A cost-effectiveness analysis of maternal and neonatal health interventions in Ethiopia

Ethiopia is one of the sub-Saharan African countries contributing to the highest number of maternal and neonatal deaths. Coverage of maternal and neonatal health (MNH) interventions has remained very low in Ethiopia. We examined the cost-effectiveness of selected MNH interventions in an Ethiopian setting. We analysed 13 case management and preventive MNH interventions. For all interventions, we used an ingredients-based approach for cost estimation. We employed a static life table model to estimate the health impact of a 20% increase in intervention coverage relative to the baseline. We used disability-adjusted life years (DALYs) as the health outcome measure while costs were expressed in 2018 US$. Analyses were based on local epidemiological, demographic and cost data when available. Our finding shows that 12 out of the 13 interventions included in our analysis were highly cost-effective. Interventions targeting newborns such as neonatal resuscitation (institutional), kangaroo mother care and management of newborn sepsis with injectable antibiotics were the most cost-effective interventions with incremental cost-effectiveness ratios of US$7, US$8 and US$17 per DALY averted, respectively. Obstetric interventions (induction of labour, active management of third stage of labour, management of pre-eclampsia/eclampsia and maternal sepsis, syphilis treatment and tetanus toxoid during pregnancy) and safe abortion cost between US$100 and US$300 per DALY averted. Calcium supplementation for pre-eclampsia and eclampsia prevention was the least cost-effective, with a cost per DALY of about US$3100. Many of the MNH interventions analysed were highly cost-effective, and this evidence can inform the ongoing essential health services package revision in Ethiopia. Our analysis also shows that calcium supplementation does not appear to be cost-effective in our setting.publishedVersio

Cost of childhood cancer treatment in Ethiopia

Background: Despite the recent interest in expanding pediatric oncology units in Ethiopia, reflected in the National Childhood and Adolescent Cancer Control Plan (NCACCP), little is known about the cost of running a pediatric oncology unit and treating childhood cancers. Methods: We collected historical cost data and quantity of services provided for the pediatric oncology unit and all other departments in Tikur Anbessa Specialized Hospital (TASH) from 8 July 2018 to 7 July 2019, using a provider perspective and mixed (top-down and bottom-up) costing approaches. Direct costs (human resources, drugs, supplies, medical equipment) of the pediatric oncology unit, costs at other relevant clinical departments, and overhead cost share are summed up to estimate the total annual cost of running the unit. Further, unit costs were estimated at specific childhood cancer levels. Results: The estimated annual total cost of running a pediatric oncology unit was USD 776,060 (equivalent to USD 577 per treated child). The cost of running a pediatric oncology unit per treated child ranged from USD 469 to USD 1,085, on the scenario-based sensitivity analysis. Drugs and supplies, and human resources accounted for 33% and 27% of the total cost, respectively. Outpatient department and inpatient department shared 37% and 63% of the cost, respectively. For the pediatric oncology unit, the cost per OPD visit, cost per bed day, and cost per episode of hospital admission were USD 36.9, 39.9, and 373.3, respectively. The annual cost per treated child ranged from USD 322 to USD 1,313 for the specific childhood cancers. Conclusion: Running a pediatric oncology unit in Ethiopia is likely to be affordable. Further analysis of cost effectiveness, equity, and financial risk protection impacts of investing in childhood cancer programs could better inform the prioritization of childhood cancer control interventions in the Ethiopia Essential Health Service Package.publishedVersio

Country contextualisation of cost-effectiveness studies: lessons from Ethiopia

Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences of country contextualisation of WHO-CHOICE methods and models to a country level. Results from three contextualised cost-effectiveness analyses (CEAs) are presented, and we discuss how this evidence can inform priority setting in Ethiopia. Existing models for a range of interventions in obstetric and neonatal care, psychiatric and neurological treatment and prevention and treatment of cardiovascular diseases are contextualised to the Ethiopian setting. CEAs are defined as contextualised if they include national analysts and use country-specific input for either costs, epidemiology, demography, baseline coverage or effects. Interventions (n=61) are ranked according to incremental cost-effectiveness rates (ICERs), and expected health outcomes (Disability Adjusted Life Years (DALYs) averted) and budget impacts are presented for each intervention. Dominated interventions (n=30) were excluded. A USD2.8 increase per capita in the annual health budget is needed in Ethiopia (currently at USD28 per capita) for increasing coverage by 20%–75% for all the 22 interventions with positive net health benefits. This investment is expected to give a net benefit at around 0.5 million DALYs averted in return in total, with a willingness to pay threshold at USD2000 per DALY averted. In particular, three interventions, neonatal resuscitation, kangaroo mother care and antibiotics for newborn sepsis, stand out as best buys in an Ethiopian setting. Our method of contextualised CEAs provides important information for policy makers. Rank ordering of interventions by ICERs, together with presentations of expected budget impact and net health benefits, is a clear and policy friendly illustration of possible efficient stepwise pathways towards universal health coverage.publishedVersio

Health gains and financial risk protection afforded by public financing of selected malaria interventions in Ethiopia: an extended cost-effectiveness analysis

Background Malaria is a public health burden and a major cause for morbidity and mortality in Ethiopia. Malaria also places a substantial financial burden on families and Ethiopia’s national economy. Economic evaluations, with evidence on equity and financial risk protection (FRP), are therefore essential to support decision-making for policymakers to identify best buys amongst possible malaria interventions. The aim of this study is to estimate the expected health and FRP benefits of universal public financing of key malaria interventions in Ethiopia. Methods Using extended cost-effectiveness analysis (ECEA), the potential health and FRP benefits were estimated, and their distributions across socio-economic groups, of publicly financing a 10% coverage increase in artemisinin-based combination therapy (ACT), long-lasting insecticide-treated bed nets (LLIN), indoor residual spraying (IRS), and malaria vaccine (hypothetical). Results ACT, LLIN, IRS, and vaccine would avert 358, 188, 107 and 38 deaths, respectively, each year at a net government cost of USD 5.7, 16.5, 32.6, and 5.1 million, respectively. The annual cost of implementing IRS would be two times higher than that of the LLIN interventions, and would be the main driver of the total costs. The averted deaths would be mainly concentrated in the poorest two income quintiles. The four interventions would eliminate about USD 4,627,800 of private health expenditures, and the poorest income quintiles would see the greatest FRP benefits. ACT and LLINs would have the largest impact on malaria-related deaths averted and FRP benefits. Conclusions ACT, LLIN, IRS, and vaccine interventions would bring large health and financial benefits to the poorest households in Ethiopia.publishedVersio

Health system modelling research : towards a whole-health-system perspective for identifying good value for money investments in health system strengthening

Global health research has typically focused on single diseases, and most economic evaluation research to date has analysed technical health interventions to identify 'best buys'. New approaches in the conduct of economic evaluations are needed to help policymakers in choosing what may be good value (ie, greater health, distribution of health, or financial risk protection) for money (ie, per budget expenditure) investments for health system strengthening (HSS) that tend to be programmatic. We posit that these economic evaluations of HSS interventions will require developing new analytic models of health systems which recognise the dynamic connections between the different components of the health system, characterise the type and interlinks of the system's delivery platforms; and acknowledge the multiple constraints both within and outside the health sector which limit the system's capacity to efficiently attain its objectives. We describe priority health system modelling research areas to conduct economic evaluation of HSS interventions and ultimately identify good value for money investments in HSS

Prevention and treatment of cardiovascular disease in Ethiopia saves more than lives: cost-effectiveness analysis, extended cost-effectiveness analysis, and financial risk protection

Introduction: The burden from cardiovascular disease (CVD) and its risk factors is growing in Ethiopia, especially in urban areas. Yet, the coverage of effective strategies towards its successful control is low. In the absence of universal coverage, affected households are forced to cover the cost of needed health care through direct out-of-pocket (OOP) payments upon use of services. OOP payments could be prohibitive to health care access and often entail trading-off other essential consumptions, especially among the poor. Therefore, protecting households from such unprecedented financial consequences is one of the key health systems objectives. Nevertheless, Ethiopia is faced with extreme resource scarcity. Therefore, priorities need to be carefully evaluated and systematically identified among competing alternatives. This thesis aims to generate policy-relevant evidence on health outcomes, costs, and financial risk protection of CVD interventions so as to inform priority setting decisions in Ethiopia. Methods: To meet these aims, we conducted three studies using distinct methods. First, to assess the financial risk related to seeking CVD care, we conducted a crosssectional cohort study among individuals who sought prevention and treatment services for CVD in selected hospitals in Addis Ababa, Ethiopia. In study II, a costeffectiveness analysis (CEA) of a broad range of prevention and treatment services for CVD was performed in an Ethiopian setting so as to identify cost-effective alternatives for a potential scale-up in Ethiopia. In study III, extended costeffectiveness analysis was used to estimate the distribution (across income quintiles) of health benefits (disability-adjusted life years (DALYs) averted) and financial risk protection (cases of catastrophic health expenditure averted (CHE)) from universal public finance (UPF) of primary prevention of CVD with a multidrug therapy (aspirin, antihypertensives, and statins) for individuals with increased absolute risk of CVD. CHE is here defined as annual OOP expenditure on CVD care 10% or more of households’ annual income. Results: Overall, 27% [95% CI (23.1, 30.6)] of the households faced CHE. About 28% among the poorest quintile, in contrast to 14% among the richest quintile faced CHE. This financial risk affected mainly the poor, those who have had stroke, those who have been hospitalized, and those who travelled to Addis Ababa from outside the city to seek CVD care. Moreover, the households that faced CHE among the poorest quintile spent 34% of their annual income on CVD care per year compared with a 15% average among the richest quintile. This shows that the poorest households suffered a more severe intensity of financial risk among than the richest quintile. We found that primary prevention of CVD with the multidrug therapy is costeffective in an Ethiopian setting with an estimated cost of USD 67 per DALY averted at > 35% absolute risk of developing a CVD event over the next 10 years. The incremental cost per an additional DALY averted increased moderately at lower risk levels and reached USD 340 per DALY averted at > 5% risk level. A package of aspirin, ACE-inhibitor, beta-blocker, and streptokinase for acute myocardial infarction (with an estimated cost of USD 1,000 per DALY averted); a package of aspirin, ACE-inhibitor, beta-blocker, and statin for secondary prevention of ischemic heart disease (with an estimated cost of USD 1,850 per DALY averted); and a package of aspirin, ACE-inhibitor and statin for secondary prevention of stroke (with an estimated cost of USD 1,060 per DALY averted), although they dominated the comparators within their respective clusters, they were deemed less cost-effective than primary prevention. Furthermore, we estimated that substantial health and financial risk protection gains can be expected from UPF of the multidrug therapy for primary prevention of CVD. In total, the policy averted about 5,800 DALYs and 850 cases of CHE per year at an estimated annual cost of USD 1.9 million. Disaggregated by risk level, the DALYs averted ranged from 1,180 (at > 25%) to 2,240 (at > 15%), whereas the cases of CHE averted ranged from 96 (at > 35%) to 394 (at > 5%). The DALYs averted were distributed across income quintiles (Q1—the poorest to Q5—the richest) as: 22% (Q1), 18% (Q2), 24% (Q3), 26% (Q4), and 10% (Q5); while CHE averted were distributed as: 23% (Q1), 20% (Q2), 21% (Q3), 23% (Q4), and 13% (Q5). These distributional patterns were maintained at all CVD risk levels. Conclusions: Seeking prevention and treatment of CVD represents a significant financial risk to households, with a disproportionate impact on the poorest, those who have had stroke, and those who reside outside Addis Ababa. Primary prevention of CVD with multidrug therapy to individuals with increased absolute risk of CVD is a cost-effective strategy that Ethiopia could consider for successful control of CVD. Public finance of this intervention would generate a sizeable financial risk protection gains in addition to the health benefits. Both the health gain and financial risk protection gains favor the poorer households—qualifying the strategy as a pro-poor with respect to both outcomes. Primary prevention of cardiovascular disease saves more than lives in Ethiopia

Towards universal health coverage for reproductive health services in Ethiopia: two policy recommendations

Abstract Reproductive health services are crucial for maternal and child health, but universal health coverage is still not within reach in most societies. Ethiopia’s goal of universal health coverage promises access to all necessary services for everyone while providing protection against financial risk. When moving towards universal health coverage, health plans and policies require contextualized knowledge about baseline indicators and their distributions. To understand more about the factors that explain coverage, we study the relationship between socioeconomic and geographic factors and the use of reproductive health services in Ethiopia, and further explore inequalities in reproductive health coverage. Based on these findings, we discuss the normative implications of these findings for health policy. Using population-level data from the Ethiopian Demographic and Health Survey (2011) in a multivariate logistic model, we find that family planning and use of antenatal care are associated with higher wealth, higher education and being employed. Skilled attendance at birth is associated with higher wealth, higher education, and urban location. There is large variation between Addis Ababa (the capital) and other administrative regions. Concentration indices show substantial inequalities in the use of reproductive health services. Decomposition of the concentration indices indicates that difference in wealth is the most important explanatory factor for inequality in reproductive health coverage, but other factors, such as urban setting and previous health care use, are also associated with inequalities. When aiming for universal health coverage, this study shows that different socioeconomic factors as well as health-sector factors should be addressed. Our study re-confirms the importance of a broader approach to reproductive health, and in particular the importance of inequality in wealth and geography. Poor, non-educated, non-employed women in rural areas are multidimensionally worse off. The needs of these women should be addressed through elimination of out-of-pocket costs and revision of the formula for resource allocation between regions as Ethiopia moves towards universal health coverage

Cost-effectiveness of running a paediatric oncology unit in Ethiopia

Objective To estimate the cost-effectiveness of running a paediatric oncology unit in Ethiopia to inform the revision of the Ethiopia Essential Health Service Package (EEHSP), which ranks the treatment of childhood cancers at a low and medium priority.Methods We built a decision analytical model—a decision tree—to estimate the cost-effectiveness of running a paediatric oncology unit compared with a do-nothing scenario (no paediatric oncology care) from a healthcare provider perspective. We used the recently (2018–2019) conducted costing estimate for running the paediatric oncology unit at Tikur Anbessa Specialized Hospital (TASH) and employed a mixed costing approach (top-down and bottom-up). We used data on health outcomes from other studies in similar settings to estimate the disability-adjusted life years (DALYs) averted of running a paediatric oncology unit compared with a do-nothing scenario over a lifetime horizon. Both costs and effects were discounted (3%) to the present value. The primary outcome was incremental cost in US dollars (USDs) per DALY averted, and we used a willingness-to-pay (WTP) threshold of 50% of the Ethiopian gross domestic product per capita (USD 477 in 2019). Uncertainty was tested using one-way and probabilistic sensitivity analyses.Results The incremental cost and DALYs averted per child treated in the paediatric oncology unit at TASH were USD 876 and 2.4, respectively, compared with no paediatric oncology care. The incremental cost-effectiveness ratio of running a paediatric oncology unit was USD 361 per DALY averted, and it was cost-effective in 90% of 100 000 Monte Carlo iterations at a USD 477 WTP threshold.Conclusions The provision of paediatric cancer services using a specialised oncology unit is most likely cost-effective in Ethiopia, at least for easily treatable cancer types in centres with minimal to moderate capability. We recommend reassessing the priority-level decision of childhood cancer treatment in the current EEHSP

Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey

Objectives HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. Design A cross-sectional survey. Setting 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. Participants A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. Outcome measures The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. Results The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). Conclusions HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed