Cost-effectiveness of COVID-19 vaccination in Latin America and the Caribbean: an analysis in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, and Peru.

OBJECTIVE: Our study analyzes the cost-effectiveness of the COVID-19 vaccination campaigns in Argentina, Brazil, Chile, Colombia, Costa Rica, Mexico, and Peru. METHODS: Using a previously published SVEIR model, we analyzed the impact of a vaccination campaign (2021) from a national healthcare perspective. The primary outcomes were quality adjusted life years (QALYs) lost and total costs. Other outcomes included COVID-19 cases, hospitalizations, deaths, and life years. We applied a discount rate of 3% for health outcomes. We modeled a realistic vaccination campaign in each country (the realistic country-specific campaign). Additionally, we assessed a standard campaign (similar, "typical" for all countries), and an optimized campaign (similar in all countries with higher but plausible population coverage). One-way deterministic sensitivity analyses were performed. FINDINGS: Vaccination was health improving as well as cost-saving in almost all countries and scenarios. Our analysis shows that vaccination in this group of countries prevented 573,141 deaths (508,826 standard; 685,442 optimized) and gained 5.07 million QALYs (4.53 standard; 6.03 optimized). Despite the incremental costs of vaccination campaigns, they had a total net cost saving to the health system of US$16.29 billion (US$16.47 standard; US$18.58 optimized). The realistic (base case) vaccination campaign in Chile was the only scenario, which was not cost saving, but it was still highly cost-effective with an ICER of US$22 per QALY gained. Main findings were robust in the sensitivity analyses. INTERPRETATION: The COVID-19 vaccination campaign in seven Latin American and Caribbean countries -that comprise nearly 80% of the region- was beneficial for population health and was also cost-saving or highly cost-effective.

Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study.

OBJECTIVE: To investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population. DESIGN: Markov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers' burden and interventions' effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model. FINDINGS: In these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries' aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures. CONCLUSIONS: Smoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

Real-world evidence: experiences and challenges for decision making in Latin America.

OBJECTIVE: The Health Technology Assessment (HTA) process aims to optimize health system funding of technologies. In recent years there has been an increase in what is known as Real-World Evidence (RWE) as a complement to clinical trials. The objective of Health Technology Assessment International's Latin American Policy Forum 2022 was to explore the utility of incorporating RWE into HTA and decision-making processes in the region. METHODS: This article is based on a background document, survey, and the deliberative work of the country representatives who participated in the Forum. RESULTS: There is a growing interest in the use of Real-World Data / Real-World Evidence in HTA processes in Latin America, although currently there are no specific local guidelines for RWE use by HTA agencies. At present, its use is limited to certain areas such as adding context to HTA reports, the evaluation of adverse events, or cost estimation.Potential future uses of RWE were identified, including the creation of risk-sharing agreements, the assessment of technology performance in routine practice, providing information on outcomes that are not so easily evaluated in clinical trials (e.g., the identification of specific subpopulations or quality of life), and the estimation of input parameters for economic evaluations. CONCLUSIONS: The participants agreed that there are several areas presenting significant potential to expand the application of RWD/RWE and that the development of normative frameworks for its use could be helpful.

Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation.

INTRODUCTION: Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model. AIMS AND METHODS: We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics. RESULTS: With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare. CONCLUSIONS: Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy. IMPLICATIONS: Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.

STAKEHOLDER INVOLVEMENT IN THE HEALTH TECHNOLOGY ASSESSMENT PROCESS IN LATIN AMERICA.

OBJECTIVES: Latin American countries are taking important steps to expand and strengthen universal health coverage, and health technology assessment (HTA) has an increasingly prominent role in this process. Participation of all relevant stakeholders has become a priority in this effort. Key issues in this area were discussed during the 2017 Latin American Health Technology Assessment International (HTAi) Policy Forum. METHODS: The Forum included forty-one participants from Latin American HTA agencies; public, social security, and private insurance sectors; and the pharmaceutical and medical device industry. A background paper and presentations by invited experts and Forum members supported discussions. This study presents a summary of these discussions. RESULTS: Stakeholder involvement in HTA remains inconsistently implemented in the region and few countries have established formal processes. Participants agreed that stakeholder involvement is key to improve the HTA process, but the form and timing of such improvements must be adapted to local contexts. The legitimization of both HTA and decision-making processes was identified as one of the main reasons to promote stakeholder involvement; but to be successful, the entire system of assessment and decision making must be properly staffed and organized, and certain basic conditions must be met, including transparency in the HTA process and a clear link between HTA and decision making. CONCLUSIONS: Participants suggested a need for establishing clear rules of participation in HTA that would protect HTA producers and decision makers from potentially distorting external influences. Such rules and mechanisms could help foster trust and credibility among stakeholders, supporting actual involvement in HTA processes.

HEALTH TECHNOLOGY ASSESSMENT FOR DECISION MAKING IN LATIN AMERICA: GOOD PRACTICE PRINCIPLES.

OBJECTIVES: The aim of this study was to identify good practice principles for health technology assessment (HTA) that are the most relevant and of highest priority for application in Latin America and to identify potential barriers to their implementation in the region. METHODS: HTA good practice principles proposed at the international level were identified and then explored during a deliberative process in a forum of assessors, funders, and product manufacturers. RESULTS: Forty-two representatives from ten Latin American countries participated. Good practice principles proposed at the international level were considered valid and potentially relevant to Latin America. Five principles were identified as priority and with the greatest potential to be strengthened at this time: transparency in the production of HTA, involvement of relevant stakeholders in the HTA process, mechanisms to appeal decisions, clear priority-setting processes in HTA, and a clear link between HTA and decision making. The main challenge identified was to find a balance between the application of these principles and the available resources in a way that would not detract from the production of reports and adaptation to the needs of decision makers. CONCLUSIONS: The main recommendation was to progress gradually in strengthening HTA and its link to decision making by developing appropriate processes for each country, without trying to impose, in the short-term, standards taken from examples at the international level without adequate adaptation of these to local contexts.

[Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, ArgentinaAvaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina]. / Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina.

OBJECTIVE: To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. METHODS: In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). RESULTS: The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. CONCLUSIONS: The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

OBJETIVO: Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. MÉTODOS: Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). RESULTADOS: Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. CONCLUSÕES: As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.

Effect of a Community Health Worker-Led Multicomponent Intervention on Blood Pressure Control in Low-Income Patients in Argentina: A Randomized Clinical Trial.

Importance: Despite extensive knowledge of hypertension treatment, the prevalence of uncontrolled hypertension is high and increasing in low- and middle-income countries. Objective: To test whether a community health worker-led multicomponent intervention would improve blood pressure (BP) control among low-income patients with hypertension. Design, Setting, and Participants: A cluster randomized trial was conducted in 18 centers for primary health care within a national public system providing free medications and health care to uninsured patients in Argentina. A total of 1432 low-income adult patients with uncontrolled hypertension were recruited between June 2013 and April 2015 and followed up to October 2016. Interventions: Nine centers (743 patients) were randomized to the multicomponent intervention, which included a community health worker-led home intervention (health coaching, home BP monitoring, and BP audit and feedback), a physician intervention, and a text-messaging intervention over 18 months. Nine centers (689 patients) were randomized to usual care. Main Outcomes and Measures: The coprimary outcomes were the differences in systolic and diastolic BP changes from baseline to the end of follow-up of patients with hypertension. Secondary outcomes included the proportion of patients with controlled hypertension (BP <140/90 mm Hg). Three BP measurements were obtained at each of 2 baseline and 2 termination visits using a standard protocol, the means of which were used for analyses. Results: Of 1432 participants (mean age, 55.8 years [SD, 13.3]; 772 women [53.0%]), 1357 (94.8%) completed the trial. Baseline mean systolic BP was 151.7 mm Hg for the intervention group and 149.8 mm Hg for the usual care group; the mean diastolic BP was 92.2 mm Hg for the intervention group and 90.1 mm Hg for the usual care group. Systolic BP reduction from baseline to month 18 was 19.3 mm Hg (95% CI, 17.9-20.8 mm Hg) for the intervention group and 12.7 mm Hg (95% CI, 11.3-14.2 mm Hg) for the usual care group; the difference in the reduction was 6.6 mm Hg (95% CI, 4.6-8.6; P < .001). Diastolic BP decreased by 12.2 mm Hg (95% CI, 11.2-13.2 mm Hg) in the intervention group and 6.9 mm Hg (95% CI, 5.9-7.8 mm Hg) in the control group; the difference in the reduction was 5.4 mm Hg (95% CI, 4.0-6.8 mm Hg; P < .001). The proportion of patients with controlled hypertension increased from 17.0% at baseline to 72.9% at 18 months in the intervention group and from 17.6% to 52.2% in the usual care group; the difference in the increase was 20.6% (95% CI, 15.4%-25.9%; P < .001). No adverse events were reported. Conclusions and Relevance: Low-income patients in Argentina with uncontrolled hypertension who participated in a community health worker-led multicomponent intervention experienced a greater decrease in systolic and diastolic BP than did patients who received usual care over 18 months. Further research is needed to assess generalizability and cost-effectiveness of this intervention and to understand which components may have contributed most to the outcome. Trial Registration: clinicaltrials.gov Identifier: NCT01834131.

What does our region need in order to strengthen public policies on sugar-sweetened beverages? decision-makers' dialogue. / ¿Qué necesita nuestra región para fortalecer políticas públicas sobre bebidas azucaradas? diálogo de decisores.

In order to prioritize public policies to reduce the consumption of sugar-sweetened beverages in Argentina, Brazil, El Salvador and Trinidad and Tobago and to identify information gaps related to the burden of disease attributable to their consumption, a policy dialogue was held with government members, civil society organizations, researchers and communicators from Latin American and Caribbean countries. Presentations and deliberative workshops were conducted using semi-structured data collection tools and group discussions. The prioritized interventions were tax increases, front labeling, restriction of advertising, promotion and sponsorship, and modifications regarding the school environment. The main perceived barrier was the interference from the food industry. This dialogue among decision-makers led to the identification of priority public policies to reduce the consumption of sugar-sweetened beverages in the region.

Con el objetivo de priorizar políticas públicas para disminuir el consumo de bebidas azucaradas en Argentina, Brasil, El Salvador y Trinidad y Tobago e identificar las necesidades de información relacionadas con la carga de enfermedad atribuible a su consumo se realizó un diálogo de políticas en el que participaron miembros de gobierno, organizaciones de la sociedad civil, investigadores y comunicadores de países de Latinoamérica y el Caribe. Se llevaron a cabo exposiciones y talleres deliberativos utilizándose herramientas de recolección de datos semiestructuradas y discusiones grupales facilitadas. Las intervenciones priorizadas fueron el incremento de impuestos, el etiquetado frontal, la restricción de la publicidad, promoción y patrocinio y las modificaciones del entorno escolar. La principal barrera percibida fue la interferencia de la industria alimentaria. La realización de este diálogo de decisores permitió la identificación de las políticas públicas prioritarias para disminuir el consumo de bebidas azucaradas en la región.

Optimizing Tobacco Advertising Bans in Seven Latin American Countries: Microsimulation Modeling of Health and Financial Impact to Inform Evidence-Based Policy.

INTRODUCTION: In Latin America, tobacco smoking prevalence is between 6.4% and 35.2%. Governments have been making efforts to support the regulation of advertising and, in many cases, banning advertising and promotion of tobacco altogether. The objective of this study was to evaluate the potential impact on health and economic outcomes of optimizing a ban on tobacco advertising and sponsorship in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru. METHODS: We built a probabilistic microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths, events, healthy years of life) and costs. To populate the model, we performed a rapid review of literature to calculate intervention effectiveness. RESULTS: With current policies, over 10 years, in Argentina, Bolivia, Brazil, Chile, and Colombia a total of 50,000 deaths and 364,000 disease events will be averted, saving $7.2 billion. If the seven countries strengthened their policies and implemented a comprehensive ban with 100% compliance, 98,000 deaths and 648,000 events would be averted over 10 years, saving almost $15 billion in healthcare costs. CONCLUSIONS: Optimizing a ban on tobacco advertising and sponsorship would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy.

Generalized cost-effectiveness analysis of a package of interventions to reduce cardiovascular disease in Buenos Aires, Argentina.

BACKGROUND: Chronic diseases, represented mainly by cardiovascular disease (CVD) and cancer, are increasing in developing countries and account for 53% of chronic diseases in Argentina. There is strong evidence that a reduction of 50% of the deaths due to CVD can be attributed to a reduction in smoking, hypertension and hypercholesterolemia. Generalized cost-effectiveness analysis (GCE) is a methodology designed by WHO to inform decision makers about the extent to which current or new interventions represent an efficient use of resources. We aimed to use GCE analysis to identify the most efficient interventions to decrease CVD. METHODS: Six individual interventions (treatment of hypertension, hypercholesterolemia, smoking cessation and combined clinical strategies to reduce the 10 year CVD Risk) and two population-based interventions (cooperation between government, consumer associations and bakery chambers to reduce salt in bread, and mass education strategies to reduce hypertension, hypercholesterolemia and obesity) were selected for analysis. Estimates of effectiveness were entered into age and sex specific models to predict their impact in terms of age-weighted and discounted DALYs saved (disability-adjusted life years). To translate the age- and sex-adjusted incidence of CVD events into health changes, we used risk model software developed by WHO (PopMod). Costs of services were measured in Argentine pesos, and discounted at an annual rate of 3%. Different budgetary impact scenarios were explored. RESULTS: The average cost-effectiveness ratio in argentine pesos (ARS$) per DALY for the different interventions were: (i) less salt in bread $151; (ii) mass media campaign $547; (iii) combination drug therapy provided to subjects with a 20%, 10% and 5% global CVD risk, $3,599, $4,113 and $4,533, respectively; (iv) high blood pressure (HBP) lowering therapy $7,716; (v) tobacco cessation with bupropion $ 33,563; and (iv) high-cholesterol lowering therapy with statins $ 70,994. CONCLUSION: Against a threshold of average per capita income in Argentina, the two selected population-based interventions (lowering salt intake and health education through mass-media campaigns) plus the modified polypill strategy targeting people with a 20% or greater risk were cost-effective. Use of this methodology in developing countries can make resource-allocation decisions less intuitive and more driven by evidence.

[Burden of disease attributable to tobacco use in Paraguay, and potential health and financial impact of increasing prices through taxing]. / Carga de enfermedad atribuible al uso del tabaco en Paraguay y potencial impacto sanitario y económico del aumento del precio a través de impuestos.

OBJECTIVES: To consider the burden of disease associated to tobacco consumption in Paraguay and to evaluate the potential economic and health effect of price increase through taxes. MATERIALS AND METHODS: A Monte Carlo simulation model was designed incorporating natural history, costs, and quality of life of diseases associated to smoking for 2015. Also, several scenarios were considered for the impact of tax raises on the prevalence of smoking and fiscal collection. RESULTS: In Paraguay, 3,354 people die every year as a consequence of smoking. Nineteen percent of deaths are due to cardiac ischemia, 15% due to stroke. 77% of deaths due to chronic obstructive pulmonary disease (COPD), and 83% of lung cancer can be attributed to smoking. These diseases in Paraguay represent an annual direct medical cost of more than 1.5 trillion PYG, while the tax collection from cigarette sales barely covers 20% of this expense. A 50% increase in the price of cigarettes via taxes could avoid 2507 deaths in ten years and generate resources by 2.4 trillion in savings in health expenses and tax of collection. CONCLUSIONS: The cost and the burden of disease associated to tobacco consumption is high in the health system in Paraguay. An increase in cigarette price through taxes could have significant health benefits and could offset health costs in part.

OBJETIVOS.: Estimar la carga de enfermedad asociada al consumo de tabaco en Paraguay y evaluar el potencial efecto económico y sanitario del aumento de precio mediante impuestos. MATERIALES Y MÉTODOS.: Se diseñó un modelo de microsimulación de Monte Carlo que incorporó la historia natural, costos y calidad de vida de enfermedades asociadas al tabaquismo para el 2015. Asimismo, se estimó el impacto en varios escenarios de aumento de impuestos sobre la prevalencia de tabaquismo y la recaudación fiscal. RESULTADOS.: 3354 personas mueren al año en Paraguay por consecuencia del tabaquismo. El 19 % de las muertes son por enfermedad isquémica cardíaca, el 15 % por accidentes cerebrovasculares. El 77 % de las muertes por enfermedad pulmonar obstructiva crónica y el 83 % de cáncer de pulmón son atribuibles al tabaquismo. Estas enfermedades en Paraguay representan un costo médico directo anual de más de 1,5 x 106 millones de guaraníes, mientras la recaudación impositiva por la venta de cigarrillos apenas llega a cubrir un 20 % de este gasto. Un aumento en el precio de los cigarrillos del 50 % vía impuestos, podría llevar a evitar 2507 muertes en diez años y generar recursos por 2,4 x 106 millones por ahorro en gastos sanitarios y aumento de recaudación. CONCLUSIONES.: El costo y la carga de enfermedad asociado al consumo de tabaco en el sistema de salud es elevado en Paraguay. Un aumento del precio de los cigarrillos a través de los impuestos tendría importantes beneficios sanitarios y podría compensar parcialmente los costos sanitarios.

Oxytocin in Uniject Disposable Auto-Disable Injection System versus Standard Use for the Prevention of Postpartum Hemorrhage in Latin America and the Caribbean: A Cost-Effectiveness Analysis.

Postpartum hemorrhage (PPH) is a leading cause of maternal death. Despite strong evidence showing the efficacy of routine oxytocin in preventing PPH, the proportion of women receiving it after delivery is still below 100%. The Uniject injection system prefilled with oxytocin (Uniject) has the potential advantage, due to its ease of use, to increase oxytocin utilization rates. We aimed to assess its cost-effectiveness in Latin America and the Caribbean (LAC). We used an epidemiological model to estimate: a) the impact of replacing oxytocin in ampoules with Uniject on the incidence of PPH, quality-adjusted life years (QALYs) and costs from a health care system perspective, and b) the minimum increment in oxytocin utilization rates required to make Uniject a cost-effective strategy. A consensus panel of LAC experts was convened to quantify the expected increase in oxytocin rates as a consequence of making Uniject available. Deterministic and probabilistic sensitivity analyses were performed. In the base case, the incremental cost of Uniject with respect to oxytocin in ampoules was estimated to be USD 1.00 (2013 US dollars). In the cost-effectiveness analysis, Uniject ranged from being cost-saving (in 8 out of 30 countries) to having an incremental cost-effectiveness ratio (ICER) of USD 8,990 per QALY gained. In most countries these ICERs were below one GDP per capita. The minimum required increment in oxytocin rates to make Uniject a cost-effective strategy ranged from 1.3% in Suriname to 16.2% in Haiti. Switching to Uniject could prevent more than 40,000 PPH events annually in LAC. Uniject was cost-saving or very cost-effective in almost all countries. Even if countries can achieve only small increases in oxytocin rates by incorporating Uniject, this strategy could be considered a highly efficient use of resources. These results were robust in the sensitivity analysis under a wide range of assumptions.

Institutionalizing health technology assessment for priority setting and health policy in Latin America: from regional endeavors to national experiences.

In this paper, we provide a short summary of recent trends and key issues regarding the current status of health technology assessment (HTA) in Latin America. Initially, we describe worldwide and region-wide initiatives that foster the institutionalization of HTA for decision making and health policy in our region. Then, we describe some countries in the region that are worth mentioning for their application of HTA at a national level. The target audiences are those researchers and decision makers interested in following HTA in our region.

Comprehensive approach for hypertension control in low-income populations: rationale and study design for the hypertension control program in Argentina.

Although the efficacy and effectiveness of lifestyle modifications and antihypertensive pharmaceutical treatment for the prevention and control of hypertension and concomitant cardiovascular disease have been demonstrated in randomized controlled trials, this scientific knowledge has not been fully applied in the general population, especially in low-income communities. This article summarizes interventions to improve hypertension management and describes the rationale and study design for a cluster randomized trial testing whether a comprehensive intervention program within a national public primary care system will improve hypertension control among uninsured hypertensive men and women and their families. We will recruit 1,890 adults from 18 clinics within a public primary care network in Argentina. Clinic patients with uncontrolled hypertension, their spouses and hypertensive family members will be enrolled. The comprehensive intervention program targets the primary care system through health care provider education, a home-based intervention among patients and their families (home delivery of antihypertensive medication, self-monitoring of blood pressure [BP], health education for medication adherence and lifestyle modification) conducted by community health workers and a mobile health intervention. The primary outcome is net change in systolic BP from baseline to month 18 between intervention and control groups among hypertensive study participants. The secondary outcomes are net change in diastolic BP, BP control and cost-effectiveness of the intervention. This study will generate urgently needed data on effective, practical and sustainable intervention programs aimed at controlling hypertension and concomitant cardiovascular disease in underserved populations in low- and middle-income countries.

Carga de enfermedad atribuible al uso del tabaco en Paraguay y potencial impacto sanitario y económico del aumento del precio a través de impuestos / Burden of disease attributable to tobacco use in Paraguay, and potential health and financial impact of increasing prices through taxing

RESUMEN Objetivos. Estimar la carga de enfermedad asociada al consumo de tabaco en Paraguay y evaluar el potencial efecto económico y sanitario del aumento de precio mediante impuestos. Materiales y métodos. Se diseñó un modelo de microsimulación de Monte Carlo que incorporó la historia natural, costos y calidad de vida de enfermedades asociadas al tabaquismo para el 2015. Asimismo, se estimó el impacto en varios escenarios de aumento de impuestos sobre la prevalencia de tabaquismo y la recaudación fiscal. Resultados. 3354 personas mueren al año en Paraguay por consecuencia del tabaquismo. El 19 % de las muertes son por enfermedad isquémica cardíaca, el 15 % por accidentes cerebrovasculares. El 77 % de las muertes por enfermedad pulmonar obstructiva crónica y el 83 % de cáncer de pulmón son atribuibles al tabaquismo. Estas enfermedades en Paraguay representan un costo médico directo anual de más de 1,5 x 106 millones de guaraníes, mientras la recaudación impositiva por la venta de cigarrillos apenas llega a cubrir un 20 % de este gasto. Un aumento en el precio de los cigarrillos del 50 % vía impuestos, podría llevar a evitar 2507 muertes en diez años y generar recursos por 2,4 x 106 millones por ahorro en gastos sanitarios y aumento de recaudación. Conclusiones. El costo y la carga de enfermedad asociado al consumo de tabaco en el sistema de salud es elevado en Paraguay. Un aumento del precio de los cigarrillos a través de los impuestos tendría importantes beneficios sanitarios y podría compensar parcialmente los costos sanitarios.

ABSTRACT Objectives . To consider the burden of disease associated to tobacco consumption in Paraguay and to evaluate the potential economic and health effect of price increase through taxes. Materials and Methods . A Monte Carlo simulation model was designed incorporating natural history, costs, and quality of life of diseases associated to smoking for 2015. Also, several scenarios were considered for the impact of tax raises on the prevalence of smoking and fiscal collection. Results . In Paraguay, 3,354 people die every year as a consequence of smoking. Nineteen percent of deaths are due to cardiac ischemia, 15% due to stroke. 77% of deaths due to chronic obstructive pulmonary disease (COPD), and 83% of lung cancer can be attributed to smoking. These diseases in Paraguay represent an annual direct medical cost of more than 1.5 trillion PYG, while the tax collection from cigarette sales barely covers 20% of this expense. A 50% increase in the price of cigarettes via taxes could avoid 2507 deaths in ten years and generate resources by 2.4 trillion in savings in health expenses and tax of collection. Conclusions . The cost and the burden of disease associated to tobacco consumption is high in the health system in Paraguay. An increase in cigarette price through taxes could have significant health benefits and could offset health costs in part.

Evaluación del impacto sanitario del Programa Estaciones Saludables en la Ciudad Autónoma de Buenos Aires, Argentina / Health impact assessment of the Program Healthy Centers in the Autonomous City of Buenos Aires, Argentina / Avaliação do impacto na saúde do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires, Argentina

RESUMEN Objetivo Explorar las motivaciones y expectativas de los usuarios del Programa de Estaciones Saludables en la Ciudad Autónoma de Buenos Aires y evaluar su potencial impacto sanitario. Métodos Se realizaron entrevistas en profundidad (n = 34) y una encuesta autoadministrada (n = 605) a usuarios del programa. Se desarrolló un modelo epidemiológico para estimar el impacto del programa sobre los eventos cardiovasculares y los años de vida ajustados por discapacidad (AVAD). Resultados Los principales factores motivadores para el uso de las estaciones saludables fueron la accesibilidad geográfica, económica (servicios gratuitos) y la satisfacción con la atención recibida. El 14,4% (intervalos de confianza del 95% [IC95%] 10,3-18,5%) de los usuarios hipertensos y el 24,8% (IC95% 17,6-32,0%) de los diabéticos informó haberse enterado de sus valores alterados en las estaciones saludables. Más de la mitad de los encuestados reportó alguna mejora de conocimientos sobre los beneficios de realizar actividad física y una alimentación saludable; esto fue más frecuente entre los usuarios más jóvenes, de menor nivel educativo, usuarios del sistema público de salud, usuarios de estaciones saludables de la zona sur y los que tenían algún factor de riesgo cardiometabólico (p<0.05). Se estimó que debido a la existencia de estaciones saludables se evitarían 12,5 eventos cardiovasculares y cerebrovasculares por año en la población asistida (4,75 eventos/100 000 personas) y 47,75 AVAD por estas causas. Conclusiones Las estaciones saludables resultan un espacio propicio para la implementación de acciones de promoción de la salud y prevención, contribuyendo en la detección y facilitando el monitoreo de los factores de riesgo, con potencialidad para prevenir eventos cardiovasculares y sus consecuencias.

ABSTRACT Objective To explore the motivations and expectations of the users of the Program for Healthy Centers in the Autonomous City of Buenos Aires and to evaluate its potential health impact. Methods In-depth interviews were conducted (n = 34) and a self-administered survey was sent to users of the program (n = 605). An epidemiological model was developed to estimate the impact of the program on cardiovascular events (CVE) and disability-adjusted life years (DALYs). Results The main motivating factors for using the healthy centers were geographic and economic accessibility (free services) and satisfaction with the care received. 14.4% (95% CI, 10.3-18.5%) of hypertensive users and 24.8% (95% CI, 17.6-32.0%) of diabetic users reported having learned of their altered values in the healthy center. More than half of the respondents reported some improvement in their knowledge about the benefits of physical activity and healthy eating; this was more frequent among those who were younger, of lower educational level, users of the public health system, users of a healthy center in the South zone and those who had a cardiometabolic risk factor (p<0.05). It was estimated that the healthy centers would prevent 12.5 cardiovascular and cerebrovascular events per year in the assisted population (4.75 events/100 000) and 47.75 DALYs due to these causes. Conclusions The healthy centers are a favorable space for the implementation of health promotion and prevention actions, contributing to the detection of and facilitating the monitoring of risk factors, with a potential to prevent cardiovascular events and its consequences.

RESUMO Objetivo Explorar as motivações e expectativas dos usuários do Programa Estações Saudáveis na Cidade Autônoma de Buenos Aires e avaliar seu impacto potencial na saúde. Métodos Foram realizadas entrevistas em profundidade (n = 34) e uma pesquisa auto-administrada (n = 605) a usuários do programa. Um modelo epidemiológico foi desenvolvido para estimar o impacto do programa em eventos cardiovasculares e anos de vida ajustados por incapacidade (DALY). Resultados Os principais fatores motivadores para o uso do estações saudáveis foram a acessibilidade geográfica, econômica (serviços gratuitos) e a satisfação com o atendimento recebido. 14,4% (intervalo de confiança de 95% [IC95%] 10,3-18,5%) de usuários hipertensos e 24,8% (IC95% 17,6-32,0%) dos diabéticos relataram ter aprendido sobre seus valores alterados na estação saudável. Mais da metade dos entrevistados relataram alguma melhora no conhecimento sobre os benefícios da atividade física e da alimentação saudável, com maior freqüência entre os mais jovens, de menor escolaridade, usuários do sistema público de saúde, usuários de estações saudáveis na zona sul e aqueles que apresentaram algum fator de risco cardiometabólico (p<0,05). Estimou-se que, devido à existência de estações saudáveis, 12,5 eventos cardiovasculares e cerebrovasculares por ano seriam evitados na população atendida (4,75 eventos/100 000) e 47,75 DALY por essas causas. Conclusões As estações saudáveis são um espaço propício para a implementação de ações de promoção e prevenção da saúde, contribuindo para a detecção e facilitação do monitoramento dos fatores de risco, com potencial para prevenir os eventos cardiovasculares e suas consequências.