Reflections on the development of health economics in low- and middle-income countries

Global trends in the scientific research of the health economics: a bibliometric analysis from 1975 to 2022

BACKGROUND

Health science is evolving extremely rapidly at worldwide level. There is a large volume of articles about health economics that are published each year. The main purpose of this research is to explore health economics in the world's scholarly literature based on a scient metric analysis to outline the evolution of research in the field.

METHOD

The Web of Science repository was used to get the data (1975-2022). The study explores 1620 documents from health economics. CiteSpace software was used to provide network visualisations. Four thousand ninety-six authors, 1723 institutions, 847 journals and 82 countries were involved in the sample. The current research contains a descriptive analysis, a co-authorship analysis, a co-citation analysis, and a co-occurrence analysis in health economics.

RESULTS

Drummond M.F (author), the USA (country), University of London (institution) and Value Health (journal) are among the most important contributors to the health economics literature. Co-authorship analysis highlights that cooperation between authors, institutions and countries is weak. However, Drummond M.F. is the most collaborative author, the USA is the most collaborative country, and University of York is the most collaborative institution. The study offers an image about the most co-cited references (Arrow K.J., 1963), authors (Margolis H.) and journals (British Medical Journal). The current research hotspots in health economics are "behavioural economics" and "economic evaluation". The main findings should be interpreted in accordance with the selection strategy used in this paper.

CONCLUSION

All in all, the paper maps the literature on health economics and may be used for future research.

Measurement of benefits in economic evaluations of nutrition interventions in low- and middle-income countries: A systematic review

Economic evaluation of nutrition interventions that compares the costs to benefits is essential to priority-setting. However, there are unique challenges to synthesizing the findings of multi-sectoral nutrition interventions due to the diversity of potential benefits and the methodological differences among sectors in measuring them. This systematic review summarises literature on the interventions, sectors, benefit terminology and benefit types included in cost-effectiveness, cost-utility and benefit-cost analyses (CEA, CUA and BCA, respectively) of nutrition interventions in low- and middle-income countries. A systematic search of five databases published from January 2010 to September 2019 with expert consultation yielded 2794 studies, of which 93 met all inclusion criteria. Eighty-seven per cent of the included studies included interventions delivered from only one sector, with almost half from the health sector (43%), followed by food/agriculture (27%), water, sanitation and hygiene (WASH) (10%), and social protection (8%). Only 9% of studies assessed programmes involving more than one sector (health, food/agriculture, social protection and/or WASH). Eighty-one per cent of studies used more than one term to refer to intervention benefits. The included studies calculated 128 economic evaluation ratios (57 CEAs, 39 CUAs and 32 BCAs), and the benefits they included varied by sector. Nearly 60% measured a single benefit category, most frequently nutritional status improvements; other health benefits, cognitive/education gains, dietary diversity, food security, knowledge/attitudes/practices and income were included in less than 10% of all ratios. Additional economic evaluation of non-health and multi-sector interventions, and incorporation of benefits beyond nutritional improvements (including cost savings) in future economic evaluations is recommended.

Nature and Composition of Earnings Reported by Health Economists and Related Professionals: Gender, Education, and job Characteristics Matter

Background

Despite the fast growth of the workforce comprising health economics (HE), outcomes research (OR), and market access (MA) professionals, little is known about their earnings determination. Only three studies have examined their earnings and none has considered the number of hours worked, traditionally a critical component of income determination models.

Objectives

(i) Estimate an indicator of annual earnings of HE/OR/MA professionals, comparing male versus female and U.S. versus non-U.S. earnings levels, and (ii) assess the magnitude of the effect of selected human-capital and job-related covariates on their annual earnings determination.

Methods

The study used 2019 self-reported survey data from a sample of 304 HE/OR/MA professionals registered in the HealthEconomics.com global subscriber list. A two-way classification model with multiple replications was used to identify and test earnings variations of HE/OR/MA professionals across genders and locations. An earnings determination function using ordinary least squares was used to identify disparities in response to covariates including average workweek, human-capital stock, and job-related variables by gender and location.

Results

Substantial earning disparities were observed between HE/OR/MA professionals living in the U.S. and those living in other countries. Non-U.S. respondents exhibited earnings gaps of 44.7% in wages/salaries and 46.8% in total earnings relative to their U.S. counterparts with greater gaps for women than men. The female earnings gap outside the U.S. was considerably greater than in the U.S. Holding a graduate degree; working in a pharmaceutical or biotechnology firm; age, a proxy for experience; and working remotely impacted earnings differentials across different subgroups.

Conclusions

The findings of this paper shed light into the nature and composition of earnings of HE/OR/MA professionals across genders and locations. Exploring the dynamics of earning disparities by gender and location has increased in relevance given the rapidly-changing and uncertain job market environment driven by the COVID-19 pandemic.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE

To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

DATA SOURCES

Articles available in electronic databases, published from inception to April 2021.

STUDY SELECTIONS

Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

RESULTS

Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it.

CONCLUSIONS

Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

When adherence and inhalation technique matter: Difficult-to-control pediatric asthma in low- to middle-income countries

Despite relatively recent advances in our understanding of the physiopathology of asthma and the availability of highly effective controller medications, such as inhaled corticosteroids (ICS), currently many pediatric patients fail to control their asthma, especially in low- and middle-income countries (LMICs). Although some of these difficult-to-control asthmatic children have severe therapy-resistant asthma, most of them experience poor asthma control due to various modifiable factors, among which poor adherence to inhaled controller therapy and inadequate inhaler technique are the most common. Although electronic monitoring devices have been considered to be essential tools in identifying patients with severe therapy-resistant asthma, their high cost and low availability have currently limited their use in clinical practice. For these reasons, clinicians might consider using validated self-reported questionnaires and the weight of inhaler canisters and as alternative and valid options for assessing adherence to inhaled controller therapy. Furthermore, clinicians might consider adopting validated instruments as an objective measurement of the adequacy of inhaler technique. Although recognizing poor adherence does not automatically lead to improved adherence, it is usually an essential first step in effectively targeting adherence behavior, especially if the reasons for low or erratic compliance are explored by means of non-judgmental doctor-patient communication. These recommendations could assist in overcoming our inability to have pediatric asthmatic patients use ICS and in avoiding escalating their controller therapy toward more expensive medications, eventually reaching the use biologics. Promoting the rational and cost-effective use of asthma controller therapy could help to optimize the limited health resources in many LMICs.

Disparities in the Wage-and-Salary Earnings, Determinants, and Distribution of Health Economics, Outcomes Research, and Market Access Professionals: An Exploratory Study

OBJECTIVE

The aim was to estimate the wage-and-salary earnings of a sample of health economics, outcomes research, and market access (HE/OR/MA) professionals; compare male versus female and US versus non-US earnings; assess the magnitude of the effect of several human-capital and job-related covariates on the determination of earnings; and examine inequality in the distribution of earnings.

METHODS

The study used self-reported survey data collected in 2017 from a subset of HE/OR/MA professionals in the HealthEconomics.com global subscriber list. HE/OR/MA professionals in this subset completed a questionnaire. The sample consisted of 372 participants who reported their wage-and-salary earnings and other indicators. The sample was not necessarily representative of the global HE/OR/MA community. The study methods included a two-way classification model with multiple replications, an ordinary least-squares model, and three inequality indicators.

PRINCIPAL FINDINGS

The results suggested substantial disparities between the wage-and-salary earnings of respondents living in the USA and those living in other countries; mild gender disparities in earnings; greater inequality outside the USA than within the USA; and, within each location, more unequal distribution of men's earnings than that of women's earnings.

CONCLUSIONS

Although the findings may not be extrapolated to the worldwide population of HE/OR/MA professionals, they provide a point of comparison with earlier studies and offer insights into the mechanics of one of the most innovative and fastest growing health-sector workforce segments in developed as well as emerging countries.

Implementing health technology assessment in Kuwait: a qualitative study of perceived barriers and facilitators

OBJECTIVES

This study sought to explore main barriers and facilitators to implementing health technology assessment (HTA) in Kuwait from the perspective of key stakeholders.

METHODS

Semi-structured qualitative interviews were conducted with ten key stakeholders: seven healthcare providers working at various departments of the Kuwaiti Ministry of Health (MOH), and three academics with substantial experience in teaching HTA or related fields. Interviews were conducted face-to-face, audio-recorded, and transcribed verbatim. Data were analyzed using an inductive thematic approach.

RESULTS

Participating stakeholders reported several factors that might act as a barrier to building HTA in Kuwait: minimal awareness of HTA, lack of institutional and human capacity, a fragmented healthcare system, poor communication between researchers and policy makers, the country's wealth, politics, as well as data quality, availability, and sharing. Institutionalizing HTA as a politically empowered body, enforcing its recommendation by law, and benefiting from neighboring countries' experiences were suggested as possible ways to move forward.

CONCLUSION

Studies exploring the unique challenges that high-income developing countries may face in implementing HTA are still scarce. The results of this study are consistent with evidence coming from other developing countries, while also suggesting that the abundance of financial resources in the country is a double-edged sword; it has the potential to facilitate the development of HTA capacity, but also hinders recognizing the need for it.

Cost-Effectiveness of Docetaxel and Paclitaxel for Adjuvant Treatment of Early Breast Cancer: Adaptation of a Model-Based Economic Evaluation From the United Kingdom to South Africa

OBJECTIVES

Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments.

METHODS

A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses.

RESULTS

The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as -R578 and -R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses.

CONCLUSIONS

Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation

OBJECTIVES

High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

METHODS

Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

RESULTS

Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

DISCUSSION

Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review

BACKGROUND

The evidence on the economic burden of cardiovascular disease (CVD) in low- and middle- income countries (LMICs) remains scarce. We conducted a comprehensive systematic review to establish the magnitude and knowledge gaps in relation to the economic burden of CVD and hypertension on households, health systems and the society.

METHODS

We included studies using primary or secondary data to produce original economic estimates of the impact of CVD. We searched sixteen electronic databases from 1990 onwards without language restrictions. We appraised the quality of included studies using a seven-question assessment tool.

RESULTS

Eighty-three studies met the inclusion criteria, most of which were single centre retrospective cost studies conducted in secondary care settings. Studies in China, Brazil, India and Mexico contributed together 50% of the total number of economic estimates identified. The quality of the included studies was generally low. Reporting transparency, particularly for cost data sources and results, was poor. The costs per episode for hypertension and generic CVD were fairly homogeneous across studies; ranging between $500 and $1500. In contrast, for coronary heart disease (CHD) and stroke cost estimates were generally higher and more heterogeneous, with several estimates in excess of $5000 per episode. The economic perspective and scope of the study appeared to impact cost estimates for hypertension and generic CVD considerably less than estimates for stroke and CHD. Most studies reported monthly costs for hypertension treatment around $22. Average monthly treatment costs for stroke and CHD ranged between $300 and $1000, however variability across estimates was high. In most LMICs both the annual cost of care and the cost of an acute episode exceed many times the total health expenditure per capita.

CONCLUSIONS

The existing evidence on the economic burden of CVD in LMICs does not appear aligned with policy priorities in terms of research volume, pathologies studied and methodological quality. Not only is more economic research needed to fill the existing gaps, but research quality needs to be drastically improved. More broadly, national-level studies with appropriate sample sizes and adequate incorporation of indirect costs need to replace small-scale, institutional, retrospective cost studies.

Challenges of Rasthryia Swasthya Bima Yojana (RSBY) in West Bengal, India: An exploratory study

This study reviews the economic viability of the Rashtriya Swasthya Bima Yojana (RSBY), India's landmark health insurance program for below poverty line (BPL) populations in West Bengal state of India. It addresses the issue through in-depth analysis of literature, national and state level data, and a number of key stakeholder interviews. The study argues that the market failure conditions of this insurance model will continue to perpetuate losses for not only the state, but also for insurance companies, unless they adjust on a continuous basis for profit by raising the premium rate. This will further deplete state budgets for health care affecting the viability of the scheme in the long run.

Growth of Global Publishing Output of Health Economics in the Twenty-First Century: A Bibliographic Insight

Background

Strong growth of interdisciplinary sciences might find exceptional example in academic health economics. We decided to observe the quantitative output in this science since the beginning of the twenty-first century.

Methods

Electronic search of the published literature was conducted in four different databases: one medical database—MEDLINE/PubMed, two general databases—Scopus/Elsevier and Web of Science (WoS), and one specialized health economic database—NHS Economic Evaluation Database (EED). The applied combination of key words was carefully chosen to cover the most commonly used terms in titles of publications dealing with conceptual areas of health economics. All bibliographic units were taken into account.

Results

Within the time horizon from January 1, 2000 to December 31, 2016, without language or limitations on bibliographic unit types, we identified an output ranging approximately from 60,345 to 88,246 records with applied search strategy in MEDLINE/PubMed, Scopus/Elsevier, and WoS. In NHS EED, we detected 14,761 records of economic evaluations of health interventions during the period in which database was maintained and regularly updated. With slightly more than one-third of the identified records, USA clearly dominates in this field. United Kingdom takes a strong second place with about 12% of identified records. Consistently, USA and UK universities are the most frequent among the top 15 affiliations/organizations of the authors of the identified records. Authors from Harvard University contributed to the largest number of the identified records.

Conclusion

There is a clear evidence of both the upward stream of blossoming in health economics publications and its acceleration. Based on this bibliographic data set, it is difficult to distinguish the actual impact growth of this output provided dominantly by academia with modest contribution by pharmaceutical/medicinal device industry and diverse national government-based agencies. Further insight into the citation track record of these individual publications could provide helpful upgrade and a perspective on ongoing development.

The influence of cost-per-DALY information in health prioritisation and desirable features for a registry: a survey of health policy experts in Vietnam, India and Bangladesh

Background

Economic evaluation has been implemented to inform policy in many areas, including coverage decisions, technology pricing, and the development of clinical practice guidelines. However, there are barriers to evidence-based policy in low- and middle-income countries (LMICs) that include limited stakeholder awareness, resources and data availability, as well as the lack of capacity to conduct country-specific economic evaluations. This study aims to survey health policy experts’ opinions on barriers to use of cost-effectiveness data in these settings and to obtain their advice on how to make a new cost-per-DALY database being developed by Tufts Medical Center more relevant to LMICs. It also identifies the factors influencing transferability.

Methods

In-depth interviews were conducted with 32 participants, including policymakers, technical advisors, and researchers in Health Ministries, universities and non-governmental organisations in Bangladesh, India (New Delhi, Tamil Nadu and Karnataka) and Vietnam.

Results

The survey revealed that, in all settings, the use of cost-effectiveness information in policy development is lacking, owing to limited knowledge among policymakers and inadequate human resources with health economics expertise in the government sector. Furthermore, researchers in universities do not have close connections with health authorities. In India and Vietnam, the demand for evidence to inform coverage decisions tends to increase as the countries are moving towards universal health coverage. The informants in all countries argue that cost-effectiveness data are useful for decision-makers; however, most of them do not perform data searches by themselves but rely on the information provided by the technical advisor counterparts. Most interviewees were familiar with using evidence from other countries and were also aware of the influences of contextual elements as a limitation of transferability. Finally, strategies to promote the newly developed database include training on basic economic evaluation for policymakers and researchers, and effective communication programs, with support from reputable global agencies.

Conclusions

Although cost-effectiveness information is recognised as essential in resource allocation, there are several impediments in the generation and use of such evidence to inform priority setting in LMICs. As such, the Cost-per-DALY database should be well-designed and introduced with appropriate promotion strategies so that it will be helpful in real-world policymaking.

Electronic supplementary material

The online version of this article (doi:10.1186/s12961-016-0156-6) contains supplementary material, which is available to authorized users.