Country-level cost-effectiveness thresholds : initial estimates and the need for further research

Objectives: Cost-effectiveness analysis (CEA) can guide policymakers in resource allocation decisions. CEA assesses whether the health gains offered by an intervention are large enough relative to any additional costs to warrant adoption. Where there are constraints on the healthcare system’s budget or ability to increase expenditures, additional costs imposed by interventions have an ‘opportunity cost’ in terms of the health foregone as other interventions cannot be provided. Cost-effectiveness thresholds (CETs) are typically used to assess whether an intervention is worthwhile and should reflect health opportunity cost. However, CETs used by some decision makers - such as the World Health Organization (WHO) suggested CETs of 1-3 times gross domestic product per capita (GDP pc) - do not. This study estimates CETs based on opportunity cost for a wide range of countries. Methods: We estimate CETs based upon recent empirical estimates of opportunity cost (from the English NHS), estimates of the relationship between country GDP pc and the value of a statistical life, and a series of explicit assumptions. Results: CETs for Malawi (the lowest income country in the world), Cambodia (borderline low/low-middle income), El Salvador (borderline low-middle/upper-middle) and Kazakhstan (borderline high-middle/high) are estimated to be $3-116 (1-51$44-518 (4-51%), $422-1,967 (11-51$4,485-8,018 (32-59%); respectively. Conclusions: To date opportunity cost-based CETs for low/middle income countries have not been available. Although uncertainty exists in the underlying assumptions, these estimates can provide a useful input to inform resource allocation decisions and suggest that routinely used CETs have been too high

Setting research priorities in Global Health : appraising the value of evidence generation activities to support decision-making in health care

The allocation of scarce resources among competing health care priorities is a key objective in all jurisdictions, whether in low- and middle-income countries (LMICs) or high-income countries. This involves allocating resources to ensure access to health care programmes, which can deliver improvements in health, but also to managing innovation in the development of new technologies, and investing in evidence generation activities to improve health for future generations. The allocation of health care resources among competing priorities requires an assessment of the expected health effects and costs of investing resources in the different activities and the opportunity costs of these expenditures, as well as an assessment of the uncertainty in health effects and costs. Uncertainty can lead to unintended adverse health consequences, e.g., when expected benefits of an activity are not realised when implemented in practice, or resources committed by an activity are transferred away from other health improving activities. The consequences of uncertainty can be reduced by investing in evidence generation activities that improve the information available to support future resource allocation decisions. An analytic framework is developed to assess the value of evidence generation activities to support international research funders, who have the responsibility for allocating funds among competing research priorities in Global Health. Within the framework, the costs and health benefits of evidence generation activities are assessed using the same principles as those employed when evaluating the cost-effectiveness of investments in service provision. Metrics of value, founded on an understanding of the health opportunity costs imposed by research expenditure, are used to quantify the scale of the potential global net health impact across all beneficiary populations (in net disability-adjusted life years averted), or the equivalent health care system resources required to deliver this net health impact, and research costs and their potential health opportunity costs. The framework can be applied to answer key questions such as: whether investment in research activities is worthwhile; which research activities should be prioritised; what type of research activity is necessary and what is the most appropriate design of the research; what are the opportunity costs associated with evidence generation; what is the optimal timing of research; and whether evidence generation activities should be prioritised over investments in service provision or new technology development. An illustrative example is used to demonstrate the application of the framework for informing research priorities in Global Health

Insights for the partitioning of ecosystem evaporation and transpiration in short‐statured croplands

Reducing water losses in agriculture needs a solid understanding of when evaporation (E) losses occur and how much water is used through crop transpiration (T). Partitioning ecosystem T is however challenging, and even more so when it comes to short-statured crops, where many standard methods lead to inaccurate measurements. In this study, we combined biometeorological measurements with a Soil-Plant-Atmosphere Crop (SPA-Crop) model to estimate T and E at a Swiss cropland over two crop seasons with winter cereals. We compared our results with two data-driven approaches: The Transpiration Estimation Algorithm (TEA) and the underlying Water Use Efficiency (uWUE). Despite large differences in the productivity of both years, the T to evapotranspiration (ET) ratio had relatively similar seasonal and diurnal dynamics, and averaged to 0.72 and 0.73. Our measurements combined with a SPA-Crop model provided T estimates similar to the TEA method, while the uWUE method produced systematically lower T even when the soil and leaves were dry. T was strongly related to the leaf area index, but additionally varied due to climatic conditions. The most important climatic drivers controlling T were found to be the photosynthetic photon flux density (R2 = 0.84 and 0.87), and vapor pressure deficit (R2 = 0.86 and 0.70). Our results suggest that site-specific studies can help establish T/ET ratios, as well as identify dominant climatic drivers, which could then be used to partition T from reliable ET measurements. Moreover, our results suggest that the TEA method is a suitable tool for ET partitioning in short-statured croplands

Examining the Use of Economic Evaluations in Health‐related Humanitarian Programs in Low- and Middle-Income Countries : A Systematic Review

The costly nature of health sector responses to humanitarian crises and resource constraints means that there is a need to identify methods for priority setting and long-term planning. One method is economic evaluation. The aim of this systematic review is to examine the use of economic evaluations in health-related humanitarian programmes in low- and middle-income countries. This review used peer-reviewed literature published between January 1980 and June 2018 extracted from four main electronic bibliographic databases. The eligibility criteria were full economic evaluations (which compare the costs and outcomes of at least two interventions and provide information on efficiency) of health-related services in humanitarian crises in low- and middle-countries. The quality of eligible studies is appraised using the modified 36-question Drummond checklist. From a total of 8127 total studies, 11 full economic evaluations were identified. All economic evaluations were cost-effectiveness analyses. Three of the 11 studies used a provider perspective, 2 studies used a healthcare system perspective, 3 studies used a societal perspective and 3 studies did not specify the perspective used. The lower quality studies failed to provide 7information on the unit of costs and did not justify the time horizon of costs and discount rates, or conduct a sensitivity analysis. There was limited geographic range of the studies, with 9 of the 11 studies conducted in Africa. Recommendations include greater use of economic evaluation methods and data to enhance the microeconomic understanding of health interventions in humanitarian settings to support greater efficiency and transparency and to strengthen capacity by recruiting economists and providing training in economic methods to humanitarian agencies

Methods to promote equity in health resource allocation in low- and middle-income countries : an overview

Unfair differences in healthcare access, utilisation, quality or health outcomes exist between and within countries around the world. Improving health equity is a stated objective for many governments and international organizations. We provide an overview of the major tools that have been developed to measure, evaluate and promote health equity, along with the data required to operationalise them. Methods are organised into four key policy questions facing decision-makers: (i) what is the current level of inequity in health; (ii) does government health expenditure benefit the worst-off; (iii) can government health expenditure more effectively promote equity; and (iv) which interventions provide the best value for money in reducing inequity. Benefit incidence analysis can be used to estimate the distribution of current public health sector expenditure, with geographical resource allocation formulae and health system reform being the main government policy levers for improving equity. Techniques from the economic evaluation literature, such as extended and distributional cost-effectiveness analysis can be used to identify ‘best buy’ interventions from a health equity perspective. A range of inequality metrics, from gap measures and slope indices to concentration indices and regression analysis, can be applied to these approaches to evaluate changes in equity. Methods from the economics literature can provide policymakers with a toolkit for addressing multiple aspects of health equity, from outcomes to financial protection, and can be adapted to accommodate data commonly available in low- and middle-income settings

Practical metrics for establishing the health benefits of research to support research prioritisation

Introduction : We present practical metrics for estimating the expected health benefits of specific research proposals. These can be used by research funders, researchers, and health-care decision makers within low- and middle-income countries (LMICs) to support evidence-based research prioritisation. Methods : The methods require three key assessments: (1) the current level of uncertainty around the endpoints the proposed study will measure; (2) how uncertainty impacts on the health benefits and costs of health-care programmes; and (3) the health opportunity costs imposed by programme costs. Research is valuable because it can improve health by informing the choice of which programmes should be implemented. We provide a Microsoft Excel tool to allow readers to generate estimates of the health benefits of research studies based on these three assessments. The tool can be populated using clinical studies, existing cost-effectiveness models and expert opinion. Where such evidence is not available, the tool can quantify the value of research under different assumptions. Estimates of the health benefits of research can be considered alongside research costs, and the consequences of delaying implementation until research reports, to determine whether research is worthwhile. We illustrate the method using a case study of research on HIV self-testing programmes in Malawi. This analysis combines data from the literature with outputs from the HIV synthesis model. Results : For this case study we found a costing study that could be completed and inform decision making within one year offered the highest health benefits (67,000 DALYs averted). Research on outcomes improved population health to a lesser extent (12,000 DALYs averted) and only if carried out alongside programme implementation. Conclusion : Our work provides a method for estimating the health benefits of research in a practical and timely fashion. This can be used to support accountable use of research funds