Stark choices: exploring health sector costs of policy responses to COVID-19 in low-income and middle-income countries

Stewarding COVID-19 health systems response in Pakistan: what more can be done for a primary health care approach to future pandemics?

We apply a primary healthcare (PHC) perspective to gauge Pakistan's health systems response to COVID-19, to identify stewardship lessons for integrating the PHC pandemic response. Analysis of Pakistan's response against the Astana PHC framework shows that the imperative for national survival helped mobilise an agile response across a fragmented health security context. The findings show effective multisector governance in responding to the health and social aspects of the pandemic, as well as the rapid roll-out of several public health functions and emergency care. However, we found weak maintenance of essential health services and ad hoc, short-lived efforts for community engagement.Critical enablers that helped steward the response across complex power-sharing arrangements included solidarity across society, collaborative data-driven decision-making, leveraging of siloed domestic resources and private sector coordination. At the same time, a more PHC-centric response was constrained by weak political prioritisation of essential health services, uneven services, weak direction to civil society volunteerism for community engagement and weak regulation of private sector contribution.We conclude that a mindset shift is required from short-term tactical measures to long-term investment in PHC-oriented transformative stewardship. Future preparedness must build attention to essential service package for emergencies, mobilisation of both private and public primary care providers, effective community engagement vision across societal actors and market regulation, within a collaborative governance framework.

High-cost users still came to hospitals during the COVID-19 pandemic during first wave data in Thailand: secondary data analysis

BACKGROUND

The phenomenon of high-cost users (HCUs) in health care occurs when a small proportion of patients account for a large proportion of health care expenditures. By understanding this phenomenon during the COVID-19 pandemic, tailored interventions can be provided to ensure that patients receive the care they need and reduce the burden on the health system.

OBJECTIVES

This study aimed to determine (1) whether the HCUs phenomenon occurred during the pandemic in Thailand by exploring the pattern of inpatient health expenditures over time from 2016 to 2021; (2) the patient characteristics of HCUs; (3) the top 5 primary diagnoses of HCUs; and (4) the potential predictors associated with being an HCU.

METHODS

The secondary data analysis was conducted via inpatient department (IPD) e-Claim data from the National Health Security Office for the Universal Coverage Scheme, which provides health care to ~ 80% of the Thai population. Health care expenditure over time was calculated, and the characteristics of the population were examined via descriptive analysis. Multinomial logistic regression was applied to explore the potential predictors associated with being an HCU.

RESULTS

The characteristics of HCUs remained relatively the same from 2016 to 2021. In terms of the proportion of male (55%) to female patients (45%), the age ranged from 55 to 57 years, with an estimated 8-day length of hospital stay and 7 admissions per year, and the average health care cost per patient was ≥ USD 2,860 (100,000 THB). The low-cost users (LCUs) group (the bottom 50% of the population), had more female patients (55%), a younger age ranging from 27 to 33 years, a 3-day length of stay, 1‒2 admissions per year, and a lower average health care cost per patient, which was less than USD 315 (≤ 11,000 THB).

CONCLUSION

The HCUs phenomenon still existed even with limited health care accessibility or lockdown measures implemented during the COVID-19 pandemic. This finding could indicate the uniqueness of the need for health services by HCUs, which differ from those of other population groups. By understanding the trends of health care utilization and expenditure, along with potential predictors associated with being an HCU, policies can be introduced to ensure the appropriate allocation of health resources to the right people in need of the right care during future pandemics.

Cost-effectiveness of COVID rapid diagnostic tests for patients with severe/critical illness in low- and middle-income countries: A modeling study

BACKGROUND

Rapid diagnostic tests (RDTs) for coronavirus disease (COVID) are used in low- and middle-income countries (LMICs) to inform treatment decisions. However, to date, it is unclear when this use is cost-effective. Existing analyses are limited to a narrow set of countries and uses. The aim of this study is to assess the cost-effectiveness of COVID RDTs to inform the treatment of patients with severe illness in LMICs, considering real world practice.

METHODS AND FINDINGS

We assessed the cost-effectiveness of COVID testing across LMICs using a decision tree model, differentiating results by country income level, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) prevalence, and testing scenario (none, RDTs, polymerase chain reaction tests-PCRs and combinations). LMIC experts defined realistic care pathways and treatment options. Using a healthcare provider perspective and net monetary benefit approach, we assessed both intended (COVID symptom alleviation) and unintended (treatment side effects) health and economic impacts for each testing scenario. We included the side effects of corticosteroids, which are often the only available treatment for COVID. Because side effects depend both on the treatment and the patient's underlying illness (COVID or COVID-like illnesses, such as influenza), we considered the prevalence of COVID-like illnesses in our analyses. We found that SARS-CoV-2 testing of patients with severe COVID-like illness can be cost-effective in all LMICs, though only in some circumstances. High influenza prevalence among suspected COVID cases improves cost-effectiveness, since incorrectly provided corticosteroids may worsen influenza outcomes. In low- and some lower-middle-income countries, only patients with a high index of suspicion for COVID should be tested with RDTs, while other patients should be presumed to not have COVID. In some lower-middle-income and upper-middle-income countries, suspected severe COVID cases should almost always be tested. Further, in these settings, negative test results in patients with a high initial index of suspicion should be confirmed through PCR and, during influenza outbreaks, positive results in patients with a low initial index of suspicion should also be confirmed with a PCR. The use of interleukin-6 receptor blockers, when supported by testing, may also be cost-effective in higher-income LMICs. The cost at which they would be cost-effective in low-income countries ($162 to $406 per treatment course) is below current prices. The primary limitation of our analysis is substantial uncertainty around some of the parameters in our model due to limited data, most notably on current COVID mortality with standard of care, and insufficient evidence on the impact of corticosteroids on patients with severe influenza.

CONCLUSIONS

COVID testing can be cost-effective to inform treatment of LMIC patients with severe COVID-like disease. The optimal algorithm is driven by country income level and health budgets, the level of suspicion that the patient may have COVID, and influenza prevalence. Further research to better characterize the unintended effects of corticosteroids, particularly on influenza cases, could improve decision making around the treatment of those with COVID-like symptoms in LMICs.

The economic impact of a COVID-19 illness from the perspective of families seeking care in a private hospital in India

Background

The Covid-19 pandemic had a tremendous impact that caused significant morbidity, mortality, and financial stress for families. Our study aimed to determine the Out-of-pocket expenses and economic impact of a Covid-19 illness for households where patients were admitted to a private hospital in India.

Methodology

This was a cost-of-illness study from a tertiary care academic institute where adult patients diagnosed with COVID-19 from May 2020 to June 2021 were included. Patients with an admission of less than one day or who had any form of insurance were excluded. The clinical and financial details were obtained from the hospital information system and a cross-sectional survey. This was stratified across three clinical severity levels and two epidemiological waves.

Results

The final analysis included 4445 patients, with 73 % admitted in Wave 1 and 99 patients interviewed. For patients with severity levels 1, 2 and 3, the median admission days were 7, 8 and 13 days respectively. The total cost of illness (general category) was $934 (₹69,010), $1507 (₹111,403) and $3611 (₹266,930) and the direct medical cost constituted 66%, 77% and 91% of the total cost for each level respectively. Factors associated with higher admission costs were higher age groups, male gender, oxygen use, ICU care, private admission, increased duration of hospital stay and Wave 2. The median annual household income was $3247 (₹240,000) and 36% of families had to rely on more than one financial coping strategies, loans with interest being the commonest one. The lockdown period affected employment and reduced income for a considerable proportion of households.

Conclusion

A Covid admission of higher severity was a significant financial burden on families. The study reaffirms the need for collaborative and sustainable health financing systems to protect populations from hardships.$-US Dollar; ₹- Indian Rupees.

Do private health providers help achieve Universal Health Coverage? A scoping review of the evidence from low-income countries

Universal Health Coverage (UHC) is the dominant paradigm in health systems research, positing that everyone should have access to a range of affordable health services. Although private providers are an integral part of world health systems, their contribution to achieving UHC is unclear, particularly in low-income countries (LICs). We scoped the literature to map out the evidence on private providers' contribution to UHC progress in LICs. Literature searches of PubMed, Scopus and Web of Science were conducted in 2022. A total of 1049 documents published between 2002 and 2022 were screened for eligibility using predefined inclusion criteria, focusing on formal as well as informal private health sectors in 27 LICs. Primary qualitative, quantitative and mixed-methods evidence was included, as well as original analysis of secondary data. The Joanna Briggs Institute's critical appraisal tool was used to assess the quality of the studies. Relevant evidence was extracted and analysed using an adapted UHC framework. We identified 34 papers documenting how most basic health care services are already provided through the private sector in countries such as Uganda, Afghanistan and Somalia. A substantial proportion of primary care, mother, child and malaria services are available through non-public providers across all 27 LICs. Evidence exists that while formal private providers mostly operate in well-served urban settings, informal and not-for-profit ones cater for underserved rural and urban areas. Nonetheless, there is evidence that the quality of the services by informal providers is suboptimal. A few studies suggested that the private sector fails to advance financial protection against ill-health, as costs are higher than in public facilities and services are paid out of pocket. We conclude that despite their shortcomings, working with informal private providers to increase quality and financing of their services may be key to realizing UHC in LICs.

Scaling Up TB Screening and TB Preventive Treatment Globally: Key Actions and Healthcare Service Costs

The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.

What, how and who: Cost-effectiveness analyses of COVID-19 vaccination to inform key policies in Nigeria

While safe and efficacious COVID-19 vaccines have achieved high coverage in high-income settings, roll-out remains slow in sub-Saharan Africa. By April 2022, Nigeria, a country of over 200 million people, had only distributed 34 million doses. To ensure the optimal use of health resources, cost-effectiveness analyses can inform key policy questions in the health technology assessment process. We carried out several cost-effectiveness analyses exploring different COVID-19 vaccination scenarios in Nigeria. In consultation with Nigerian stakeholders, we addressed three key questions: what vaccines to buy, how to deliver them and what age groups to target. We combined an epidemiological model of virus transmission parameterised with Nigeria specific data with a costing model that incorporated local resource use assumptions and prices, both for vaccine delivery as well as costs associated with care and treatment of COVID-19. Scenarios of vaccination were compared with no vaccination. Incremental cost-effectiveness ratios were estimated in terms of costs per disability-adjusted life years averted and compared to commonly used cost-effectiveness ratios. Viral vector vaccines are cost-effective (or cost saving), particularly when targeting older adults. Despite higher efficacy, vaccines employing mRNA technologies are less cost-effective due to high current dose prices. The method of delivery of vaccines makes little difference to the cost-effectiveness of the vaccine. COVID-19 vaccines can be highly effective and cost-effective (as well as cost-saving), although an important determinant of the latter is the price per dose and the age groups prioritised for vaccination. From a health system perspective, viral vector vaccines may represent most cost-effective choices for Nigeria, although this may change with price negotiation.

Assessing the impacts of COVID-19 vaccination programme's timing and speed on health benefits, cost-effectiveness, and relative affordability in 27 African countries

BACKGROUND

The COVID-19 vaccine supply shortage in 2021 constrained roll-out efforts in Africa while populations experienced waves of epidemics. As supply improves, a key question is whether vaccination remains an impactful and cost-effective strategy given changes in the timing of implementation.

METHODS

We assessed the impact of vaccination programme timing using an epidemiological and economic model. We fitted an age-specific dynamic transmission model to reported COVID-19 deaths in 27 African countries to approximate existing immunity resulting from infection before substantial vaccine roll-out. We then projected health outcomes (from symptomatic cases to overall disability-adjusted life years (DALYs) averted) for different programme start dates (01 January to 01 December 2021, n = 12) and roll-out rates (slow, medium, fast; 275, 826, and 2066 doses/million population-day, respectively) for viral vector and mRNA vaccines by the end of 2022. Roll-out rates used were derived from observed uptake trajectories in this region. Vaccination programmes were assumed to prioritise those above 60 years before other adults. We collected data on vaccine delivery costs, calculated incremental cost-effectiveness ratios (ICERs) compared to no vaccine use, and compared these ICERs to GDP per capita. We additionally calculated a relative affordability measure of vaccination programmes to assess potential nonmarginal budget impacts.

RESULTS

Vaccination programmes with early start dates yielded the most health benefits and lowest ICERs compared to those with late starts. While producing the most health benefits, fast vaccine roll-out did not always result in the lowest ICERs. The highest marginal effectiveness within vaccination programmes was found among older adults. High country income groups, high proportions of populations over 60 years or non-susceptible at the start of vaccination programmes are associated with low ICERs relative to GDP per capita. Most vaccination programmes with small ICERs relative to GDP per capita were also relatively affordable.

CONCLUSION

Although ICERs increased significantly as vaccination programmes were delayed, programmes starting late in 2021 may still generate low ICERs and manageable affordability measures. Looking forward, lower vaccine purchasing costs and vaccines with improved efficacies can help increase the economic value of COVID-19 vaccination programmes.

The risk of SARS-CoV-2 Omicron variant emergence in low and middle-income countries (LMICs)

We estimated the probability of undetected emergence of the SARS-CoV-2 Omicron variant in 25 low and middle-income countries (LMICs) prior to December 5, 2021. In nine countries, the risk exceeds 50 %; in Turkey, Pakistan and the Philippines, it exceeds 99 %. Risks are generally lower in the Americas than Europe or Asia.

Essential emergency and critical care as a health system response to critical illness and the COVID19 pandemic: what does it cost?

Essential Emergency and Critical Care (EECC) is a novel approach to the care of critically ill patients, focusing on first-tier, effective, low-cost, life-saving care and designed to be feasible even in low-resourced and low-staffed settings. This is distinct from advanced critical care, usually conducted in ICUs with specialised staff, facilities and technologies. This paper estimates the incremental cost of EECC and advanced critical care for the planning of care for critically ill patients in Tanzania and Kenya.The incremental costing took a health systems perspective. A normative approach based on the ingredients defined through the recently published global consensus on EECC was used. The setting was a district hospital in which the patient is provided with the definitive care typically provided at that level for their condition. Quantification of resource use was based on COVID-19 as a tracer condition using clinical expertise. Local prices were used where available, and all costs were converted to USD2020.The costs per patient day of EECC is estimated to be 1 USD, 11 USD and 33 USD in Tanzania and 2 USD, 14 USD and 37 USD in Kenya, for moderate, severe and critical COVID-19 patients respectively. The cost per patient day of advanced critical care is estimated to be 13 USD and 294 USD in Tanzania and USD 17 USD and 345 USD in Kenya for severe and critical COVID-19 patients, respectively.EECC is a novel approach for providing the essential care to all critically ill patients. The low costs and lower tech approach inherent in delivering EECC mean that EECC could be provided to many and suggests that prioritizing EECC over ACC may be a rational approach when resources are limited.

Standardising policy and technology responses in the immediate aftermath of a pandemic: a comparative and conceptual framework

BACKGROUND

The initial policy response to the COVID-19 pandemic has differed widely across countries. Such variability in government interventions has made it difficult for policymakers and health research systems to compare what has happened and the effectiveness of interventions across nations. Timely information and analysis are crucial to addressing the lag between the pandemic and government responses to implement targeted interventions to alleviate the impact of the pandemic.

METHODS

To examine the effect government interventions and technological responses have on epidemiological and economic outcomes, this policy paper proposes a conceptual framework that provides a qualitative taxonomy of government policy directives implemented in the immediate aftermath of a pandemic announcement and before vaccines are implementable. This framework assigns a gradient indicating the intensity and extent of the policy measures and applies the gradient to four countries that share similar institutional features but different COVID-19 experiences: Italy, New Zealand, the United Kingdom and the United States of America.

RESULTS

Using the categorisation framework allows qualitative information to be presented, and more specifically the gradient can show the dynamic impact of policy interventions on specific outcomes. We have observed that the policy categorisation described here can be used by decision-makers to examine the impacts of major viral outbreaks such as SARS-CoV-2 on health and economic outcomes over time. The framework allows for a visualisation of the frequency and comparison of dominant policies and provides a conceptual tool to assess how dominant interventions (and innovations) affect different sets of health and non-health related outcomes during the response phase to the pandemic.

CONCLUSIONS

Policymakers and health researchers should converge toward an optimal set of policy interventions to minimize the costs of the pandemic (i.e., health and economic), and facilitate coordination across governance levels before effective vaccines are produced. The proposed framework provides a useful tool to direct health research system resources and build a policy benchmark for future viral outbreaks where vaccines are not readily available.

Is there a role for RDTs as we live with COVID-19? An assessment of different strategies

INTRODUCTION

By 2022, high levels of past COVID-19 infections, combined with substantial levels of vaccination and the development of Omicron, have shifted country strategies towards burden reduction policies. SARS-CoV-2 rapid antigen tests (rapid diagnostic tests (RDTs)) could contribute to these policies by helping rapidly detect, isolate and/or treat infections in different settings. However, the evidence to inform RDT policy choices in low and middle-income countries (LMICs) is limited.

METHOD

We provide an overview of the potential impact of several RDT use cases (surveillance; testing, tracing and isolation without and with surveillance; hospital-based screening to reduce nosocomial COVID-19; and testing to enable earlier/expanded treatment) for a range of country settings. We use conceptual models and literature review to identify which use cases are likely to bring benefits and how these may change with outbreak characteristics. Impacts are measured through multiple outcomes related to gaining time, reducing the burden on the health system and reducing deaths.

RESULTS

In an optimal scenario in terms of resources and capacity and with baseline parameters, we find marginal time gains of 4 days or more through surveillance and testing tracing and isolation with surveillance, a reduction in peak intensive care unit (ICU) or ICU admissions by 5% or more (hospital-based screening; testing, tracing and isolation) and reductions in COVID-19 deaths by over 6% (hospital-based screening; test and treat). Time gains may be used to strengthen ICU capacity and/or boost vulnerable individuals, though only a small minority of at-risk individuals could be reached in the time available. The impact of RDTs declines with lower country resources and capacity, more transmissible or immune-escaping variants and reduced test sensitivity.

CONCLUSION

RDTs alone are unlikely to dramatically reduce the burden of COVID-19 in LMICs, though they may have an important role alongside other interventions such as vaccination, therapeutic drugs, improved healthcare capacity and non-pharmaceutical measures.

Out-of-pocket expenditure and catastrophic costs due to COVID-19 in Indonesia: A rapid online survey

Background

The Corona Virus Disease 2019 (COVID-19) pandemic has created a substantial socioeconomic impact, particularly in developing countries such as Indonesia.

Purposes/objectives

This study aimed to describe the COVID-19-related out-of-pocket spending of Indonesian citizens and the proportion of whom experienced catastrophic health spending during the COVID-19 pandemic using the patient's perspective.

Methodology

We conducted a rapid cross-sectional online survey across provinces in Indonesia to capture participants' experiences due to COVID-19. Data were collected between September 23rd to October 7th of 2021 including demographics, income, and expenditures. Descriptive statistics were used to analyze the respondents' characteristics. Patients's perspective of total cost was estimated from out-of-pocket of COVID-19 direct costs and compared them to total expenditure. If the proportion of COVID-19 total costs exceeded 40% of the total expenditure, the respondents were deemed to have faced catastrophic costs.

Results

A total of 1,859 respondents answered the questionnaire. The average monthly income and expenditure of respondents were 800 USD, and 667 USD respectively. The monthly expenditure was categorized into food expenditure (367 USD) and non-food expenditure (320 USD). The average of COVID-19-related monthly expenditure was 226 USD, including diagnostic expenditure (36 USD), preventive expenditure (58 USD), medical expenditure (37 USD for COVID-19 treatment; and 57 USD for post-COVID-19 medical expenses), and non-medical expenditure (30 USD). Analysis showed that 18.6% of all respondents experienced catastrophic costs while 38.6% of the respondents who had COVID-19 treatment experienced catastrophic costs.

Conclusion

The high proportion of catastrophic costs among respondents suggests the need for COVID-19 social protection, especially for COVID-19 diagnostic and prevention costs. The survey findings have led the government to increase the benefit coverage other than medical costs at the hospitals.

Population-Level Strategies for Nirmatrelvir/Ritonavir Prescribing-A Cost-effectiveness Analysis

Background

New coronavirus disease 2019 (COVID-19) medications force decision-makers to weigh limited evidence of efficacy and cost in determining which patient populations to target for treatment. A case in point is nirmatrelvir/ritonavir, a drug that has been recommended for elderly, high-risk individuals, regardless of vaccination status, even though clinical trials have only evaluated it in unvaccinated patients. A simple optimization framework might inform a more reasoned approach to the trade-offs implicit in the treatment allocation decision.

Methods

We conducted a cost-effectiveness analysis using a decision-analytic model comparing 5 nirmatrelvir/ritonavir prescription policy strategies, stratified by vaccination status and risk for severe disease. We considered treatment effectiveness at preventing hospitalization ranging from 21% to 89%. Sensitivity analyses were performed on major parameters of interest. A web-based tool was developed to permit decision-makers to tailor the analysis to their settings and priorities.

Results

Providing nirmatrelvir/ritonavir to unvaccinated patients at high risk for severe disease was cost-saving when effectiveness against hospitalization exceeded 33% and cost-effective under all other data scenarios we considered. The cost-effectiveness of other allocation strategies, including those for vaccinated adults and those at lower risk for severe disease, depended on willingness-to-pay thresholds, treatment cost and effectiveness, and the likelihood of severe disease.

Conclusions

Priority for nirmatrelvir/ritonavir treatment should be given to unvaccinated persons at high risk of severe disease from COVID-19. Further priority may be assigned by weighing treatment effectiveness, disease severity, drug cost, and willingness to pay for deaths averted.

COVID-19 Vaccine Acceptance and Its Determinants among Myanmar Migrant Workers in Southern Thailand

Success in eradicating COVID-19 will rely on the rate of vaccination adoption worldwide. Vaccine acceptance among vulnerable groups is critical for preventing the spread of COVID-19 and decreasing unnecessary deaths. The purpose of this study was to report on the willingness to obtain COVID-19 immunization and the factors related to its acceptance among Myanmar migrant workers in southern Thailand. This cross-sectional study consisted of 301 samples collected between October and November 2021 and analyzed using multiple logistic regression. Thirty-nine percent of workers intended to receive the COVID-19 vaccine within a year. The following factors were associated with obtaining the COVID-19 vaccine: a high level of perception of COVID-19 (AOR = 5.43), income less than or equal to 10,000 baht/month (AOR = 6.98), financial status at a sufficient level (AOR = 7.79), wearing a face mask in the previous month almost all the time (AOR =4.26), maintaining 1-2 m of distance from anyone in the last month (AOR =2.51), and measuring temperature in the previous month (AOR = 5.24). High reluctance to accept the COVID-19 vaccine among Myanmar migrant workers can influence efforts to eliminate COVID-19. Collaboration with all stakeholders is critical to helping Myanmar workers understand COVID-19, social measures, and preventive beliefs to increase vaccine uptake.