at about US$ 3.6 million, estimated to be only 0.6% of the annual child health budget in Kenya. The ETAT+ strategy is argued to be cost-effective in improving the quality of care of children admitted in hospitals in Kenya.
Costs and choices: Financing the long-term fight against AIDS
Results for Development Institute: 2010
Despite the enormous progress that has been made over the past decade, there are still huge gaps and deficiencies in national plans, budgets, and expenditure tracking systems, according to this paper. Few countries have developed detailed cost estimates of their national strategic plans. All too often, they do not specify how limited resources will be allocated, nor how priorities will be set if they are unable to achieve their goals. The paper argues that, even if AIDS costs are almost certain to rise between now and 2031, the cost trajectory can be significantly influenced by our actions today. Policy choices have different price tags – ranging from $397 billion to $722 billion over the 22-year period. Reducing costs will demand stronger political will and AIDS financing capacity, but the potential payoff in making the right choices is great, leading to fewer infections and more lives saved. Governments and development partners could be much more effective in the AIDS activities they back, and more financially efficient, if they focused resources on prevention programmes that are more closely aligned with specific epidemics. The paper also argues that showing that money for AIDS can be used more efficiently and to achieve greater benefits will also help to maintain political support and enthusiasm for the large-scale efforts that will need to be sustained for decades to come. These steps will require global creativity, national and international leadership, and improved policies and programmes.
Costs of Eliminating Malaria and the Impact of the Global Fund in 34 Countries
Zelman B, Kiszewski A, Cotter C, Liu J: PLoS ONE 9(12), December 2014
This study aims to 1) assess past total and Global Fund funding to the 34 current malaria-eliminating countries, and 2) estimate their future funding needs to achieve malaria elimination and prevent reintroduction through 2030. Historical funding is assessed against trends in country-level malaria annual parasite incidences (APIs) and income per capita. Following Kizewski et al. (2007), program costs to eliminate malaria and prevent reintroduction through 2030 are estimated using a deterministic model. The cost parameters are tailored to a package of interventions aimed at malaria elimination and prevention of reintroduction.The majority of Global Fund-supported countries experiencing increases in total funding from 2005 to 2010 coincided with reductions in malaria APIs and also overall GNI per capita average annual growth. The total amount of projected funding needed for the current malaria-eliminating countries to achieve elimination and prevent reintroduction through 2030 is approximately US$8.5 billion, or about $1.84 per person at risk per year (PPY). Although external funding, particularly from the Global Fund, has been key for many malaria-eliminating countries, sustained and sufficient financing is argued to be critical for furthering global malaria elimination.
Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?
Drake TL, Chalabi Z and Coker R: Bulletin of the World Health Organisation 90(10): 940-941, 10 October 2012
Pandemic influenza presents the greatest risk in low- and middle-income countries. The objective of this paper is to suggest improvements to the methods and scope of economic evaluations surrounding pandemic influenza and other epidemic or pandemic events in these countries. The evidence base for the cost-effectiveness of pandemic influenza preparedness policy options is small but growing rapidly. Modelling methods vary considerably between studies and the literature is limited in scope. To contribute to improving quality and consistency in this emerging study area, the authors recommend: greater focus on low-resource settings; inclusion of non-pharmaceutical interventions; incorporation of health system capacity; and more robust analysis and presentation of pandemic event uncertainty. So, what’s missing from pandemic influenza preparedness cost-effectiveness analysis and research? In the final analysis, the authors identify some crucial research gaps: poor countries, non-pharmaceutical interventions, health system capacity and pandemic uncertainty.
Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?
Mann C; Ng C; Akseer N; Bhutta Z; et al.: BMC Public Health 16(Suppl 2) (792), 2016, doi: 10.1186/s12889-016-3403-4
Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20–64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005–2010) for RMNH expenditures (2005–2010) and 165 % for CH expenditures (2005–2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.
Countdown to 2015: Assessment of official development assistance to maternal, newborn, and child health
Pitt C, Greco G, Powell-Jackson T and Mills Anne: The Lancet 376(9745): no page no’s, 18 September 2010
This paper analysed aid flows for maternal, newborn, and child health for 2007 and 2008 and updated previous estimates for 2003-2006 in the 68 priority countries in the Countdown to 2015 Initiative. The complete aid activities database of the Organisation for Economic Co-operation and Development for 2007 and 2008 was manually coded and analysed with methods that were previously developed to track overseas development assistance (ODA). The researchers analysed the degree to which external funders target their ODA to recipients with the greatest maternal and child health needs and examined trends over the six years. They found that, in 2007 and 2008, US$4.7 billion and $5.4 billion (constant 2008 US$), respectively, were disbursed in support of maternal, newborn, and child health activities in all developing countries, reflecting a 105% increase between 2003 and 2008, but no change relative to overall ODA for health, which also increased by 105%. Targeting of ODA to countries with high rates of maternal and child mortality improved over the 6-year period, although some of these countries persistently received far less ODA per head than did countries with much lower mortality rates and higher income levels. Funding from the GAVI Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria exceeded core funding from multilateral institutions, and bilateral funding also increased substantially between 2003 and 2008, especially from the United States and the United Kingdom. The paper welcomes increases in ODA to maternal, newborn, and child health during 2003-2008 and the improved targeting of ODA to countries with greater needs. Nonetheless, these increases do not reflect increased prioritisation relative to other health areas.