Cost-effectiveness analysis of alternative screening strategies for the detection of cervical cancer among women in rural areas of Western Kenya.

While the incidence of cervical cancer has dropped in high-income countries due to organized cytology-based screening programs, it remains the leading cause of cancer death among women in Eastern Africa. Therefore, the World Health Organization (WHO) now urges providers to transition from widely prevalent but low-performance visual inspection with acetic acid (VIA) screening to primary human papillomavirus (HPV) DNA testing. Due to high HPV prevalence, effective triage tests are needed to identify those lesions likely to progress and so avoid over-treatment. To identify the optimal cost-effective strategy, we compared the VIA screen-and-treat approach to primary HPV DNA testing with p16/Ki67 dual-stain cytology or VIA as triage. We used a Markov model to calculate the budget impact of each strategy with incremental quality-adjusted life years and incremental cost-effectiveness ratios (ICER) as the main outcome. Deterministic cost-effectiveness analyses show that the screen-and-treat approach is highly cost-effective (ICER 2469 Int$), while screen, triage, and treat with dual staining is the most effective with favorable ICER than triage with VIA (ICER 9943 Int$ compared with 13,177 Int$). One-way sensitivity analyses show that the results are most sensitive to discounting, VIA performance, and test prices. In the probabilistic sensitivity analyses, the triage option using dual stain is the optimal choice above a willingness to pay threshold of 7115 Int$ being cost-effective as per WHO standards. The result of our analysis favors the use of dual staining over VIA as triage in HPV-positive women and portends future opportunities and necessary research to improve the coverage and acceptability of cervical cancer screening programs.

Improving the first-line treatment of febrile illnesses in Ghana: willingness to pay for malaria rapid diagnostic tests at licensed chemical shops in the Kintampo area.

BACKGROUND: Use of malaria rapid diagnostic test (mRDT) enhances patient management and reduces costs associated with the inappropriate use of antimalarials. Despite its proven clinical effectiveness, mRDT is not readily available at licensed chemical shops in Ghana. Therefore, in order to improve the use of mRDT, there is the need to understand the willingness to pay for and sell mRDT. This study assessed patients' willingness to pay and licensed chemical operators' (LCS) willingness to sell mRDTs. METHODS: The study was a cross-sectional survey conducted in Kintampo North Municipality and Kintampo South District of Ghana. Contingent valuation method using the dichotomous approach was applied to explore patient's willingness to pay. In-depth interviews (IDIs) were used to obtain information from licensed chemical operators' willingness to sell. RESULTS: Majority 161 (97%) of the customers were willing to pay for mRDT while 100% of licensed chemical operators were also willing to sell mRDT. The average lowest amount respondents were willing to pay was Ghana cedis (GH¢) 1.1 (US$ 0.26) and an average highest amount of GH¢ 2.1 (US$ 0.49). LCS operators were willing to sell the test kit at an average lowest price of GH¢1 (US$ 0.23) and average highest price of GH¢2 (US$ 0.47). CONCLUSION: Community members were willing to pay for mRDT and LCS operators are willing to sell mRDTs. However, the high cost of the mRDT is likely to prevent the widespread use of mRDT. There is a clear need to find system-compatible ways to subsidize the use of mRDT via National Health Insurance scheme.

Comparison of cost-effectiveness of anticoagulation with dabigatran, rivaroxaban and apixaban in patients with non-valvular atrial fibrillation across countries.

We did a cost-utility analysis for the new oral anticoagulants (NOACs) in the German population based on the quality-adjusted life years (QALY), total costs, and incremental cost-effectiveness ratios (ICER). The aim of our investigation was to examine cost-utility for current German drug market costs and compared to other countries. Outcome data were taken from dabigatran's RE-LY, rivaroxaban's ROCKET AF, and apixaban's ARISTOTLE trials. A Markov decision model, the Monte Carlo simulation (MCS), and further sensitivity analyses were used to simulate comparisons between NOACs over a follow up period of 20 years. The main perspective used for the analyses is from a German public health care insurance perspective. The base-case analyses of a 65 years old person with a CHADS2 score >1 resulted in 7.56-7.64 QALYs gained for warfarin. NOACs added 0.04-0.19 QALYs. Total costs for warfarin ranged from 7622 to 9069 and for NOACs from 19537 to 20048. The sensitivity analysis indicated that current German market costs for the NOACs exceed a willingness-to-pay threshold of (hypothetical) 50000/QALY in all treatment regimen. The MCS showed willingness-to-pay thresholds from 60500/QALY for apixaban to 278000/QALY for dabigatran 110 mg bid, with values for dabigatran 150 mg bid and rivaroxaban in between. In conclusion, from a German public health care insurance perspective current market costs are high in relation to the quality of life gained. These results from clinical studies (efficacy) remain to be confirmed under real life conditions (effectiveness).

Exploring improvement plans of fourteen European integrated care sites for older people with complex needs.

Integrated care programmes are increasingly being put in place to provide care to older people living at home. However, knowledge about further improving integrated care is limited. In fourteen integrated care sites in Europe, plans to improve existing ways of working were designed, implemented and evaluated to enlarge the understanding of what works and with what outcomes when improving integrated care. This paper provides insight into the existing ways that the sites were working with respect to integrated care, their perceived difficulties and their plans for working towards improvement. The seven components of the Expanded Chronic Care Model provided a conceptual framework for describing the fourteen sites. Although sites were spread across Europe and differed in basic characteristics and existing ways of working, a number of difficulties in delivering integrated care were similar. Existing ways of working and improvement plans mostly focused on three components of the Expanded Chronic Care Model: delivery system design; decision support; self-management. Two components were represented less frequently in existing ways of working and improvement plans: building healthy public policy; building community capacity. These findings suggest that broadly-based prevention efforts, population health promotion and community involvement remain limited. From the Expanded Chronic Care Model perspective, therefore, opportunities for improving integrated care outcomes may continue to be restricted by the narrow focus of developed improvement plans.

Lessons for health care reform from the less developed world: the case of the Philippines.

International technical and financial cooperation for health-sector reform is usually a one-way street: concepts, tools and experiences are transferred from more to less developed countries. Seldom, if ever, are experiences from less developed countries used to inform discussions on reforms in the developed world. There is, however, a case to be made for considering experiences in less developed countries. We report from the Philippines, a country with high population growth, slow economic development, a still immature democracy and alleged large-scale corruption, which has embarked on a long-term path of health care and health financing reforms. Based on qualitative health-related action research between 2002 and 2005, we have identified three crucial factors for achieving progress on reforms in a challenging political environment: (1) strive for local solutions, (2) make use of available technology and (3) work on the margins towards pragmatic solutions whilst having your ethical goals in mind. Some reflection on these factors might stimulate and inform the debate on how health care reforms could be pursued in developed countries.

The role of national health insurance for achieving UHC in the Philippines: a mixed methods analysis.

BACKGROUND: Achieving Universal Health Coverage (UHC) has by now become a key health policy goal in many countries and some form of National Health Insurance (NHI) is often used for this. The Philippines has had more than 50 years' experience with social health insurance and in 1995 established PhilHealth, the country's national health insurer. OBJECTIVES: Analyzing the role of the Philippine NHI scheme in moving towards UHC, identifying potential avenues for improvement as well as indicating challenges and areas for further development. METHODS: This paper is based on a mixed methods approach including extensive literature search, data from PhilHealth and other sources, and key informant interviews with staff at PhilHealth, health care providers, and policy experts at national and international level. RESULTS: Major achievements were the expansion of population coverage using an earmarked revenue source ('Sin Tax'), the introduction of the no-balance-billing to prevent co-payments, and the Health Facilities Enhancement Program to improve quality. The share of PhilHealth in total health expenditures is still only 14%, managing quality and cost of providers remains insufficient, the benefit coverage does not reflect the country's burden of disease, and financial protection for PhilHealth members is low. The UHC bill would provide a massive jump forward as all Filipinos would then be automatically enrolled in and thus entitled to the benefits of PhilHealth. CONCLUSIONS: For expanding a contribution-based NHI beyond formal employment there needs to be a large increase in budget transfers to cover for citizens unable to contribute. The Philippine UHC bill shifts from the idea of contribution leading to entitlement to the idea of citizenship leading to entitlement and can thus be seen as a paradigmatic change in thinking about NHI. There are three areas that we believe are of key importance in developing further NHI: (i) governance, (ii) financial impact, and (iii) strategic purchasing.

The shaded side of the UHC cube: a systematic review of human resources for health management and administration in social health protection schemes.

Managers and administrators in charge of social protection and health financing, service purchasing and provision play a crucial role in harnessing the potential advantage of prudent organization, management and purchasing of health services, thereby supporting the attainment of Universal Health Coverage. However, very little is known about the needed quantity and quality of such staff, in particular when it comes to those institutions managing mandatory health insurance schemes and purchasing services. As many health care systems in low- and middle-income countries move towards independent institutions (both purchasers and providers) there is a clear need to have good data on staff and administrative cost in different social health protection schemes as a basis for investing in the development of a cadre of health managers and administrators for such schemes. We report on a systematic literature review of human resources in health management and administration in social protection schemes and suggest some aspects in moving research, practical applications and the policy debate forward.

[Acute Kidney Injury - Potentials to Improve AKI-Related Health Care Structure]. / Akutes Nierenversagen ­ Optimierungspotenziale zur Gewährleistung einer verbesserten Versorgungsstruktur.

Since 2005 the AKI numbers nearly increased threefold. The prevailing health care structure for AKI-management in Germany possesses major potential for improvement. Despite a clear advantage regarding mortality and renal recovery, the cost-intensive CRRT is the predominant procedure in AKI-therapy. Conversion of 85 % of the CRRT-procedures to a dialysis procedure (IHD/SLED) enables annual savings in AKI-therapy by 7.3 million Euros. A reinvestment can finance a strengthened collaboration with licensed nephrologists to improve therapy quality and availability of RRT-units in local hospitals. The the long term aim is the establishment of national therapy guidelines. Lower consequential costs are crucial incentives.

Social health insurance in a developing country: the case of the Philippines.

Very little is known about the Philippine health care system, and in particular its experience with social health insurance (SHI). Having initiated an SHI programme 35 years ago, the Philippines hold many lessons for the development of such schemes in other low and middle-income countries. We analyse the challenges currently facing PhilHealth, the national health insurer. PhilHealth was formed in 1995 as a successor to the Medicare programme and was given a mandate to achieve universal coverage by 2010. To date, PhilHealth has been quite successful in some areas (e.g. enrollment), but lags behind in others (e.g. quality and price control). We conclude that SHI in the Philippines has been a success story so far and provides lessons for countries in a similar situation. For example: (i) SHI is based on value decisions and the clear statement of societal goals can give guidance in the technical execution, (ii) SHI is a financing institution and needs to be treated accordingly, (iii) SHI can be implemented independently of the current economic situation and might actually contribute to economic development, (iv) community-based health care financing schemes should be merged with the national SHI in the long run, and (v) there is a strong need to push for high quality care and improved physical access. No clear suggestions can be given with respect to the benefit catalogue and the balance between economies of scale and decentralisation. Although riddled with many inadequacies, PhilHealth was set up as a strong and largely politically independent institution for the development of SHI. SHI can act as a stabilizing institution in a politically and economically volatile environment.

Governance in Health - The Need for Exchange and Evidence Comment on "Governance, Government, and the Search for New Provider Models".

Governance in health is cited as one of the key factors in balancing the concerns of the government and public sector with the interests of civil society/private players, but often remains poorly described and operationalized. Richard Saltman and Antonio Duran look at two aspects in the search for new provider models in a context of health markets signalling liberalisation: (i) the role of the government to balance public and private interests and responsibilities in delivering care through modernised governance arrangements, and (ii) the finding that operational complexities may hinder well-designed provider governance models, unless governance reflects country-specific realities. This commentary builds on the discussion by Saltman and Duran, and argues that the concept of governance needs to be clearly defined and operationalized in order to be helpful for policy debate as well as for the development of an applicable framework for performance improvement. It provides a working definition of governance and includes a reflection on the prevailing cultural norms in an organization or society upon which any governance needs to be build. It proposes to explore whether the "evidence-based governance" concept can be introduced to generate knowledge about innovative and effective governance models, and concludes that studies similar to the one by Saltman and Duran can inform this debate.

Data for development in health: a case study and monitoring framework from Kazakhstan.

Healthcare reforms are often not coupled with a relevant and appropriate monitoring framework, leaving policymakers and the public without evidence about the implications of such reforms. Kazakhstan has embarked on a large-scale reform of its healthcare system in order to achieve Universal Health Coverage. The health-related 2020 Strategic Development Goals reflect this political ambition. In a case-study approach and on the basis of published and unpublished evidence as well as personal involvement and experience (A) the indicators in the 2020 Strategic Development Goals were assessed and (B) a 'data-mapping' exercise was conducted, where the WHO health system framework was used to describe the data available at present in Kazakhstan and comment on the different indicators regarding their usefulness for monitoring the current health-related 2020 Strategic Development Goals in Kazakhstan. It was concluded that the country's current monitoring framework needs further development to track the progress and outcomes of policy implementation. The application of a modified WHO/World Bank/Global Fund health system monitoring framework was suggested to examine the implications of recent health sector reforms. Lessons drawn from the Kazakhstan experience on tailoring the suggested framework, collecting the data, and using the generated intelligence in policy development and decision-making can serve as a useful example for other middle-income countries, potentially enabling them to fast-track developments in the health sector.

Cost-effectiveness of anticoagulation in patients with nonvalvular atrial fibrillation with edoxaban compared to warfarin in Germany.

We compared the cost-utility analysis for edoxaban at both doses with that of dabigatran at both doses, rivaroxaban, and apixaban (non vitamin K antagonist oral anticoagulants, NOAC) in a German population. Data of clinical outcome events were taken from edoxaban's ENGAGE-AF, dabigatran's RE-LY, rivaroxaban's ROCKET, and apixaban's ARISTOTLE trials. The base-case analyses of a 65-year-old person with a CHADS2 score >1 gained 0.17 and 0.21 quality-adjusted life years over warfarin for 30 mg od and 60 mg od edoxaban, respectively. The incremental cost-effectiveness ratio was 50.000 and 68.000 euro per quality-adjusted life years for the higher and lower dose of edoxaban (Monte Carlo simulation). These findings were also similar to those for apixaban and more cost-effective than the other NOAC regimens. The current market costs for direct oral anticoagulants are high in relation to the quality of life gained from a German public health care insurance perspective. The willingness-to-pay threshold was lowest for 60 mg edoxaban compared to all direct oral anticoagulants and for 30 mg edoxaban compared to dabigatran and rivaroxaban.