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Hauck K, Morton A, Chalkidou K, Chi YL, Culyer A, Levin C, Meacock R, Over M, Thomas R, Vassall A, Verguet S, Smith PC. How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations. Soc Sci Med 2019; 220:141-149. [PMID: 30428401 PMCID: PMC6323413 DOI: 10.1016/j.socscimed.2018.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/22/2018] [Accepted: 10/31/2018] [Indexed: 11/23/2022]
Abstract
Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.
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Affiliation(s)
- K Hauck
- Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Morton
- Department of Management Science, Strathclyde Business School, University of Strathclyde, 199 Cathedral Street, Glasgow, G4 0QU, United Kingdom.
| | - K Chalkidou
- Center for Global Development, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - Y-Ling Chi
- Global Health and Development Group, Department of Infectious Disease Epidemiology, School of Public Health, Imperial College London, Medical School Building, St Mary's Campus, London, W2 1PG, United Kingdom.
| | - A Culyer
- Department of Economics and Related Studies, University of York, Heslington, York, YO10 5DD, United Kingdom.
| | - C Levin
- Department of Global Health, University of Washington, NJB Box #359931, 325 Ninths Avenue, Seattle, WA, 98104, USA.
| | - R Meacock
- Centre for Primary Care, The University of Manchester, 4.311 Jean McFarlane Building, Oxford Road, Manchester, M13 9PL, United Kingdom.
| | - M Over
- Center for Global Development, 2055 L Street NW, Fifth Floor, Washington, DC, 20036, USA.
| | - R Thomas
- Department of Health Policy, London School of Economics and Political Science, Cowdray House, Houghton Street, London, WC2A 2AE, United Kingdom.
| | - A Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
| | - S Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 665 Huntington Avenue, Boston, MA, 02115, USA.
| | - P C Smith
- Imperial College Business School, Imperial College London, South Kensington Campus, London, SW7 2AZ, United Kingdom.
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de Siqueira-Filha NT, Legood R, Cavalcanti A, Santos AC. Cost of Tuberculosis Diagnosis and Treatment in Patients with HIV: A Systematic Literature Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:482-490. [PMID: 29680106 DOI: 10.1016/j.jval.2017.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/30/2017] [Accepted: 09/06/2017] [Indexed: 06/08/2023]
Abstract
OBJECTIVES To summarize the costs of tuberculosis (TB) diagnosis and treatment in human immunodeficiency virus (HIV)-infected patients and to assess the methodological quality of these studies. METHODS We included cost, cost-effectiveness, and cost-utility studies that reported primary costing data, conducted worldwide and published between 1990 and August 2016. We retrieved articles in PubMed, Embase, EconLit, CINAHL plus, and LILACS databases. The quality assessment was performed using two guidelines-the Consolidated Health Economic Evaluation Reporting Standards and the Tool to Estimate Patient's Costs. TB diagnosis was reported as cost per positive result or per suspect case. TB treatment was reported as cost of TB drugs, TB/HIV hospitalization, and treatment. We analyzed the data per level of TB/HIV endemicity and perspective of analysis. RESULTS We included 34 articles, with 24 addressing TB/HIV treatment and 10 addressing TB diagnosis. Most of the studies were carried out in high TB/HIV burden countries (82%). The cost of TB diagnosis per suspect case varied from $0.5 for sputum smear microscopy to $175 for intensified case finding. The cost of TB/HIV hospitalization was higher in low/medium TB/HIV burden countries than in high TB/HIV burden countries ($75,406 vs. $2,474). TB/HIV co-infection presented higher costs than TB from the provider perspective ($814 vs. $604 vs. $454). Items such as "choice of discount rate," "patient interview procedures," and "methods used for valuing indirect costs" did not achieve a good score in the quality assessment. CONCLUSIONS Our findings point to the need of generation of more standardized methods for cost data collection to generate more robust estimates and thus, support decision-making process.
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Affiliation(s)
| | - Rosa Legood
- London School of Hygiene and Tropical Medicine, London, UK
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Naidoo K, Grobler AC, Deghaye N, Reddy T, Gengiah S, Gray A, Karim SA. Cost-Effectiveness of Initiating Antiretroviral Therapy at Different Points in TB Treatment in HIV-TB Coinfected Ambulatory Patients in South Africa. J Acquir Immune Defic Syndr 2015; 69:576-84. [PMID: 26167618 PMCID: PMC4503368 DOI: 10.1097/qai.0000000000000673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Initiation of antiretroviral therapy (ART) during tuberculosis (TB) treatment improves survival in TB-HIV coinfected patients. In patients with CD4 counts <50 cells per cubic millimeter, there is a substantial clinical and survival benefit of early ART initiation. The purpose of this study was to assess the costs and cost-effectiveness of starting ART at various time points during TB treatment in patients with CD4 counts ≥50 cells per cubic millimeter. METHODS In the SAPiT trial, 642 HIV-TB coinfected patients were randomized to 3 arms: receiving ART within 4 weeks of starting TB treatment (early treatment arm; Arm-1), after the intensive phase of TB treatment (late treatment arm; Arm-2), or after completing TB treatment (sequential arm; Arm-3). Direct health care costs were measured from a provider perspective using a micro-costing approach. The incremental cost per death averted was calculated using the trial outcomes. RESULTS For patients with CD4 count ≥50 cells per cubic millimeter, median monthly variable costs per patient were US $116, US $113, and US $102 in Arm-1, Arm-2 and Arm-3, respectively. There were 12 deaths in 177 patients in Arm-1, 8 deaths in 180 patients in the Arm-2, and 19 deaths in 172 patients in Arm-3. Although the costs were lower in Arm-3, it had a substantially higher mortality rate. The incremental cost per death averted associated with moving from Arm-3 to Arm-2 was US $4199. There was no difference in mortality between Arm-1 and Arm-2, but Arm-1 was slightly more expensive. CONCLUSIONS Initiation of ART after the completion of the intensive phase of TB treatment is cost-effective for patients with CD4 counts ≥50 cells per cubic millimeter.
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Affiliation(s)
- Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Anneke C Grobler
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Nicola Deghaye
- Health Economics and HIV & AIDS Research Division (HEARD), University of KwaZulu-Natal, South Africa
| | - Tarylee Reddy
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Biostatistics Unit, Medical Research Council, South Africa
| | - Santhanalakshmi Gengiah
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
| | - Andrew Gray
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Discipline of Pharmaceutical Sciences, University of KwaZulu-Natal, South Africa
| | - Salim Abdool Karim
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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Influence of transportation cost on long-term retention in clinic for HIV patients in rural Haiti. J Acquir Immune Defic Syndr 2015; 67:e123-30. [PMID: 25162815 DOI: 10.1097/qai.0000000000000315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND With improved access to antiretroviral therapy in resource-constrained settings, long-term retention in HIV clinics has become an important means of reducing costs and improving outcomes. Published data on retention in HIV clinics beyond 24 months are, however, limited. In our clinic in rural Haiti, we hypothesized that individuals residing in locations with higher transportation costs to clinic would have poorer retention than those who had lower costs. METHODS We used a retrospective cohort design to evaluate potential predictors of HIV clinic retention. Patient information was abstracted from the electronic medical records. Cox proportional hazards regression was used to identify independent predictors of 4-year clinic retention. RESULTS There were 410 patients in our cohort, 266 (64.9%) females and 144 (35.1%) males. Forty-five (11%) patients lived in locations with transportation costs >$2. Males were 1.5 times more likely to live in municipalities with transportation costs to clinic of >$2. Multivariate analysis suggested that age <30 years, male gender, and transportation cost were independent predictors of loss to follow-up (LTFU): risk ratio of 2.98, 95% confidence interval (CI): 1.73 to 4.96, P < 0.001; 1.71, CI: 1.08 to 2.70, P = 0.02; and 1.91, CI: 1.08 to 3.36, P = 0.02, respectively. CONCLUSIONS Patients with transportation costs greater than $2 were 1.9 times more likely to be lost to care compared with those who paid less for transportation. HIV treatment programs in resource-constrained settings may need to pay closer attention to issues related to transportation cost to improve patient retention.
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Superior outcomes and lower outpatient costs with scale-up of antiretroviral therapy at the GHESKIO clinic in Port-au-Prince, Haiti. J Acquir Immune Defic Syndr 2014; 66:e72-9. [PMID: 24984189 DOI: 10.1097/qai.0000000000000200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Treatment protocols and prices of antiretroviral therapy (ART) have changed over time. Yet, limited data exist to evaluate the impact of these changes on patient outcomes and treatment costs in resource-poor settings. METHODS We compared patient-level data on outcomes, utilization, and cost for the first 2 years of ART for a cohort of adult patients initiating ART in 2003-2004 and a cohort initiating ART in 2006-2008 at the Haitian Group for the Study of Kaposi's Sarcoma and Opportunistic Infections clinic (GHESKIO) in Port-au-Prince, Haiti. Costs were measured from the health center perspective. Multivariate analyses were conducted to account for the potential impact of differences in disease severity at baseline. RESULTS With the exclusion of patients who transferred care, 92% (167/181) of patients in the 2006-2008 cohort and 75% (150/200) in the 2003-2004 cohort were alive and in care at the end of the study period. The mean cost per patient for the 2-year study period was US$723 for the 2006-2008 cohort vs. US$1191 for the 2003-2004 cohort, a cost difference of US$468 (P < 0.0001). The mean cost per patient alive and in care at the end of the 2-year study period was US$744 for the 2006-2008 cohort vs. US$1489 for the 2003-2004 cohort (P < 0.0001). CONCLUSIONS HIV treatment outcomes in Haiti have improved over time while treatment costs declined by over 50% per patient alive and in care at the end of the 2-year study period. The major drivers in the reduction of treatment costs were the lower price of ART, lower costs for laboratory testing, and lower overhead costs.
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Marseille E, Jiwani A, Raut A, Verguet S, Walson J, Kahn JG. Scaling up integrated prevention campaigns for global health: costs and cost-effectiveness in 70 countries. BMJ Open 2014; 4:e003987. [PMID: 24969782 PMCID: PMC4078786 DOI: 10.1136/bmjopen-2013-003987] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE This study estimated the health impact, cost and cost-effectiveness of an integrated prevention campaign (IPC) focused on diarrhoea, malaria and HIV in 70 countries ranked by per capita disability-adjusted life-year (DALY) burden for the three diseases. METHODS We constructed a deterministic cost-effectiveness model portraying an IPC combining counselling and testing, cotrimoxazole prophylaxis, referral to treatment and condom distribution for HIV prevention; bed nets for malaria prevention; and provision of household water filters for diarrhoea prevention. We developed a mix of empirical and modelled cost and health impact estimates applied to all 70 countries. One-way, multiway and scenario sensitivity analyses were conducted to document the strength of our findings. We used a healthcare payer's perspective, discounted costs and DALYs at 3% per year and denominated cost in 2012 US dollars. PRIMARY AND SECONDARY OUTCOMES The primary outcome was cost-effectiveness expressed as net cost per DALY averted. Other outcomes included cost of the IPC; net IPC costs adjusted for averted and additional medical costs and DALYs averted. RESULTS Implementation of the IPC in the 10 most cost-effective countries at 15% population coverage would cost US$583 million over 3 years (adjusted costs of US$398 million), averting 8.0 million DALYs. Extending IPC programmes to all 70 of the identified high-burden countries at 15% coverage would cost an adjusted US$51.3 billion and avert 78.7 million DALYs. Incremental cost-effectiveness ranged from US$49 per DALY averted for the 10 countries with the most favourable cost-effectiveness to US$119, US$181, US$335, US$1692 and US$8340 per DALY averted as each successive group of 10 countries is added ordered by decreasing cost-effectiveness. CONCLUSIONS IPC appears cost-effective in many settings, and has the potential to substantially reduce the burden of disease in resource-poor countries. This study increases confidence that IPC can be an important new approach for enhancing global health.
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Affiliation(s)
| | - Aliya Jiwani
- Health Strategies International, Arlington, Virginia, USA
| | - Abhishek Raut
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Stéphane Verguet
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Judd Walson
- Departments of Global Health, Medicine, Pediatrics, and Epidemiology, University of Washington, Seattle, Washington, USA
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
- Global Health Sciences, University of California, San Francisco, California, USA
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Siapka M, Remme M, Obure CD, Maier CB, Dehne KL, Vassall A. Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries. Bull World Health Organ 2014; 92:499-511AD. [PMID: 25110375 DOI: 10.2471/blt.13.127639] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 12/26/2013] [Accepted: 12/31/2013] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model.
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Affiliation(s)
- Mariana Siapka
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Michelle Remme
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Carol Dayo Obure
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
| | - Claudia B Maier
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Karl L Dehne
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Anna Vassall
- SaME Modelling and Economics, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, England
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The Haiti research-based model of international public health collaboration: the GHESKIO Centers. J Acquir Immune Defic Syndr 2014; 65 Suppl 1:S5-9. [PMID: 24321987 DOI: 10.1097/qai.0000000000000031] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
For 3 decades, GHESKIO (the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes), the Haitian Ministry of Health, and Weill Cornell have pursued a tripartite mission of service, training, and translational research. The initial focus was on AIDS and tuberculosis. The mission has expanded to include the local community and now provides maternal-child health, family planning, cancer prevention and treatment, immunizations (including human papillomavirus, cholera), and primary education through vocational and microcredit programs. Outcome measures include a reduction in HIV prevalence from 6.2% to the current 2.2%, extensive tuberculosis and cholera prevention and treatment programs, and national training programs for biomedical and community health workers.
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Sarti FM, Nishijima M, Coelho Campino AC, Cyrillo DC. A comparative analysis of outpatient costs in HIV treatment programs. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1590/s0104-42302012000500013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Sarti FM, Nishijima M, Coelho Campino AC, Cyrillo DC. A comparative analysis of outpatient costs in HIV treatment programs. Rev Assoc Med Bras (1992) 2012. [DOI: 10.1016/s0104-4230(12)70250-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Apanga S, Punguyire D, Adjei G. Estimating the cost to rural ambulating HIV/AIDS patients on highly active antiretroviral therapy (HAART) in rural Ghana: a pilot study. Pan Afr Med J 2012; 12:21. [PMID: 22826745 PMCID: PMC3396868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 04/26/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Subsidized antiretroviral therapy programs obviously lowers the cost of antiretroviral drugs but other major costs are still incurred, which makes the overall cost of accessing and consuming antiretroviral treatment very high and sometimes catastrophic. The objective of this study was to estimate the total cost to rural ambulating HIV/AIDS patients on highly active antiretroviral therapy in a rural area of the middle belt of Ghana. METHODS This was a convenient cross-sectional study of people diagnosed with HIV/AIDS receiving outpatient care and carried out from September to October 2009 involving 80 HIV/AIDS patients on HAART. Data was derived from patients' medical records on health care utilization and a completed pre tested questionnaire used to obtain the cost of transportation and estimates of individual earned income from which the labor productivity loses (opportunity cost) for days not worked as a result of attending the antiretroviral clinic were derived. RESULTS The median total, indirect and direct annual costs to rural ambulating HIV/AIDS patients on HAART were estimated to be $US71.18 (115.16 Ghana cedis), $US2.740 (3.92 Ghana cedis) and $US53.04 (75.00 Ghana cedis) respectively. CONCLUSION Although the cost of antiretroviral drugs has been subsidized by government from $360 to $41.38 per annum, HIV/AIDS patients on HAART spend double of this subsidized amount out of their pocket seeking health care. We recommend that agencies associated with HIV/AIDS activities, supplements government's effort by helping to get antiretroviral closer to the door step of patients so as to reduce this huge financial burden which constitutes more than 100% of their median annual earned income.
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Affiliation(s)
- Stephen Apanga
- School of Public Health University of Ghana, Ghana,Kintampo Municipal Hospital Kintampo, Ghana,Corresponding author: Stephen Apanga, Kintampo Municipal Hospital P.O.Box 192 Kintampo, Ghana
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Abstract
BACKGROUND PEPFAR, national governments, and other stakeholders are investing unprecedented resources to provide HIV treatment in developing countries. This study reports empirical data on costs and cost trends in a large sample of HIV treatment sites. DESIGN In 2006-2007, we conducted cost analyses at 43 PEPFAR-supported outpatient clinics providing free comprehensive HIV treatment in Botswana, Ethiopia, Nigeria, Uganda, and Vietnam. METHODS We collected data on HIV treatment costs over consecutive 6-month periods starting from scale-up of dedicated HIV treatment services at each site. The study included all patients receiving HIV treatment and care at study sites [62,512 antiretroviral therapy (ART) and 44,394 pre-ART patients]. Outcomes were costs per patient and total program costs, subdivided by major cost categories. RESULTS Median annual economic costs were US$ 202 (2009 USD) for pre-ART patients and US$ 880 for ART patients. Excluding antiretrovirals, per patient ART costs were US$ 298. Care for newly initiated ART patients cost 15-20% more than for established patients. Per patient costs dropped rapidly as sites matured, with per patient ART costs dropping 46.8% between first and second 6-month periods after the beginning of scale-up, and an additional 29.5% the following year. PEPFAR provided 79.4% of funding for service delivery, and national governments provided 15.2%. CONCLUSION Treatment costs vary widely between sites, and high early costs drop rapidly as sites mature. Treatment costs vary between countries and respond to changes in antiretroviral regimen costs and the package of services. Whereas cost reductions may allow near-term program growth, programs need to weigh the trade-off between improving services for current patients and expanding coverage to new patients.
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Koenig SP, Bang H, Severe P, Jean Juste MA, Ambroise A, Edwards A, Hippolyte J, Fitzgerald DW, McGreevy J, Riviere C, Marcelin S, Secours R, Johnson WD, Pape JW, Schackman BR. Cost-effectiveness of early versus standard antiretroviral therapy in HIV-infected adults in Haiti. PLoS Med 2011; 8:e1001095. [PMID: 21949643 PMCID: PMC3176754 DOI: 10.1371/journal.pmed.1001095] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2010] [Accepted: 08/10/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In a randomized clinical trial of early versus standard antiretroviral therapy (ART) in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm³ in Haiti, early ART decreased mortality by 75%. We assessed the cost-effectiveness of early versus standard ART in this trial. METHODS AND FINDINGS Trial data included use of ART and other medications, laboratory tests, outpatient visits, radiographic studies, procedures, and hospital services. Medication, laboratory, radiograph, labor, and overhead costs were from the study clinic, and hospital and procedure costs were from local providers. We evaluated cost per year of life saved (YLS), including patient and caregiver costs, with a median of 21 months and maximum of 36 months of follow-up, and with costs and life expectancy discounted at 3% per annum. Between 2005 and 2008, 816 participants were enrolled and followed for a median of 21 months. Mean total costs per patient during the trial were US$1,381 for early ART and US$1,033 for standard ART. After excluding research-related laboratory tests without clinical benefit, costs were US$1,158 (early ART) and US$979 (standard ART). Early ART patients had higher mean costs for ART (US$398 versus US$81) but lower costs for non-ART medications, CD4 cell counts, clinically indicated tests, and radiographs (US$275 versus US$384). The cost-effectiveness ratio after a maximum of 3 years for early versus standard ART was US$3,975/YLS (95% CI US$2,129/YLS-US$9,979/YLS) including research-related tests, and US$2,050/YLS excluding research-related tests (95% CI US$722/YLS-US$5,537/YLS). CONCLUSIONS Initiating ART in HIV-infected adults with a CD4 cell count between 200 and 350 cells/mm³ in Haiti, consistent with World Health Organization advice, was cost-effective (US$/YLS <3 times gross domestic product per capita) after a maximum of 3 years, after excluding research-related laboratory tests. TRIAL REGISTRATION ClinicalTrials.gov NCT00120510.
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Affiliation(s)
- Serena P. Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Heejung Bang
- Department of Public Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Patrice Severe
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Marc Antoine Jean Juste
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Alex Ambroise
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Alison Edwards
- Department of Public Health, Weill Cornell Medical College, New York, New York, United States of America
| | - Jessica Hippolyte
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Daniel W. Fitzgerald
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Jolion McGreevy
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Cynthia Riviere
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Serge Marcelin
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Rode Secours
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
| | - Warren D. Johnson
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Jean W. Pape
- Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port au Prince, Haiti
- Department of Medicine, Weill Cornell Medical College, New York, New York, United States of America
| | - Bruce R. Schackman
- Department of Public Health, Weill Cornell Medical College, New York, New York, United States of America
- * E-mail:
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Corrick F, Watson R, Budhdeo S. Should patents for antiretrovirals be waived in the developing world? Annual Varsity Medical Debate--London, 21 January 2011. Philos Ethics Humanit Med 2011; 6:13. [PMID: 21740573 PMCID: PMC3160882 DOI: 10.1186/1747-5341-6-13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 07/08/2011] [Indexed: 05/31/2023] Open
Abstract
The 2011 Varsity Medical Debate, between Oxford and Cambridge Universities, brought students and faculty together to discuss the waiving of patents for antiretroviral therapies in the developing world. With an estimated 29.5 million infected by Human Immunodeficiency Virus (HIV) in low- and middle-income countries and only 5.3 million of those being treated, the effective and equitable distribution of anti-retroviral therapy (ART) is an issue of great importance. The debate centred around three areas of contention. Firstly, there was disagreement about whether patents were the real barrier to the access of anti-retroviral therapy in the developing world. Secondly, there were differing views on the effectiveness of a patent pool. Thirdly, concerns were raised over the impact of waiving patents on research to produce new and better anti retro-viral drugs.
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Affiliation(s)
- Fenella Corrick
- Oriel College, University of Oxford, Oriel Square, Oxford, OX1 4EW, UK
| | - Robert Watson
- Green Templeton College, University of Oxford, Woodstock Road, Oxford, OX2 6HG, UK
| | - Sanjay Budhdeo
- New College, University of Oxford, Holywell Street, Oxford, OX1 3BN, UK
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Galárraga O, Wirtz VJ, Figueroa-Lara A, Santa-Ana-Tellez Y, Coulibaly I, Viisainen K, Medina-Lara A, Korenromp EL. Unit costs for delivery of antiretroviral treatment and prevention of mother-to-child transmission of HIV: a systematic review for low- and middle-income countries. PHARMACOECONOMICS 2011; 29:579-99. [PMID: 21671687 PMCID: PMC3833352 DOI: 10.2165/11586120-000000000-00000] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
As antiretroviral treatment (ART) for HIV/AIDS is scaled up globally, information on per-person costs is critical to improve efficiency in service delivery and to maximize coverage and health impact. The objective of this study was to review studies on unit costs for delivery of adult and paediatric ART per patient-year, and prevention of mother-to-child transmission (PMTCT) interventions per mother-infant pair screened or treated, in low- and middle-income countries. A systematic review was conducted of English, French and Spanish publications from 2001 to 2009, reporting empirical costing that accounted for at least antiretroviral (ARV) medicines, laboratory testing and personnel. Expenditures were analysed by country-income level and cost component. All costs were standardized to $US, year 2009 values. Several sensitivity analyses were conducted. Analyses covered 29 eligible, comprehensive, costing studies. In the base case, in low-income countries (LIC), median ART cost per patient-year was $US792 (mean: 839, range: 682-1089); for lower-middle-income countries (LMIC), the median was $US932 (mean: 1246, range: 156-3904); and, for upper-middle-income countries (UMIC), the median was $US1454 (mean: 2783, range: 1230-5667). ARV drugs were the largest component of overall ART costs in all settings (64%, 50% and 47% in LIC, LMIC and UMIC, respectively). Of 26 ART studies, 14 reported the drug regimes used, and only one study explicitly reported second-line treatment costs. The second cost driver was laboratory cost in LIC and LMIC (14% and 20%), and personnel costs in UMIC (26%). Two ART studies specified the types of laboratory tests costed, and three studies specifically included above facility-level personnel costs. Three studies reported detailed PMTCT costs, and three studies reported on paediatric ART. There is a paucity of data on the full unit costs for delivery of ART and PMTCT, particularly for LIC and middle-income countries. Heterogeneity in activities costed, and insufficient detail regarding components included in the costing, hampers standardization of unit cost measures. Evaluation of programme-level unit costs would benefit from international guidance on standardized costing methods, and expenditure categories and definitions. Future work should help elucidate the sources of the large variations in delivery unit costs across settings with similar income and epidemiological characteristics.
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Affiliation(s)
- Omar Galárraga
- International Health Institute; Population Studies and Training
Center & Department of Community Health (Health Services, Policy and Practice),
Brown University, Providence, RI, USA
- Center for Evaluation Research and Surveys, Division of Health
Economics, National Institute of Public Health (INSP)/Mexican School of Public
Health, Cuernavaca, Mexico
| | - Veronika J. Wirtz
- Center for Health Systems Research, National Institute of Public
Health, Cuernavaca, Mexico
| | | | - Yared Santa-Ana-Tellez
- Center for Evaluation Research and Surveys, Division of Health
Economics, National Institute of Public Health (INSP)/Mexican School of Public
Health, Cuernavaca, Mexico
| | - Ibrahima Coulibaly
- The Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva,
Switzerland
| | - Kirsi Viisainen
- The Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva,
Switzerland
| | - Antonieta Medina-Lara
- Center for Research on Health and Social Care Management (CERGAS),
Bocconi University, Milan, Italy
| | - Eline L. Korenromp
- The Global Fund to fight AIDS, Tuberculosis and Malaria, Geneva,
Switzerland
- Department of Public Health, Erasmus MC, University Medical Center
Rotterdam, The Netherlands
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Etienne M, Burrows L, Osotimehin B, Macharia T, Hossain B, Redfield RR, Amoroso A. Situational analysis of varying models of adherence support and loss to follow up rates; findings from 27 treatment facilities in eight resource limited countries. Trop Med Int Health 2011; 15 Suppl 1:76-81. [PMID: 20586964 DOI: 10.1111/j.1365-3156.2010.02513.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Large-scale provision of ART in the absence of viral load monitoring, resistance testing, and limited second-line treatment options places adherence support as a vital therapeutic intervention. We aimed to compare patient loss to follow up rates with the degree of adherence support through a retrospective review of patients enrolled in the AIDSRelief program between August 2004 and June 2005. METHODS Loss to follow up data were analysed and programs were categorised into one of four tiered levels of adherence support models: Tier I, II, III, and IV which increase from lowest to highest support. Bivariate and t-test analyses were used to test for significant differences between the models. RESULTS 13,391 patients at 27 treatment facilities from six African and two Caribbean countries began antiretroviral therapy within the first year of the AIDSRelief program. The mean loss to follow up within the first year was 7.5%. Eight facilities were Tier I, three (Tier II), nine (Tier III), and seven (Tier IV). Facilities in Tier I had a loss to follow up rate of 14%, Tier II (10%), Tier III (5%), and Tier IV (1%). The proportion of loss to follow up for Tier I and Tier III were significantly different from each other (P < 0.02), as were Tier I and Tier IV (P < 0.006). There were differences between Tier II and Tier IV (P < 0.009) as well as Tier III and Tier IV (P < 0.017). CONCLUSION These data strongly support the use of proactive adherence support programs, beyond routine patient counselling and defaulter tracking to support the'public health approach'to ART.
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Affiliation(s)
- M Etienne
- Institute of Human Virology of the University of Maryland School of Medicine, Baltimore, MD, USA.
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Balcha TT, Jeppsson A. Outcomes of antiretroviral treatment: a comparison between hospitals and health centers in Ethiopia. ACTA ACUST UNITED AC 2010; 9:318-24. [PMID: 20923956 DOI: 10.1177/1545109710367518] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE the objective of this study was to compare the outcomes of antiretroviral therapy (ART) between hospital and health center levels in Ethiopia. METHODS medical records of 1709 ART patients followed for 24 months at 2 hospitals and 3 health centers in the Oromia region of Ethiopia were reviewed. Noted outcomes of ART were currently alive and on treatment; lost to follow-up (LTFU); transferred out (TO); and died (D). RESULTS of 1709 HIV-positive patients started on ART between September 2006 and February 2007, 1044 (61%) remained alive and were on treatment after 24-month follow-up. In all, 835 (57%) of ART patients at hospitals and 209 (83%) at health centers were retained in the program. Of those who were alive and receiving ART, 79% of patients at health centers and 72% at hospitals were clinically or immunologically improving. In addition, 331 (23%) patients at hospitals were LFTU as compared to 24 (10%) of patients at health centers (relative risk [RR] at 95% confidence interval [CI]: .358 [.231-.555]). While 11% was the mortality rate at hospitals, 5% of patients at health centers also died (RR at 95% CI: .360 [.192-.673]). CONCLUSION antiretroviral therapy at health centers was associated with more favorable outcomes than at hospitals.
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Affiliation(s)
- Taye T Balcha
- Lund University, Social Medicine & Global Health, University Hospital, Malmo, Sweden
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Koenig SP, Schackman BR, Riviere C, Leger P, Charles M, Severe P, Lastimoso C, Colucci N, Pape JW, Fitzgerald DW. Clinical impact and cost of monitoring for asymptomatic laboratory abnormalities among patients receiving antiretroviral therapy in a resource-poor setting. Clin Infect Dis 2010; 51:600-8. [PMID: 20649436 DOI: 10.1086/655762] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Laboratory monitoring for toxicity among patients receiving antiretroviral therapy (ART) in less-developed settings is technically challenging and consumes significant resources. METHODS We conducted a cohort study of the 1800 adult patients who initiated ART at the Haitian Study Group for Kaposi's Sarcoma and Opportunistic Infections (GHESKIO) in Haiti from 2003 to 2006, using baseline data to establish the prevalence and using follow-up data to establish the incidence of hepatitis, renal insufficiency, hyperglycemia, anemia, neutropenia, and thrombocytopenia. We determined how frequently routine (not symptom-driven) testing detected significant laboratory abnormalities and calculated the cost per disability-adjusted life year (DALY) averted by detection of these events in the asymptomatic stage, compared with a strategy of symptom-prompted testing only. RESULTS Forty-eight patients (3.5%) had severe anemia at baseline testing and consequently did not receive zidovudine. Fifty-three patients receiving zidovudine therapy developed severe anemia during follow-up (incidence, 2.5 cases/100 person-years). Monitoring for asymptomatic anemia with hematocrit testing was cost-saving at baseline and had a cost-effectiveness ratio of US$317/DALY averted during follow-up; with a complete blood count, costs increased to US$1182 and $10,781/DALY averted, respectively. With glucose monitoring, 11 patients were diagnosed with new-onset hyperglycemia during follow-up (incidence, 0.7 cases/100 person-years), resulting in a cost-effectiveness ratio of US$9845 per DALY averted. Monitoring for asymptomatic hepatitis and renal insufficiency was expensive and rarely affected care. CONCLUSIONS Resource-poor countries should select which laboratory tests to perform on the basis of the cost-effectiveness of each test. This will depend on the national ART drug regimen and the prevalence of other comorbidities. Routine monitoring with multitest hematological and chemistry panels is unlikely to be cost-effective.
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Affiliation(s)
- Serena P Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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The cost of treatment and care for people living with HIV infection: implications of published studies, 1999–2008. Curr Opin HIV AIDS 2010; 5:215-24. [DOI: 10.1097/coh.0b013e32833860e9] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Affiliation(s)
- Eline L Korenromp
- Global Fund to Fight AIDS, Tuberculosis and Malaria, Vernier (Geneva) CH-1214, Switzerland; Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Netherlands.
| | - Kirsi M Viisainen
- Global Fund to Fight AIDS, Tuberculosis and Malaria, Vernier (Geneva) CH-1214, Switzerland
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Bikilla AD, Jerene D, Robberstad B, Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2009; 7:6. [PMID: 19364399 PMCID: PMC2672061 DOI: 10.1186/1478-7547-7-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Accepted: 04/13/2009] [Indexed: 11/30/2022] Open
Abstract
Background Little is known about the costs of HIV care in Ethiopia. Objective To estimate the average per person year (PPY) cost of care for HIV patients with and without anti-retroviral therapy (ART) in a district hospital. Methods Data on costs and utilization of HIV-related services were taken from Arba Minch Hospital (AMH) in southern Ethiopia. Mean annual outpatient and inpatient costs and corresponding 95% confidence intervals (CI) were calculated. We adopted a district hospital perspective and focused on hospital costs. Findings PPY average (95% CI) costs under ART were US$235.44 (US$218.11–252.78) and US$29.44 (US$24.30–34.58) for outpatient and inpatient care, respectively. Estimates for the non-ART condition were US$38.12 (US$34.36–41.88) and US$80.88 (US$63.66–98.11) for outpatient and inpatient care, respectively. The major cost driver under the ART scheme was cost of ART drugs, whereas it was inpatient care and treatment in the non-ART scheme. Conclusion The cost profile of ART at a district hospital level may be useful in the planning and budgeting of implementing ART programs in Ethiopia. Further studies that focus on patient costs are warranted to capture all patterns of service use and relevant costs. Economic evaluations combining cost estimates with clinical outcomes would be useful for ranking of ART services.
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Affiliation(s)
- Asfaw Demissie Bikilla
- Center for International Health, University of Bergen, PO Box 7804, 5020 Bergen, Norway.,Faculty of Business and Economics, Hawassa University. PO Box 278, Hawassa, Ethiopia
| | | | - Bjarne Robberstad
- Center for International Health, University of Bergen, PO Box 7804, 5020 Bergen, Norway.,Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway
| | - Bernt Lindtjorn
- Center for International Health, University of Bergen, PO Box 7804, 5020 Bergen, Norway
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The role of HIV research in building health system capacity in developing countries. Curr Opin HIV AIDS 2008; 3:481-8. [DOI: 10.1097/coh.0b013e328304382a] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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