Economic evaluation of a leprosy innovation project in Northern Nigeria: cost-effectiveness analysis.

BACKGROUND: The state of leprosy in Nigeria and the realities of post elimination era underscore the need for evidence- based cost-effective approach to early case detection for enhanced control and elimination of leprosy. This study evaluated the operational cost-effectiveness of a community delivered Legacy Innovative Project implemented to enhance leprosy case detection in northern Nigeria. METHODS: Data were collected from an explorative cross-sectional study, undertaken in a practice setting among endemic communities in three states in northern Nigeria. Primary and secondary data were collected from the project, routine records and programme annual reports. Costs and effects were measured from both providers' and patients' perspectives, and outcome expressed as cost per new case detected. Incremental estimates of costs and effects of the project compared to routine practice were used to obtain the cost-effectiveness result, as incremental cost-effectiveness ratio (ICER). All costs were converted to the US Dollar at 2018exchange rate (N350 = US$1.00). Univariate sensitivity analysis was performed to evaluate uncertainties around the ICER. RESULTS: The Project overall detected a total of 347 newly confirmed leprosy cases at a total annual cost of US$49,337.19, averaging US$142.18 per new case detected. Key cost drivers included routine meetings, which accounted for 28% of total expenditure, while Social Mobilization and Training/Workshop accounted for17% respectively. Findings were similar across the states. Overall, the Project dominated routine practice with ICER of US$(-17.73) per additional/new case detected, as a very cost-effective strategy. Sensitivity analysis reinforced the cost-effectiveness result. CONCLUSIONS: The Legacy Innovative Project demonstrated a more efficient and cost-saving approach to leprosy case detection. Findings present important information to policy and programmes for enhanced control and elimination of leprosy in related settings. .

Evaluating a capacity development intervention in health economics among producers and users of evidence in Nigeria: a case study in Getting Research Into Policy and Practice (GRIPP) in Anambra State.

BACKGROUND: The use of research evidence to inform policy and practice cannot be overemphasized especially in low and middle-income countries (LMICs). To promote the use of research evidence in the provision of health services for enhanced effective control of communicable diseases in developing countries, the World Health Organization (WHO) in collaboration with the Health Policy Research Group (HPRG) commissioned a capacity development workshop in health economics among producers and users of research evidence in the healthcare system of Anambra state, south east Nigeria. This study was aimed to evaluate the impact of the workshop training on selected stakeholders on the use of health economics evidence to inform health policy and practice in the state. METHODS: Participants were purposively selected based either as producers and users of evidence at various levels of healthcare decision making in Anambra state, comprising mostly senior managers and executives from the ministry of health, the academic and health institutions in the state. A two-day capacity development workshop was conducted to train the participants on the use of economic evidence to inform health policy and practice. Pre-post test approach and group exercises were used to assess the knowledge and impact of the training exercises on the participants regarding the use of health economics evidence. Analysis was based on the framework of process-output-outcome-impact approach using the pre-post test and scores technique to assess the impact of the training programme. RESULTS: Pretest average scores varied from 39.7% to 60.5% while posttest scores varied from 47.6% to 65.7%, showing big differences in individual scores among participants, between the producers and users of evidence both prior to and after the training. The significant differences between the test scores indicated success in increasing the knowledge of participants on the use of health economics evidence. Results corroborated participants' perceptions that the workshop impacted positively on their ability to apply the knowledge of health economic evidence to inform decision making in their respective practices. CONCLUSION: Findings underscored the need for regular upgrade of stakeholders in the health system for enhanced uptake and sustainability of the programme to achieve the desired goal of getting research into policy and practice in the state applicable to other settings.

Heavy metal content of rice meals sold in a Nigerian market population with a high prevalence of hypertension.

Context: Some market populations in Nigeria have been shown to have high prevalence of hypertension. Current evidence includes environmental pollutants such as heavy metals as risk factors for hypertension. Aim: To study the heavy metal content of rice meals sold in a market population with a high prevalence of hypertension. Settings and Design: This was a descriptive, cross-sectional study conducted in Ogbete market in Enugu, Southeast Nigeria. Subjects and Methods: Five different cooked rice meals were obtained from 25 locations of the market. The rice meals included jollof rice, white rice and tomato stew, fried rice, white rice and vegetable sauce, and white rice and palm oil stew (ofeakwu). Accompanying protein (meat, fish, and egg) and vegetable salad were excluded. Similar rice meals were homogenized and analyzed in triplicates using spectrophotometric methods for mercury, copper, cadmium, lead, and arsenic determination. Statistical Analysis Used: The mean concentrations of the heavy metals were compared using analysis of variance, and P < 0.05 was considered statistically significant. Results: Twenty-five rice dishes were evaluated, five of each kind. Arsenic content ranged from 503 to 550 mg/kg and was comparable across the five rice dishes (P = 0.148). Copper was significantly highest (16767 mg/kg) in the white rice and tomato stew dish (P < 0.001), while mercury was significantly highest (33 mg/kg) in white rice and ofeakwu (P < 0.001). Jollof rice had the highest cadmium content (23 mg/kg), which was statistically significant (P = 0.021). Lead was not found in any of the rice dishes. Conclusions: Risk factors such as heavy metals may play a role in the high prevalence of hypertension observed in market populations, and rice meals may be a major source of these heavy metals.

RésuméContexte: Il a été démontré que certaines populations du marché au Nigéria présentent une prévalence élevée d'hypertension. Les preuves actuelles incluent l'environnement des polluants tels que les métaux lourds comme facteurs de risque d'hypertension. Objectif: étudier la teneur en métaux lourds des farines de riz vendues dans une population de marché avec une prévalence élevée d'hypertension. Paramètres et conception: il s'agit d'une étude descriptive et transversale menée sur le marché d'Ogbete en Enugu, sud-est du Nigéria. Sujets et méthodes: Cinq plats de riz cuit différents ont été obtenus dans 25 emplacements du marché. Le riz les repas comprenaient du riz jollof, du riz blanc et du ragoût de tomates, du riz frit, du riz blanc et de la sauce aux légumes, et du riz blanc et du ragoût d'huile de palme (ofeakwu). Les protéines d'accompagnement (viande, poisson et œuf) et la salade de légumes ont été exclues. Des farines de riz similaires ont été homogénéisées et analysées triplicats utilisant des méthodes spectrophotométriques pour la détermination du mercure, du cuivre, du cadmium, du plomb et de l'arsenic. Analyse statistique utilisée: le les concentrations moyennes des métaux lourds ont été comparées à l'aide d'une analyse de variance, et P <0.05 a été considéré comme statistiquement significatif. Résultats: Vingt-cinq plats de riz ont été évalués, cinq de chaque type. La teneur en arsenic variait de 503 à 550 mg / kg et était comparable dans les cinq plats de riz (P = 0,148). Le cuivre était significativement plus élevé (16767 mg / kg) dans le plat de ragoût de riz blanc et de tomate (P <0.001), tandis que le mercure était significativement plus élevé (33 mg / kg) dans le riz blanc et l'ofeakwu (P <0.001). Le riz Jollof avait la plus forte teneur en cadmium (23 mg / kg), qui était statistiquement significatif (P = 0.021). Le plomb n'a été trouvé dans aucun des plats de riz. Conclusions: Des facteurs de risque tels que les métaux lourds peuvent jouent un rôle dans la prévalence élevée de l'hypertension observée dans les populations du marché, et les farines de riz peuvent être une source majeure de ces métaux lourds.

Evaluating the Treatment Costs for Uncomplicated Malaria at a Public Healthcare Facility in Nigeria and the Implications.

BACKGROUND: Accurate information on the facility costs of treatment is essential to enhance decision making and funding for malaria control. OBJECTIVE: The objective of this study was to estimate the costs of providing treatment for uncomplicated malaria through a public health facility in Nigeria. METHODS: Hospital costs were estimated from a provider perspective, applying a standard costing procedure. Capital and recurrent expenditures were estimated using an ingredient approach combined with step-down methodology. Costs attributable to malaria treatment were calculated based on the proportion of malaria cases to total outpatient visits. The costs were calculated in local currency [Naira (N)] and converted to US dollars at the 2013 exchange rate. RESULTS: Total annual costs of N28.723 million (US$182,953.65) were spent by the facility on the treatment of uncomplicated malaria, at a rate of US$31.49 per case, representing approximately 25% of the hospital's total expenditure in the study year. Personnel accounted for over 82.5% of total expenditure, followed by antimalarial medicines at 6.6%. More than 45% of outpatients visits were for uncomplicated malaria. Changes in personnel costs, drug prices and malaria prevalence significantly impacted on the study results, indicating the need for improved efficiency in the use of hospital resources. CONCLUSION: Malaria treatment currently consumes a considerable amount of resources in the facility, driven mainly by personnel cost and a high proportion of malaria cases. There is scope for enhanced efficiency to prevent waste and reduce costs to the provider and ultimately the consumer.

Evaluating the sensitivity of EQ-5D in a sample of patients with type 2 diabetes mellitus in two tertiary health care facilities in Nigeria.

BACKGROUND: The EQ-5D instrument is arguably the most well-known and commonly used generic measure of health status internationally. Although the instrument has been employed in outcomes studies of diabetes mellitus in many countries, it has not yet been used in Nigeria. OBJECTIVE: This study was carried out to assess the sensitivity of the EQ-5D instrument in a sample of Nigerian patients with type 2 diabetes mellitus (T2DM). METHODS: A cross-sectional study was conducted using the EQ-5D instrument to assess the self-reported quality of life of patients with T2DM attending two tertiary healthcare facilities in south eastern Nigeria consenting patients completed the questionnaire while waiting to see a doctor. A priori hypotheses were examined using multiple regression analysis to model the relationship between the dependent variables (EQ VAS and EQ-5D Index) and hypothesized independent variables. RESULTS: A total of 226 patients with T2DM participated in the study. The average age of participants was 57 years (standard deviation 10 years) and 61.1% were male. The EQ VAS score and EQ-5D index averaged 66.19 (standard deviation 15.42) and 0.78 (standard deviation 0.21) respectively. Number of diabetic complications, number of co-morbidities, patient's age and being educated predicted EQ VAS score by -6.76, -6.15, -0.22, and 4.51 respectively. Also, number of diabetic complications, number of co-morbidities, patient's age and being educated predicted EQ-5D index by -0.12, -0.07, -0.003, and 0.06 respectively.. CONCLUSION: Our findings indicate that the EQ-5D could adequately capture the burden of type 2 diabetes and related complications among Nigerian patients.

Limitations to the dynamics of pharmaceutical care practice among community pharmacists in Enugu urban, southeast Nigeria.

BACKGROUND: The introduction of pharmaceutical care in Nigeria has been faced with many challenges in addition to limited information regarding the practice. OBJECTIVE: This study aimed to determine the barriers encountered by community pharmacists in Nigeria in the provision of pharmaceutical care. METHODS: A cross-sectional descriptive survey was carried out in Enugu urban, southeast Nigeria. Data were collected using pretested and structured 5-point Likert scale questionnaires that were self-administered to the respondents. Data were analyzed using descriptive statistics. RESULTS: The 78 community pharmacists comprised 62 males and 16 females. Out of the 78 respondents, 69 (88.5%) had the basic Bachelor of Pharmacy degree while three (3.9%) had Fellowship, Master's, and Doctor of Pharmacy degrees respectively. The mean number of years of practice was 8.2 (±0.6). The key limitations to the implementation of pharmaceutical care were: pharmacists' attitude and lack of pharmaceutical care skills, as well as resource and system-related constraints. Others challenges were interprofessional and academic obstacles like lack of collaboration (66.6%) and lack of role models (42.1%). Most of the respondents (81%) were strongly willing to adopt and implement pharmaceutical care, while 19.2% were not strongly willing to practice pharmaceutical care. CONCLUSION: Despite limitations to practice, community pharmacists in the area are very inclined to implement pharmaceutical care in the private sector to improve patients' quality of life.

Drugs use pattern for uncomplicated malaria in medicine retail outlets in Enugu urban, southeast Nigeria: implications for malaria treatment policy.

BACKGROUND: Malaria treatment policy recommends regular monitoring of drug utilization to generate information for ensuring effective use of anti-malarial drugs in Nigeria. This information is currently limited in the retail sector which constitutes a major source of malaria treatment in Nigeria, but are characterized by significant inappropriate use of drugs. This study analyzed the use pattern of anti-malarial drugs in medicine outlets to assess the current state of compliance to policy on the use of artemisinin-based combination therapy (ACT). METHODS: A prospective cross-sectional survey of randomly selected medicine outlets in Enugu urban, southeast Nigeria, was conducted between May and August 2013, to determine the types, range, prices, and use pattern of anti-malarial drugs dispensed from pharmacies and patent medicine vendors (PMVs). Data were collected and analyzed for anti-malarial drugs dispensed for self-medication to patients, treatment by retail outlets and prescription from hospitals. RESULTS: A total of 1,321 anti-malarial drugs prescriptions were analyzed. ACT accounted for 72.7%, while monotherapy was 27.3%. Affordable Medicines Facility-malaria (AMFm) drugs contributed 33.9% (326/961) of ACT. Artemether-lumefantrine (AL), 668 (50.6%) was the most used anti-malarial drug, followed by monotherapy sulphadoxine-pyrimethamine (SP), 248 (18.8%). Median cost of ACT at $2.91 ($0.65-7.42) per dose, is about three times the median cost of monotherapy, $0.97 ($0.19-13.55). Total cost of medication (including co-medications) with ACT averaged $3.64 (95% CI; $3.53-3.75) per prescription, about twice the mean cost of treatment with monotherapy, $1.83 (95% CI; $1.57-2.1). Highest proportion 46.5% (614), of the anti-malarial drugs was dispensed to patients for self-treatment. Treatment by retail outlets accounted for 35.8% while 17.7% of the drugs were dispensed from hospital prescriptions. Self-medication, 82%, accounted for the highest source of monotherapy and a majority of prescriptions, 85.6%, was adults. CONCLUSION: Findings suggest vastly improved use of ACT in the retail sector after eight years of policy change, with significant contributions from AMFm drugs. However the use of monotherapy, particularly through self-medication remains significant with increasing risk of undermining treatment policy, suggesting additional measures to directly target consumers and providers in the sector for improved use of anti-malarial drugs in Nigeria.

Adherence to treatment guidelines for uncomplicated malaria at two public health facilities in Nigeria; Implications for the 'test and treat' policy of malaria case management.

OBJECTIVES: Adherence to treatment guidelines for uncomplicated malaria is critical to the success of malaria case management. Poor adherence has implications for increased malaria burden, in view of the risk of widespread parasite resistance and treatment failures. This study analyzed the diagnostic and prescription pattern for uncomplicated malaria at two public health facilities, south east Nigeria, to assess the current state of compliance to policy guidelines on the use of artemisinin-based combination therapy (ACT). METHODS: Retrospective audit of patients' records, treated for uncomplicated malaria, between the months of January and March 2013, was undertaken at two public health facilities. Demographics, diagnostic information, medication and cost data were extracted. Questionnaires were distributed to providers to assess their malaria treatment intent. Data from the facilities were analyzed and compared for similarities and systematic differences, and conformity to malaria treatment policy, in terms of laboratory diagnosis, use of ACT, co-medication and cost of medication. RESULTS: A total of 2,171 records of patients who had been treated for uncomplicated malaria were analyzed. Of these, 1066 (49%) were sent for laboratory confirmation of malaria using mostly microscopy, out of which 480 (45%) tested positive. 51% (1105) of the prescriptions was on the basis of presumptive treatment. 58% of slide negative results received antimalarial drugs. 93% of patients received ACT, with artemether-lumefantrin, AL (50.5%) as the most prescribed antimalarial drug. Monotherapy accounted for 7% of prescriptions, comprising mostly sulphadoxine + pyrimethamine, SP (46.5%) and monotherapy artemisinin, AS (29.2%). 97% of the prescriptions received at least one co-medication. Antibiotics were prescribed to 50% of patients. Overall, median cost of medication was N1160.00 (US$7.48 (US$0.19 - 267.87) per case, higher in tertiary than the secondary facility. There were significant variations in treatment practices between the two facilities. CONCLUSION: Evidence suggests good compliance to policy on the use of ACT as first line treatment for uncomplicated malaria. However, there exists significant scope for improved diagnosis and rational drug use, to enhance accuracy of treatment, reduced wastages and risks of adverse drug reactions, in line with the goals of 'test and treat' policy of malaria case management.

Cost-utility analysis of antihypertensive medications in Nigeria: a decision analysis.

BACKGROUND: Many drugs are available for control of hypertension and its sequels in Nigeria but some are not affordable for majority of the populace. This serious pharmacoeconomic question has to be answered by the nation's health economists. The objective of this study was to evaluate the cost-effectiveness of drugs from 4 classes of antihypertensive medications commonly used in Nigeria in management of hypertension without compelling indication to use a particular antihypertensive drug. METHODS: The study employed decision analytic modeling. Interventions were obtained from a meta-analysis. The Markov process model calculated clinical outcomes and costs during a life cycle of 30 years of 1000 hypertensive patients stratified by 3 cardiovascular risk groups, under the alternative intervention scenarios. Quality adjusted life year (QALY) was used to quantify clinical outcome. The average cost of treatment for the 1000 patient was tracked over the Markov cycle model of the alternative interventions and results were presented in 2010 US Dollars. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability frontiers. Expected value of perfect information (EVPI) and expected value of parameter perfect information (EVPPI) analyses were also conducted for the hypothetical population. RESULTS: Thiazide diuretic was the most cost-effective option across the 3 cardiovascular risk groups. Calcium channel blocker was the second best for Moderate risk and high risk with a willingness to pay of at least 2000$/QALY. The result was robust since it was insensitive to the parameters alteration. CONCLUSIONS: The result of this study showed that thiazide diuretic followed by calcium channel blocker could be a feasible strategy in order to ensure that patients in Nigeria with hypertension are better controlled.