Estimating average inpatient and outpatient costs and childhood pneumonia and diarrhoea treatment costs in an urban health centre in Zambia

<p>Abstract</p> <p>Background</p> <p>Millions of children die every year in developing countries, from preventable diseases such as pneumonia and diarrhoea, owing to low levels of investment in child health. Investment efforts are hampered by a general lack of adequate information that is necessary for priority setting in this sector. This paper measures the health system costs of providing inpatient and outpatient services, and also the costs associated with treating pneumonia and diarrhoea in under-five children at a health centre in Zambia.</p> <p>Methods</p> <p>Annual economic and financial cost data were collected in 2005-2006. Data were summarized in a Microsoft excel spreadsheet to obtain total department costs and average disease treatment costs.</p> <p>Results</p> <p>The total annual cost of operating the health centre was US$1,731,661 of which US$1 284 306 and US$447,355 were patient care and overhead departments costs, respectively. The average cost of providing out-patient services was US$3 per visit, while the cost of in-patient treatment was US$18 per bed day. The cost of providing dental services was highest at US$20 per visit, and the cost of VCT services was lowest, with US$1 per visit. The cost per out-patient visit for under-five pneumonia was US$48, while the cost per bed day was US$215. The cost per outpatient visit attributed to under-five diarrhoea was US$26, and the cost per bed day was US$78.</p> <p>Conclusion</p> <p>In the face of insufficient data, a cost analysis exercise is a difficult but feasible undertaking. The study findings are useful and applicable in similar settings, and can be used in cost effectiveness analyses of health interventions.</p

The health related quality of life of people living with HIV/AIDS in sub-Saharan Africa - a literature review and focus group study

<p>Abstract</p> <p>Background</p> <p>While health outcomes of HIV/AIDS treatments in terms of increased <it>longevity </it>has been the subject of much research, there appears to be very limited research on the improved <it>health related quality of life </it>(HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara (SSA). Most of the literature that does exist present HRQL measured by disease specific instruments, but such data is of little use as input to economic evaluations.</p> <p>Methods</p> <p>A systematic review of the literature on HRQL weights for people living with HIV/AIDS in Africa was performed, and the findings are presented and interpreted. We also use focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. We contrast quality of life with and without antiretroviral treatment (ART), and with and without treatment failure.</p> <p>Results</p> <p>In only four papers were the HRQL weights for HIV/AIDS in sub-Saharan Africa estimated with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. While such 'health profiles' are not preference based, the scores could potentially be transformed into health state utilities. Most of the available literature (20 papers) utilized disease specific instrument, which are not applicable for economic evaluation.</p> <p>The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance.</p> <p>Conclusions</p> <p>EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV/AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV/AIDS prevention and treatment interventions.</p

Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania

BACKGROUND: Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania. METHODS: Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in US $using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated. RESULTS: The total cost of treating a patient with conventional health facility based DOT and community based DOT were$ 145 and $94 respectively. Community based DOT reduced cost by 35$ 43 to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at $128 per patient successfully treated compared to$ 203 for a patient successfully treated with health facility based DOT. CONCLUSION: Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources

Public participation: healthcare rationing in the newspaper media

Background It is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing has been subject to public debate both before and after the establishment of “The National System for Managed Introduction of New Health Technologies within the Specialist Health Service” (New Methods) in 2013. Aim To describe and assess the development of the public debate on Norwegian healthcare rationing through three cases in print media. Methods We purposively sampled Norwegian newspaper articles between 2012 and 2018 concerning three reimbursement decisions in the Norwegian system. The reimbursement decisions were ipilimumab (Yervoy, n = 45) against metastatic melanoma, nivolumab (Opdivo, n = 23) against non-small cell lung cancer, and nusinersen (Spinraza, n = 68) against spinal muscular atrophy. Cases were analysed separately using the qualitative method of systematic text condensation. Results Our analysis highlighted four common themes—money, rationales, patient stories, and process—and a unique theme for each case. Ipilimumab was uniquely themed by rationing rejection, nivolumab by healthcare two-tiering, and Spinraza by patients’ rights. We found wide media deliberation among a multitude of stakeholders in all cases. Perceptions of rationing were found to be chiefly aligned with previous empirical research. We found that the media reported more frequently on opposition to rationing compared to findings from previous studies on Norwegian healthcare decision-making attitudes. We think this was influenced by our selection of cases receiving extraordinary media attention, and from media sources being subject to political communication from special interest groups. Conclusion We observed that the introduction of New Methods institutionalised Norwegian healthcare rationing and isolated the public debate into conversations between stakeholders and decision makers outside the political sphere. The findings from these three extraordinary debates are not generalisable and should be seen as a stakeholder learning opportunity regarding media coverage and engagement with expensive specialist healthcare decision-making in Norway.publishedVersio

Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Saharan African country – the case of Tanzania

BACKGROUND: There is a high and rising prevalence of cardiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interventions to prevent cardiovascular disease are implemented only on a limited scale in these settings. There is a widespread concern that such treatment is not cost-effective compared to alternative health interventions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical interventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsalicylic acid, a diuretic drug (Hydrochlorothiazide), a β-blocker (Atenolol), a calcium channel blocker (Nifedepine), a statin (Lovastatin) and various combinations of these. METHODS: Effect sizes were derived from systematic reviews or meta-analyses, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs were calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life-cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value laden single parameters were explored in one-way sensitivity analyses. RESULTS: The incremental cost-effectiveness ratios for the fourteen interventions and four different levels of risk (totally 56 alternative interventions) ranged from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yielding the most favorable cost-effectiveness ratio, although not significantly lower than when it is combined in duo-therapy with Aspirin or a β-blocker, in triple-therapy with Aspirin and a β-blocker, or than Aspirin given as mono-therapy. CONCLUSION: Preventive cardiology is not cost-effective for any patient group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pay, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optimal to provide this treatment also to patients with lower cardiovascular risk, and to substitute to more sophisticated interventions

Does payment for performance increase performance inequalities across health providers? A case study of Tanzania.

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers

Further benefits by early start of HIV treatment in low income countries: Survival estimates of early versus deferred antiretroviral therapy

<p>Abstract</p> <p>Background</p> <p>International HIV guidelines have recently shifted from a medium-late to an early-start treatment strategy. As a consequence, more people will be eligible to Highly Active Antiretroviral Therapy (HAART). We estimate mean life years gained using different treatment indications in low income countries.</p> <p>Methods</p> <p>We carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35 047.</p> <p>Results</p> <p>Providing HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2.0 and 0.7 life years respectively.</p> <p>Conclusions</p> <p>This study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.</p

Implementing standard antenatal care interventions: health system cost at primary health facilities in Tanzania

Background Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system are unknown, particularly in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania. Methods We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Costs were collected in Tanzanian shillings and converted to 2018 US$. Results The health system cost of providing ANC services at six facilities (2 health centres and 4 dispensaries) was USD185,282 under the focused model. We estimated that the cost would increase by about 90% at health centres and 97% at dispensaries to USD358,290 by introducing the standard model. Personnel cost accounted for more than one third of the total cost, and more than two additional nurses are required per facility for the standard model. The costs per pregnancy increased from about USD33 to USD63 at health centres and from about USD37 to USD72 at dispensaries. Conclusion Introduction of a standard ANC model at primary health facilities in Tanzania may double resources requirement compared to current practice. Resources availability has been one of the challenges to effective implementation of the current focused ANC model. More research is required, to consider whether the additional costs are reasonable compared to the additional value for maternal and child health.publishedVersio

Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia

<p>Abstract</p> <p>Background</p> <p>As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. So far, there is no such information available from Ethiopia.</p> <p>Objective</p> <p>To assess the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.</p> <p>Methods</p> <p>We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenditure of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and inpatient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.</p> <p>Findings</p> <p>ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.</p> <p>Conclusion</p> <p>The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.</p

Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia

<p>Abstract</p> <p>Background</p> <p>Little is known about the costs of HIV care in Ethiopia.</p> <p>Objective</p> <p>To estimate the average per person year (PPY) cost of care for HIV patients with and without anti-retroviral therapy (ART) in a district hospital.</p> <p>Methods</p> <p>Data on costs and utilization of HIV-related services were taken from Arba Minch Hospital (AMH) in southern Ethiopia. Mean annual outpatient and inpatient costs and corresponding 95% confidence intervals (CI) were calculated. We adopted a district hospital perspective and focused on hospital costs.</p> <p>Findings</p> <p>PPY average (95% CI) costs under ART were US$235.44 (US$218.11–252.78) and US$29.44 (US$24.30–34.58) for outpatient and inpatient care, respectively. Estimates for the non-ART condition were US$38.12 (US$34.36–41.88) and US$80.88 (US$63.66–98.11) for outpatient and inpatient care, respectively. The major cost driver under the ART scheme was cost of ART drugs, whereas it was inpatient care and treatment in the non-ART scheme.</p> <p>Conclusion</p> <p>The cost profile of ART at a district hospital level may be useful in the planning and budgeting of implementing ART programs in Ethiopia. Further studies that focus on patient costs are warranted to capture all patterns of service use and relevant costs. Economic evaluations combining cost estimates with clinical outcomes would be useful for ranking of ART services.</p