Adjusting for Inflation and Currency Changes Within Health Economic Studies

OBJECTIVES

Within health economic studies, it is often necessary to adjust costs obtained from different time periods for inflation. Nevertheless, many studies do not report the methods used for this in sufficient detail. In this article, we outline the principal methods used to adjust for inflation, with a focus on studies relating to healthcare interventions in low- and middle-income countries. We also discuss issues relating to converting local currencies to international dollars and US$ and adjusting cost data collected from other countries or previous studies.

METHODS

We outlined the 3 main methods used to adjust for inflation for studies in these settings: exchanging the local currency to US$ or international dollars and then inflating using US inflation rates (method 1); inflating the local currency using local inflation rates and then exchanging to US$ or international dollars (method 2); splitting the costs into tradable and nontradable resources and using method 1 on the tradable resources and method 2 on the nontradable resources (method 3).

RESULTS

In a hypothetical example of adjusting a cost of US$100 incurred in Vietnam from 2006 to 2016 prices, the adjusted cost from the 3 methods were US$116.84, US$172.09, and US$161.04, respectively.

CONCLUSIONS

The different methods for adjusting for inflation can yield substantially different results. We make recommendations regarding the most appropriate method for various scenarios. Moving forward, it is vital that studies report the methodology they use to adjust for inflation more transparently.

Economic evaluation of sildenafil for the treatment of pulmonary arterial hypertension in Indonesia

Background

This study aims to assess the cost-effectiveness and budget impact of adopting sildenafil to the benefits package for the indication of pulmonary arterial hypertension (PAH), compared to beraprost.

Methods

Based on a societal perspective, a model-based economic evaluation was performed using local and international data to quantify the potential costs and health-related outcomes in terms of life years (LYs) and quality-adjusted life years (QALYs).

Results

The economic model calculated the incremental cost-effectiveness ratio (ICER) per QALY gained for using sildenafil as first-line therapy compared to beraprost for the patient in functional class (FC) II and III, i.e. USD 3098 and USD 2827, respectively. The results indicated that in spite of sildenafil being more expensive than beraprost, generic sildenafil could potentially be a good value for money since ICER per QALY is below one times gross domestic product (GDP) per capita in Indonesia. Furthermore, budget impact analysis estimated that the incremental budget needed within 5 years for including sildenafil compared to beraprost for PAH patients starting in FC II and FC III was USD 436,775 and USD 3.6 million, respectively.

Conclusions

Compared to beraprost, sildenafil would be preferable for the treatment of PAH patients in FC II and FC III in Indonesia. The additional budget for adopting sildenafil compared to beraprost as the treatment of PAH in the benefits package was estimated at around USD 4.0 million.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4422-5) contains supplementary material, which is available to authorized users.

Adherence to the iDSI reference case among published cost-per-DALY averted studies

BACKGROUND

The iDSI reference case, originally published in 2014, aims to improve the quality and comparability of cost-effectiveness analyses (CEA). This study assesses whether the development of the guideline is associated with an improvement in methodological and reporting practices for CEAs using disability-adjusted life-years (DALYs).

METHODS

We analyzed the Tufts Medical Center Global Health CEA Registry to identify cost-per-DALY averted studies published from 2011 to 2017. Among each of 11 principles in the iDSI reference case, we translated all methodological specifications and reporting standards into a series of binary questions (satisfied or not satisfied) and awarded articles one point for each item satisfied. We then calculated methodological and reporting adherence scores separately as a percentage of total possible points, measured as normalized adherence score (0% = no adherence; 100% = full adherence). Using the year 2014 as the dissemination period, we conducted a pre-post analysis. We also conducted sensitivity analyses using: 1) optional criteria in scoring, 2) alternate dissemination period (2014-2015), and 3) alternative comparator classification.

RESULTS

Articles averaged 60% adherence to methodological specifications and 74% adherence to reporting standards. While methodological adherence scores did not significantly improve (59% pre-2014 vs. 60% post-2014, p = 0.53), reporting adherence scores increased slightly over time (72% pre-2014 vs. 75% post-2014, p<0.01). Overall, reporting adherence scores exceeded methodological adherence scores (74% vs. 60%, p<0.001). Articles seldom addressed budget impact (9% reporting, 10% methodological) or equity (7% reporting, 7% methodological).

CONCLUSIONS

The iDSI reference case has substantial potential to serve as a useful resource for researchers and policy-makers in global health settings, but greater effort to promote adherence and awareness is needed to achieve its potential.

A real-world study of effectiveness of intravitreal bevacizumab and ranibizumab injection for treating retinal diseases in Thailand

Background

To evaluate the effectiveness of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) in actual practice for treating patients with retinal diseases in Thailand.

Methods

A prospective, multi-centre, observational study was conducted among eight hospitals in their ophthalmology outpatient departments. Participants consisted of patients who had previously not received any IVB or IVR treatment between 2013 and 2014. The primary outcome measurement was the change in best-corrected visual acuity (BCVA) at the end of the follow-up period compared to baseline.

Results

There were 1629 treatment-naïve patients for the pro re nata (PRN) treatment pattern and 226 treatment-naive patients for the three-injections (3Inj) treatment pattern. BCVA improvements were found in 35% of the PRN group and 47% of the 3Inj group; however, it was not clinically meaningful between the IVB and IVR groups (P-value = 0.568 for PRN, P-value = 0.103 for 3Inj). A multivariable logistic regression (using the propensity score) showed that positive factors associated with vision improvement for the PRN pattern were the number of drug injections, having retinal vein occlusion, and under 60 years of age, while good BCVA at baseline was a negative predictive factor. For the 3Inj pattern, under 60 years of age and baseline BCVA were statistically significant predictors. Nonetheless, diabetes mellitus (DM) without other comorbidities was a statistically significant predictor of low response to vision improvement compared to DM with other comorbidities.

Conclusions

This study was the first observational, prospective study to evaluate the real-life effectiveness of IVB and IVR in Thailand. The majority of participants who used IVB or IVR showed improvements in BCVA after treatment. Further evaluation such as long-term follow-ups and subsequent comparison of effectiveness between IVB and IVR should be investigated due to the limited sample of IVR patients.

Trial registration

Thai Clinical Trial Registry TCTR20141002001. Registered 02 October 2014 (retrospectively registered).

Selecting topic areas for developing quality standards in a resource-limited setting

Variation in practices of and access to health promotion and disease prevention (P&P) across geographical areas have been studied in Thailand as well as other healthcare settings. The implementation of quality standards (QS)—a concise set of evidence-informed quality statements designed to drive and measure priority quality improvements—can be an option to solve the problem. This paper aims to provide an overview of the priority setting process of topic areas for developing QS and describes the criteria used. Topic selection consisted of an iterative process involving several steps and relevant stakeholders. Review of existing documents on the principles and criteria used for prioritising health technology assessment topics were performed. Problems with healthcare services were reviewed, and stakeholder consultation meetings were conducted to discuss current problems and comment on the proposed prioritisation criteria. Topics were then prioritised based on both empirical evidence derived from literature review and stakeholders’ experiences through a deliberative process. Preterm birth, pre-eclampsia and postpartum haemorrhage were selected. The three health problems had significant disease burden; were prevalent among pregnant women in Thailand; led to high mortality and morbidity in mothers and children and caused variation in the practices and service uptake at health facilities. Having agreed-on criteria is one of the important elements of the priority setting process. The criteria should be discussed and refined with various stakeholders. Moreover, key stakeholders, especially the implementers of QS initiative, should be engaged in a constructive way and should be encouraged to actively participate and contribute significantly in the process.

Disease Control Priorities Third Edition: Time to Put a Theory of Change Into Practice Comment on "Disease Control Priorities Third Edition Is Published: A Theory of Change Is Needed for Translating Evidence to Health Policy"

The Disease Control Priorities program (DCP) has pioneered the use of economic evidence in health. The theory of change (ToC) put forward by Norheim is a further welcome and necessary step towards translating DCP evidence into better priority setting in low- and middle-income countries (LMICs). We also agree that institutionalising evidence for informed priority-setting processes is crucial. Unfortunately, there have been missed opportunities for the DCP program to challenge ill-judged global norms about opportunity costs and too little respect has been shown for the wider set of local circumstances that may enable, or disable, the productive application of the DCP evidence base. We suggest that the best way forward for the global health community is a new platform that integrates the many existing development initiatives and that is driven by countries’ asks.

Cost-utility analysis of adjuvant imatinib treatment in patients with high risk of recurrence after gastrointestinal stromal tumour (GIST) resection in Thailand

Background

Many patients develop tumour recurrence within a few years after undergoing surgical resection of gastrointestinal stromal tumours (GIST). Adjuvant imatinib treatment is recommended for patients with high risk of GIST recurrence as it can improve recurrence-free survival and overall survival of patients. This study aims to assess the cost-utility of adjuvant imatinib in patients with high risk of GIST recurrence after surgery compared with no adjuvant therapy in Thailand.

Methods

A Markov model was developed to estimate lifetime costs and outcomes of using adjuvant imatinib treatment and other treatment alternatives if recurrence occurred compared with the current situation of no adjuvant therapy in high-risk patients after surgery. A 1-month cycle length was deployed in the model. Transition probabilities were derived from literature review. Costs were collected and calculated for the year 2014 from a societal perspective. Future costs and outcomes were discounted at 3% per year. One-way and probabilistic sensitivity analyses were conducted to assess parameter uncertainties.

Results

Three years of adjuvant imatinib treatment followed by imatinib treatment and best supportive care if recurrence occurred after or during adjuvant therapy, respectively, was the best option as it produced more health outcomes (1.23 life years (LYs) and 1.16 quality-adjusted life years (QALYs)) compared to no adjuvant therapy while yielding the lowest incremental cost-effectiveness ratio (ICER) of 1,648,801 Thai Baht (THB) per QALY gained. Three years of adjuvant imatinib treatment followed by sunitinib treatment if recurrence occurred had an ICER of 2,608,264 THB per QALY gained compared to the best option, while other options were dominated. A one-way sensitivity analysis showed that the utility of patients receiving adjuvant imatinib had the greatest effect on the model, followed by the discount rate and probability of GIST recurrence.

Conclusions

Adjuvant imatinib treatment improved the health benefits of patients with high risk of GIST recurrence. However, in the Thai context, it was not cost-effective at the current price.

Real-World Safety of Intravitreal Bevacizumab and Ranibizumab Treatments for Retinal Diseases in Thailand: A Prospective Observational Study

BACKGROUND

There is very limited evidence examining serious systemic adverse events (SSAEs) and post-injection endophthalmitis of intravitreal bevacizumab (IVB) and intravitreal ranibizumab (IVR) treatments in Thailand and low- and middle-income countries. Moreover, findings from the existing trials might have limited generalizability to certain populations and rare SSAEs.

OBJECTIVES

This prospective observational study aimed to assess and compare the safety profiles of IVB and IVR in patients with retinal diseases in Thailand.

METHODS

Between 2013 and 2015, 6354 patients eligible for IVB or IVR were recruited from eight hospitals. Main outcomes measures were prevalence and risk of SSAEs, mortality, and endophthalmitis during the 6-month follow-up period.

RESULTS

In the IVB and IVR groups, 94 and 6% of patients participated, respectively. The rates of outcomes in the IVB group were slightly greater than in the IVR group. All-cause mortality rates in the IVB and IVR groups were 1.10 and 0.53%, respectively. Prevalence rates of endophthalmitis and non-fatal strokes in the IVB group were 0.04% of 16,421 injections and 0.27% of 5975 patients, respectively, whereas none of these events were identified in the IVR group. There were no differences between the two groups in the risks of mortality, arteriothrombotic events (ATE), and non-fatal heart failure (HF). Adjustment for potential confounding factors and selection bias using multivariable models for time-to-event outcomes and propensity scores did not alter the results.

CONCLUSIONS

The rates of SAEs in both groups were low. The IVB and IVR treatments were not associated with significant risks of mortality, ATE, and non-fatal HF.

TRIAL REGISTRATION

Thai Clinical Trial Registry identifier TCTR20141002001.

Cost-utility analysis of the screening program for early oral cancer detection in Thailand

Objective

To assess the cost-utility of an oral precancer screening program compared to a no-screening program in Thailand.

Materials and methods

Markov models were performed to simulate costs and Quality Adjusted Life-Years (QALYs) of both the screening and no-screening programs in the Thai population aged over 40 years. There are four steps to the screening program in Thailand: 1) mouth self-examination (MSE); 2) visual examination by trained dental nurses (VETDN); 3) visual examination by trained dentists (VETD); and 4) visual examination by oral surgeons (VEOS). The societal perspective and lifetime horizon were applied. Variables used were derived from the pilot study of the oral precancer screening program in Roi Et province as well as through patient interviews and local and international literature reviews. Results were presented in terms of Incremental Cost-Effectiveness Ratios (ICER). Sensitivity analysis was performed to assess parameters uncertainty.

Results

The screening program yielded higher costs (1,362 Baht) and QALYs (0.0044 years) than the no screening program, producing an ICER of 311,030 Baht per QALY gained. This indicates that the screening program is cost-ineffective in the Thai context, where the cost-effectiveness threshold is THB 160,000 per QALY gained. However, the programs will be cost-effective if the screening program are improved in one of three ways; 1) the sensitivity and specificity of MSE are more than 60%, 2) the sensitivity and specificity of VETDN are greater than 90%, or 3) the low accuracy steps like MSE or VETDN are removed from the screening program.

Conclusion

The screening program is found to be cost-ineffective for oral precancer detection in Thailand. However, this study suggests 3 alternative policy options to ensure the cost-effectiveness of the program.

Budgeting for a billion: applying health technology assessment (HTA) for universal health coverage in India

BACKGROUND

India recently launched the largest universal health coverage scheme in the world to address the gaps in providing healthcare to its population. Health technology assessment (HTA) has been recognised as a tool for setting priorities as the government seeks to increase public health expenditure. This study aims to understand the current situation for healthcare decision-making in India and deliberate on the opportunities for introducing HTA in the country.

METHODS

A paper-based questionnaire, adapted from a survey developed by the International Decision Support Initiative (iDSI), was administered on the second day of the Topic Selection Workshop that was conducted as part of the HTA Awareness Raising Workshop held in New Delhi on 25-27 July, 2016. Participants were invited to respond to questions covering the need, demand and supply for HTA in their context as well as the role of their organisation vis-à-vis HTA. The response rate for the survey was about 68% with 41 participants having completed the survey.

RESULTS

Three quarters of the respondents (71%) stated that the government allocated healthcare resources on the basis of expert opinion. Most respondents indicated reimbursement of individual health technologies and designing a basic health benefit package (93% each) were important health policy areas while medical devices and screening programmes were cited as important technologies (98% and 92%, respectively). More than half of the respondents noted that relevant local data was either not available or was limited. Finally, technical capacity was seen as a strength and a constraint facing organisations.

CONCLUSION

The findings from this study shed light on the current situation, the opportunities, including potential topics, and challenges in conducting HTA in India. There are limitations to the study and further studies may need to be conducted to inform the role that HTA will play in the design or implementation of universal health coverage in India.

The EQ-5D-5L Valuation study in Thailand

BACKGROUND

At present, health technology assessment (HTA) guidelines of many countries including Thailand have recommended EQ-5D as the preferred method for assessing utility. This study aims to generate an EQ-5D-5L value set based on societal preferences of Thai population.

METHODS

A 1,207 representative sample was recruited using a stratified multi-stage quota sampling technique. Face-to-face, computer-assisted interviews using the EuroQol Valuation Technology (EQ-VT) software were employed. To elicit preference score, each respondent was asked to value health states using composite time trade-off (cTTO), and discrete choice experiment (DCE). All data were integrated and analyzed using a hybrid regression model to estimate the value set.

RESULTS

Characteristics of 1,207 participants were generally similar to those of Thai general population. The coefficients generated from a hybrid model were logically consistent. The second best value is 0.9436 for health state 11121 and the worst state (55555) value is -0.4212. Mobility shows the greatest impact to utility decrement.

CONCLUSIONS

Our study developed a Thai value set for EQ-5D using hybrid model. The findings from this study are of important to facilitate health technology assessment studies to inform policy decision-making as well as to promote the use of EQ-5D-5L in various health research in Thailand.

An economic analysis of chromosome testing in couples with children who have structural chromosome abnormalities

Background

Structural chromosome abnormalities can cause significant negative reproductive outcomes as they typically result in morbidity and mortality of newborns. The prevalence of structural chromosomal abnormalities in live births is at least 0.05%, of which many of them have parental origins. It is uncommon to predict structural chromosome abnormalities at birth in the first child but it is possible to prevent repeated abnormalities through screening and diagnostic programmes. This study will provide an economic analysis of the prenatal detection of these abnormalities.

Methods

A cost-benefit analysis using a decision analytic model was employed to compare the status quo (doing nothing) with two interventional strategies. The first strategy (Strategy I) is preconceptional screening plus amniocentesis, and the second strategy (Strategy II) is amniocentesis alone. The monetary values in Thai baht (THB) were adjusted to international dollars (I$) using purchasing power parity (PPP) (I$1 = THB 17.60 for the year 2013). The robustness of the results was tested by applying a probabilistic sensitivity analysis.

Results

Both diagnostic strategies can reduce approximately 10.7–11.1 births with abnormal chromosomes per 1,000 diagnosed couples. The benefit cost ratios were 1.62 for Strategy I and 1.24 for Strategy II. Net present values per 1,000 diagnoses in couples were I$464,000 for Strategy I and I$267,000 for Strategy II. The probabilistic sensitivity analysis suggested that the cost-benefit analysis was sufficiently robust, confirming that both strategies provided higher benefits than costs.

Conclusions

Since the benefits of both diagnostic strategies exceeded their costs, both strategies are economical–with Strategy I being more economically attractive. Strategy I is superior to Strategy II because it decreases the risk of normal children potentially dying from the amniocentesis process.

The Development of the Guide to Economic Analysis and Research (GEAR) Online Resource for Low- and Middle-Income Countries' Health Economics Practitioners: A Commentary

Public health authorities around the world are increasingly using economic evaluation to set priorities and inform decision making in health policy, especially in the development of health benefit packages. Nevertheless, researchers in low- and middle-income countries (LMICs) encounter many barriers when conducting economic evaluations. In 2015, the Health Intervention and Technology Assessment Program identified key technical and context-specific challenges faced in conducting and using health economic evaluations in LMICs. On the basis of these research findings, the Guide to Economic Analysis and Research (GEAR) online resource (www.gear4health.com) was developed as a reliable aid to researchers in LMICs that would help overcome those challenges. Funded by the Thailand Research Fund and the Bill and Melinda Gates Foundation, GEAR is a free online resource that provides a visual aid tool for planning economic evaluation studies (GEAR mind maps), a repository of national and international economic evaluation guidelines (GEAR guideline comparison), and an active link to a network of volunteer international experts (GEAR: Ask an expert). GEAR will evolve over time to provide relevant, reliable, and up-to-date information through inputs from its users (e.g., periodic survey on methodological challenges) and experts (e.g., in responding to users' questions). The objective of this commentary was to give a brief description of the development and key features of this unique collective information hub aimed at facilitating high-quality research and empowering health care decision makers and stakeholders to use economic evaluation evidence.

Towards the introduction of pneumococcal conjugate vaccines in Bhutan: A cost-utility analysis to determine the optimal policy option

BACKGROUND

Due to competing health priorities and limited resources, many low-income countries, even those with a high disease burden, are not able to introduce pneumococcal conjugate vaccines.

OBJECTIVE

To determine the cost-utility of 10- and 13-valent pneumococcal conjugate vaccines (PCV10 and PCV13) compared to no vaccination in Bhutan.

METHODS

A model-based cost-utility analysis was performed in the Bhutanese context using a government perspective. A Markov simulation model with one-year cycle length was used to estimate the costs and outcomes of three options: PCV10, PCV13 and no PCV programmes for a lifetime horizon. A discount rate of 3% per annum was applied. Results are presented using an incremental cost-effectiveness ratio (ICER) in United State Dollar per quality-adjusted life year (QALY) gained (USD 1 = Ngultrum 65). A one-way sensitivity analysis and a probabilistic sensitivity analysis were conducted to assess uncertainty.

RESULTS

Compared to no vaccination, PCV10 and PCV13 gained 0.0006 and 0.0007 QALYs with additional lifetime costs of USD 0.02 and USD 0.03 per person, respectively. PCV10 and PCV13 generated ICERs of USD 36 and USD 40 per QALY gained compared to no vaccination. In addition, PCV13 produced an ICER of USD 92 compared with PCV10. When including PCV into the Expanded Programme on Immunization, the total 5-year budgetary requirement is anticipated to increase to USD. 3.77 million for PCV10 and USD 3.75 million for PCV13. Moreover, the full-time equivalent (FTE) of one health assistant would increase by 2.0 per year while the FTE of other health workers can be reduced each year, particularly of specialist (0.6-1.1 FTE) and nurse (1-1.6 FTE).

CONCLUSION

At the suggested threshold of 1xGDP per capita equivalent to USD 2708, both PCVs are cost-effective in Bhutan and we recommend that they be included in the routine immunization programme.

Revisiting policy on chronic HCV treatment under the Thai Universal Health Coverage: An economic evaluation and budget impact analysis

Thailand is encountering challenges to introduce the high-cost sofosbuvir for chronic hepatitis C treatment as part of the Universal Health Care's benefit package. This study was conducted in respond to policy demand from the Thai government to assess the value for money and budget impact of introducing sofosbuvir-based regimens in the tax-based health insurance scheme. The Markov model was constructed to assess costs and benefits of the four treatment options that include: (i) current practice-peginterferon alfa (PEG) and ribavirin (RBV) for 24 weeks in genotype 3 and 48 weeks for other genotypes; (ii) Sofosbuvir plus peginterferon alfa and ribavirin (SOF+PEG-RBV) for 12 weeks; (iii) Sofosbuvir and daclatasvir (SOF+DCV) for 12 weeks; (iv) Sofosbuvir and ledipasvir (SOF+LDV) for 12 weeks for non-3 genotypes and SOF+PEG-RBV for 12 weeks for genotype 3 infection. Given that policy options (ii) and (iii) are for pan-genotypic infection, the cost of genotype testing was applied only for policy options (i) and (iv). Results reveal that all sofosbuvir-based regimens had greater quality adjusted life years (QALY) gains compared with the current treatment, therefore associated with lower lifetime costs and more favourable health outcomes. Additionally, among the three regimens of sofosbuvir, SOF+PEG-RBV for genotype 3 and SOF+LDV for non-3 genotype are the most cost-effective treatment option with the threshold of 160,000 THB per QALY gained. The results of this study had been used in policy discussion which resulted in the recent inclusion of SOF+PEG-RBV for genotype 3 and SOF+LDV for non-3 genotype in the Thailand's benefit package.

Incorporating economies of scale in the cost estimation in economic evaluation of PCV and HPV vaccination programmes in the Philippines: a game changer?

Background

Many economic evaluations ignore economies of scale in their cost estimation, which means that cost parameters are assumed to have a linear relationship with the level of production. Economies of scale is the situation when the average total cost of producing a product decreases with increasing volume caused by reducing the variable costs due to more efficient operation. This study investigates the significance of applying the economies of scale concept: the saving in costs gained by an increased level of production in economic evaluation of pneumococcal conjugate vaccines (PCV) and human papillomavirus (HPV) vaccinations.

Methods

The fixed and variable costs of providing partial (20% coverage) and universal (100% coverage) vaccination programs in the Philippines were estimated using various methods, including costs of conducting questionnaire survey, focus-group discussion, and analysis of secondary data. Costing parameters were utilised as inputs for the two economic evaluation models for PCV and HPV. Incremental cost-effectiveness ratios (ICERs) and 5-year budget impacts with and without applying economies of scale to the costing parameters for partial and universal coverage were compared in order to determine the effect of these different costing approaches.

Results

The program costs of the partial coverage for the two immunisation programs were not very different when applying and not applying the economies of scale concept. Nevertheless, the program costs for universal coverage were 0.26 and 0.32 times lower when applying economies of scale compared to not applying economies of scale for the pneumococcal and human papillomavirus vaccinations, respectively. ICERs varied by up to 98% for pneumococcal vaccinations, whereas the change in ICERs in the human papillomavirus vaccination depended on both the costs of cervical cancer screening and the vaccination program. This results in a significant difference in the 5-year budget impact, accounting for 30 and 40% of reduction in the 5-year budget impact for the pneumococcal and human papillomavirus vaccination programs.

Conclusions

This study demonstrated the feasibility and importance of applying economies of scale in the cost estimation in economic evaluation, which would lead to different conclusions in terms of value for money regarding the interventions, particularly with population-wide interventions such as vaccination programs. The economies of scale approach to costing is recommended for the creation of methodological guidelines for conducting economic evaluations.

Identifying priority technical and context-specific issues in improving the conduct, reporting and use of health economic evaluation in low- and middle-income countries

Background

The use of economic evaluation in healthcare policies and decision-making, which is limited in low- and middle-income countries (LMICs), might be promoted through the improvement of the conduct and reporting of studies. Although the literature indicates that there are many issues affecting the conduct, reporting and use of this evidence, it is unclear which factors should be prioritised in finding solutions. This study aims to identify the top priority issues that impede the conduct, reporting and use of economic evaluation as well as potential solutions as an input for future research topics by the international Decision Support Initiative and other movements.

Methods

A survey on issues regarding the conduct, reporting and use of economic evaluation as well as on potential solutions was conducted using an online questionnaire among researchers who have experience in conducting economic evaluations in LMICs. The respondents were requested to consider the list of issues provided, rank the most important ones and propose solutions. A scoring system was applied to derive the ranking of difficulties according to researchers’ responses. Issues were grouped into technical and context-specific difficulties and analysed separately as a whole and by region.

Results

Researchers considered the lack of quality local clinical data, poor reporting and insufficient data to conduct the analysis from the chosen perspective as the most important technical difficulties. On the other hand, the non-integration of economic evaluations into decision-making was considered the most important context-specific issue. Finally, context-specific issues were considered the larger barrier to the use of economic evaluation.

Conclusion

The technical issues that were considered most important were closely linked with the lack of an appropriately functioning information system as well as the capacity to generate essential contextual information (e.g. data and locally relevant utility values), especially when the methodology is complex. To overcome this, simpler approaches to collect data that yields information of comparable quality to more rigorous methods should be developed. The international community can play a major role through research on methodologies feasible for LMIC settings as well as in building research capacity in countries. Context-specific issues, which were recognised as larger barriers, should be improved in parallel.

Electronic supplementary material

The online version of this article (10.1186/s12961-018-0280-6) contains supplementary material, which is available to authorized users.

Rival perspectives in health technology assessment and other economic evaluations for investing in global and national health. Who decides? Who pays?

There seems to be a general agreement amongst practitioners of economic evaluations, including Health Technology Assessment, that the explicit statement of a perspective is a necessary element in designing and reporting research. Moreover, there seems also to be a general presumption that the ideal perspective is “societal”. In this paper we endorse the first principle but dissent from the second. A review of recommended perspectives is presented. The societal perspective is frequently not the one recommended. The societal perspective is shown to be less comprehensive than is commonly supposed, is inappropriate in many contexts and, in any case, is in general not a perspective to be determined independently of the context of a decision problem. Moreover, the selection of a perspective, societal or otherwise, is not the prerogative of analysts.

Health Technology Assessment capacity development in low- and middle-income countries: Experiences from the international units of HITAP and NICE

Health Technology Assessment (HTA) is policy research that aims to inform priority setting and resource allocation. HTA is increasingly recognized as a useful policy tool in low- and middle-income countries (LMICs), where there is a substantial need for evidence to guide Universal Health Coverage policies, such as benefit coverage, quality improvement interventions and quality standards, all of which aim at improving the efficiency and equity of the healthcare system. The Health Intervention and Technology Assessment Program (HITAP), Thailand, and the National Institute for Health and Care Excellence (NICE), UK, are national HTA organizations providing technical support to governments in LMICs to build up their priority setting capacity. This paper draws lessons from their capacity building programs in India, Colombia, Myanmar, the Philippines, and Vietnam. Such experiences suggest that it is not only technical capacity, for example analytical techniques for conducting economic evaluation, but also management, coordination and communication capacity that support the generation and use of HTA evidence in the respective settings. The learned lessons may help guide the development of HTA capacity in other LMICs.

How Should Global Fund Use Value-for-Money Information to Sustain its Investments in Graduating Countries?

It has been debated whether the Global Fund (GF), which is supporting the implementation of programs on the prevention and control of HIV/AIDS, tuberculosis (TB) and malaria, should consider the value-for-money (VFM) for programs/interventions that they are supporting. In this paper, we critically analyze the uses of economic information for GF programs, not only to ensure accountability to their donors but also to support country governments in continuing investment in cost-effective interventions initiated by the GF despite the discontinuation of financial support after graduation. We demonstrate that VFM is not a static property of interventions and may depend on program start-up cost, economies of scales, the improvement of effectiveness and efficiency of providers once the program develops, and acceptance and adherence of the target population. Interventions that are cost-ineffective in the beginning may become cost-effective in later stages. We consider recent GF commitments towards value for money and recommend that the GF supports interventions with proven cost-effectiveness from program initiation as well as interventions that may be cost-effective afterwards. Thus, the GF and country governments should establish mechanisms to monitor cost-effectiveness of interventions invested over time.

Institutionalising health technology assessment: establishing the Medical Technology Assessment Board in India

India is at crossroads with a commitment by the government to universal health coverage (UHC), driving efficiency and tackling waste across the public healthcare sector. Health technology assessment (HTA) is an important policy reform that can assist policy-makers to tackle inequities and inefficiencies by improving the way in which health resources are allocated towards cost-effective, appropriate and feasible interventions. The equitable and efficient distribution of health budget resources, as well as timely uptake of good value technologies, are critical to strengthen the Indian healthcare system. The government of India is set to establish a Medical Technology Assessment Board to evaluate existing and new health technologies in India, assist choices between comparable technologies for adoption by the healthcare system and improve the way in which priorities for health are set. This initiative aims to introduce a more transparent, inclusive, fair and evidence-based process by which decisions regarding the allocation of health resources are made in India towards the ultimate goal of UHC. In this analysis article, we report on plans and progress of the government of India for the institutionalisation of HTA in the country. Where India is home to one-sixth of the global population, improving the health services that the population receives will have a resounding impact not only for India but also for global health.

Health Technology Assessment: Global Advocacy and Local Realities Comment on "Priority Setting for Universal Health Coverage: We Need Evidence-Informed Deliberative Processes, Not Just More Evidence on Cost-Effectiveness"

Cost-effectiveness analysis (CEA) can help countries attain and sustain universal health coverage (UHC), as long as it is context-specific and considered within deliberative processes at the country level. Institutionalising robust deliberative processes requires significant time and resources, however, and countries often begin by demanding evidence (including local CEA evidence as well as evidence about local values), whilst striving to strengthen the governance structures and technical capacities with which to generate, consider and act on such evidence. In low- and middle-income countries (LMICs), such capacities could be developed initially around a small technical unit in the health ministry or health insurer. The role of networks, development partners, and global norm setting organisations is crucial in supporting the necessary capacities.

Designing the Free Drugs List in Nepal: A Balancing Act Between Technical Strengths and Policy Processes

As more countries provide free health care, pharmaceutical reimbursement lists are becoming a concern, especially in low- and middle-income countries. In 2007, Nepal decreed that health is a human right and began basic health coverage for a target group of the poor, destitute, elderly, and disabled. The Ministry of Health and Population (MoHP) also provided 40 drugs without cost to all citizens through the Free Drugs List (FDL) program. The FDL was later expanded from 40 to 70 drugs; however, the process of review and update remains unclear. To propose a mechanism for future development of the FDL, we conducted a document review and in-depth consultations with representatives from the MoHP and the World Health Organization Country Office during a workshop in Kathmandu. The FDL suffers from lack of an appropriate process, gaps between the listed drugs and Nepal’s burden of disease, and no consideration of the unit costs or cost-effectiveness of drugs included in the list. We propose a new drug selection process that is a variant of the health technology assessment process. This process can be applied not only in Nepal but also in other resource-limited countries that wish to ensure their citizens’ access to essential medicines through a pharmaceutical reimbursement list.