Assessing health state utilities for people with myalgic encephalomyelitis/chronic fatigue syndrome in Australia using the EQ-5D-5L, AQoL-8D and EQ-5D-5L-psychosocial instruments.

PURPOSE: Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is a chronic condition with a constellation of symptoms presenting as severe and profound fatigue of ≥ 6 months not relieved by rest. ME/CFS affects health-related quality of life (HRQoL), which can be measured using multi-attribute health state utility (HSU) instruments. The aims of this study were to quantify HSUs for people living with ME/CFS, and to identify an instrument that is preferentially sensitive for ME/CFS. METHODS: Cross-sectional national survey of people with ME/CFS using the AQoL-8D and EQ-5D-5L. Additional questions from the AQoL-8D were used as 'bolt-ons' to the EQ-5D-5L (i.e., EQ-5D-5L-Psychosocial). Disability and fatigue severity were assessed using the De Paul Symptom Questionnaire-Short Form (DSQ-SF). HSUs were generated using Australian tariffs. Mean HSUs were stratified for sociodemographic and clinical factors. Bland-Altman plots were used to compare the three HSU instruments. RESULTS: For the 198 participants, mean HSUs (95% confidence intervals) were EQ-5D-5L: 0.46 (0.42-0.50); AQoL-8D: 0.43 (0.41-0.45); EQ-5D-5L-Psychosocial: 0.44 (0.42-0.46). HSUs were substantially lower than population norms: EQ-5D-5L: 0.89; AQoL-8D: 0.77. As disability and fatigue severity increased, HSUs decreased in all three instruments. Bland-Altman plots revealed interchangeability between the AQoL-8D and EQ-5D-5LPsychosocial. Floor and ceiling effects of 13.5% and 2.5% respectively were observed for the EQ-5D-5L instrument only. CONCLUSIONS: ME/CFS has a profound impact on HRQoL. The AQoL-8D and EQ-5D-5L-Psychosocial can be used interchangeably: the latter represents a reduced participant burden.

Is Nigeria on course to achieve universal health coverage in the context of its epidemiological and financing transition? A knowledge, capacity and policy gap analysis (a qualitative study).

OBJECTIVES: This study aimed to assess Nigeria's preparedness to finance and drive the universal health coverage (UHC) agenda within the context of changing health conditions and resource needs associated with the disease, demographic and funding transitions.Nigeria is undergoing transitions in the healthcare system that include a double burden of infectious and non-communicable diseases, and transition from concessional donor assistance towards domestic financing for health. These transitions will affect Nigeria's attainment of UHC. DESIGN AND SETTING: We conducted a qualitative study, including semistructured interviews with relevant stakeholders at national and subnational levels in Nigeria. Data from the interviews were analysed using thematic analysis. PARTICIPANTS: Our study involved 18 respondents from government ministries, departments, and agencies, development partners, civil society organisations and academia. RESULTS: Capacity gaps identified by respondents included limited knowledge to implement health insurance schemes at subnational levels, poor information/data management to monitor progress towards UHC and limited communication and interagency collaboration between government agencies and ministries. Furthermore, participants in our study expressed those current policies driving major health reforms like the National Health Act (basic healthcare provision fund) appear adequate to support UHC advancement in theory, but policy implementation is a key challenge due to a lack of policy awareness, low government spending on health and poor evidence generation for information to support decisions. CONCLUSION: Our study found major gaps in knowledge and capacity for UHC advancement in the context of Nigeria's demographic, epidemiological and financing transitions. These included poor knowledge of demographic transitions, poor capacity for health insurance implementation at subnational levels, low government spending on health, poor policy implementation and poor communication and collaboration among stakeholders. To address these challenges, collaborative efforts are needed to bridge knowledge gaps and increase policy awareness through targeted knowledge products, improved communication and interagency collaboration.

Prevalence of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) in Australian primary care patients: only part of the story?

BACKGROUND: ME/CFS is a disorder characterized by recurrent fatigue and intolerance to exertion which manifests as profound post-exertional malaise. Prevalence studies internationally have reported highly variable results due to the 20 + diagnostic criteria. For Australia, the prevalence of ME/CFS based on current case definitions is unknown. OBJECTIVES: To report prevalence of ME/CFS in patients aged ≥ 13 years attending Australian primary care settings for years 2015-2019, and provide context for patterns of primary care attendance by people living with ME/CFS. METHODOLOGY: Conducted in partnership with the Patient Advisory Group, this study adopted a mixed methods approach. De-identified primary care data from the national MedicineInsight program were analyzed. The cohort were regularly attending patients, i.e. 3 visits in the preceding 2 years. Crude prevalence rates were calculated for years 2015-2019, by sex, 10-year age groups, remoteness and socioeconomic status. Rates are presented per 100,000population (95% confidence intervals (CI)). Qualitative data was collected through focus groups and in-depth 1:1 interview. RESULTS: Qualitative evidence identified barriers to reaching diagnosis, and limited interactions with primary care due to a lack of available treatments/interventions, stigma and disbelief in ME/CFS as a condition. In each year of interest, crude prevalence in the primary care setting ranged between 94.9/100,000 (95% CI: 91.5-98.5) and 103.9/100,000 population (95%CI: 100.3-107.7), equating to between 20,140 and 22,050 people living with ME/CFS in Australia in 2020. Higher rates were observed for age groups 50-59 years and 40-49 years. Rates were substantially higher in females (130.0-141.4/100,000) compared to males (50.9-57.5/100,000). In the context of the qualitative evidence, our prevalence rates likely represent an underestimate of the true prevalence of ME/CFS in the Australian primary care setting. CONCLUSION: ME/CFS affects a substantial number of Australians. Whilst this study provides prevalence estimates for the Australian primary care setting, the qualitative evidence highlights the limitations of these. Future research should focus on using robust case ascertainment criteria in a community setting. Quantification of the burden of disease can be used to inform health policy and planning, for this understudied condition.

Strategic Health Purchasing in Nigeria: Investigating Governance and Institutional Capacities within Federal Tax-Funded Health Schemes and the Formal Sector Social Health Insurance Programme.

For Nigeria to make progress on its commitment to universal health coverage, additional public funding will be required. But more resources alone will not be enough. Government health spending must be more efficient and effective, through more strategic purchasing-a critical policy tool. Studies on health purchasing in Nigeria's health financing schemes are limited, however. This study examines the purchasing arrangements in schemes funded by the federal budget and in the Formal Sector Social Health Insurance Programme (FSSHIP) within the National Health Insurance Scheme. We adopted a qualitative, descriptive case-study approach and collected data through document reviews and key informant interviews based on the Strategic Health Purchasing Progress Tracking Framework. Our analysis used a thematic framework approach. Our findings reveal that legal frameworks and governance structures for strategic purchasing are in place for both schemes. Steps toward strategic purchasing are more advanced in FSSHIP, particularly in the design of benefit packages, accreditation and monitoring of health maintenance organizations (HMOs) and providers, and provider payment mechanisms. The limited share of health funding flowing through these mechanisms, and further fragmentation of that funding, impede strategic purchasing. Strategic purchasing is also hampered by weak regulation and monitoring of providers and purchasers, delays in provider payment, and corrupt practices by HMOs. Improving strategic purchasing in Nigeria will require a concerted effort to reduce fragmentation of health spending, significant investment in human resources, technical know-how, and information systems of purchasing institutions, and actions to improve the accountability of all actors in the system.

Engaging stakeholders to identify gaps and develop strategies to inform evidence use for health policymaking in Nigeria.

Introduction: recent efforts to bridge the evidence-policy gap in low-and middle-income countries have seen growing interest from key audiences such as government, civil society, international organizations, private sector players, academia, and media. One of such engagement was a two-day virtual participant-driven conference (the convening) in Nigeria. The aim of the convening was to develop strategies for improving evidence use in health policy. The convening witnessed a participant blend of health policymakers, researchers, political policymakers, philanthropists, global health practitioners, program officers, students, and the media. Methods: in this study, we analyzed conversations at the convening with the aim to disseminate findings to key stakeholders in Nigeria. The recordings from the convening were transcribed and analyzed inductively to identify emerging themes, which were interpreted, and inferences are drawn. Results: a total of 630 people attended the convening. Participants joined from 13 countries. Participants identified poor collaboration between researchers and policymakers, poor community involvement in research and policy processes, poor funding for research, and inequalities as key factors inhibiting the use of evidence for policymaking in Nigeria. Strategies proposed to address these challenges include the use of participatory and embedded research methods, leveraging existing systems and networks, advocating for improved funding and ownership for research, and the use of context-sensitive knowledge translation strategies. Conclusion: overall, better interaction among the various stakeholders will improve the evidence generation, translation, and use in Nigeria. A road map for the dissemination of findings from this conference has been developed for implementation across the strata of the health system.

Evidence from the Kaduna State Health Accounts on the pattern of sub-national health spending in Nigeria, 2016.

Health accounts provide accurate estimates of health expenditure, which are important for effective resource allocation and planning in the health sector. In Nigeria, four rounds of health accounts have been conducted at the national level. However, the national estimates do not necessarily reflect realities at the subnational level and may only provide limited information for decision making at that level. This study highlights the pattern of health spending in Kaduna State from the 2016 Health Accounts, with a view to providing more reliable evidence for decision making in the state.Health accounts expenditure surveys were administered to government, donors, non-governmental organizations (NGOs), private health insurance organisations and employers in the health sector for the reference year 2016. Household health expenditure was derived from a household survey administered across a representative sample of 1024 households selected from six local government areas across the three senatorial districts in the state. We estimated disease expenditure by deploying a health provider survey across a sample of 100 health facilities. Analysis was conducted using Microsoft Excel, Stata and the Health Accounts Production Tool.Findings show that current health expenditure (CHE) accounted for only 7% of the total health expenditure in 2016. Out-of-pocket spending among households was about 81% of CHE, compared with a national average of 71.5% of CHE between 2010 and 2014. The health expenditure findings highlight several policy imperatives for the Kaduna State Health System. Primary among these is the heavy dependence on out-of-pocket financing for health, which has negative implications on vulnerable households. A shift to pooled prepaid mechanisms would reduce the financial burden on the most vulnerable households in Kaduna State. In addition, considering the government's current contribution to health expenditure, there is a strong need for increased government prioritisation of the Kaduna State health sector.

What are we paying for? A cost-effectiveness analysis of patented denosumab and generic alendronate for postmenopausal osteoporotic women in Australia.

OBJECTIVE: Zoledronic acid and denosumab were funded by the Australian government for the management of osteoporosis at an equivalent price to alendronate. The price of alendronate has declined by around 65 %, but the price of the other two therapies has remained stable. Using data published since the listing, this paper reports current estimates of the value of denosumab compared to alendronate from an Australian health system perspective. METHODS: A cohort-based state transition model was developed that predicted changes in bone mineral density (BMD), and calibrated fracture probabilities as a function of BMD, age and previous fracture to estimate differences in costs and QALYs gained over a 10-year time horizon. RESULTS: The base-case incremental cost per QALY gained for denosumab versus alendronate was $246,749. There is a near zero probability that denosumab is cost-effective at a threshold value of $100,000 per QALY gained. If the price of denosumab was reduced by 50 %, the incremental cost per QALY gained falls to $50,068. DISCUSSION: Current Australian legislation precludes price reviews when comparator therapies come off patent. The presented analysis illustrates a review process, incorporating clinical data collected since the original submission to inform a price at which denosumab would provide value for money.

Option B+ for the prevention of mother-to-child transmission of HIV infection in developing countries: a review of published cost-effectiveness analyses.

OBJECTIVE: To review the published literature on the cost effectiveness of Option B+ (lifelong antiretroviral therapy) for preventing mother-to-child transmission (PMTCT) of HIV during pregnancy and breastfeeding to inform decision making in low- and middle-income countries. METHODS: PubMed, Scopus, Google scholar and Medline were searched to identify studies of the cost effectiveness of the World Health Organization (WHO) treatment guidelines for PMTCT. Study quality was appraised using the consolidated health economic evaluation reporting standards checklist. Eligible studies were reviewed in detail to assess the relevance and impact of alternative evaluation frameworks, assumptions and input parameter values. RESULTS: Five published cost effectiveness analyses of Option B+ for the PMTCT of HIV were identified. The reported cost-effectiveness of Option B+ varies substantially, with the results of different studies implying that Option B+ is dominant (lower costs, greater benefits), cost-effective (additional benefits at acceptable additional costs) or not cost-effective (additional benefits at unacceptable additional costs). This variation is due to significant differences in model structures and input parameter values. Structural differences were observed around the estimation of programme effects on infants, HIV-infected mothers and their HIV negative partners, over multiple pregnancies, as well assumptions regarding routine access to antiretroviral therapies. Significant differences in key input parameters were observed in transmission rates, intervention costs and effects and downstream cost savings. CONCLUSIONS: Across five model-based cost-effectiveness analyses of strategies for the PMTCT of HIV, the most comprehensive analysis reported that option B+ is highly likely to be cost-effective. This evaluation may have been overly favourable towards option B+ with respect to some input parameter values, but potentially important additional benefits were omitted. Decision makers might be best advised to review this analysis, with a view to requesting additional analyses of the model to inform local funding decisions around alternative strategies for the PMTCT of HIV.