Outcomes in Economic Evaluations of Public Health Interventions in Low- and Middle-Income Countries: Health, Capabilities and Subjective Wellbeing

Measuring refugees' capabilities: translation, adaptation, and valuation of the OxCAP-MH into Juba Arabic for use among South Sudanese male refugees in Uganda

BACKGROUND

Forcibly displaced populations are highly vulnerable to psychosocial distress and mental disorders, including alcohol misuse. In an ongoing trial that seeks to develop a transdiagnostic intervention addressing psychological distress and alcohol use disorders among conflict-affected populations, we will carry out a cost-effectiveness evaluation using a capability-based Oxford Capabilities Mental Health (OxCAP-MH) measure. The OxCAP-MH is a 16-item questionnaire developed from the Capability Approach, that covers multiple domains of functioning and welfare. The aim of the current paper is to present the results of the translation, cultural adaptation and valuation of the OxCAP-MH into Juba Arabic for South Sudanese refugees living in Uganda. We adhered to the official Translation and Linguistic Validation process of the OxCAP-MH. To carry out the translation, the Concept Elaboration document, official English version of the OxCAP-MH, and the Back-Translation Review Template were used. Four independent translators were used for forward and back translations. The reconciled translated version was then piloted in two focus group discussions (N = 16) in Rhino refugee settlement. A most important to least important valuation of the sixteen capability domains covered in the OxCAP-MH was also done.

RESULTS

The Juba Arabic version of the OxCAP-MH was finalized following a systematic iterative process. The content of the Juba Arabic version remained unchanged, but key concepts were adapted to ensure cultural acceptability, feasibility, and comprehension of the measure in the local context of Rhino refugee settlement. Most participants had low levels of literacy and required support with filling in the tool. Participants suggested an additional capability that is currently not reflected in the OxCAP-MH, namely access to food. Furthermore, discussions around the valuation exercise of the sixteen domains led to two separate importance scales, which showed relevant differences.

CONCLUSIONS

In this context, the OxCAP-MH was considered culturally acceptable. The valuation exercise proved cognitively demanding. Participants voiced confusion over how to answer the questions on the OxCAP-MH instrument due to low levels of literacy. These concerns invite consideration for future research to consider how measures such as the OxCAP-MH can be made more accessible to individuals with low literacy rates in resource poor settings.

The Children and Young People Quality of Life Study: A protocol for the qualitative development of attributes for capability wellbeing measures for use in health economic evaluation with children and young people

Background: Health services face difficult choices regarding how to allocate scarce health and social care resources. Economic evaluation can aid this process of decision making by allowing competing healthcare interventions or services to be compared in terms of their costs and consequences. However, existing use of economic evaluation of health services largely focuses on comparing interventions in terms of their impact on health only, missing factors potentially important to broader wellbeing. The capability approach measures outcomes in terms of what people are able to do and be. It provides an alternative evaluative space for economic evaluation, which may be especially beneficial for populations such as children and young people, for whom health might not be the only outcome of importance to their wellbeing. Study aims: This study aims to develop conceptual attributes and descriptive systems for capability wellbeing measures for children and young people to be used in economic evaluation, using qualitative methods with children and young people directly and their parents/guardians. Methods: Qualitative interviews will be used with children and young people and parents/guardians to develop the conceptual attributes (items) and wording for the capability wellbeing measures. Recruitment will be undertaken through organisations such as schools and charities and online using Facebook. Interviews will be face-to-face or online and will focus on identifying factors important to children and young people’s wellbeing to create an initial draft of the capability wellbeing measures. Subsequent interviews will focus on refining the wording used in the measures. Interviews will be analysed using methods of constant comparison, to explore similarities and differences in what participants considered important to children and young people’s wellbeing and to develop appropriate wording for the measures based on participant responses. Ethics: The study received approval from the University of Bristol Faculty of Health Sciences Research Ethics Committee (reference 77121).

Measuring and valuing broader impacts in public health: Development of a sanitation-related quality of life instrument in Maputo, Mozambique

Two billion people globally lack access to a basic toilet. While improving sanitation reduces infectious disease, toilet users often identify privacy, safety and dignity as more important. However, these outcomes have not been incorporated in sanitation-related economic evaluations. This illustrates the general challenge of outcome measurement and valuation in the economic evaluation of public health interventions, and risks misallocating the US$ 20 billion invested in sanitation in low- and middle-income countries every year. In this study in urban Mozambique, we develop an instrument to measure sanitation-related quality of life (SanQoL). Applying methods from health economics and the capability approach, we develop a descriptive system to measure five attributes identified in prior qualitative research: disgust, health, shame, safety and privacy. Sampling individuals from the intervention and control groups of a sanitation intervention trial, we elicit attribute ranks to value a SanQoL index and assess its validity and reliability. In combination with a measure of time using a sanitation service, SanQoL can quantify incremental benefits in a sanitation-focused cost-effectiveness analysis. After monetary valuation based on willingness to pay, QoL benefits could be summed with health gains in cost-benefit analysis, the most common method in sanitation economic evaluations.

Development of a framework to promote rural health workforce capability through digital solutions: A qualitative study of user perspectives

A high-quality, sustained, health workforce contributes to a healthy population. However, a global reality is that rural health services, and the workforces that provide those services, are under unprecedented pressure. It is posited that improving a rural health practitioners’ capability could help to retain them working rurally for longer. Capability refers to skills and experience and the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance. With rapidly increasing access to, and use of, digital technology worldwide, there are new opportunities to build capability and leverage personal and professional support for those who are working rurally. In 2021, semi-structured interviews were conducted in rural Australia with thirteen General Practitioners and allied health professionals. Thematic analysis was adopted to analyse the data and map it to the Health Information Technology Acceptance Model. Whilst it could be assumed that low technology literacy would act as a barrier to the use of digital tools, the study demonstrated that this was not a significant impediment to participants’ willingness to adopt digital tools when social and professional networks weren't available face to face to address their capability challenges. The findings provide insight into the concept of health workforce capability and important considerations when designing capability support. This includes key features of health apps or digital tools to support the capability of the rural health workforce. Understanding the factors that make up a health professionals’ capability and the motivations or cues to act to build or maintain their capability may have a positive effect on their retention in a rural location.

Outcomes reported in evaluations of programs designed to improve health in Indigenous people

OBJECTIVE

To assess the outcomes reported and measured in evaluations of complex health interventions in Indigenous communities.

DATA SOURCES

We searched all publications indexed in MEDLINE, PreMEDLINE, EMBASE, PsycINFO, EconLit, and CINAHL until January 2020 and reference lists from included papers were hand-searched for additional articles.

STUDY DESIGN

Systematic review.

DATA COLLECTION/EXTRACTION METHODS

We included all primary studies, published in peer-reviewed journals, where the main objective was to evaluate a complex health intervention developed specifically for an Indigenous community residing in a high-income country. Only studies published in English were included. Quantitative and qualitative data were extracted and summarized.

PRINCIPAL FINDINGS

Of the 3523 publications retrieved, 62 evaluation studies were included from Australia, the United States, Canada, and New Zealand. Most studies involved less than 100 participants and were mainly adults. We identified outcomes across 13 domains: clinical, behavioral, process-related, economic, quality of life, knowledge/awareness, social, empowerment, access, environmental, attitude, trust, and community. Evaluations using quantitative methods primarily measured outcomes from the clinical and behavioral domains, while the outcomes reported in the qualitative studies were mostly from the process-related and empowerment domains.

CONCLUSION

The outcomes from qualitative evaluations, which better reflect the impact of the intervention on participant health, remain different from the outcomes routinely measured in quantitative evaluations. Measuring the outcomes from qualitative evaluations alongside outcomes from quantitative evaluations could result in more relevant evaluations to inform decision making in Indigenous health.

Economic Evaluation of Public Health Interventions: An Application to Interventions for the Prevention of Violence Against Women and Girls Implemented by the "What Works to Prevent Violence Against Women and Girls?" Global Program

Violence against women and girls (VAWG) has important social, economic, and public health impacts. Governments and international donors are increasing their investment in VAWG prevention programs, yet clear guidelines to assess the "value for money" of these interventions are lacking. Improved costing and economic evaluation of VAWG prevention can support programming through supporting priority setting, justifying investment, and planning the financing of VAWG prevention services. This article sets out a standardized methodology for the economic evaluation of complex, that is, multicomponent and/or multiplatform, programs designed to prevent VAWG in low- and middle-income countries (LMICs). It outlines an approach that can be used alongside the most recent guidance for the economic evaluation of public health interventions in LMICs. It defines standardized methods of data collection and analysis, outcomes, and unit costs (i.e., average costs per person reached, output or service delivered), and provides guidance to investigate the uncertainty in cost-effectiveness estimates and report results. The costing approach has been developed and piloted as part of the "What Works to Prevent Violence Against Women and Girls?" (What Works?) program in five countries. This article and its supplementary material can be used by both economists and non-economists to contribute to the generation of new cost-effectiveness data on VAWG prevention, and ultimately improve the allocative efficiency and financing across VAWG programs.

Challenges in developing capability measures for children and young people for use in the economic evaluation of health and care interventions

Methods for measuring outcomes suitable for economic evaluations of health and care interventions have primarily focused on adults. The validity of such methods for children and young people is questionable in areas including the outcome domains measured and how they are measured and valued, with most existing measures narrowly focusing on health. Novel methods for assessing benefits beyond health by focusing on a person's capability have also concentrated on adults to date. This paper aims to set out the rationale for capability measures in children and young people. It argues for the need to expand the evaluative space beyond health functioning towards broader capabilities, with children and young people playing an integral role in capability measure development. Drawing from existing literature, specific challenges related to the identification, measurement, and valuation of capabilities in children and young people are also discussed. Finally, the practical implications for conducting economic evaluation when measuring and valuing capabilities at different stages across the life-course are illustrated. We develop an alternative framework based on conceiving capabilities as evolving across the life-course. This framework may also be helpful in thinking about how to model health outcomes across the life-course.

Evaluation of a self-help intervention to promote the health and wellbeing of marginalised people including those living with leprosy in Nepal: a prospective, observational, cluster-based, cohort study with controls

BACKGROUND

People affected by leprosy are at increased risk of ulcers from peripheral nerve damage. This in turn can lead to visible impairments, stigmatisation and economic marginalisation. Health care providers suggest that patients should be empowered to self-manage their condition to improve outcomes and reduce reliance on services. Self-care involves carrying out personal care tasks with the aim of preventing disabilities or preventing further deterioration. Self-help, on the other hand, addresses the wider psychological, social and economic implications of leprosy and incorporates, for example, skills training and microfinance schemes. The aim of this study, known as SHERPA (Self-Help Evaluation for lepRosy and other conditions in NePAl) is to evaluate a service intervention called Integrated Mobilization of People for Active Community Transformation (IMPACT) designed to encourage both self-care and self-help in marginalised people including those affected by leprosy.

METHODS

A mixed-method evaluation study in Province 5, Nepal comprising two parts. First, a prospective, cluster-based, non-randomised controlled study to evaluate the effectiveness of self-help groups on ulcer metrics (people affected by leprosy only) and on four generic outcome measures (all participants) - generic health status, wellbeing, social integration and household economic performance. Second, a qualitative study to examine the implementation and fidelity of the intervention.

IMPACT

This research will provide information on the effectiveness of combined self-help and self-care groups, on quality of life, social integration and economic wellbeing for people living with leprosy, disability or who are socially and economically marginalised in low- and middle- income countries.

A qualitative enquiry into the meaning and experiences of wellbeing among young people living with and without HIV in KwaZulu-Natal, South Africa

Young people in sub-Saharan Africa encounter health and livelihood challenges which may compromise their wellbeing. Understanding how young people's wellbeing is defined could strengthen wellbeing policies. We investigated perceptions and experiences of young people's wellbeing, and whether these aligned with Ryff's psychological wellbeing (PWB) model. Data were collected between January-August 2018 through focus-group discussions (n = 12) and in-depth interviews (n = 16) with young people living with and without HIV, selected purposively from South African healthcare facilities. Key informant interviews (n = 14) were conducted with healthcare workers and subject-matter experts. Using a framework approach, we situated our analysis around dimensions of Ryff's PWB model: autonomy, self-acceptance, purpose in life, environmental mastery, positive relationships, personal growth. Young people's wellbeing was rooted in family and peer relationships. Acceptance and belongingness received from these networks fostered social integration. HIV-related stigma, crime and violence reduced their perceived control and social trust. For males, fulfilling gendered roles made them feel socially valued. Self-perceived failure to uphold sexual norms undermined women's social contribution and autonomy. Social integration and contribution framed young people's wellbeing. However, these dimensions were not fully captured by Ryff's PWB model. Models that consider relationality across socio-ecological levels may be relevant for understanding young people's wellbeing.

Capability instruments in economic evaluations of health-related interventions: a comparative review of the literature

PURPOSE

Given increasing interest in using the capability approach for health economic evaluations and a growing literature, this paper aims to synthesise current information about the characteristics of capability instruments and their application in health economic evaluations.

METHODS

A systematic literature review was conducted to assess studies that contained information on the development, psychometric properties and valuation of capability instruments, or their application in economic evaluations.

RESULTS

The review identified 98 studies and 14 instruments for inclusion. There is some evidence on the psychometric properties of most instruments. Most papers found moderate-to-high correlation between health and capability measures, ranging between 0.41 and 0.64. ASCOT, ICECAP-A, -O and -SCM instruments have published valuation sets, most frequently developed using best-worst scaling. Thirteen instruments were originally developed in English and one in Portuguese; however, some translations to other languages are available. Ten economic evaluations using capability instruments were identified. The presentation of results show a lack of consensus regarding the most appropriate way to use capability instruments in economic evaluations with discussion about capability-adjusted life years (CALYs), years of capability equivalence and the trade-off between maximisation of capability versus sufficient capability.

CONCLUSION

There has been increasing interest in applying the capability-based approach in health economic evaluations, but methodological and conceptual issues remain. There is still a need for direct comparison of the different capability instruments and for clear guidance on when and how they should be used in economic evaluations.

Informing the measurement of wellbeing among young people living with HIV in sub-Saharan Africa for policy evaluations: a mixed-methods systematic review

Young people living with HIV (YPLHIV) in sub-Saharan Africa (SSA) are at high risk of having a poor quality of life. Addressing wellbeing explicitly within HIV/AIDS policies could assist mitigation efforts. However, guidance on wellbeing measures to evaluate policies for YPLHIV is scarce. The aims of this mixed-methods review were to identify: i) key dimensions of wellbeing and ii) wellbeing measures that align to these dimensions among YPLHIV (15-24 years) in SSA. We searched six social science and medical databases, including grey literature. We included studies that examined correlates and lived experiences of wellbeing, among YPLHIV in SSA, from January 2000 to May 2019. Two reviewers independently screened abstracts and full texts and assessed methodological quality of included articles. We analysed quantitative and qualitative data using descriptive and meta-ethnographic approaches, respectively. Thereafter, we integrated findings using a framework approach. We identified 6527 citations. Of these, 10 quantitative and 30 qualitative studies were included. Being male, higher educational status, less stigma and more social support were likely correlates of wellbeing. Themes that shaped experiences suggestive of wellbeing were: 1) acceptance and belonging- stigma, social support; 2) coping; 3) standard of living. Our final synthesis found that the following dimensions potentially characterise wellbeing: self-acceptance, belonging, autonomy; positive relations, environmental mastery, purpose in life. Wellbeing for YPLHIV is multi-dimensional and relational. Relevant measures include the Personal Wellbeing Index, Ryff's Psychological Wellbeing Scale and Mental Health Continuum Short Form. However, psychometric evaluations of these scales among YPLHIV in SSA are needed.

The impact of health vs. non-health goals on individuals' lifestyle program choices: a discrete choice experiment approach

BACKGROUND

Goals play an important role in the choices that individuals make. Yet, there is no clear approach of how to incorporate goals in discrete choice experiments. In this paper, we present such an approach and illustrate it in the context of lifestyle programs. Furthermore, we investigate how non-health vs. health goals affect individuals' choices via non-goal attributes.

METHODS

We used an unlabeled discrete choice experiment about lifestyle programs based on two experimental conditions in which either a non-health goal (i.e., looking better) or a health goal (i.e., increasing life expectancy) was presented to respondents as a fixed attribute level for the goal attribute. Respondents were randomly distributed over the experimental conditions. Eventually, we used data from 407 Dutch adults who reported to be overweight (n = 212 for the non-health goal, and n = 195 for the health goal).

RESULTS

Random parameter logit model estimates show that the type of goal significantly (p < 0.05) moderates the effect that the attribute diet has on lifestyle program choice, but that this is not the case for the attributes exercise per week and expected weight loss.

CONCLUSIONS

A flexible diet is more important for individuals with a non-health goal than for individuals with a health goal. Therefore, we advise policy makers to use information on goal interactions for developing new policies and communication strategies to target population segments that have different goals. Furthermore, we recommend researchers to consider the impact of goals when designing discrete choice experiments.

Estimating conversion rates: A new empirical strategy with an application to health care in Italy

This study proposes a new empirical strategy for assessing how "efficient" different individuals and groups are in converting their available resources into achievements. Following the capabilities approach, pioneered by Amartya Sen, we employ the concept of "conversion rates" to capture the efficiency of the link from resources to achievements. The methodology is both simpler and more conceptually precise than previous options, this offering the potential to support significant expanded work in this area. The proposed methodology is then tested in relation to health care in Italy. The findings suggest that investments in education may carry particular health benefits for women, which public resources are particularly important for the elderly, and that single individuals pose special challenges because they benefit less from all types of resources than married couples. The results thus highlight significant heterogeneities in the abilities of different groups to convert public, private, and nonfinancial resources into health, and we conclude by noting the possible consequences for health care and public policies.

A framework for conducting economic evaluations alongside natural experiments

Internationally, policy makers are increasingly focussed on reducing the detrimental consequences and rising costs associated with unhealthy diets, inactivity, smoking, alcohol and other risk factors on the health of their populations. This has led to an increase in the demand for evidence-based, cost-effective Population Health Interventions (PHIs) to reverse this trend. Given that research designs such as randomised controlled trials (RCTs) are often not suited to the evaluation of PHIs, Natural Experiments (NEs) are now frequently being used as a design to evaluate such complex, preventive PHIs. However, current guidance for economic evaluation focusses on RCT designs and therefore does not address the specific challenges of NE designs. Using such guidance can lead to sub-optimal design, data collection and analysis for NEs, leading to bias in the estimated effectiveness and cost-effectiveness of the PHI. As a consequence, there is a growing recognition of the need to identify a robust methodological framework for the design and conducting of economic evaluations alongside such NEs. This paper outlines the challenges inherent to the design and conduct of economic evaluations of PHIs alongside NEs, providing a comprehensive framework and outlining a research agenda in this area.

Health beliefs associated with poor disease self-management in smokers with asthma and/or COPD: a pilot study

Background: Compared to nonsmokers, smokers with chronic disease are less likely to adhere to self-management recommendations for the management of their chronic conditions. Although the literature notes poor adherence trends in smokers, actual influences of adherence in these patients require further study. This study examines the health beliefs that influence self-management behaviors in smokers with chronic lung disease. Methods: This prospective, cross-sectional study surveyed patients (n = 83) seen in the pulmonary outpatient clinics of the University Medical Center of New Orleans between November 2015 and February 2016. Eligible patients included those between 40-64 years old diagnosed with asthma and/or chronic obstructive pulmonary disease (COPD). Primary measures included perceived beliefs related to the susceptibility to asthma and/or COPD becoming worse, perceived barriers to adherence, and perceived benefits to adherence. Patient characteristics under-study included smoking status, race, gender, and diagnosis. Descriptive and chi-square analyses were performed to characterize the sample. Student's t and and regression analyses were conducted to examine the relationships between perceptions, smoking status, race, gender, and diagnosis. Results: Compared to nonsmokers, smokers perceived their asthma and/or COPD becoming worse (p = 0.0023). Smokers also perceived more barriers (p < 0.0001), and fewer benefits to adherence than nonsmokers (p = 0.0021). Conclusion: The health beliefs of smokers may influence their self-management behaviors. Results of this study can inform the development of services that target smokers in order to improve adherence to self-management behaviors and health outcomes.

Variation in the apparent importance of health-related problems with the instrument used to measure patient welfare

AIMS

This paper investigates the distributional implications for eight population groups of using six different instruments to measure wellbeing and to prioritise access to health services. Specifically, it examines the importance of different physical and psycho-social problems for the scores obtained using each instrument and whether scores differ because of differences in the concept measured by the instrument or because of the instrument's construction.

METHODS

Patients with seven chronic conditions and a sample of the 'healthy' public were administered six instruments: two utility instruments; two self-rating scales; a subjective wellbeing instrument and the ICECAP measure of capability. Scores were regressed upon the subscales of the SF-36 and the AQoL-8D. Each instrument's 'problem mix' was measured by the numerical importance of the subscales for the instrument's score and compared with the problem mix of patients constructed from all of the instruments.

RESULTS

The apparent importance of different problems varied significantly with the instrument used to assess welfare but not with the chronic conditions. The correspondence between an instrument's problem mix and the patients' problem mix was highly variable.

CONCLUSION

Different instruments give prominence to different physical and psycho-social problems and consequently favour different groups of patients. Budgetary decisions which appear to be based on efficiency criteria such as the cost per quality-adjusted life year (QALY) conceal distributive effects attributable to the instrument used in the analysis. The effects are additional to the ethical questions considered in making an equity-efficiency trade-off as they arise from the measurement of efficiency.

Cost-effectiveness of health care service delivery interventions in low and middle income countries: a systematic review

Background

Low and middle income countries (LMICs) face severe resource limitations but the highest burden of disease. There is a growing evidence base on effective and cost-effective interventions for these diseases. However, questions remain about the most cost-effective method of delivery for these interventions. We aimed to review the scope, quality, and findings of economic evaluations of service delivery interventions in LMICs.

Methods

We searched PUBMED, MEDLINE, EconLit, and NHS EED for studies published between 1st January 2000 and 30th October 2016 with no language restrictions. We included all economic evaluations that reported incremental costs and benefits or summary measures of the two such as an incremental cost effectiveness ratio. Studies were grouped by both disease area and outcome measure and permutation plots were completed for similar interventions. Quality was judged by the Drummond checklist.

Results

Overall, 3818 potentially relevant abstracts were identified of which 101 studies were selected for full text review. Thirty-seven studies were included in the final review. Twenty-three studies reported on interventions we classed as “changing by whom and where care was provided”, specifically interventions that entailed task-shifting from doctors to nurses or community health workers or from facilities into the community. Evidence suggests this type of intervention is likely to be cost-effective or cost-saving. Nine studies reported on quality improvement initiatives, which were generally found to be cost-effective. Quality and methods differed widely limiting comparability of the studies and findings.

Conclusions

There is significant heterogeneity in the literature, both methodologically and in quality. This renders further comparisons difficult and limits the utility of the available evidence to decision makers.

Does multidisciplinary rehabilitation of tortured refugees represent 'value-for-money'? A follow-up of a Danish case-study

BACKGROUND

The recent surge of asylum seekers in the European Union (EU) is raising questions about the EU's ability to integrate newcomers into the economy and into society; particularly those who need specialized services for the treatment of severe trauma. This study investigated whether rehabilitating traumatised refugees represents 'value-for-money' (VfM) in terms of intervention cost per health gain and in a long-term and societal perspective.

METHODS

The economic evaluation comprised a cost-utility analysis (CUA) and a partial cost-benefit analysis (CBA). The CUA incorporated data on Quality Adjusted Life Years (QALY) for 45 patients who were treated at the Rehabilitation and Research Centre for Torture Victims, Copenhagen, Denmark, in 2001-2004 and followed for up to 2 years, to determine the incremental cost effectiveness ratio (ICER). For the CBA, data was collected for 44 patients who completed treatment between 2001 and 2004 and 44 matched controls on the waiting list, for the patients' primary health care utilisation, and personal and family labour income from 2001 to 2014. This was analysed to evaluate the Net Social Benefit (NSB) of the programme.

RESULTS

The average cost of treatment was found to be about 32,000 USD per patient (2016 prices) with an average gain in QALY of 0.82. The treatment was cost effective according to the ICER threshold suggested by the National Institute of Health and Care Excellence (UK). At the individual level, the NSB remained negative throughout the study period. However, at the family income level the intervention proved to have been beneficial after 3 years.

CONCLUSION

The implication of the study is, that providing rehabilitation to severely traumatised refugee families can be an economically viable strategy, considering the economic effects observed at the family level.

Economic evaluation of the Good School Toolkit: an intervention for reducing violence in primary schools in Uganda

Introduction

This paper presents the cost and cost-effectiveness of the Good School Toolkit (GST), a programme aimed at reducing physical violence perpetrated by school staff to students in Uganda.

Methods

The effectiveness of the Toolkit was tested with a cluster randomised controlled trial in 42 primary schools in Luwero District, Uganda. A full economic costing evaluation and cost-effectiveness analysis were conducted alongside the trial. Both financial and economic costs were collected retrospectively from the provider’s perspective to estimate total and unit costs.

Results

The total cost of setting up and running the Toolkit over the 18-month trial period is estimated at US$397 233, excluding process monitor (M&E) activities. The cost to run the intervention is US$7429 per school annually, or US$15 per primary school pupil annually, in the trial intervention schools. It is estimated that the intervention has averted 1620 cases of past-week physical violence during the 18-month implementation period. The total cost per case of violence averted is US$244, and the annual implementation cost is US$96 per case averted during the trial.

Conclusions

The GST is a cost-effective intervention for reducing violence against pupils in primary schools in Uganda. It compares favourably against other violence reduction interventions in the region.

Improving the health and welfare of people who live in slums

In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.

Economic Evaluation in Ethiopian Healthcare Sector Decision Making: Perception, Practice and Barriers

BACKGROUND

Globally, economic evaluation (EE) is increasingly being considered as a critical tool for allocating scarce healthcare resources. However, such considerations are less documented in low-income countries, such as in Ethiopia. In particular, to date there has been no assessment conducted to evaluate the perception and practice of and barriers to health EE.

OBJECTIVE

This paper assesses the use and perceptions of EE in healthcare decision-making processes in Ethiopia.

METHODS

In-depth interview sessions with decision makers/healthcare managers and program coordinators across six regional health bureaus were conducted. A qualitative analysis approach was conducted on three thematic areas.

RESULTS

A total of 57 decision makers/healthcare managers were interviewed from all tiers of the health sector in Ethiopia, ranging from the Federal Ministry of Health down to the lower levels of the health facility pyramid. At the high-level healthcare decision-making tier, only 56 % of those interviewed showed a good understanding of EE when explaining in terms of cost and consequences of alternative courses of action and value for money. From the specific program perspective, 50 % of the prevention of mother-to-child transmission of HIV/AIDS program coordinators indicated the relevance of EE to program planning and decision making. These respondents reported a limited application of costing studies on the HIV/AIDS prevention and control program, which were most commonly used during annual planning and budgeting.

CONCLUSION

The study uncovered three important barriers to growth of EE in Ethiopia: a lack of awareness, a lack of expertise and skill, and the traditional decision-making culture.

Setting the Weights: The Women's Capabilities Index for Malawi

Standard indicators of wellbeing such as the QALY for health and GDP per capita for economic development have been increasingly regarded as being too narrow in focus. There is a need to develop multidimensional measures of wellbeing that encompass the full range of factors that make life worth living. This study is part of a project that aims at developing a multidimensional index based on Sen's capability framework to assess women's wellbeing in rural Malawi: the Women's Capabilities Index. The project identifies a set of capabilities relevant to the context; proposes a methodology to measure robustly these capabilities; aggregates the capabilities into a single metric (index); and validates and tests the index. This paper focuses on the weighting and aggregation of the index. Four weighting methods of aggregation are chosen: two normative approaches; a data-driven approach; and a hybrid method. The different methods have implications on the results which are critically assessed and compared. This study contributes to the literature on the implications of adopting different methods for setting the weights in composite measures of wellbeing.

Economic Evaluation in Global Perspective: A Bibliometric Analysis of the Recent Literature

We present a bibliometric analysis of recently published full economic evaluations of health interventions and reflect critically on the implications of our findings for this growing field. We created a database drawing on 14 health, economic, and/or general literature databases for articles published between 1 January 2012 and 3 May 2014 and identified 2844 economic evaluations meeting our criteria. We present findings regarding the sensitivity, specificity, and added value of searches in the different databases. We examine the distribution of publications between countries, regions, and health areas studied and compare the relative volume of research with disease burden. We analyse authors' country and institutional affiliations, journals and journal type, language, and type of economic evaluation conducted. More than 1200 economic evaluations were published annually, of which 4% addressed low-income countries, 4% lower-middle-income countries, 14% upper-middle-income countries, and 83% high-income countries. Across country income levels, 53, 54, 86, and 100% of articles, respectively, included an author based in a country within the income level studied. Biomedical journals published 74% of economic evaluations. The volume of research across health areas correlates more closely with disease burden in high-income than in low-income and middle-income countries. Our findings provide an empirical basis for further study on methods, research prioritization, and capacity development in health economic evaluation.