Modelling the Cost-Effectiveness of Hepatitis A in South Africa.

The World Health Organization (WHO) recommends the consideration of introducing routine hepatitis A vaccination into national immunization schedules for children ≥ 1 years old in countries with intermediate HAV endemicity. Recent data suggest that South Africa is transitioning from high to intermediate HAV endemicity, thus it is important to consider the impact and cost of potential routine hepatitis A vaccination strategies in the country. An age-structured compartmental model of hepatitis A transmission was calibrated with available data from South Africa, incorporating direct costs of hepatitis A treatment and vaccination. We used the calibrated model to evaluate the impact and costs of several childhood hepatitis A vaccination scenarios from 2023 to 2030. We assessed how each scenario impacted the burden of hepatitis A (symptomatic hepatitis A cases and mortality) as well as calculated the incremental cost per DALY averted as compared to the South African cost-effectiveness threshold. All costs and outcomes were discounted at 5%. For the modelled scenarios, the median estimated cost of the different vaccination strategies ranged from USD 1.71 billion to USD 2.85 billion over the period of 2023 to 2030, with the cost increasing for each successive scenario and approximately 39-52% of costs being due to vaccination. Scenario 1, which represented the administration of one dose of the hepatitis A vaccine in children < 2 years old, requires approximately 5.3 million vaccine doses over 2023-2030 and is projected to avert a total of 136,042 symptomatic cases [IQR: 88,842-221,483] and 31,106 [IQR: 22,975-36,742] deaths due to hepatitis A over the period of 2023 to 2030. The model projects that Scenario 1 would avert 8741 DALYs over the period of 2023 to 2030; however, it is not cost-effective against the South African cost-effectiveness threshold with an ICER per DALY averted of USD 21,006. While Scenario 3 and 4 included the administration of more vaccine doses and averted more symptomatic cases of hepatitis A, these scenarios were absolutely dominated owing to the population being infected before vaccination through the mass campaigns at older ages. The model was highly sensitive to variation of access to liver transplant in South Africa. When increasing the access to liver transplant to 100% for the baseline and Scenario 1, the ICER for Scenario 1 becomes cost-effective against the CET (ICER = USD 2425). Given these findings, we recommend further research is conducted to understand the access to liver transplants in South Africa and better estimate the cost of liver transplant care for hepatitis A patients. The modelling presented in this paper has been used to develop a user-friendly application for vaccine policy makers to further interrogate the model outcomes and consider the costs and benefits of introducing routine hepatitis A vaccination in South Africa.

Systematic review of economic evaluations for paediatric pulmonary diseases.

BACKGROUND: Paediatric pulmonary diseases are the leading causes of mortality amongst children under five globally. Economic evaluations (EEs) seek to guide decision-makers on which health care interventions to adopt to reduce the paediatric pulmonary disease burden. This study aims to systematically review economic evaluations on different aspects of the inpatient management of paediatric pulmonary diseases globally. METHODS: We systematically reviewed EEs published between 2010 and 2020, with a subsequent search conducted for 2020-2022. We searched PubMed, Web of Science, MEDLINE, Paediatric Economic Database Evaluation (PEDE) and the Cochrane library. We extracted data items guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. We collected qualitative and quantitative data which we analysed in Microsoft Excel and R software. RESULTS: Twenty-two articles met the inclusion criteria. Six of the articles were cost-effectiveness analyses, six cost-utility analyses, two cost-minimisation analyses and eight cost analyses. Twelve articles were from high-income countries (HICs) and ten were from low- and middle-income countries (LMICs). Eight articles focused on asthma, eleven on pneumonia, two on asthma and pneumonia, and one on tuberculosis. CONCLUSION: Conducting more EEs for paediatric pulmonary diseases in LMICs could allow for more evidence-based decision-making to improve paediatric health outcomes.

Economic evaluation of psychological treatments for common mental disorders in low- and middle-income countries: a systematic review.

Common mental disorders (CMDs) constitute a major public health and economic burden on low- and middle-income countries (LMICs). Systematic reviews of economic evaluations of psychological treatments for CMDs are limited. This systematic review examines methods, reports findings and appraises the quality of economic evaluations of psychological treatments for CMDs in LMICs. We searched a range of bibliographic databases (including PubMed, EconLit, APA-PsycINFO and Cochrane library) and the African Journals Online (AJoL) and Google Scholar platforms. We used a pre-populated template to extract data and the Drummond & Jefferson checklist for quality appraisal. We present results as a narrative synthesis. The review included 26 studies, mostly from Asia (12) and Africa (9). The majority were cost-effectiveness analyses (12), some were cost-utility analyses (5), with one cost-benefit analysis or combinations of economic evaluations (8). Most interventions were considered either cost-effective or potentially cost-effective (22), with 3 interventions being not cost-effective. Limitations were noted regarding appropriateness of conclusions drawn on cost-effectiveness, the use of cost-effectiveness thresholds and application of 'societal' incremental cost-effectiveness ratios to reflect value for money (VfM) of treatments. Non-specialist health workers (NSHWs) delivered most of the treatments (16) for low-cost delivery at scale, and costs should reflect the true opportunity cost of NSHWs' time to support the development of a sustainable cadre of health care providers. There is a 4-fold increase in economic evaluations of CMD psychological treatments in the last decade over the previous one. Yet, findings from this review highlight the need for better application of economic evaluation methodology to support resource allocation towards the World Health Organization recommended first-line treatments of CMDs. We suggest impact inventories to capture societal economic gains and propose a VfM assessment framework to guide researchers in evaluating cost-effectiveness.

Cost utility and budget impact analysis of dexamethasone compared with bortezomib and lenalidomide for the treatment of second line multiple myeloma from a South African public health perspective.

BACKGROUND: Multiple myeloma is an incurable haematological malignancy that is associated with a high probability of relapse. The survival of relapsed patients has been greatly improved by the development of novel drugs such as lenalidomide and bortezomib. We assessed the cost-effectiveness of these drugs as second-line treatment for relapsed/refractory multiple myeloma (RRMM) patients in the South African public health care system. METHODS: We modelled 3 treatment strategies for second-line RRMM treatment: dexamethasone (standard of care), bortezomib (BORT) and lenalidomide plus dexamethasone (LEN/DEX) from the South African public health perspective. For each strategy we modelled a hypothetical cohort of relapsed/refractory multiple myeloma patients using a three-state Markov model over a 15-year time horizon. Efficacy and utilization data were obtained from the MM009/010 and APEX trials and external studies. Price and cost data were from local sources and presented in 2021 South African Rands. Outcomes were reported in quality adjusted life years (QALYs). Incremental cost effectiveness ratios (ICERs) were calculated for BORT and LEN/DEX and compared to a local cost-effectiveness threshold of R38 500 per DALY averted using the assumption that 1 DALY averted is equal to 1 QALY gained. A budget impact analysis was conducted to evaluate the financial impact of the introduction of BORT and LEN/DEX, respectively. Deterministic sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS: The modelled total costs of DEX, BORT and LEN/DEX were estimated to be R8 312, R234 996 and R1 135 323, respectively. DEX treatment provided 1.14 QALYs while BORT and LEN/DEX treatments provided 1.49 and 2.22 QALYs, respectively. The ICER of BORT versus DEX was R654 649 and that of LEN/DEX versus BORT was R1 225 542. Both BORT and LEN/DEX treatments were not cost-effective relative to a cost-effectiveness threshold of R38 500 per DALY averted. Both BORT and LEN/DEX significantly increase the 1 year budget-cost of RRMM treatment. CONCLUSION: Both BORT and LEN/DEX treatments are unlikely to be cost-effective strategies for second-line treatment of RRMM in South Africa. The results indicate that the drug prices of lenalidomide and bortezomib are key drivers of value for money. Price reductions could potentially make BORT more cost-effective.

A cost analysis of a sports-based sexual health education programme for adolescent girls in South African schools.

Studies have shown that school-based sexual health promotion interventions can improve adolescent sexual and reproductive health outcomes. However, there has been insufficient evidence on the cost and cost-effectiveness of such programmes, driving poor and inconsistent investment and prioritization. This paper analyses the costs of the SKILLZ Health for Girls programme, a sports-based sexual education intervention targeted at adolescent girls in the secondary school environment. Costs were collected alongside a cluster-randomized trial, including 38 secondary schools in Cape Town, South Africa. The analysis was conducted from a provider (multi-sector) perspective and used a mixed-methods costing approach. We developed a cost data collection tool to compile cost information from one-on-one interviews, administrative data and non-participant observations of the intervention. Costs were analysed for 2019, representing a full academic year of programme implementation. The intention-to-treat analysis revealed an average cost per learner per session of $9.92, and the cost per learner reached was estimated at $69.43. Sensitivity analysis indicated that these costs were sensitive to the participation rates of the learners who did not complete the intervention. The cumulative cost for the scale-up scenario for the Western Cape Province based on the base-case analysis (maximizing coverage of schools but only including 30% of eligible learners within schools) was estimated at $5 311 453.00 for a 3-year period, which exceeds the provincial conditional grant allocation dedicated to the human immunodeficiency virus and acquired immune deficiency syndrome (life skills education) for the same period, yet is comparable to the expenditure for a similar donor-funded programme within the province. The study's results will contribute to decision-making for implementing sexual education interventions in schools in South Africa and similar contexts.

Stepped care to optimize pre-exposure prophylaxis (PrEP) effectiveness in pregnant and postpartum women (SCOPE-PP) in South Africa: a randomized control trial.

BACKGROUND: HIV incidence among pregnant and postpartum women remains high in South Africa. Pre-exposure prophylaxis (PrEP) use remains suboptimal in this population, particularly during the postpartum period when women's engagement with routine clinic visits outside PrEP decreases. Key barriers to sustained PrEP use include the need for ongoing contact with the health facility and suboptimal counseling around effective PrEP use. METHODS: Stepped Care to Optimize PrEP Effectiveness in Pregnant and Postpartum women (SCOPE-PP), is a two-stepped unblinded, individually randomized controlled trial (RCT) that aims to optimize peripartum and postpartum PrEP use by providing a stepped package of evidence-based interventions. We will enroll 650 pregnant women (> 25 weeks pregnant) who access PrEP at a busy antenatal clinic in Cape Town at the time of recruitment and follow them for 15 months. We will enroll and individually randomize pregnant women > 16 years who are not living with HIV who are either on PrEP or interested in starting PrEP during pregnancy. In step 1, we will evaluate the impact of enhanced adherence counselling and biofeedback (using urine tenofovir tests for biofeedback) and rapid PrEP collection (to reduce time required) on PrEP use in early peripartum compared to standard of care (SOC) (n = 325 per arm). The primary outcome is PrEP persistence per urine tenofovir levels and dried blood spots of tenofovir diphosphate (TFV-DP) after 6-months. The second step will enroll and individually randomize participants from Step 1 who discontinue taking PrEP or have poor persistence in Step 1 but want to continue PrEP. Step 2 will test the impact of enhanced counseling and biofeedback plus rapid PrEP collection compared to community PrEP delivery with HIV self-testing on PrEP use (n = up to 325 postpartum women). The primary outcome is PrEP continuation and persistence 6-months following second randomization (~ 9-months postpartum). Finally, we will estimate the cost effectiveness of SCOPE-PP vs. SOC per primary outcomes and disability-adjusted life-years (DALYs) averted in both Step 1 and 2 using micro-costing with trial- and model-based economic evaluation. DISCUSSION: This study will provide novel insights into optimal strategies for delivering PrEP to peripartum and postpartum women in this high-incidence setting. TRIAL REGISTRATION: NCT05322629 : Date of registration: April 12, 2022.

Sexually transmitted infection screening to prevent adverse birth and newborn outcomes: study protocol for a randomized-controlled hybrid-effectiveness trial.

BACKGROUND: Sexually transmitted infections (STIs) during pregnancy are associated with adverse birth outcomes, including preterm birth, low birth weight, perinatal death, and congenital infections such as increased mother-to-child HIV transmission. Prevalence of STIs among pregnant women in South Africa remains high, with most women being asymptomatic for their infection(s). Unfortunately, most STIs remain undetected and untreated due to standard practice syndromic management in accordance with World Health Organization (WHO) guidelines. Although lab-based and point-of-care molecular tests are available, optimal screening strategies during pregnancy, their health impact, and cost-effectiveness are unknown. METHODS: We will implement a 3-arm (1:1:1) type-1 hybrid effectiveness-implementation randomized-controlled trial (RCT). We will enroll 2500 pregnant women attending their first antenatal care (ANC) visit for their current pregnancy at participating health facilities in Buffalo City Metro District, Eastern Cape Province, South Africa. Participants allocated to arms 1 and 2 (intervention) will receive GeneXpert® point-of-care diagnostic testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis, with same-day treatment for detected infection(s). Arm 1 will additionally receive a test-of-cure 3 weeks post-treatment, while Arm 2 will receive a repeat test at 30-34 weeks' gestation. Those allocated to Arm 3 will receive syndromic management (standard-of-care). The RE-AIM framework will be used to guide collection of implementation indicators to inform potential future scale up. Primary outcome measures include (1) frequency of adverse birth outcomes among study arms, defined by a composite measure of low birth weight and pre-term delivery, and (2) change in STI prevalence between baseline and birth outcome among intervention arms and compared to standard-of-care. Estimates and comparative costs of the different screening strategies relative to standard-of-care and the costs of managing adverse birth outcomes will be calculated. Cost-effectiveness will be assessed per STI and disability-adjusted life year averted. DISCUSSION: This trial is the first RCT designed to identify optimal, cost-effective screening strategies that decrease the burden of STIs during pregnancy and reduce adverse birth outcomes. Demonstrating the impact of diagnostic screening and treatment, compared to syndromic management, on birth outcomes will provide critical evidence to inform changes to WHO guidelines for syndromic management of STIs during pregnancy. TRIAL REGISTRATION: ClinicalTrials.gov NCT04446611 . Registered on 25 June 2020.

Health Technology Assessment in Support of National Health Insurance in South Africa.

South Africa has embarked on major health policy reform to deliver universal health coverage through the establishment of National Health Insurance (NHI). The aim is to improve access, remove financial barriers to care, and enhance care quality. Health technology assessment (HTA) is explicitly identified in the proposed NHI legislation and will have a prominent role in informing decisions about adoption and access to health interventions and technologies. The specific arrangements and approach to HTA in support of this legislation are yet to be determined. Although there is currently no formal national HTA institution in South Africa, there are several processes in both the public and private healthcare sectors that use elements of HTA to varying extents to inform access and resource allocation decisions. Institutions performing HTAs or related activities in South Africa include the National and Provincial Departments of Health, National Treasury, National Health Laboratory Service, Council for Medical Schemes, medical scheme administrators, managed care organizations, academic or research institutions, clinical societies and associations, pharmaceutical and devices companies, private consultancies, and private sector hospital groups. Existing fragmented HTA processes should coordinate and conform to a standardized, fit-for-purpose process and structure that can usefully inform priority setting under NHI and for other decision makers. This transformation will require comprehensive and inclusive planning with dedicated funding and regulation, and provision of strong oversight mechanisms and leadership.

A retrospective study assessing the clinical outcomes and costs of acute hepatitis A in Cape Town, South Africa.

BACKGROUND: While some evidence has been demonstrated the cost-effectiveness of routine hepatitis A vaccination in middle-income countries, the evidence is still limited in other settings including in South Africa. Given this, the evidence base around the cost of care for hepatitis A needs to be developed towards considerations of introducing hepatitis A vaccines in the national immunisation schedule and guidelines. OBJECTIVES: To describe the severity, clinical outcomes, and cost of hepatitis A cases presenting to two tertiary healthcare centers in Cape Town, South Africa. METHODS: We conducted a retrospective folder review of patients presenting with hepatitis A at two tertiary level hospitals providing care for urban communities of metropolitan Cape Town, South Africa. Patients included in this folder review tested positive for hepatitis A immunoglobulin M between 1 January 2008 and 1 March 2018. RESULTS: In total, 239 folders of hepatitis A paediatric patients < 15 years old and 212 folders of hepatitis A adult patients [Formula: see text] 15 years old were included in the study. Before presenting for tertiary level care, more than half of patients presented for an initial consultation at either a community clinic or general physician. The mean length of hospital stay was 7.45 days for adult patients and 3.11 days for paediatric patients. Three adult patients in the study population died as a result of hepatitis A infection and 29 developed complicated hepatitis A. One paediatric patient in the study population died as a result of hepatitis A infection and 27 developed complicated hepatitis A, including 4 paediatric patients diagnosed with acute liver failure. The total cost per hepatitis A hospitalisation was $1935.41 for adult patients and $563.06 for paediatric patients, with overhead costs dictated by the length of stay being the largest cost driver. CONCLUSION: More than 1 in every 10 hepatitis A cases (13.3%) included in this study developed complicated hepatitis A or resulted in death. Given the severity of clinical outcomes and high costs associated with hepatitis A hospitalisation, it is important to consider the introduction of hepatitis A immunisation in the public sector in South Africa to potentially avert future morbidity, mortality, and healthcare spending.

A review of simulation models for the long-term management of type 2 diabetes in low-and-middle income countries.

INTRODUCTION: The burden of type 2 diabetes is steadily increasing in low-and-middle-income countries, thereby posing a major threat from both a treatment, and funding standpoint. Although simulation modelling is generally relied upon for evaluating long-term costs and consequences associated with diabetes interventions, no recent article has reviewed the characteristics and capabilities of available models used in low-and-middle-income countries. We review the use of computer simulation modelling for the management of type 2 diabetes in low-and-middle-income countries. METHODS: A search for studies reporting computer simulation models of the natural history of individuals with type 2 diabetes and/or decision models to evaluate the impact of treatment strategies on these populations was conducted in PubMed. Data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed using modelling checklists. Publications before the year 2000, from high-income countries, studies involving animals and analyses that did not use mathematical simulations were excluded. The full text of eligible articles was sourced and information about the intervention and population being modelled, type of modelling approach and the model structure was extracted. RESULTS: Of the 79 articles suitable for full text review, 44 studies met the inclusion criteria. All were cost-effectiveness/utility studies with the majority being from the East Asia and Pacific region (n = 29). Of the included studies, 34 (77.3%) evaluated the cost-effectiveness of pharmacological interventions and approximately 75% of all included studies used HbA1c as one of the treatment effects of the intervention. 32 (73%) of the publications were microsimulation models, and 29 (66%) were state-transition models. Most of the studies utilised annual cycles (n = 29, 71%), and accounted for costs and outcomes over 20 years or more (n = 38, 86.4%). CONCLUSIONS: While the use of simulation modelling in the management of type 2 diabetes has been steadily increasing in low-and-middle-income countries, there is an urgent need to invest in evaluating therapeutic and policy interventions related to type 2 diabetes in low-and-middle-income countries through simulation modelling, especially with local research data. Moreover, it is important to improve transparency and credibility in the reporting of input data underlying model-based economic analyses, and studies.

Economic evaluations of psychological treatments for common mental disorders in low- and middle-income countries: protocol for a systematic review.

BACKGROUND: Common mental disorders (CMDs) are highly prevalent conditions that constitute a major public health and economic burden on society in low- and middle-income countries (LMICs). Despite the increased demand for economic evidence to support resource allocation for scaled-up implementation of mental health services in these contexts, economic evaluations of psychological treatments for CMDs remain scarce. OBJECTIVE: The proposed systematic review aims to synthesize findings on methods and outcomes of economic evaluations of psychological treatments for CMDs in LMICs and appraise quality. METHODS: We will identify, select, and extract data from published economic evaluations of psychological interventions for CMDs conducted in LMICs. We will search bibliographic databases (PubMed, EMBASE, CINAHL, Web of Science, EconLit, PsycINFO, Africa-Wide Information, Cochrane library, Centre for Reviews and Dissemination (CRD), Cost Effectiveness Analysis (CEA) Registry), and the African Journals Online (AJOL) and Google Scholar platforms. Only full economic evaluations (Cost-Effectiveness Analysis (CEA), Cost-Utility Analysis (CUA), Cost-Consequence Analysis (CCA), or Cost-Benefit Analysis (CBA)) of psychological treatments for CMDs (defined as depressive, anxiety, and substance use disorders) conducted in LMICs will be included. There will be no restrictions based on date of publication, perspective, follow-up duration or sample size. Data extraction will be guided by the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. RESULTS: The results presented will be examined using a narrative synthesis approach. The quality of included studies will be assessed using the Drummond & Jefferson checklist. CONCLUSION: The fledgling evidence base in this area provides an opportunity to promote improved economic evaluation methods in line with repeated calls for economic evidence alongside effectiveness evidence in these settings. A rigorously developed economic evaluation evidence base will support resource allocation decisions for scaled up implementation of psychological interventions in LMIC settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42020185277.

Prevention of hepatitis B mother-to-child transmission in Namibia: A cost-effectiveness analysis.

Despite access to a safe and effective vaccine, mother-to-child transmission (MTCT) of hepatitis B virus (HBV) persists in Africa. This is of concern since perinatally-infected infants are at highest risk of developing hepatocellular carcinoma, a life-threatening consequence of chronic HBV infection. While tools to prevent HBV MTCT are available, the cost implications of these interventions need consideration prior to implementation. A Markov model was developed to determine the costs and health outcomes of (1) universal HBV birth dose (BD) vaccination, (2) universal BD vaccination and targeted hepatitis B immunoglobulin (HBIG), (3) maternal antiviral prophylaxis using sequential HBV viral load testing added to HBV BD vaccination and HBIG, and (4) maternal antiviral prophylaxis using sequential HBeAg testing combined with HBV BD vaccination and HBIG. Health outcomes were assessed as the number of paediatric infections averted and disability-adjusted life years (DALYs) averted. Primary cost data included consumables, human resources, and hospital facilities. HBV epidemiology, transitions probabilities, disability weights, and the risks of HBV MTCT were extracted from the literature. Incremental cost-effectiveness ratios (ICERs) were calculated to compare successive more expensive interventions to the previous less expensive one. One-way sensitivity analyses were conducted to test the robustness of the model's outputs. At the Namibian cost/DALY averted threshold of US$3 142, the (1) BD vaccination + targeted HBIG, and (2) maternal antiviral prophylaxis with sequential HBeAg testing interventions were cost-effective. These interventions had ICERs equal to US$1909.03/DALY and US$2598.90/DALY averted, respectively. In terms of effectiveness, the maternal antiviral prophylaxis with sequential HBeAg testing intervention was the intervention of choice. The analysis showed that elimination of HBV MTCT is achievable using maternal antiviral prophylaxis with active and passive immunization. There is an urgent need for low cost diagnostic tests to identify those women who will most benefit from drug therapy to attain this laudable goal.

Strengthening health systems to improve the value of tuberculosis diagnostics in South Africa: A cost and cost-effectiveness analysis.

BACKGROUND: In South Africa, replacing smear microscopy with Xpert-MTB/RIF (Xpert) for tuberculosis diagnosis did not reduce mortality and was cost-neutral. The unchanged mortality has been attributed to suboptimal Xpert implementation. We developed a mathematical model to explore how complementary investments may improve cost-effectiveness of the tuberculosis diagnostic algorithm. METHODS: Complementary investments in the tuberculosis diagnostic pathway were compared to the status quo. Investment scenarios following an initial Xpert test included actions to reduce pre-treatment loss-to-follow-up; supporting same-day clinical diagnosis of tuberculosis after a negative result; and improving access to further tuberculosis diagnostic tests following a negative result. We estimated costs, deaths and disability-adjusted-life-years (DALYs) averted from provider and societal perspectives. Sensitivity analyses explored the mediating influence of behavioural, disease- and organisational characteristics on investment effectiveness. FINDINGS: Among a cohort of symptomatic patients tested for tuberculosis, with an estimated active tuberculosis prevalence of 13%, reducing pre-treatment loss-to-follow-up from ~20% to ~0% led to a 4% (uncertainty interval [UI] 3; 4%) reduction in mortality compared to the Xpert scenario. Improving access to further tuberculosis diagnostic tests from ~4% to 90% among those with an initial negative Xpert result reduced overall mortality by 28% (UI 27; 28) at $39.70/ DALY averted. Effectiveness of investment scenarios to improve access to further diagnostic tests was dependent on a high return rate for follow-up visits. INTERPRETATION: Investing in direct and indirect costs to support the TB diagnostic pathway is potentially highly cost-effective.

Economic evaluation and health systems strengthening: a review of the literature.

Health systems strengthening (HSS) is firmly on the global health and development agenda. While a growing evidence base seeks to understand the effectiveness of HSS, there is limited evidence regarding cost and cost-effectiveness. Without such evidence, it is hard to argue that HSS represents value for money and the level of investment needed cannot be quantified. This paper seeks to review the literature regarding the economic evaluation of HSS from low- and middle-income country (LMIC) settings, and to contribute towards the development of methods for the economic evaluation of HSS. A systematic search for literature was conducted in PubMed, Scopus and the Health Systems Evidence database. MeSH terms related to economic evaluation were combined with key words related to the concept of HSS. Of the 204 records retrieved, 52 were retained for full text review and 33 were included. Of these, 67% were published between January 2015 and June 2019. While many HSS interventions have system wide impacts, most studies (71%) investigated these impacts using a disease-specific lens (e.g. the impact of quality of care improvements on uptake of facility deliveries). HSS investments were categorized, with the majority being investments in platform efficiency (e.g. quality of care), followed by simultaneous investment in platform efficiency and platform capacity (e.g. quality of care and task shifting). This review identified a growing body of work seeking to undertake and/or conceptualize the economic evaluation of HSS in low- and middle-income countries. The majority assess HSS interventions using a disease-specific or programmatic lens, treating HSS in a similar manner to the economic evaluation of medicines and diagnostics. While this approach misses potential economies of scope from HSS investments, it allows for a preliminary understanding of relative value for money. Future research is needed to complement the emerging evidence base.

Does an Orthopedic Ward Round Pro Forma Improve Inpatient Documentation?

INTRODUCTION: Thorough documentation is of utmost importance in a patient hospital experience. It forms an accurate record of an inpatient stay, facilitates handover between medical colleagues, and is also a legal document. Medical notes tend to be detailed and insightful on admission, but the daily ward round notes have often fallen short of expectation. With most patient records entered by junior level of staff, it is important to ensure that adequate documentation occurs. METHODS: We analyzed notes entered in patient charts at set periods and compared them against standards set out in the Royal College of Surgeons Ireland and England, as well as Medical Council guidelines from the two countries. After this, a pro forma was established to standardize the medical record keeping on patient ward rounds. Compliance with guidelines was assessed by comparing notes before introduction of the pro forma and after their introduction. RESULTS: Before its introduction, 0% of notes fulfilled the full criteria selected for the pro forma documentation. After intervention, there was a good initial response, with notes capturing an average 86% of the required information. A reaudit of compliance 2 months after introduction showed a 9% decrease of information completeness to 75%. CONCLUSIONS: Introduction of a pro forma for the documentation of daily ward rounds improved compliance of ward round notes when compared with internationally recognized guidelines, with no additional time required during ward rounds. Despite improved compliance, continued effort is needed to achieve a better standard of care.

The impact of social, national and community-based health insurance on health care utilization for mental, neurological and substance-use disorders in low- and middle-income countries: a systematic review.

BACKGROUND: Whilst several systematic reviews conducted in Low- and Middle-Income Countries (LMICs) have revealed that coverage under social (SHI), national (NHI) and community-based (CBHI) health insurance has led to increased utilization of health care services, it remains unknown whether, and what aspects of, these shifts in financing result in improvements to mental health care utilization. The main aim of this review was to examine the impact of SHI, NHI and CBHI enrollment on mental health care utilization in LMICs. METHODS: Systematic searches were performed in nine databases of peer-reviewed journal articles: Pubmed, Scopus, SciELO via Web of Science, Africa Wide, CINAHL, PsychInfo, Academic Search Premier, Health Source Nursing Academic and EconLit for studies published before October 2018. The quality of the studies was assessed using the Effective Public Health Practice Project quality assessment tool for quantitative studies. The systematic review was reported according to the PRISMA guidelines (PROSPERO;2018; CRD42018111576). RESULTS: Eighteen studies were included in the review. Despite some heterogeneity across countries, the results demonstrated that enrollment in SHI, CBHI and NHI schemes increased utilization of mental health care. This was consistent for the length of inpatient admissions, number of hospitalizations, outpatient use of rehabilitation services, having ever received treatment for diagnosed schizophrenia and depression, compliance with drug therapies and the prescriptions of more favorable medications and therapies, when compared to the uninsured. The majority of included studies did not describe the insurance schemes and their organizational details at length, with limited discussion of the links between these features and the outcomes. Given the complexity of mental health service utilization in these diverse contexts, it was difficult to draw overall judgements on whether the impact of insurance enrollment was positive or negative for mental health care outcomes. CONCLUSIONS: Studies that explore the impact of SHI, NHI and CBHI enrollment on mental health care utilization are limited both in number and scope. Despite the fact that many LMICs have been hailed for financing reforms towards universal health coverage, evidence on the positive impact of the reforms on mental health care utilization is only available for a small sub-set of these countries.

Economic burden of maternal depression among women with a low income in Cape Town, South Africa.

BACKGROUND: Maternal depression is a notable concern, yet little evidence exists on its economic burden in low- and middle-income countries. AIMS: This study assessed societal costs and economic outcomes across pregnancy to 12 months postpartum comparing women with depression with those without depression. Trial registration: ClinicalTrials.gov: NCT01977326 (registered on 24 October 2013); Pan African Clinical Trials Registry (www.pactr.org): PACTR201403000676264 (registered on 11 October 2013). METHOD: Participants were recruited during the first antenatal visit to primary care clinics in Khayelitsha, Cape Town. In total, 2187 women were screened, and 419 women who were psychologically distressed were retained in the study. Women were interviewed at baseline, 8 months gestation and at 3 and 12 months postpartum; the Hamilton Rating Scale for Depression was used to categorise women as having depression or not having depression at each interview. Collected data included sociodemographics; health service costs; user fees; opportunity costs of accessing care; and travelling expenses for the women and their child(ren). Using Markov modelling, the incremental economic burden of maternal depression was estimated across the period. RESULTS: At 12 months postpartum, women with depression were significantly more likely to be unemployed, to have lower per capita household income, to incur catastrophic costs and to be in a poorer socioeconomic group than those women without depression. Costs were higher for women with depression and their child(ren) at all time points. Modelled provider costs were US$805 among women without depression versus US$1303 in women with depression. CONCLUSIONS: Economic costs and outcomes were worse in perinatal women with depression. The development of interventions to reduce this burden is therefore of significant policy importance.

The household economic costs associated with depression symptoms: A cross-sectional household study conducted in the North West province of South Africa.

AIM: The aim of this study was to assess the association between depression symptom severity and household income, consumption, asset-based wealth, debt and use of distress financing strategies, to understand how depression symptom severity and household economic welfare are related. METHODS: A household survey was administered to the households of primary health clinic-attenders who were screened for depression symptoms using the 9-item Patient Health Questionnaire in the chronic care units of four primary health clinics in the North West province of South Africa. Univariate and multivariable regression models were used to assess whether a range of household economic measures were significant predictors of depression symptom severity; and whether depression symptom severity significantly predicted changes to household economic welfare, across a number of different economic measures using both multiple linear regression and logistic regression analyses. RESULTS: On univariate analysis, certain characteristics were associated with significantly worse (higher) PHQ-9 scores, namely: households in which the household head was younger, female, and unmarried; households in which the indexed patient was younger, and did not receive an education beyond primary school; increasing household size, receipt of a social grant, households living in housing constructed of metal sheet walls and households making use of a public tap as their primary water source. In addition, univariate analysis demonstrated that higher log-transformed food expenditure, lower log-transformed capacity to pay, the presence of household debt and both reducing the size or frequency of meals and drawing up retail shop accounts in response to financial distress over the past three years were associated with significantly worse (higher) PHQ-9 scores. Multivariable analysis demonstrated that larger household sizes (p<0.05), receipt of social grants (p<0.05), higher food expenditure (p<0.01), and drawing up retail shop accounts in response to financial distress (p<0.05) were independently predictive of worse (higher) PHQ-9 scores. Inversely, increasing age of the household head (p<0.05), having piped water directly into the household (as opposed to making use of a public water sources) (p<0.01), and increasing capacity to pay (p<0.01) were independently predictive of better (lower) PHQ-9 scores. Similarly, multivariable analysis demonstrated that worse (higher) PHQ-9 scores were independently predictive of lower household capacity to pay (p<0.10) and higher food expenditure (p<0.01). CONCLUSIONS: This study is the first of its kind in South Africa, identifying household economic factors associated with increased depression symptom severity on a continuum; and demonstrating that financial risk protection efforts are needed across this continuum. The study demonstrates that the relationship between poverty and mental health extends beyond the individual to affect household economic functioning. These findings must be included in policy considerations to achieve effective protection for vulnerable households facing the interaction of depression and adverse economic circumstances.

Mental health system costs, resources and constraints in South Africa: a national survey.

The inclusion of mental health in the Sustainable Development Goals represents a global commitment to include mental health among the highest health and development priorities for investment. Low- and middle-income countries (LMICs), such as South Africa, contemplating mental health system scale-up embedded into wider universal health coverage-related health system transformations, require detailed and locally derived estimates on existing mental health system resources and constraints. The absence of these data has limited scale-up efforts to address the burden of mental disorders in most LMICs. We conducted a national survey to quantify public expenditure on mental health and evaluate the constraints of the South African mental health system. The study found that South Africa's public mental health expenditure in the 2016/17 financial year was USD615.3 million, representing 5.0% of the total public health budget (provincial range: 2.1-7.7% of provincial health budgets) and USD13.3 per capita uninsured. Inpatient care represented 86% of mental healthcare expenditure, with nearly half of total mental health spending occurring at the psychiatric hospital-level. Almost one-quarter of mental health inpatients are readmitted to hospital within 3 months of a previous discharge, costing the public health system an estimated USD112 million. Crude estimates indicate that only 0.89% and 7.35% of the uninsured population requiring care received some form of public inpatient and outpatient mental healthcare, during the study period. Further, mental health human resource availability, infrastructure and medication supply are significant constraints to the realization of the country's progressive mental health legislation. For the first time, this study offers a nationally representative reflection of the state of mental health spending and elucidates inefficiencies and constraints emanating from existing mental health investments in South Africa. With this information at hand, the government now has a baseline for which a rational process to planning for system reforms can be initiated.