Building implementable packages for universal health coverage.

Since no country or health system can provide every possible health service to everyone who might benefit, the prioritisation of a defined subset of services for universal availability is intrinsic to universal health coverage (UHC). Creating a package of priority services for UHC, however, does not in itself benefit a population-packages have impact only through implementation. There are inherent tensions between the way services are formulated to facilitate criteria-driven prioritisation and the formulations that facilitate implementation, and service delivery considerations are rarely well incorporated into package development. Countries face substantial challenges bridging from a list of services in a package to the elements needed to get services to people. The failure to incorporate delivery considerations already at the prioritisation and design stage can result in packages that undermine the goals that countries have for service delivery. Based on a range of country experiences, we discuss specific choices about package structure and content and summarise some ideas on how to build more implementable packages of services for UHC, arguing that well-designed packages can support countries to bridge effectively from intent to implementation.

Global return on investment and cost-effectiveness of WHO's HEAR interventions for hearing loss: a modelling study.

BACKGROUND: To address the growing prevalence of hearing loss, WHO has identified a compendium of key evidence-based ear and hearing care interventions to be included within countries' universal health coverage packages. To assess the cost-effectiveness of these interventions and their budgetary effect for countries, we aimed to analyse the investment required to scale up services from baseline to recommended levels, and the return to society for every US$1 invested in the compendium. METHODS: We did a modelling study using the proposed set of WHO interventions (summarised under the acronym HEAR: hearing screening and intervention for newborn babies and infants, pre-school and school-age children, older adults, and adults at higher risk of hearing loss; ear disease prevention and management; access to technologies such as hearing aids, cochlear implants, or hearing assistive technologies; and rehabilitation service provision), which span the life course and include screening and management of hearing loss and related ear diseases, costs and benefits for the national population cohorts of 172 countries. The return on investment was analysed for the period between 2020 and 2030 using three scenarios: a business-as-usual scenario, a progress scenario with a scale-up to 50% of recommended coverage, and an ambitious scenario with scale-up to 90% of recommended coverage. Using data for hearing loss burden from the Global Burden of Disease Study 2019, a transition model with three states (general population, diagnosed, and those who have died) was developed to model the national populations in countries. For the return-on-investment analysis, the monetary value of disability-adjusted life-years (DALYs) averted in addition to productivity gains were compared against the investment required in each scenario. FINDINGS: Scaling up ear and hearing care interventions to 90% requires an overall global investment of US$238·8 billion over 10 years. Over a 10-year period, this investment promises substantial health gains with more than 130 million DALYs averted. These gains translate to a monetary value of more than US$1·3 trillion. In addition, investment in hearing care will result in productivity benefits of more than US$2 trillion at the global level by 2030. Together, these benefits correspond to a return of nearly US$15 for every US$1 invested. INTERPRETATION: This is the first-ever global investment case for integrating ear and hearing care interventions in countries' universal health coverage services. The findings show the economic benefits of investing in this compendium and provide the basis for facilitating the increase of country's health budget for strengthening ear and hearing care services. FUNDING: None.

Introduction to the Special Issue on "The World Health Organization Choosing Interventions That Are Cost-Effective (WHO-CHOICE) Update".

The WHO-CHOICE (World Health Organization CHOosing Interventions that are Cost-Effective) approach is unique in the global health landscape, as it takes a "generalized" approach to cost-effectiveness analysis (CEA) that can be seen as a quantitative assessment of current and future efficiency within a health system. CEA is a critical contribution to the process of priority setting and decision-making in healthcare, contributing to deliberative dialogue processes to select services to be funded. WHO-CHOICE provides regional level estimates of cost-effectiveness, along with tools to support country level analyses. This series provides an update to the methodological approach used in WHO-CHOICE and presents updated cost-effectiveness estimates for 479 interventions. Five papers are presented, the first focusing on methodological updates, followed by three results papers on maternal, newborn and child health; HIV, tuberculosis and malaria; and non-communicable diseases and mental health. The final paper presents a set of example universal health coverage (UHC) benefit packages selected through only a value for money lens, showing that all disease areas have interventions which can fall on the efficiency frontier. Critical for all countries is institutionalizing decision-making processes. A UHC benefit package should not be static, as the countries needs and ability to pay change over time. Decisions will need to be continually revised and new interventions added to health benefit packages. This is a vital component of progressive realization, as the package is expanded over time. Developing an institutionalized process ensures this can be done consistently, fairly, and transparently, to ensure an equitable path to UHC.

Contextualization of cost-effectiveness evidence from literature for 382 health interventions for the Ethiopian essential health services package revision.

BACKGROUND: Cost-effectiveness of interventions was a criterion decided to guide priority setting in the latest revision of Ethiopia's essential health services package (EHSP) in 2019. However, conducting an economic evaluation study for a broad set of health interventions simultaneously is challenging in terms of cost, timeliness, input data demanded, and analytic competency. Therefore, this study aimed to synthesize and contextualize cost-effectiveness evidence for the Ethiopian EHSP interventions from the literature. METHODS: The evidence synthesis was conducted in five key steps: search, screen, evaluate, extract, and contextualize. We searched MEDLINE and EMBASE research databases for peer-reviewed published articles to identify average cost-effectiveness ratios (ACERs). Only studies reporting cost per disability-adjusted life year (DALY), quality-adjusted life year (QALY), or life years gained (LYG) were included. All the articles were evaluated using the Drummond checklist for quality, and those with a score of at least 7 out of 10 were included. Information on cost, effectiveness, and ACER was extracted. All the ACERs were converted into 2019 US dollars using appropriate exchange rates and the GDP deflator. RESULTS: In this study, we synthesized ACERs for 382 interventions from seven major program areas, ranging from US$3 per DALY averted (for the provision of hepatitis B vaccination at birth) to US$242,880 per DALY averted (for late-stage liver cancer treatment). Overall, 56% of the interventions have an ACER of less than US$1000 per DALY, and 80% of the interventions have an ACER of less than US$10,000 per DALY. CONCLUSION: We conclude that it is possible to identify relevant economic evaluations using evidence from the literature, even if transferability remains a challenge. The present study identified several cost-effective candidate interventions that could, if scaled up, substantially reduce Ethiopia's disease burden.

Cost-Effectiveness of Population Level and Individual Level Interventions to Combat Non-communicable Disease in Eastern Sub-Saharan Africa and South East Asia: A WHO-CHOICE Analysis.

BACKGROUND: To determine the health system costs and health-related benefits of interventions for the prevention and control of non-communicable diseases (NCDs), including mental health disorders, for the purpose of identifying the most cost-effective intervention options in support of global normative guidance on the best-buy interventions for NCDs. In addition, tools are developed to allow country contextualisation of the analyses to support local priority setting exercises. METHODS: This analysis follows the standard WHO-CHOICE (World Health Organization-Choosing Interventions that are Cost-Effective) approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and South-East Asia. The scope of the analysis is all NCD and mental health interventions included in WHO guidelines or guidance documents for which the health impact of the intervention is able to be identified and attributed. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, both for a period of 100 years. RESULTS: There are many interventions for NCD prevention and management that are highly cost-effective, generating one year of healthy life for less than Int. $100. These interventions include tobacco and alcohol control policies such as taxation, voluntary and legislative actions to reduce sodium intake, mass media campaigns for reducing physical activity, and treatment options for cardiovascular disease (CVD), cervical cancer and epilepsy. In addition a number of interventions fall just outside this range, including breast cancer, depression and chronic lung disease treatment. CONCLUSION: Interventions that represent good value for money, are technically feasible and are delivered for a low per-capita cost, are available to address the rapid rise in NCDs in low- and middle-income countries. This paper also describes a tool to support countries in developing NCD action plans.

Cost-Effectiveness of Interventions to Improve Maternal, Newborn and Child Health Outcomes: A WHO-CHOICE Analysis for Eastern Sub-Saharan Africa and South-East Asia.

BACKGROUND: Information on cost-effectiveness allows policy-makers to evaluate if they are using currently available resources effectively and efficiently. Our objective is to examine the cost-effectiveness of health interventions to improve maternal, newborn and child health (MNCH) outcomes, to provide global evidence relative to the context of two geographic regions. METHODS: We consider interventions across the life course from adolescence to pregnancy and for children up to 5 years old. Interventions included are those that fall within the areas of immunization, child healthcare, nutrition, reproductive health, and maternal/newborn health, and for which it is possible to model impact on MNCH mortality outcomes using the Lives Saved Tool (LiST). Generalized cost-effectiveness analysis (GCEA) was used to derive average cost-effectiveness ratios (ACERs) for individual interventions and combinations (packages). Costs were assessed from the health system perspective and reported in international dollars. Health outcomes were estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. The model was run for 2 regions: Eastern sub-Saharan Africa (SSA-E) and South-East Asia (SEA). RESULTS: The World Health Organization (WHO) recommended interventions to improve MNCH are generally considered cost-effective, with the majority of interventions demonstrating ACERs below I$100/HLY saved in the chosen settings (low-and middle-income countries [LMICs]). Best performing interventions are consistent across the two regions, and include family planning, neonatal resuscitation, management of pneumonia and neonatal infection, vitamin A supplementation, and measles vaccine. ACERs below I$100 can be found across all delivery platforms, from community to hospital level. The combination of interventions into packages (such as antenatal care) produces favorable ACERs. CONCLUSION: Within each region there are interventions which represent very good value for money. There are opportunities to gear investments towards high-impact interventions and packages for MNCH outcomes. Cost-effectiveness tools can be used at national level to inform investment cases and overall priority setting processes.

Methods for the Economic Evaluation of Health Care Interventions for Priority Setting in the Health System: An Update From WHO CHOICE.

The World Health Organization's (WHO's) Choosing Interventions that are Cost-Effective (CHOICE) programme has been a global leader in the field of economic evaluation, specifically cost-effectiveness analysis for almost 20 years. WHO-CHOICE takes a "generalized" approach to cost-effectiveness analysis that can be seen as a quantitative assessment of current and future efficiency within a health system. This supports priority setting processes, ensuring that health stewards know how to spend resources in order to achieve the highest health gain as one consideration in strategic planning. This approach is unique in the global health landscape. This paper provides an overview of the methodological approach, updates to analytic framework over the past 10 years, and the added value of the WHO-CHOICE approach in supporting decision makers as they aim to use limited health resources to achieve the Sustainable Development Goals (SDGs) by 2030.

Progressive Realisation of Universal Health Coverage in Low- and Middle-Income Countries: Beyond the "Best Buys".

BACKGROUND: World Health Organization Choosing Interventions that are Cost-Effective (WHO CHOICE) has been a programme of the WHO for 20 years. In this latest update, we present for the first time a cross-programme analysis of the comparative cost-effectiveness of 479 intervention scenarios across 20 disease programmes and risk factors. METHODS: This analysis follows the standard WHO CHOICE approach to generalized cost-effectiveness analysis applied to two regions, Eastern sub-Saharan Africa and Southeast Asia. The scope of the analysis is all interventions included in programme specific WHO CHOICE analyses, using WHO treatment guidelines for major disease areas as the foundation. Costs are measured in 2010 international dollars, and benefits modelled beginning in 2010, or the nearest year for which validated data was available, both for a period of 100 years. RESULTS: Across both regions included in the analysis, interventions span multiple orders of magnitude in terms of cost-effectiveness ratios. A health benefit package optimized through a value for money lens incorporates interventions responding to all of the main drivers of disease burden. Interventions delivered through first level clinical and non-clinical services represent the majority of the high impact cost-effective interventions. CONCLUSION: Cost-effectiveness is one important criterion when selecting health interventions for benefit packages to progress towards universal health coverage (UHC), but it is not the only criterion and all calculations should be adapted to the local context. To support country decision-makers, WHO CHOICE has developed a downloadable tool to support the development of data for this criterion.

Generalised cost-effectiveness analysis of 159 health interventions for the Ethiopian essential health service package.

BACKGROUND: Cost effectiveness was a criterion used to revise Ethiopia's essential health service package (EHSP) in 2019. However, there are few cost-effectiveness studies from Ethiopia or directly transferable evidence from other low-income countries to inform a comprehensive revision of the Ethiopian EHSP. Therefore, this paper reports average cost-effectiveness ratios (ACERs) of 159 health interventions used in the revision of Ethiopia's EHSP. METHODS: In this study, we estimate ACERs for 77 interventions on reproductive maternal neonatal and child health (RMNCH), infectious diseases and water sanitation and hygiene as well as for 82 interventions on non-communicable diseases. We used the standardised World Health Organization (WHO) CHOosing Interventions that are cost effective methodology (CHOICE) for generalised cost-effectiveness analysis. The health benefits of interventions were determined using a population state-transition model, which simulates the Ethiopian population, accounting for births, deaths and disease epidemiology. Healthy life years (HLYs) gained was employed as a measure of health benefits. We estimated the economic costs of interventions from the health system perspective, including programme overhead and training costs. We used the Spectrum generalised cost-effectiveness analysis tool for data analysis. We did not explicitly apply cost-effectiveness thresholds, but we used US$100 and $1000 as references to summarise and present the ACER results. RESULTS: We found ACERs ranging from less than US$1 per HLY gained (for family planning) to about US$48,000 per HLY gained (for treatment of stage 4 colorectal cancer). In general, 75% of the interventions evaluated had ACERs of less than US$1000 per HLY gained. The vast majority (95%) of RMNCH and infectious disease interventions had an ACER of less than US$1000 per HLY while almost half (44%) of non-communicable disease interventions had an ACER greater than US$1000 per HLY. CONCLUSION: The present study shows that several potential cost-effective interventions are available that could substantially reduce Ethiopia's disease burden if scaled up. The use of the World Health Organization's generalised cost-effectiveness analysis tool allowed us to rapidly calculate country-specific cost-effectiveness analysis values for 159 health interventions under consideration for Ethiopia's EHSP.

Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective?

OBJECTIVE: Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported. METHODS: Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs). RESULTS: The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied. SIGNIFICANCE: CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Revision of the Ethiopian Essential Health Service Package: An Explication of the Process and Methods Used.

To make progress toward universal health coverage, countries should define the type and mix of health services that respond to their populations' needs. Ethiopia revised its essential health services package (EHSP) in 2019. This paper describes the process, methodology and key features of the new EHSP. A total of 35 consultative workshops were convened with experts and the public to define the scope of the revision, develop a list of health interventions, agree on the prioritization criteria, gather evidence and compare health interventions. Seven prioritization criteria were employed: disease burden, cost effectiveness, equity, financial risk protection, budget impact, public acceptability and political acceptability. In the first phase, 1,749 interventions were identified, including existing and new interventions, which were regrouped and reorganized to identify 1,442 interventions as relevant. The second phase removed interventions that did not match the burden of disease or were not relevant in the Ethiopian setting, reducing the number of interventions to 1,018. These were evaluated further and ranked by the other criteria. Finally, 594 interventions were classified as high priority (58%), 213 as medium priorities (21%) and 211 as low priority interventions (21%). The current policy is to provide 570 interventions (56%) free of charge while guaranteeing the availability of the remaining services with cost-sharing (38%) and cost-recovery (6%) mechanisms in place. In conclusion, the revision of Ethiopia's EHSP followed a participatory, inclusive and evidence-based prioritization process. The interventions included in the EHSP were comprehensive and were assigned to health care delivery platforms and linked to financing mechanisms.

Investing in non-communicable diseases: an estimation of the return on investment for prevention and treatment services.

The global burden of non-communicable diseases (NCDs) is growing, and there is an urgent need to estimate the costs and benefits of an investment strategy to prevent and control NCDs. Results from an investment-case analysis can provide important new evidence to inform decision making by governments and donors. We propose a methodology for calculating the economic benefits of investing in NCDs during the Sustainable Development Goals (SDGs) era, and we applied this methodology to cardiovascular disease prevention in 20 countries with the highest NCD burden. For a limited set of prevention interventions, we estimated that US$120 billion must be invested in these countries between 2015 and 2030. This investment represents an additional $1·50 per capita per year and would avert 15 million deaths, 8 million incidents of ischaemic heart disease, and 13 million incidents of stroke in the 20 countries. Benefit-cost ratios varied between interventions and country-income levels, with an average ratio of 5·6 for economic returns but a ratio of 10·9 if social returns are included. Investing in cardiovascular disease prevention is integral to achieving SDG target 3.4 (reducing premature mortality from NCDs by a third) and to progress towards SDG target 3.8 (the realisation of universal health coverage). Many countries have implemented cost-effective interventions at low levels, so the potential to achieve these targets and strengthen national income by scaling up these interventions is enormous.

Investing in non-communicable disease prevention and management to advance the Sustainable Development Goals.

Reduction of the non-communicable disease (NCD) burden is a global development imperative. Sustainable Development Goal (SDG) 3 includes target 3·4 to reduce premature NCD mortality by a third by 2030. Progress on SDG target 3·4 will have a central role in determining the success of at least nine SDGs. A strengthened effort across multiple sectors with effective economic tools, such as price policies and insurance, is necessary. NCDs are heavily clustered in people with low socioeconomic status and are an important cause of medical impoverishment. They thereby exacerbate economic inequities within societies. As such, NCDs are a barrier to achieving SDG 1, SDG 2, SDG 4, SDG 5, and SDG 10. Productivity gains from preventing and managing NCDs will contribute to SDG 8. SDG 11 and SDG 12 offer clear opportunities to reduce the NCD burden and to create sustainable and healthy cities.

Global health worker salary estimates: an econometric analysis of global earnings data.

BACKGROUND: Human resources are consistently cited as a leading contributor to health care costs; however the availability of internationally comparable data on health worker earnings for all countries is a challenge for estimating the costs of health care services. This paper describes an econometric model using cross sectional earnings data from the International Labour Organization (ILO) that the World Health Organizations (WHO)-Choosing Interventions that are Cost-effective programme (CHOICE) has used to prepare estimates of health worker earnings (in 2010 USD) for all WHO member states. METHODS: The ILO data contained 324 observations of earnings data across 4 skill levels for 193 countries. Using this data, along with the assumption that data were missing not at random, we used a Heckman two stage selection model to estimate earning data for each of the 4 skill levels for all WHO member states. RESULTS: It was possible to develop a prediction model for health worker earnings for all countries for which GDP data was available. Health worker earnings vary both within country due to skill level, as well as across countries. As a multiple of GDP per capita, earnings show a negative correlation with GDP-that is lower income countries pay their health workers relatively more than higher income countries. CONCLUSIONS: Limited data on health worker earnings is a limiting factor in estimating the costs of global health programmes. It is hoped that these estimates will support robust health care intervention costings and projections of resources needs over the Sustainable Development Goal period.

Disease control programme support costs: an update of WHO-CHOICE methodology, price databases and quantity assumptions.

BACKGROUND: Estimating health care costs, either in the context of understanding resource utilization in the implementation of a health plan, or in the context of economic evaluation, has become a common activity of health planners, health technology assessment agencies and academic groups. However, data sources for costs outside of direct service delivery are often scarce. WHO-CHOICE produces global price databases and guidance on quantity assumptions to support country level costing exercises. This paper presents updates to the WHO-CHOICE methodology and price databases for programme costs. METHODS: We collated publicly available databases for 14 non-traded cost variables, as well as a set of traded items used within health systems (traded goods are those which can be purchased from anywhere in the world, whereas non-traded goods are those which must be produced locally, such as human resources). Within each of the variables, missing data was present for some proportion of the WHO member states. For each variables statistical or econometric models were used to model prices for each of the 194 WHO member states in 2010 International Dollars. Literature reviews were used to update quantity assumptions associated with each variable to contribute to the support costs of disease control programmes. RESULTS: A full database of prices for disease control programme support costs is available for country-specific costing purposes. Human resources are the largest driver of disease control programme support costs, followed by supervision costs. CONCLUSIONS: Despite major advances in the availability of data since the previous version of this work, there are still some limitations in data availability to respond to the needs of those wishing to develop cost and cost-effectiveness estimates. Greater attention to programme support costs in cost data collection activities would contribute to an understanding of how these costs contribute to quality of health service delivery and should be encouraged.

Priority Setting for Universal Health Coverage: We Need to Focus Both on Substance and on Process Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, not Just More Evidence on Cost-Effectiveness".

In an editorial published in this journal, Baltussen et al argue that information on cost-effectiveness is not sufficient for priority setting for universal health coverage (UHC), a claim which is correct as far as it goes. However, their focus on the procedural legitimacy of 'micro' priority setting processes (eg, decisions concerning the reimbursement of specific interventions), and their related assumption that values for priority setting are determined only at this level, leads them to ignore the relevance of higher level, 'macro' priority setting processes, for example, consultations held by World Health Organization (WHO) Member States and other global stakeholders that have resulted in widespread consensus on the principles of UHC. Priority setting is not merely about discrete choices, nor should the focus be exclusively (or even mainly) on improving the procedural elements of micro priority setting processes. Systemic activities that shape the health system environment, such as strategic planning, as well as the substantive content of global policy instruments, are critical elements for priority setting for UHC.

Cost-effectiveness thresholds: pros and cons.

Cost-effectiveness analysis is used to compare the costs and outcomes of alternative policy options. Each resulting cost-effectiveness ratio represents the magnitude of additional health gained per additional unit of resources spent. Cost-effectiveness thresholds allow cost-effectiveness ratios that represent good or very good value for money to be identified. In 2001, the World Health Organization's Commission on Macroeconomics in Health suggested cost-effectiveness thresholds based on multiples of a country's per-capita gross domestic product (GDP). In some contexts, in choosing which health interventions to fund and which not to fund, these thresholds have been used as decision rules. However, experience with the use of such GDP-based thresholds in decision-making processes at country level shows them to lack country specificity and this - in addition to uncertainty in the modelled cost-effectiveness ratios - can lead to the wrong decision on how to spend health-care resources. Cost-effectiveness information should be used alongside other considerations - e.g. budget impact and feasibility considerations - in a transparent decision-making process, rather than in isolation based on a single threshold value. Although cost-effectiveness ratios are undoubtedly informative in assessing value for money, countries should be encouraged to develop a context-specific process for decision-making that is supported by legislation, has stakeholder buy-in, for example the involvement of civil society organizations and patient groups, and is transparent, consistent and fair.

Les analyses de rentabilité permettent de comparer les coûts et les résultats de différentes options politiques. Chaque ratio coût-efficacité qui en découle indique l'importance des avantages supplémentaires pour la santé par unité supplémentaire de ressources dépensée. Les seuils de rentabilité permettent de déterminer les ratios coût-efficacité qui représentent une bonne ou une très bonne rentabilité. En 2001, la Commission macroéconomie et santé de l'Organisation mondiale de la Santé a suggéré des seuils de rentabilité définis d'après des multiples du produit intérieur brut (PIB) par habitant d'un pays. Dans certains pays, ces seuils ont servi de règles pour décider quelles interventions financer ou non. Cependant, l'expérience d'utilisation de ces seuils fondés sur le PIB dans les processus décisionnels des pays montre qu'ils ne tiennent pas compte des spécificités des pays; cela, ajouté à une certaine incertitude concernant la modélisation des ratios coût-efficacité, peut entraîner la prise de mauvaises décisions quant à l'utilisation des ressources sanitaires. Les informations sur la rentabilité des interventions devraient être prises en compte parallèlement à d'autres considérations, comme l'impact budgétaire et la faisabilité, dans le cadre d'un processus décisionnel transparent et non de façon isolée sur la base d'une seule valeur seuil. Bien que le caractère informatif des ratios coût-efficacité soit indéniable lorsqu'il s'agit d'évaluer la rentabilité des interventions, les pays devraient être encouragés à développer un processus de prise de décision spécifique au contexte, qui soit encadré par la législation et qui ait l'adhésion des parties intéressées, avec par exemple l'implication d'organisations de la société civile et de groupes de patients, et qui soit transparent, cohérent et équitable.

El análisis de rentabilidad se utiliza para comparar los costes y resultados de opciones políticas alternativas. Cada relación de rentabilidad resultante representa la magnitud de sanidad adicional obtenida por unidad adicional de recursos utilizados. Los umbrales de rentabilidad permiten la identificación de las relaciones de rentabilidad que representan un valor bueno o muy bueno del capital. En 2001, los umbrales de rentabilidad propuestos por la Comisión sobre Macroeconomía y Salud de la Organización Mundial de la Salud se basaron en múltiplos del producto interior bruto (PIB) per cápita de un país. En algunos contextos, se han utilizado estos umbrales para decidir qué intervenciones sanitarias financiar y cuáles no. No obstante, la experiencia con el uso de dichos umbrales basados en el PIB en los procesos de toma de decisiones a nivel nacional muestra la ausencia de especificidad según el país. Esto, además de la incertidumbre de las relaciones de rentabilidad modelo, puede dar lugar a una toma de decisiones equivocada sobre cómo emplear los recursos sanitarios. La información relativa a la rentabilidad debería utilizarse teniendo en cuenta otros factores (por ejemplo, el impacto presupuestario y aspectos de viabilidad) en un proceso transparente de toma de decisiones, en lugar de únicamente teniendo como referencia un solo valor del umbral. A pesar de que las relaciones de rentabilidad son indudablemente esclarecedoras a la hora de evaluar el valor del capital, es necesario fomentar que los países desarrollen un proceso específico del contexto apoyado por la legislación para tomar decisiones, como, por ejemplo, si las partes interesadas han aceptado la implicación de las organizaciones de la sociedad civil y grupos de pacientes y si es transparente, coherente y justa.

Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey.

BACKGROUND: Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care. METHODS: Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients' out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined. RESULTS: Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic. CONCLUSIONS: Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care.

Burden of stroke attributable to selected lifestyle risk factors in rural South Africa.

BACKGROUND: Rural South Africa (SA) is undergoing a rapid health transition characterized by increases in non-communicable diseases; stroke in particular. Knowledge of the relative contribution of modifiable risk factors on disease occurrence is needed for public health prevention efforts and community-oriented health promotion. Our aim was to estimate the burden of stroke in rural SA that is attributable to high blood pressure, excess weight and high blood glucose using World Health Organization's comparative risk assessment (CRA) framework. METHODS: We estimated current exposure distributions of the risk factors in rural SA using 2010 data from the Agincourt health and demographic surveillance system (HDSS). Relative risks of stroke per unit of exposure were obtained from the Global Burden of Disease Study 2010. We used data from the Agincourt HDSS to estimate age-, sex-, and stroke specific deaths and disability adjusted life years (DALYs). We estimated the proportion of the years of life lost (YLL) and DALY loss attributable to the risk factors and incorporate uncertainty intervals into these estimates. RESULTS: Overall, 38 % of the documented stroke burden was due to high blood pressure (12 % males; 26 % females). This translated to 520 YLL per year (95 % CI: 325-678) and 540 DALYs (CI: 343-717). Excess Body Mass Index (BMI) was calculated as responsible for 20 % of the stroke burden (3.5 % males; 16 % females). This translated to 260 YLLs (CI: 199-330) and 277 DALYs (CI: 211-350). Burden was disproportionately higher in young females when BMI was assessed. CONCLUSIONS: High blood pressure and excess weight, which both have effective interventions, are responsible for a significant proportion of the stroke burden in rural SA; the burden varies across age and sex sub-groups. The most effective way forward to reduce the stroke burden requires both population wide policies that have an impact across the age spectra and targeted (health promotion/disease prevention) interventions on women and young people.

Differing Methods and Definitions Influence DALY estimates: Using Population-Based Data to Calculate the Burden of Convulsive Epilepsy in Rural South Africa.

BACKGROUND: The disability adjusted life year (DALY) is a composite measure of disease burden that includes both morbidity and mortality, and is relevant to conditions such as epilepsy that can limit productive functioning. The 2010 Global Burden of Disease (GBD) study introduced a number of new methods and definitions, including a prevalence-based approach and revised disability weights to calculate morbidity and new standard life expectancies to calculate premature mortality. We used these approaches, and local, population-based data, to estimate the burden of convulsive epilepsy in rural South Africa. METHODS & FINDINGS: Comprehensive prevalence, incidence and mortality data on convulsive epilepsy were collected within the Agincourt sub-district in rural northeastern South Africa between 2008 and 2012. We estimated DALYs using both prevalence- and incidence-based approaches for calculating years of life lived with disability. Additionally, we explored how changing the disease model by varying the disability weights influenced DALY estimates. Using the prevalence-based approach, convulsive epilepsy in Agincourt resulted in 332 DALYs (95% uncertainty interval (UI): 216-455) and 4.1 DALYs per 1,000 individuals (95%UI: 2.7-5.7) annually. Of this, 26% was due to morbidity while 74% was due to premature mortality. DALYs increased by 10% when using the incidence-based method. Varying the disability weight from 0.072 (treated epilepsy, seizure free) to 0.657 (severe epilepsy) caused years lived with disability to increase from 18 (95%UI: 16-19) to 161 (95%UI: 143-170). CONCLUSIONS: DALY estimates are influenced by both the methods applied and population parameters used in the calculation. Irrespective of method, a significant burden of epilepsy is due to premature mortality in rural South Africa, with a lower burden than rural Kenya. Researchers and national policymakers should carefully interrogate the methods and data used to calculate DALYs as this will influence policy priorities and resource allocation.