Evidence for scaling up HIV treatment in sub-Saharan Africa: A call for incorporating health system constraints.

Jan Hontelez and colleagues argue that the cost-effectiveness studies of HIV treatment scale-up need to include health system constraints to be more informative.

Incorporating equity-efficiency interactions in cost-effectiveness analysis-three approaches applied to breast cancer control.

BACKGROUND: The past decade, medical technology assessment focused on cost-effectiveness analysis, yet there is an increasing need to consider equity implications of health interventions as well. This article addresses three equity-efficiency trade-off methods proposed in the literature. Moreover, it demonstrates their impact on cost-effectiveness analyses in current breast cancer control options for women of different age groups. METHODS: We adapted an existing breast cancer model to estimate cost-effectiveness and equity effects of breast cancer interventions. We applied three methods to quantify the equity-efficiency trade-offs: 1) targeting specific groups, comparing disparities at baseline and in different intervention scenarios; 2) equity weighting, valuing low and high health gains differently; and 3) multicriteria decision analysis, weighing multiple equity and efficiency criteria. We compared the resulting composite league tables of all approaches. RESULTS: The approaches show that a comprehensive breast cancer program, including screening, for women below 75 years of age was most attractive in both the group targeting approach and the equity weighting approach. Such control programs would reduce disparities with 56% and at euro1908 per equity quality-adjusted life-year gained. In the multicriteria approach, a comprehensive treatment program for women below 75 years of age and treatment in stage III breast cancer were most attractive, with both an 82% selection probability, followed by screening programs for the two age groups. CONCLUSION: In the three equity weighing approaches, targeting women below 75 years of age was more cost-effective and led to more equitable distributions of health. This likely is similar in other fatal diseases with similar age distributions. The approaches may lead to different outcomes in nonfatal disease.

An eye for inequality: how trachoma relates to poverty in Tanzania and Vietnam.

PURPOSE: An important challenge for trachoma control strategies is to break the circle of poverty, poor hygiene and poor health by bringing its benefits to the poor. This article aims to assess to what extent trachoma is a disease of the poor, and trachoma services reach the poor in Tanzania and Vietnam. METHODS: Individual level data on trachoma prevalence (active trachoma and trichiasis) and utilization of trachoma-related services were collected in both countries in 2004. Prevalence data were also available for Vietnam in 2001. We used household level data to construct an asset index as our living standards measure. Next, we related trachoma prevalence and service use to living standards, and used concentration indices to summarize and test the degree of inequality. RESULTS: Trachoma prevalence was higher among the poorest groups in Tanzania. No such relation could be established in Vietnam where prevalence declined over the period 2001-2004 and particularly so among the least poor. Antibiotics were used more by the poorest in Tanzania and by the less poor in Vietnam. In both countries, there was no unequivocal pattern for the relation between living standards and the use of trachoma services. CONCLUSIONS: Trachoma is found to be a disease of the poorest in Tanzania, but not in Vietnam. In the latter country there are indications that district characteristics have an important impact on trachoma prevalence. The higher use of antibiotics among the better-off in Vietnam may have contributed to their larger decline in active trachoma prevalence between 2001 and 2004 compared to the poorer segments.

Cost-effectiveness of trachoma control in seven world regions.

BACKGROUND/AIMS: The fight against blinding trachoma is being addressed with an integrated strategy of surgery, antibiotics, hygiene promotion, and environmental improvement-the SAFE strategy, but its cost-effectiveness is largely unknown. This paper estimates the cost effectiveness of surgery and antibiotics in trachoma-endemic areas in seven world regions. METHODS: A population model was applied to follow the lifelong impact on individuals receiving trachoma control. Intervention costs and effectiveness estimates were based on a combination of primary data collection and literature review. RESULTS: Providing trichiasis surgery to 80% of those who need it would avert over 11 million DALYs per year globally, with cost effectiveness ranging from I$13 to I$78 per DALY averted across regions. Mass antibiotic treatment of all children using azythromycin at prevailing market prices would avert more than 4 million DALYs per year globally with cost-effectiveness ranging between I$9,000 and I$65,000 per DALY averted. The intervention is only cost-effective if azythromycin is donated or becomes available at reduced prices. Mass treatment of all children with tetracycline and targeted treatment with azythromycin are not cost-effective. CONCLUSIONS: As individual components of the SAFE strategy, trichiasis surgery for trachoma is a cost-effective way of restoring sight in all epidemiological sub-regions considered, as is the use of azythromycin, if donated or at reduced prices. Large study uncertainties do not change study conclusions. The results should be interpreted in the context of the overall SAFE strategy to address issues of sustainability.

A dollar is a dollar is a dollar--or is it?

It is normally stated that an economic evaluation should take the societal perspective and that this implies the incorporation of all costs and effects, regardless of where these occur. Nevertheless, this broad perspective may be in conflict with the narrower perspective of the health-care decision-makers we are usually trying to aid. In this article, it is argued that not all costs have to be considered equally important for health-care decision-making and that there is a discrepancy between the economically preferred societal perspective and the aim of aiding health-care decision-makers. This is related to the concept of local rationality. Three reasons why some costs may be considered more important for health-care decision-makers than others are: 1) relevance; 2) equity; and 3) responsibility. We suggest that it may be useful to adopt a two-perspective approach as a standard, presenting one cost-effectiveness ratio following a strict health-care perspective and one following the common societal perspective. The health-care perspective may assist the health-care policymaker better in achieving health-care goals, while the societal perspective indicates whether the local rationality of the narrow health-care perspective is also in line with societal optimality. More research on actual decisions should provide more insight into the relative weights attached to different types of costs.

Uncertainty in cost-effectiveness analysis. Probabilistic uncertainty analysis and stochastic league tables.

Interest is growing in the application of standard statistical inferential techniques to the calculation of cost-effectiveness ratios (CER), but individual level data will not be available in many cases because it is very difficult to undertake prospective controlled trials of many public health interventions. We propose the application of probabilistic uncertainty analysis using Monte Carlo simulations, in combination with nonparametric bootstrapping techniques where appropriate. This paper also discusses how decision makers should interpret the CER of interventions where uncertainty intervals overlap. We show how the incorporation of uncertainty around costs and effects of interventions into a stochastic league table provides additional information to decision makers for priority setting. Stochastic league tables inform decision makers about the probability that a specific intervention would be included in the optimal mix of interventions for different resource levels, given the uncertainty surrounding the interventions.