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.

Cost-Effectiveness of Testing and Treatment for Hepatitis B Virus and Hepatitis C Virus Infections: An Analysis by Scenarios, Regions, and Income.

OBJECTIVES: Testing and treatment for hepatitis B virus (HBV) and hepatitis C virus (HCV) infection are highly effective, high-impact interventions. This article aims to estimate the cost-effectiveness of scaling up these interventions by scenarios, regions, and income groups. METHODS: We modeled costs and impacts of hepatitis elimination in 67 low- and middle-income countries from 2016 to 2030. Costs included testing and treatment commodities, healthcare consultations, and future savings from cirrhosis and hepatocellular carcinomas averted. We modeled disease progression to estimate disability-adjusted life-years (DALYs) averted. We estimated incremental cost-effectiveness ratios (ICERs) by regions and World Bank income groups, according to 3 scenarios: flatline (status quo), progress (testing/treatment according to World Health Organization guidelines), and ambitious (elimination). RESULTS: Compared with no action, current levels of testing and treatment had an ICER of $807/DALY for HBV and -$62/DALY (cost-saving) for HCV. Scaling up to progress scenario, both interventions had ICERs less than the average gross domestic product/capita of countries (HBV: $532/DALY; HCV: $613/DALY). Scaling up from flatline to elimination led to higher ICERs across countries (HBV: $927/DALY; HCV: $2528/DALY, respectively) that remained lower than the average gross domestic product/capita. Sensitivity analysis indicated discount rates and commodity costs were main factors driving results. CONCLUSIONS: Scaling up testing and treatment for HBV and HCV infection as per World Health Organization guidelines is a cost-effective intervention. Elimination leads to a much larger impact though ICERs are higher. Price reduction strategies are needed to achieve elimination given the substantial budget impact at current commodity prices.

Building the foundations for sustainable development: a case for global investment in the capabilities of adolescents.

Investment in the capabilities of the world's 1·2 billion adolescents is vital to the UN's Sustainable Development Agenda. We examined investments in countries of low income, lower-middle income, and upper-middle income covering the majority of these adolescents globally to derive estimates of investment returns given existing knowledge. The costs and effects of the interventions were estimated by adapting existing models and by extending methods to create new modelling tools. Benefits were valued in terms of increased gross domestic product and averted social costs. The initial analysis showed high returns for the modelled interventions, with substantial variation between countries and with returns generally higher in low-income countries than in countries of lower-middle and upper-middle income. For interventions targeting physical, mental, and sexual health (including a human papilloma virus programme), an investment of US$4·6 per capita each year from 2015 to 2030 had an unweighted mean benefit to cost ratio (BCR) of more than 10·0, whereas, for interventions targeting road traffic injuries, a BCR of 5·9 (95% CI 5·8-6·0) was achieved on investment of $0·6 per capita each year. Interventions to reduce child marriage ($3·8 per capita each year) had a mean BCR of 5·7 (95% CI 5·3-6·1), with the effect high in low-income countries. Investment to increase the extent and quality of secondary schooling is vital but will be more expensive than other interventions-investment of $22·6 per capita each year from 2015 to 2030 generated a mean BCR of 11·8 (95% CI 11·6-12·0). Investments in health and education will not only transform the lives of adolescents in resource-poor settings, but will also generate high economic and social returns. These returns were robust to substantial variation in assumptions. Although the knowledge base on the impacts of interventions is limited in many areas, and a major research effort is needed to build a more complete investment framework, these analyses suggest that comprehensive investments in adolescent health and wellbeing should be given high priority in national and international policy.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Estimating health plan costs with the OneHealth tool, Cambodia.

OBJECTIVE: To do resource and cost projections for the entire Cambodian health sector using the OneHealth tool, during the development of the third national health strategic plan 2016-2020. METHODS: Through a consultative process, the health ministry estimated the needed and available resources to implement the strategic plan. The health ministry used the OneHealth Tool to estimate costs of expanding public sector service provision and compared these to estimates of projected available financing. Cost estimates covered implementation of health programmes including commodities and programme management costs, and six cross-cutting health system strengthening components. The tool is populated with local demographic, epidemiological, programmatic and unit cost data. We present costs in constant 2015 United States dollars (US$). FINDINGS: We estimated the five-year cost of the strategic plan to be US$ 2973.8 million. Costs are split between health systems strengthening components (US$ 1516.3 million) and investments in individual disease or public health programmes (US$ 1457.5 million). Health programmes for maternal and neonatal health (US$ 367 million), child health and immunization (US$ 197 million) and noncommunicable disease (US$ 157 million) have the highest costs. Although projected resource needs increase over time, a financial space analysis with ambitious projected increases in government funding indicates that government and donor funding jointly could be sufficient to cover the cost of the strategic plan from 2018 to 2020. CONCLUSION: The results both informed development of the strategic plan, and contributed to the evidence base for improved budgeting, resource mobilization strategies and stronger overall public sector financial planning.

Econometric estimation of WHO-CHOICE country-specific costs for inpatient and outpatient health service delivery.

BACKGROUND: Policy makers require information on costs related to inpatient and outpatient health services to inform resource allocation decisions. METHODS: Country data sets were gathered in 2008-2010 through literature reviews, website searches and a public call for cost data. Multivariate regression analysis was used to explore the determinants of variability in unit costs using data from 30 countries. Two models were designed, with the inpatient and outpatient models drawing upon 3407 and 9028 observations respectively. Cost estimates are produced at country and regional level, with 95% confidence intervals. RESULTS: Inpatient costs across 30 countries are significantly associated with the type of hospital, ownership, as well as bed occupancy rate, average length of stay, and total number of inpatient admissions. Changes in outpatient costs are significantly associated with location, facility ownership and the level of care, as well as to the number of outpatient visits and visits per provider per day. CONCLUSIONS: These updated WHO-CHOICE service delivery unit costs are statistically robust and may be used by analysts as inputs for economic analysis. The models can predict country-specific unit costs at different capacity levels and in different settings.

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.

Advancing social and economic development by investing in women's and children's health: a new Global Investment Framework.

A new Global Investment Framework for Women's and Children's Health demonstrates how investment in women's and children's health will secure high health, social, and economic returns. We costed health systems strengthening and six investment packages for: maternal and newborn health, child health, immunisation, family planning, HIV/AIDS, and malaria. Nutrition is a cross-cutting theme. We then used simulation modelling to estimate the health and socioeconomic returns of these investments. Increasing health expenditure by just $5 per person per year up to 2035 in 74 high-burden countries could yield up to nine times that value in economic and social benefits. These returns include greater gross domestic product (GDP) growth through improved productivity, and prevention of the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. These gains could be achieved by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending.

The geography of maternal and newborn health: the state of the art.

As the deadline for the millennium development goals approaches, it has become clear that the goals linked to maternal and newborn health are the least likely to be achieved by 2015. It is therefore critical to ensure that all possible data, tools and methods are fully exploited to help address this gap. Among the methods that are under-used, mapping has always represented a powerful way to 'tell the story' of a health problem in an easily understood way. In addition to this, the advanced analytical methods and models now being embedded into Geographic Information Systems allow a more in-depth analysis of the causes behind adverse maternal and newborn health (MNH) outcomes. This paper examines the current state of the art in mapping the geography of MNH as a starting point to unleashing the potential of these under-used approaches. Using a rapid literature review and the description of the work currently in progress, this paper allows the identification of methods in use and describes a framework for methodological approaches to inform improved decision-making. The paper is aimed at health metrics and geography of health specialists, the MNH community, as well as policy-makers in developing countries and international donor agencies.

Design, Methods, and Participation in Riksmaten Young Children-A Swedish National Dietary Survey.

Background: National dietary surveys provide essential data for risk benefit assessments of foods and nutrients, for management and policy development. Physical activity measurement and biomonitoring can provide important complementary data but are less commonly included. Objectives: This study aimed to describe the study design and methods of the cross-sectional Swedish national dietary survey Riksmaten Young Children (Riksmaten småbarn), of children aged 9 mo, 18 mo, and 4 y. Participation/dropout rates for the 2 older age groups are also presented. The impact of different recruitment strategies is discussed. Methods: Children (N = 16,655) were randomly selected from the population register; invitations to guardians were sent by post and where possible, followed up by telephone. Food intake was assessed by a 2-d food diary and/or questionnaire. Height and weight were reported after measurement. Physical activity (accelerometery, 7 d) and stool, blood, and urine samples were assessed in subgroups. Results: Food consumption data were collected in 1828 children (11% of the invited; 18 mo: n = 1078, and 4 y: n = 750). Of participants also in subgroups, 71% provided physical activity data (n = 1307), 60% stool samples (n = 630), and 51% blood and/or urine samples (n = 593). The study population represented all geographic regions and types of municipalities in Sweden, but participating households had both higher education level and higher income than the target population. Only minor differences were seen in participation rates between recruitment via post and telephone compared with those through post only (12% compared with 10%). Repeated contact attempts were needed for the majority of participants (65%). Despite the low-participation rate, 99% of the participants completed the study once started. Conclusions: Although it was a challenge to recruit participants, Riksmaten Young Children provides a substantial amount of information at national level, representative in terms of sex, geography, and family structure. The underrepresentation of households with lower socioeconomic position must be considered when generalizing results.

Using costing to facilitate policy making towards Universal Health Coverage: findings and recommendations from country-level experiences.

As countries progress towards universal health coverage (UHC), they frequently develop explicit packages of health services compatible with UHC goals. As part of the Disease Control Initiative 3 Country Translation project, a systematic survey instrument was developed and used to review the experience of five low-income and lower-middle-income countries-Afghanistan, Ethiopia, Pakistan, Somalia and Sudan-in estimating the cost of their proposed packages. The paper highlights the main results of the survey, providing information about how costing exercises were conducted and used and what country teams perceived to be the main challenges. Key messages are identified to facilitate similar exercises and improve their usefulness. Critical challenges to be addressed include inconsistent application of costing methods, measurement errors and data reliability issues, the lack of adequate capacity building, and the lack of integration between costing and budgeting. The paper formulates four recommendations to address these challenges: (1) developing more systematic guidance and standard ways to implement costing methodologies, particularly regarding the treatment of health systems-related common costs, (2) acknowledging ranges of uncertainty of costing results and integrating sensitivity analysis, (3) building long-term capacity at the local level and institutionalising the costing process in order to improve both reliability and policy relevance, and (4) closely linking costing exercises to public budgeting.

Global cost of child survival: estimates from country-level validation.

OBJECTIVE: To cross-validate the global cost of scaling up child survival interventions to achieve the fourth Millennium Development Goal (MDG4) as estimated by the World Health Organization (WHO) in 2007 by using the latest country-provided data and new assumptions. METHODS: After the main cost categories for each country were identified, validation questionnaires were sent to 32 countries with high child mortality. Publicly available estimates for disease incidence, intervention coverage, prices and resources for individual-level and programme-level activities were validated against local data. Nine updates to the 2007 WHO model were generated using revised assumptions. Finally, estimates were extrapolated to 75 countries and combined with cost estimates for immunization and malaria programmes and for programmes for the prevention of mother-to-child transmission of the human immunodeficiency virus (HIV). FINDINGS: Twenty-six countries responded. Adjustments were largest for system- and programme-level data and smallest for patient data. Country-level validation caused a 53% increase in original cost estimates (i.e. 9 billion 2004 United States dollars [US$]) for 26 countries owing to revised system and programme assumptions, especially surrounding community health worker costs. The additional effect of updated population figures was small; updated epidemiologic figures increased costs by US$ 4 billion (+15%). New unit prices in the 26 countries that provided data increased estimates by US$ 4.3 billion (+16%). Extrapolation to 75 countries increased the original price estimate by US$ 33 billion (+80%) for 2010-2015. CONCLUSION: Country-level validation had a significant effect on the cost estimate. Price adaptations and programme-related assumptions contributed substantially. An additional 74 billion US$ 2005 (representing a 12% increase in total health expenditure) would be needed between 2010 and 2015. Given resource constraints, countries will need to prioritize health activities within their national resource envelope.

Is Universal Health Coverage Affordable? Estimated Costs and Fiscal Space Analysis for the Ethiopian Essential Health Services Package.

Estimating the required resources for implementing an essential health services package (EHSP) is vital to examine its feasibility and affordability. This study aimed to estimate the financial resources required to implement the Ethiopian EHSP from 2020 to 2030. Furthermore, we explored potential alternatives to increase the fiscal space for health in Ethiopia. We used the OneHealth Tool (OHT) to estimate the costs of expanding the EHSP service provision in the public sector in Ethiopia. Combinations of ingredient-based bottom-up and program-based summary costing approaches were applied. We predicted the fiscal space using assumptions for economic growth, government resource allocations to health, external aid for health, the magnitude of out-of-pocket expenditure, and other private health expenditures as critical factors affecting available resources devoted to health. All costs were valued using 2020 US dollars (USD). To implement the EHSP, 13.0 billion USD (per capita: 94 USD) would be required in 2030. The largest (50-70%) share of estimated costs was for medicines, commodities, and supplies, followed by human resources costs (10-17%). However, the expected available resources based on a business-as-usual fiscal space estimate would be 63 USD per capita for the same year. Therefore, the gap as a percentage of the required resources would be 33% in 2030. The resources needed to implement the EHSP would increase steadily over the projection period due mainly to increases in service coverage targets over time. Allocating gains from economic growth to increase the total government health expenditure could partly address the gap.

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.

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.