Health Gains and Financial Protection Provided by the Ethiopian Mental Health Strategy: an Extended Cost-Effectiveness Analysis

Access to essential psychotropic medicines in Addis Ababa: A cross-sectional study

BACKGROUND

Mental disorders are becoming a growing public health problem worldwide, especially in low- and middle-income countries. Regular and adequate supplies of appropriate, safe, and affordable medications are required to provide quality mental health services. However, significant proportions of the population with severe mental disorders are not getting access to treatment. Among others, the availability and affordability of psychotropic medicines are significant barriers for many patients in meeting their medication needs. This study aimed to assess the availability, prices, and affordability of essential psychotropic medicines in the private and public health sectors of Addis Ababa, the capital city of Ethiopia.

METHODS

A cross-sectional study design was used in 60 retail medicine outlets from the public and private sectors. Stratified random and quota sampling were applied to select the retail outlets. Data was entered and analyzed using the preprogrammed WHO/HAI workbook and SPSS V.25.

RESULTS

The mean availability of Lower Priced Generic (LPG) psychotropic medicines was 24.33% in Addis Ababa (28.7% in the public sector and 19.80% in the private sector). The Patient prices for the LPG ranged from 0.52-6.43 MPRs in public and 1.08-24.28 MPRs in private sectors. Standard treatment costs varied from 0.1-7.8 days' wages in public and 0.8-25 days' wages in private sectors for the lowest-paid government worker to purchase a month's supply.

CONCLUSIONS

Essential psychotropic medicines were poorly available, with high prices and low affordability in Addis Ababa. An efficient supply across all levels of care and financial protection for essential medicines should be in place to ensure access.

Availability, Price and Affordability of Psychotropic Medicines in Addis Ababa, Ethiopia

Background

Access to affordable, quality-assured essential medicines is crucial to reduce the burden of disease. However, one third of the world's population lacks regular access to essential medicines. The purpose of this study was to assess the availability, price, and affordability of medicines for mental disorders in Addis Ababa, Ethiopia.

Methods

A cross-sectional study was done in selected pharmacies after modification of a WHO/HAI methodology developed questionnaire. Data on the availability and price of 28 lowest priced generics and originator brand essential psychotropic medicines were collected from seven public sectors, five private sectors, and seven other sectors (five Kenema Public Community Pharmacies and two Red Cross Pharmacies) in Addis Ababa between May 9 and May 31, 2022. The data were analyzed using the developed WHO/HAI workbook part I Excel sheet. Descriptive results were reported in text and table format.

Results

The overall availability of lowest-priced generics medication was 41.69%. The availability of lowest-priced generics and originator brand medication was 54.68% and 1.7% in the public pharmacies; 24.14% and 0.0% in private pharmacies; 43% and 0.0% in Red Cross Pharmacies; and 42% and 3.2% in Kenema Public Community Pharmacies. The median price ratio in the public, private, Red Cross, and Kenema Public Community pharmacies was 1.26, 3.72, 1.65, and 1.59, respectively. Most of the medications were unaffordable. A patient could be required to pay up to 73 days wages to purchase a standard treatment for 1 month.

Conclusion

The availability of psychotropic medicines was lower than the WHO target for non-communicable diseases and most of the available medicines were unaffordable.

Incorporating Equity Concerns in Cost-Effectiveness Analyses: A Systematic Literature Review

OBJECTIVE

The aim of this study was to review analytical methods that enable the incorporation of equity concerns within economic evaluation.

METHODS

A systematic search of PubMed, Embase, and EconLit was undertaken from database inception to February 2021. The search was designed to identify methodological approaches currently employed to evaluate health-related equity impacts in economic evaluation studies of healthcare interventions. Studies were eligible if they described or elaborated on a formal quantitative method used to integrate equity concerns within economic evaluation studies. Cost-utility, cost-effectiveness, cost-benefit, cost-minimisation, and cost-consequence analyses, as well as health technology appraisals, budget impact analyses, and any relevant literature reviews were included. For each of the identified methods, we provided summaries of the scope of equity considerations covered, the methods employed and their key attributes, data requirements, outcomes, and strengths and weaknesses. A traffic light assessment of the practical suitability of each method was undertaken, alongside a worked example applying the different methods to evaluate the same decision problem. Finally, the review summarises the typical trade-offs arising in cost-effectiveness analyses and discusses the extent to which the evaluation methods are able to capture these.

RESULTS

In total, 68 studies were included in the review. Methods could broadly be grouped into equity-based weighting (EBW) methods, extended cost-effectiveness analysis (ECEA), distributional cost-effectiveness analysis (DCEA), multi-criteria decision analysis (MCDA), and mathematical programming (MP). EBW and MP methods enable equity consideration through adjustment to incremental cost-effectiveness ratios, whereas equity considerations are represented through financial risk protection (FRP) outcomes in ECEA, social welfare functions (SWFs) in DCEA, and scoring/ranking systems in MCDA. The review identified potential concerns for EBW methods and MCDA with respect to data availability and for EBW methods and MP with respect to explicitly measuring changes in inequality. The only potential concern for ECEA related to the use of FRP metrics, which may not be relevant for all healthcare systems. In contrast, DCEA presented no significant concerns but relies on the use of SWFs, which may be unfamiliar to some audiences and requires societal preference elicitation. Consideration of typical cost-effectiveness and equity-related trade-offs highlighted the flexibility of most methods with respect to their ability to capture such trade-offs. Notable exceptions were trade-offs between quality of life and length of life, for which we found DCEA and ECEA unsuitable, and the assessment of lost opportunity costs, for which we found only DCEA and MP to be suitable. The worked example demonstrated that each method is designed with fundamentally different analytical objectives in mind.

CONCLUSIONS

The review emphasises that some approaches are better suited to particular decision problems than others, that methods are subject to different practical requirements, and that significantly different conclusions can be observed depending on the choice of method and the assumptions made. Further, to fully operationalise these frameworks, there remains a need to develop consensus over the motivation for equity assessment, which should necessarily be informed with stakeholder involvement. Future research of this topic should be a priority, particularly within the context of equity evaluation in healthcare policy decisions.

Country contextualisation of cost-effectiveness studies: lessons from Ethiopia

Emerging demographic, epidemiological and health system changes in low-income countries require revisions of national essential health services packages in accordance with standard healthcare priority setting methods. Policy makers are in need of explicit and user-friendly methods to compare impact of multiple interventions. We provide experiences of country contextualisation of WHO-CHOICE methods and models to a country level. Results from three contextualised cost-effectiveness analyses (CEAs) are presented, and we discuss how this evidence can inform priority setting in Ethiopia. Existing models for a range of interventions in obstetric and neonatal care, psychiatric and neurological treatment and prevention and treatment of cardiovascular diseases are contextualised to the Ethiopian setting. CEAs are defined as contextualised if they include national analysts and use country-specific input for either costs, epidemiology, demography, baseline coverage or effects. Interventions (n=61) are ranked according to incremental cost-effectiveness rates (ICERs), and expected health outcomes (Disability Adjusted Life Years (DALYs) averted) and budget impacts are presented for each intervention. Dominated interventions (n=30) were excluded. A US$2.8 increase per capita in the annual health budget is needed in Ethiopia (currently at US$28 per capita) for increasing coverage by 20%–75% for all the 22 interventions with positive net health benefits. This investment is expected to give a net benefit at around 0.5 million DALYs averted in return in total, with a willingness to pay threshold at US$2000 per DALY averted. In particular, three interventions, neonatal resuscitation, kangaroo mother care and antibiotics for newborn sepsis, stand out as best buys in an Ethiopian setting. Our method of contextualised CEAs provides important information for policy makers. Rank ordering of interventions by ICERs, together with presentations of expected budget impact and net health benefits, is a clear and policy friendly illustration of possible efficient stepwise pathways towards universal health coverage.

Depression and Its Help Seeking Behaviors: A Systematic Review and Meta-Analysis of Community Survey in Ethiopia

BACKGROUND

Depression is one of the most common mental illnesses affecting around 322 million individual in the world. Although the prevalence of depression is high and its treatment is effective, little is known about its pooled prevalence and help seeking behaviors in the community settings of Ethiopia. Thus, this study aimed to determine the pooled prevalence of depression and its help seeking behaviors in Ethiopia.

METHODS

A systematic literature search in the databases of Pub-Med, Cochrane, and Google Scholar was performed. The quality of studies was assessed using the Newcastle-Ottawa quality assessment tool adapted for cross-sectional studies. Heterogeneity test and evidence of publication bias were assessed. Moreover, sensitivity test was also performed. Pooled prevalence of depression and its help seeking behavior were calculated using random effects model.

RESULTS

A total 13 studies for depression, 4 studies for help seeking intention, and 5 studies for help seeking behaviour were included in this review. The pooled prevalence of depression and help seeking intention and behaviour was found to be 20.5% (95% CI; 16.5% -24.4%), 42% (95% CI; 23%-60%), and 38% (95% CI; 23%-52%), respectively. There is no significant heterogeneity for depression (I² = 0%, p =0.620), help seeking intention (I² = 0%, p =0.996), and behaviour (I² = 0%, p =0.896). There is no publication bias for depression egger's test (p =0.689).

CONCLUSION

More than one in every five individuals were experiencing depression. Less than one-third of individuals with depression seek help from modern treatment. Authors suggest community based mental health screening and treatment.