Factors affecting health-related quality of life of HIV-infected key population in Myanmar.

This cross-sectional study examined factors affecting Health-related Quality of Life (HRQoL) among 273 HIV-infected key populations. This included, men who have sex with men (MSM), people, who inject drugs (PWID), and sex workers (SW), who were currently receiving antiretroviral therapy (ART) in Myanmar. Participants were recruited from four non-government clinics in four main cities. Overall HRQoL score derived from the WHOQOL-HIV BREF questionnaire was 86.08 ± 10.78. The lowest score was found in the environment domain (13.64 ± 2.06), while the highest score was found in the spirituality domain (15.54 ± 3.04). According to the multiple logistic regression analysis, participants, reported having an adequate income (OR = 3.32, P = 0.006), regularly taking meditation (OR = 3.79, P = 0.009), living in Tachileik (OR = 15.43, P = 0.011), and reported having no symptoms during previous 2 weeks (OR = 14.50, P < 0.001), were more likely to have good HRQoL level. In contrast, patients receiving ART < 1 year (OR = 0.163, P = 0.028) reported having low ART adherence (OR = 0.17, P = 0.018) and reported anticipated stigma (OR = 0.23, P < 0.001) and internalized stigma (OR = 0.29, P = 0.006) were less likely to have good HRQoL level.

COST-UTILITY ANALYSIS OF MULTIPLE SCLEROSIS TREATMENT IN THAILAND.

OBJECTIVES: Although interferon beta-1a (IFNß-1a), 1b (IFNß-1b), and fingolimod have been approved as multiple sclerosis (MS) treatments, they have not yet been included on the National List of Essential Medicines (NLEM) formulary in Thailand. This study aimed to evaluate the cost-utility of MS treatments compared with best supportive care (BSC) based on a societal perspective in Thailand. METHODS: A Markov model with cost and health outcomes over a lifetime horizon with a 1-month cycle length was conducted for relapsing-remitting MS (RRMS) patients. Cost and outcome data were obtained from published studies, collected from major MS clinics in Thailand and a discount rate of 3 percent was applied. The incremental cost-effectiveness ratio (ICER) was calculated and univariate and probabilistic sensitivity analyses were performed. RESULTS: When compared with BSC, the ICERs for patients with RRMS aged 35 years receiving fingolimod, IFNß-1b, and IFNß-1a were 33,000, 12,000, and 42,000 US dollars (USD) per quality-adjusted life-year (QALY) gained, respectively. At the Thai societal willingness to pay (WTP) threshold of USD 4,500 per QALY gained, BSC had the highest probability of being cost-effective (49 percent), whereas IFNß-1b and fingolimod treatments showed lower chance being cost-effective at 25 percent and 18 percent, respectively. CONCLUSIONS: Compared with fingolimod and interferon treatments, BSC remains to be the most cost-effective treatment for RRMS in Thailand based on a WTP threshold of USD 4,500 per QALY gained. The results do not support the inclusion of fingolimod or interferon in the NLEM for the treatment of RRMS unless their prices are decreased or special schema arranged.

What criteria do decision makers in Thailand use to set priorities for vaccine introduction?

BACKGROUND: There is a need to identify rational criteria and set priorities for vaccines. In Thailand, many licensed vaccines are being considering for introduction into the Expanded Program on Immunization; thus, the government has to make decisions about which vaccines should be adopted. This study aimed to set priorities for new vaccines and to facilitate decision analysis. METHODS: We used a best-worst scaling study for rank-ordering of vaccines. The candidate vaccines were determined by a set of criteria, including burden of disease, target age group, budget impact, side effect, effectiveness, severity of disease, and cost of vaccine. The criteria were identified from a literature review and by in-depth, open-ended interviews with experts. The priority-setting model was conducted among three groups of stakeholders, including policy makers, healthcare professionals and healthcare administrators. The vaccine data were mapped and then calculated for the probability of selection. RESULTS: From the candidate vaccines, the probability of hepatitis B vaccine being selected by all respondents (96.67 %) was ranked first. This was followed, respectively, by pneumococcal conjugate vaccine-13 (95.09 %) and Haemophilus influenzae type b vaccine (90.87 %). The three groups of stakeholders (policy makers, healthcare professionals and healthcare administrators) showed the same ranking trends. Most severe disease, high fever rate and high disease burden showed the highest coefficients for criterion levels being selected by all respondents. This result can be implied that a vaccine which can prevent most severe disease with high disease burden and has low safety has a greater chance of being selected by respondents in this study. CONCLUSIONS: The priority setting of vaccines through a multiple-criteria approach could contribute to transparency and accountability in the decision-making process. This is a step forward in the development of an evidence-based approach that meets the need of developing country. The methodology is generalizable but its application to another country would require the criteria as relevant to that country.

Cost of rotavirus diarrhea for programmatic evaluation of vaccination in Vietnam.

BACKGROUND: Rotavirus is the most common etiology of diarrhea-associated hospitalizations and clinic visits in Vietnamese children < 5 years old. To estimate the economic burden of rotavirus-associated formal healthcare encounters, an economic study was conducted. METHODS: A cost-of-illness study was performed from a societal perspective. Data were collected from children below the age of five years who presented to a clinic or hospital with symptoms of acute gastroenteritis (AGE). Patient-specific information on resource use and cost was obtained through caregiver interviews and medical chart review. Costs are presented in 2014 US dollar ($). RESULTS: A total of 557 children with symptoms of AGE were enrolled from March through June 2009, with mean age of 16.5 months. Of the 340 outpatients and 217 admitted patients enrolled, 41 % tested rotavirus positive. It was found that, from a societal perspective, the mean total cost of AGE was $175. Costs of patients with and without rotavirus were $217 and $158, respectively. From multiple regression analysis, it was found that rotavirus infection, patient age and receiving oral rehydration solution before visiting health facility had significant effect on the costs. CONCLUSIONS: This study clearly demonstrated substantial economic burden of AGE including rotavirus disease. They were significantly greater than the previously reported cost estimates in Vietnam. These updated costs of illness result in more favorable vaccine cost-effectiveness than in previous economic evaluations.

Cost of illness due to typhoid Fever in pemba, zanzibar, East Africa.

The aim of this study was to estimate the economic burden of typhoid fever in Pemba, Zanzibar, East Africa. This study was an incidence-based cost-of-illness analysis from a societal perspective. It covered new episodes of blood culture-confirmed typhoid fever in patients presenting at the outpatient or inpatient departments of three district hospitals between May 2010 and December 2010. Cost of illness was the sum of direct costs and costs for productivity loss. Direct costs covered treatment, travel, and meals. Productivity costs were loss of income by patients and caregivers. The analysis included 17 episodes. The mean age of the patients, was 23 years (range=5-65, median=22). Thirty-five percent were inpatients, with a mean of 4.75 days of hospital stay (range=3-7, median=4.50). The mean cost for treatment alone during hospital care was US$ 21.97 at 2010 prices (US$ 1=1,430.50 Tanzanian Shilling─TSH). The average societal cost was US$ 154.47 per typhoid episode. The major expenditure was productivity cost due to lost wages of US$ 128.02 (83%). Our results contribute to the further economic evaluation of typhoid fever vaccination in Zanzibar and other sub-Saharan African countries.

Measurement of costs for health economic evaluation.

The provision of guidelines on cost measurement for health economic evaluations enable research to be more standardized and hence more comparable, which offers clear benefits for policy formulation and health management. The guidelines herein focus on three aspects-the cost of health intervention/health care programs, the cost of illness/health risks, and use of costs in health economic evaluation. For each aspect, the main concepts and methods are outlined, and recommendations for the Thai context are presented. There is particular focus on how to calculate various costs according to different evaluation methods and perspectives, how to evaluate source of cost data, how to make value adjustments and how to present cost measurement findings.

Standard cost lists for health economic evaluation in Thailand.

This analysis was undertaken to generate a set of standard costs for medical services and those incurred by patient receiving treatment, for use in health economic evaluations. Medical service unit cost data were derived from a survey of 3,091 hospital medical services in five hospitals, disaggregated by type of hospital (district or provincial/regional) and analyzed using the relative value unit method. Patient-borne ambulatory cost values were derived from data gathered through 905 patient interviews that took place in six health centers, three district hospitals, and three provincial/regional hospitals. The survey gathered data on costs a rising from the distance travelled to access the medical service, the time spent in the healthcare facility, as well as travel and meal costs. The analysis generated a set of standard cost data for Thailand that will make conducting economic evaluations more accurate, faster and more convenient, as well as allowing better comparability between studies. This is the first standard cost menu that has been developed specifically for Thailand, and as such should be revised and refined in the future. Some areas that would benefit from revision are suggested.

Exploring cost drivers to improve disease management: the case of type 2 diabetes at a tertiary hospital in Burundi, Africa.

Background: In Burundi, the International Diabetes Federation estimated the prevalence of diabetes mellitus (DM) as high as 2.4% in adults aged between 20 and 79 years old. Thus, the healthcare expenditure for the treatment of diabetic patients is considerably high. Objective: This study explores the economic burden of type 2 DM and its cost drivers at a tertiary hospital in 2018. It included adult type 2 DM patients who received treatment from a tertiary hospital (Hospital Prince Regent Charles) in 2018. In this study, 81 patients were included. Methods: Data on illness treatment and complications were collected through patient interviews and by reviewing patients' medical and financial records. A stepwise multiple linear regression model was used to explore factors affecting the cost of type 2 diabetes mellitus. Results: The average total cost per patient per year was estimated at $2621.06. The fitted cost model had an adjusted R2 of 0.427, which explained up to 43% of the variation in the total cost. The results suggest primary cost drivers such as treatment regimen, duration of the disease, payment method, and number of complications. Conclusion: The findings confirm the profound economic burden of type 2 DM and the need to improve patient care and prevent disease progression. The establishment of a special clinic for patients with diabetes is recommended, as is financial support for underprivileged patients. A specific focus on cost drivers could help establish appropriate disease management programs to control the costs for type 2 diabetes patients.

Cost-Utility Analysis of Community Case Management for Malaria Control in Burundi.

BACKGROUND: The community case management (CCM) program for malaria control is a community-based strategy implemented to regulate malaria in children in Burundi. This study compared the cost and utility of implementing the CCM program combined with health facility management (HFM) versus HFM alone for malaria control in children under five in Burundi. METHODS: This study constructed a five-year Markov model with one-week cycles to estimate cost-utility and budget impact analysis (BIA). The model defined 10 health states, simulating the progression of the disease and the risk of recurrent malaria in children under five years of age. Cost data were empirically collected and presented for 2019. Incremental cost per disability-adjusted life year (DALY) averted, and a five-year budget was estimated. One-way and probabilistic sensitivity analyses (PSAs) were then performed. RESULTS: From provider and societal perspectives, combining the CCM program with HFM for malaria control in Burundi was more cost-effective than implementing HFM alone. The addition of CCM, using artesunate amodiaquine (ASAQ) as the first-line treatment, increased by US$1.70, and US$ 1.67 per DALY averted from the provider and societal perspectives, respectively. Using Artemether Lumefantrine (AL) as the first-line treatment, adding the CCM program to HFM increased by US$ 1.92, and US$ 1.87 per DALY averted from the provider and societal perspectives. At a willingness-to-pay of one GDP/capita, the CCM program remained a 100% chance of being cost-effective. In addition, implementing the program for five years requires a budget of US$ 15 800 486-19 765 117. CONCLUSION: Implementing the CCM program and HFM is value for money for malaria control in Burundi. The findings can support decision-makers in Burundi in deciding on resource allocation, especially during the program's scale up.

Does the Choice of Health Metric, DALY or QALY, Influence Conclusions of Health Economic Evaluation? A Case Study of Rotavirus Vaccine in Burundi.

BACKGROUND: Two metrics, quality-adjusted life-year (QALY) and disability-adjusted life-year (DALY), have been commonly used to measure health benefits associated with health interventions. This study aimed to explore the effect of the choice of health metric (DALY or QALY) on economic evaluation conclusion. METHODS: A previous published model for a cost-utility analysis (CUA) of rotavirus vaccine was adapted to estimate the QALYs gained and DALYs averted from four rotavirus vaccines: Rotarix, RotaTeq, Rotavac, and Rotasiil. The study was conducted in both Burundi provider and societal perspectives over a five-year time horizon. Disability weights (DW) were derived from the Global Burden of Disease (GBD) study. Scenario analysis was performed to evaluate the impact of age weights and source of utility weight. RESULTS: In base-case analysis, the QALYs gained ranged from 46 to 78% of the DALYs averted. The incremental cost-effectiveness ratios (ICER) per QALY gained were higher than ICER per DALY averted by 28 to 113%, leading to less favorable cost effectiveness. The QALYs gained from using 1-DW as utility weight were slightly higher than those using EQ-5D utility weight obtained from previous literature, yet less likely to alter CUA conclusions. When age-weighting was incorporated in the DALY calculation, the ICERs per DALY averted were reduced leading to more favorable cost effectiveness. CONCLUSION: In case of rotavirus diarrhea, in which mortality burden is considered larger than morbidity due to short duration of disease, although the use of DALY consistently led to more favorable cost-effective result than the use of QALY such effects were considered small and less likely to affect the EE conclusion under current CET of 1 GDP per capita.

A comparison of six approaches for measuring utility values among patients with locally advanced cervical cancer.

BACKGROUND: Several instruments are available to measure health utility values. However, limited studies have not yet comprehensively assessed the agreement among these instruments. This study therefore aimed to investigate the performance and agreement of six instruments for utility measures: EQ-5D-3L, EQ-5D-5L (cTTO model), EQ-5D-5L (DCE model), EQ-5D-5L (Hybrid model), TTO, and VAS, among locally advanced cervical cancer (LACC) patients in Thailand. METHODS: We compared utility scores derived from six approaches using Friedman's test. We also assessed the agreement of utility scores between each pairwise comparison by intraclass correlation coefficient (ICC) and Bland-Altman plot. RESULTS: The mean (SD) utility values derived from six approaches were as follows: 0.755 ± 0.248 (EQ-5D-3L), 0.801 ± 280 (TTO), 0.806 ± 0.156 (VAS), 0.871 ± 0.184 (cTTO model), 0.875 ± 0.168 (Hybrid model), and 0.900 ± 0.142 (DCE model). Significant differences across six approaches were found in Friedman's test. The ICC showed high agreement between EQ-5D-5L and EQ-5D-3L, and very high agreement between all three models of EQ-5D-5L. The Bland-Altman plots showed wide limit of agreement, except the pairwise comparison, between each model of the EQ-5D-5L. CONCLUSION: TTO, VAS, EQ-5D-3L and EQ-5D-5L could not be used interchangeably in LACC patients. The impact of using different instruments on economic evaluation findings warrants further investigation.

How Economic Analysis Increases the Awareness of Clinical Services: A Case of Diabetes Mellitus at a Teaching Hospital in Myanmar.

OBJECTIVES: Myanmar faces a growing epidemic of type 2 diabetes mellitus, which has significant impact on the individual health and health service system; nevertheless, reliable cost estimate for treating diabetes is still unknown. Therefore, this study aimed to explore the treatment cost of hospitalization by type 2 diabetes mellitus and the association of complications and comorbidities with the treatment cost. METHODS: The retrospective incidence-based cost of illness analysis was performed at the diabetes ward of 800-bed teaching hospital in Yangon, Myanmar. The data were retrieved from hospital financial reports and patient's medical records for the fiscal year 2017 to 2018. Data was analyzed by using descriptive statistics and multivariate statistics. One-way sensitivity analysis was used to assess the uncertainty of input parameters. RESULTS: This study involved 87 inpatients with type 2 diabetes mellitus with an average length of stay of 16.1 ± 12.6 days. Of the study sample, 67% had complications whereas 74% had comorbidities. The average treatment cost per admission was $718.7 (equal to 58% of gross domestic product - GDP per capita) at 2018 prices. Based on the multiple regression analysis, cost savings per admission were $276.5, $307.3, and $319.5 from preventing foot ulcer, nephropathy, and retinopathy, respectively. CONCLUSIONS: This study found that the treatment of diabetes is costly because of its preventable health consequences. Better disease management to prevent complications results in considerable cost savings. This quantitative evidence would increase awareness in health service system.

Economic burden on people living with HIV who attend self-help groups in Yangon, Myanmar.

This study aims to determine economic burden or cost of human immunodeficiency virus (HIV) and its consequences from patient perspective and to examine factors influencing the cost. This is a prevalence-based cost-of-illness (COI) study. A cross-sectional survey was carried out in Yangon, Myanmar during March and April 2018. Face-to-face structured interview was conducted among 264 people living with HIV (PLHIV) who were members of the selected four self-help groups (SHGs) that provided HIV peer support. Micro-costing approach was adopted for the cost calculation. Direct medical cost, direct non-medical cost and indirect cost were considered. Cost of HIV per patient in the year 2017 was estimated at 228.2 international dollar (Int$). Direct medical cost was only small portion of the total cost (5.6%). Indirect cost or cost of time loss was the largest contributor among the cost components, accounted for 61.2% of the total cost. First year of the antiretroviral therapy (ART) initiation and second line drug regimen have positive effect on the costs. HIV resulted in substantial economic burden for the patients. Effective interventions aim at reducing the economic burden on patients by providing compensation on transportation cost and providing job opportunity are essential. Further researchers examining cost from provider and societal perspectives are warranted to provide complete picture of the economic burden of HIV in Myanmar.

Cost-effectiveness of parenteral artesunate for treating children with severe malaria in sub-Saharan Africa.

OBJECTIVE: To explore the cost-effectiveness of parenteral artesunate for the treatment of severe malaria in children and its potential impact on hospital budgets. METHODS: The costs of inpatient care of children with severe malaria were assessed in four of the 11 sites included in the African Quinine Artesunate Malaria Treatment trial, conducted with over 5400 children. The drugs, laboratory tests and intravenous fluids provided to 2300 patients from admission to discharge were recorded, as was the length of inpatient stay, to calculate the cost of inpatient care. The data were matched with pooled clinical outcomes and entered into a decision model to calculate the cost per disability-adjusted life year (DALY) averted and the cost per death averted. FINDINGS: The mean cost of treating severe malaria patients was similar in the two study groups: 63.5 United States dollars (US$) (95% confidence interval, CI: 61.7-65.2) in the quinine arm and US$ 66.5 (95% CI: 63.7-69.2) in the artesunate arm. Children treated with artesunate had 22.5% lower mortality than those treated with quinine and the same rate of neurological sequelae: (artesunate arm: 2.3 DALYs per patient; quinine arm: 3.0 DALYs per patient). Compared with quinine as a baseline, artesunate showed an incremental cost per DALY averted and an incremental cost per death averted of US$ 3.8 and US$ 123, respectively. CONCLUSION: Artesunate is a highly cost-effective and affordable alternative to quinine for treating children with severe malaria. The budgetary implications of adopting artesunate for routine use in hospital-based care are negligible.

Cost of illness due to typhoid fever in five Asian countries.

OBJECTIVE: To generate community-based estimates of the public (paid by the government) and private (paid by households) costs of blood culture-confirmed typhoid fever in Hechi, China; North Jakarta, Indonesia; Kolkata, India; Karachi, Pakistan and Hue, Vietnam. METHODS: To measure out-of-pocket costs of illness and lost earnings, families with culture-proven cases were surveyed 7, 14 and 90 days after onset of illness. Public costs of treatment were measured at local health facilities using a micro costing (bottom-up) method. RESULTS: The costs of hospitalized cases ranged from USD 129 in Kolkata to USD 432 in North Jakarta (hospitalization rates varied from 2% in Kolkata to 40% in Hechi) and the costs of non-hospitalized cases ranged from USD 13 in Kolkata to USD 67 in Hechi. Where costs were highest (Hechi, North Jakarta and Karachi), the bulk of the costs of hospitalized cases was borne by families, comprising up to 15% of annual household income. CONCLUSION: Although these estimates may understate true costs due to the fact that higher quality treatment may have been provided earlier-than-usual, this multi-country community-based study contributes to evidence on the public and private costs of typhoid fever in developing countries. These cost estimates were used in a cost-effectiveness analysis of typhoid vaccines and will help policymakers respond to World Health Organization's updated typhoid fever immunization recommendations.

Disability and cost for diabetic patients at a public district hospital in Thailand.

OBJECTIVE: The study determined the rate of disability among diabetic patients at a public district hospital in Thailand and compared the costs of illness among different levels of severity of disability. This was the first such study carried out in Thailand. METHODS: The study was conducted at Waritchaphum Hospital in northeastern Thailand. Data were collected from 475 randomly selected diabetic patients identified by the World Health Organization's International Classification of Diseases, tenth revision (ICD-10 codes E10 - E14) who received treatment from the study hospital during the fiscal year of 2008. The disability levels were determined by using Thailand ministerial guidelines as well as the Barthel index score. Cost-of-illness estimates followed the prevalence-based approach and it presented the societal perspective of cost-of-illness of diabetes in 2008. KEY FINDINGS: The study results showed that 9.68% of the study participants had physical impairment while 9.26% had impairment in eyesight. The Barthel index score showed that 13.5% of the study participants were disabled. When comparing costs between independent and disabled persons, considering the Barthel index score, average costs for the disabled diabetic persons were significantly higher than for those who were independent (US$2700.29 versus 598.24; P<0.001). CONCLUSIONS: The study concluded that the presence of complications and disability among diabetic patients impacts severely on Thai society. At present, the Thai government allocates US$187.5 per annum to registered disabled persons as a disability living allowance. The study found a large difference between the direct economic outlay of the patients and the allowance provided, which suggests that there is probably a need to revise the welfare payment upwards.

Cost of premature mortality attributable to smoking in the Middle East and North Africa.

BACKGROUND: Tobacco smoking is a leading cause of premature mortality, incurring substantial economic costs. AIMS: To estimate the rate and cost of premature mortality attributable to smoking in the 24 Middle East and North Africa (MENA) countries in 2015. METHODS: Smoking attributable fractions were estimated. Twenty-four smoking-related diseases were included in the analysis. For each country, the total number of deaths by disease, age, and gender among individuals aged ≥ 15 years were derived from a World Health Organization database. Human capital approach was used in calculating cost of premature mortality. RESULTS: Smoking was responsible for 465 285 deaths in MENA countries, resulting in 7 122 706 years of potential life lost, or an average of 15.23 years lost per smoking-related death. Of the total 465 285 smoking-related deaths, 412 415 (88.6%) occurred in men, accounting for 37% of all deaths from the diseases considered in this analysis among men. The total mortality cost attributable to smoking was estimated at US$ 29.7 billion in 2015 (0.76% of MENA's gross domestic product). Turkey was the country most affected by the tobacco epidemic, representing 41% of smoking-related mortality cost in the whole region, followed by Saudi Arabia (8.76%) and Egypt (7.88%). CONCLUSION: Smoking is an important preventable cause of premature mortality in MENA countries. Substantial decline in smoking-attributable deaths and significant economic cost saving can be achieved in this region through more effective tobacco control policies.

The Cost of Locally Advanced Cervical Cancer in Thailand: an Empirical Study for Economic Analysis.

OBJECTIVE: To evaluate cost of illness of locally advanced cervical cancer patients from societal perspective in three scenarios including completely cured without severe late side effects (S1), completely cured with late grade 3-4 gastrointestinal side effects (S2.1) or genitourinary side effects (S2.2), and disease recurrence and death (S3). METHODS:  The incidence-based approach was conducted. The cost was calculated for 5-year time horizon starting for the treatment initiation. Direct medical costs were extracted from hospital database. Cost of using two-dimensional technique and three-dimensional conformal radiation therapy were calculated separately. Direct non-medical costs and indirect costs in terms of productivity loss were based on actual expenses from the interview of 194 locally advanced cervical cancer patients from two tertiary hospitals in Bangkok, during June to December 2019. All costs were converted to US dollar in 2019 values. RESULTS: For 5 years, cost of illness per patient for using two-dimensional technique and three-dimensional conformal radiation therapy were US $8,391 and US $10,418 for S1, US $18,018 and US $20,045 for S2.1, US $17,908 and US $19,936 for S2.2, and US $61,076 and US $63,103 for S3, respectively. The economic burden for newly diagnosed locally advanced cervical cancer patients in Thailand in 2018 was approximately US $129 million and US $131 million for using two-dimensional technique and three-dimensional conformal radiation therapy, respectively. Cost from S3 accounted for 70% of all total cost. Premature death was the most important cost driver of cost of illness accounted for 64 % of the total cost estimates. CONCLUSIONS: Cost of illness of locally advanced cervical cancer patients produced significant economic burden from societal perspective. Disease recurrence and early death from cancer was the most influential cause of this burden.

Economic analysis for national immunization program planning: A case of rotavirus vaccines in Burundi.

BACKGROUND: In Burundi, diarrhea is the third leading cause of mortality among children under five years of age. This study conducted an economic analysis of rotavirus vaccination program in Burundi. METHODS: A Markov model was constructed to simulate clinical and economic outcomes for the 2019 birth cohort for a period of 5 years. Empirical costing data were collected. ICER per episode averted, ICER per death averted, ICER per DALY averted, net present value, and budget impact were estimated for 4 brands of WHO pre-qualified rotavirus vaccines. One-way and probabilistic sensitivity analysis as well as threshold analysis were performed. RESULTS: For the base case, while all four WHO pre-qualified rotavirus vaccines were cost-effective (ICER < 3 GDP per capita), three of them (i.e. Rotarix, Rotavac and Rotasiil) were very cost-effective (ICER <1 GDP per capita) from both the provider and societal perspectives. The vaccines were still very cost-effective at a price increase of up to US$ 5.09, US$ 3.16, US$ 3.89, and US$ 2.69 for Rotarix, RotaTeq, Rotavac, and Rotasiil, respectively. Probabilistic sensitivity analysis indicated that vaccination programs with Rotarix, RotaTeq, Rotavac, and Rotasiil are cost-effective at a probability of 93.8%, 27%, 99.1%, and 92.7%, respectively. All vaccination programs were cost-beneficial with a net present value in the range of US$ 5,214,912 and US$ 11,135,997.The budget required to run the vaccination program, estimated with break-even prices, ranged between US$ 42,249,498 and US$ 53,487,935 for a 5-year time period. When compared to the GDP of Burundi in 2019, these are are less than 2%. CONCLUSION: The rotavirus vaccine is good value for money. Findings from this study offer evidence on potential economic benefits as well as the required budget for different rotavirus vaccination programs, which could be useful for future planning related to rotavirus vaccine coverage in Burundi after graduation from GAVI.

Cost-Effectiveness Analysis of Community Case Management of Childhood Diarrhea in Burundi.

OBJECTIVE: This study aimed to evaluate the cost-effectiveness of community case management (CCM) program of childhood diarrhea by providing oral rehydration salts and zinc through community health workers in Burundi. METHODS: A cost-effectiveness analysis study using a Markov modeling approach was undertaken to assess the CCM program of diarrhea from both provider and societal perspectives. The CCM program was compared with the routine management of childhood diarrhea at health facilities. Primary data on the cost of childhood diarrhea management were collected. Both economic and health outcomes were assessed for a period of 5 years, and a discount rate of 3% was applied. One-way and probabilistic sensitivity analyses were performed. RESULTS: The CCM program was found to be both less costly and more effective resulting to a negative value of incremental cost-effectiveness ratios, indicating that the program was dominant producing cost savings. Compared with the routine treatment of diarrhea at health facilities, the CCM program would avert 2749 additional disability-adjusted life years over a period of 5 years. The economic burden was reduced of US$1 056 699 and US$2 328 531 from the provider and societal perspectives, respectively. The cost-effectiveness estimates were mostly sensitive to the discount rate and the cost of outpatient visits at health facilities. The intervention remained dominant with a 100% probability of cost savings within 10 000 simulations of the sensitivity analysis. CONCLUSIONS: Providing inexpensive diarrheal treatment (oral rehydration salts and zinc) in communities is an attractive cost-effective intervention. Evidence from this study should be used to scale up the coverage of this life- and cost-saving intervention.