Economic Evaluation of Family Planning Interventions in Low and Middle Income Countries; A Systematic Review

Digital Health Technology Interventions for Improving Medication Safety: Systematic Review of Economic Evaluations

BACKGROUND

Medication-related harm, including adverse drug events (ADEs) and medication errors, represents a significant iatrogenic burden in clinical care. Digital health technology (DHT) interventions can significantly enhance medication safety outcomes. Although the clinical effectiveness of DHT for medication safety has been relatively well studied, much less is known about the cost-effectiveness of these interventions.

OBJECTIVE

This study aimed to systematically review the economic impact of DHT interventions on medication safety and examine methodological challenges to inform future research directions.

METHODS

A systematic search was conducted across 3 major electronic databases (ie, PubMed, Scopus, and EBSCOhost). The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. Two independent investigators conducted a full-text review after screening preliminary titles and abstracts. We adopted recommendations from the Panel on Cost-Effectiveness in Health and Medicine for data extraction. A narrative analysis was conducted to synthesize clinical and economic outcomes. The quality of reporting for the included studies was assessed using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines.

RESULTS

We included 13 studies that assessed the cost-effectiveness (n=9, 69.2%), cost-benefit (n=3, 23.1%), and cost-utility (n=1, 7.7%) of DHT for medication safety. Of the included studies, more than half (n=7, 53.9%) evaluated a clinical decision support system (CDSS)/computerized provider order entry (CPOE), 4 (30.8%) examined automated medication-dispensing systems, and 2 (15.4%) focused on pharmacist-led outreach programs targeting health care professionals. In 12 (92.3% ) studies, DHT was either cost-effective or cost beneficial compared to standard care. On average, DHT interventions reduced ADEs by 37.12% (range 8.2%-66.5%) and medication errors by 54.38% (range 24%-83%). The key drivers of cost-effectiveness included reductions in outcomes, the proportion of errors resulting in ADEs, and implementation costs. Despite a significant upfront cost, DHT showed a return on investment within 3-4.25 years due to lower cost related with ADE treatment and improved workflow efficiency. In terms of reporting quality, the studies were classified as good (n=10, 76.9%) and moderate (n=3, 23.1%). Key methodological challenges included short follow-up periods, the absence of alert compliance tracking, the lack of ADE and error severity categorization, and omission of indirect costs.

CONCLUSIONS

DHT interventions are economically viable to improve medication safety, with a substantial reduction in ADEs and medication errors. Future studies should prioritize incorporating alert compliance tracking, ADE and error severity classification, and evaluation of indirect costs, thereby increasing clinical benefits and economic viability.

Evaluation of Reporting Quality of Systematic Reviews on Health Economic Evaluation Studies Based on the CHEERS Statement: An Overview of Reviews

Background

Economic evaluations in healthcare are designed to inform decisions by the estimation of cost and effect trade-off of two or more interventions. We aimed to evaluate the standards of systematic reviews on health economic evaluation studies using the CHEERS (Consolidated Health Economic Evaluation Report Standards) tool.

Methods

We searched the PubMed database with keywords CHEERS and its complete form in combination with keywords related to cost or economic evaluation without language and time limits until November 17, 2021. The CHEERS tool was then used to include systematic reviews.

Results

Overall, 32 systematic reviews, included 610 primary studies were included. Of the 32 included studies, only 1 study (3.1%) had poor quality, 5 studies (15.6%) had good quality, remaining studies had very good and excellent quality.

Conclusion

Some studies still have problems in expressing the standards. The necessity of standards for reporting economic evaluation studies in the field of health is very serious, and Cheers is one of the most important tools.

Economic Evaluations of Digital Health Interventions for Patients With Heart Failure: Systematic Review

BACKGROUND

Digital health interventions (DHIs) have shown promising results in enhancing the management of heart failure (HF). Although health care interventions are increasingly being delivered digitally, with growing evidence on the potential cost-effectiveness of adopting them, there has been little effort to collate and synthesize the findings.

OBJECTIVE

This study's objective was to systematically review the economic evaluations that assess the adoption of DHIs in the management and treatment of HF.

METHODS

A systematic review was conducted using 3 electronic databases: PubMed, EBSCOhost, and Scopus. Articles reporting full economic evaluations of DHIs for patients with HF published up to July 2023 were eligible for inclusion. Study characteristics, design (both trial based and model based), input parameters, and main results were extracted from full-text articles. Data synthesis was conducted based on the technologies used for delivering DHIs in the management of patients with HF, and the findings were analyzed narratively. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed for this systematic review. The reporting quality of the included studies was evaluated using the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) guidelines.

RESULTS

Overall, 27 economic evaluations were included in the review. The economic evaluations were based on models (13/27, 48%), trials (13/27, 48%), or a combination approach (1/27, 4%). The devices evaluated included noninvasive remote monitoring devices (eg, home telemonitoring using digital tablets or specific medical devices that enable transmission of physiological data), telephone support, mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems. Most of the studies (24/27, 89%) used cost-utility analysis. The majority of the studies (25/27, 93%) were conducted in high-income countries, particularly European countries (16/27, 59%) such as the United Kingdom and the Netherlands. Mobile apps and wearables, remote monitoring follow-up in patients with implantable medical devices, and videoconferencing systems yielded cost-effective results or even emerged as dominant strategies. However, conflicting results were observed, particularly in noninvasive remote monitoring devices and telephone support. In 15% (4/27) of the studies, these DHIs were found to be less costly and more effective than the comparators (ie, dominant), while 33% (9/27) reported them to be more costly but more effective with incremental cost-effectiveness ratios below the respective willingness-to-pay thresholds (ie, cost-effective). Furthermore, in 11% (3/27) of the studies, noninvasive remote monitoring devices and telephone support were either above the willingness-to-pay thresholds or more costly than, yet as effective as, the comparators (ie, not cost-effective). In terms of reporting quality, the studies were classified as good (20/27, 74%), moderate (6/27, 22%), or excellent (1/27, 4%).

CONCLUSIONS

Despite the conflicting results, the main findings indicated that, overall, DHIs were more cost-effective than non-DHI alternatives.

TRIAL REGISTRATION

PROSPERO CRD42023388241; https://tinyurl.com/2p9axpmc.

Evidence on Scaling in Health and Social Care: An Umbrella Review

Policy Points More rigorous methodologies and systematic approaches should be encouraged in the science of scaling. This will help researchers better determine the effectiveness of scaling, guide stakeholders in the scaling process, and ultimately increase the impacts of health innovations. The practice and the science of scaling need to expand worldwide to address complex health conditions such as noncommunicable and chronic diseases. Although most of the scaling experiences described in the literature are occurring in the Global South, most of the authors publishing on it are based in the Global North. As the science of scaling spreads across the world with the aim of reducing health inequities, it is also essential to address the power imbalance in how we do scaling research globally.

CONTEXT

Scaling of effective innovations in health and social care is essential to increase their impact. We aimed to synthesize the evidence base on scaling and identify current knowledge gaps.

METHODS

We conducted an umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We included any type of review that 1) focused on scaling, 2) covered health or social care, and 3) presented a methods section. We searched MEDLINE (Ovid), Embase, PsycINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstracts (ProQuest), Academic Search Premier (EBSCO), and ProQuest Dissertations & Theses Global from their inception to August 6, 2020. We searched the gray literature using, e.g., Google and WHO-ExpandNet. We assessed methodological quality with AMSTAR2. Paired reviewers independently selected and extracted eligible reviews and assessed study quality. A narrative synthesis was performed.

FINDINGS

Of 24,269 records, 137 unique reviews were included. The quality of the 58 systematic reviews was critically low (n = 42). The most frequent review type was systematic review (n = 58). Most reported on scaling in low- and middle-income countries (n = 59), whereas most first authors were from high-income countries (n = 114). Most reviews concerned infectious diseases (n = 36) or maternal-child health (n = 28). They mainly focused on interventions (n = 37), barriers and facilitators (n = 29), frameworks (n = 24), scalability (n = 24), and costs (n = 14). The WHO/ExpandNet scaling definition was the definition most frequently used (n = 26). Domains most reported as influencing scaling success were building scaling infrastructure (e.g., creating new service sites) and human resources (e.g., training community health care providers).

CONCLUSIONS

The evidence base on scaling is evolving rapidly as reflected by publication trends, the range of focus areas, and diversity of scaling definitions. Our study highlights knowledge gaps around methodology and research infrastructures to facilitate equitable North-South research relationships. Common efforts are needed to ensure scaling expands the impacts of health and social innovations to broader populations.

The Impact of Behavioral Economics-Based Counseling and Mobile Phone Text Educational and Reminder Messages on the Use of Modern Family Planning in Jordan: A Cluster Randomized Controlled Trial

BACKGROUND

Favorable attitudes toward modern family planning methods (MFPMs) among Jordanian and Syrian women do not always translate into behavioral changes, and the availability and cost of MFPMs do not appear to be related to either prior stalls in fertility rates in Jordan or to the current and likely temporary decline in fertility rates. This study aimed to determine whether behavioral economics (BE)-based family planning interventions influence the use of any family planning method, MFPMs use, continuation of MFPMs use, and pregnancy rates among women in Jordan. The BE-based family planning interventions included personalized text messaging and augmented counseling based on framing and identity-priming BE principles, with their effects tested over a 9-month period in the postpartum period following the birth of a child.

METHODS

A parallel-group cluster randomized controlled trial was conducted to compare two interventions, augmented counseling based on framing and identity-priming BE principles and personalized mobile phone text messages reminders, aiming to improve the utilization of MFPMs among postpartum women over status quo family planning services in comprehensive health centers in the north of Jordan.

RESULTS

In total, 1032 participated in the study: 295 women in the control group; 326 women in Intervention Group 1, which received only augmented counseling; and 411 women in intervention Group 2, which received augmented counseling and monthly text messages. The rates of using MFPMs in the counseling group and the counseling and messages group 3 months (54.7% and 57.1%, respectively), 6 months (50.0% and 51.7%, respectively), and 9 months (49.5% and 52.0%, respectively) were significantly higher than the rates among women in the control group (40.6% at 3 months, 37.6% at 6 months, and 34.3% at 9 months). Overall, 26.8% of women in the control group, 42.1% of women in the counseling-only group, and 45.2% of women in the counseling and messages group used MFPMs continuously for all 9 months. At 9 months, the pregnancy rate was significantly much higher in the control group (13.7%) compared to women in the counseling-only group (7.0%) and to women in the counseling and messages group (7.4%).

CONCLUSIONS

Simple BE-based interventions can be effective methods for enhancing the use of MFPMs and maintaining the anticipated decline in Jordan's total fertility rate.

Cost-Effectiveness of Screening to Identify Patients With Atrial Fibrillation: A Systematic Review

BACKGROUND

Screening for Atrial Fibrillation (AF) is recommended for people aged above 65 years. Screening for AF in asymptomatic individuals can be beneficial by enabling earlier diagnosis and the commencement of interventions to reduce the risk of early events, thus improving patient outcomes. This study systematically reviews the literature about the cost-effectiveness of various screening methods for previously undiagnosed AF.

METHODS

Four databases were searched to identify articles that are cost-effectiveness studies conducted on screening for AF published from January 2000 to August 2022. The Consolidated Health Economic Evaluation Reporting Standards 2022 checklist was used to assess the quality of the selected studies. A previously published approach was used to assess the usefulness of each study for health policy makers.

RESULTS

The database search yielded 799 results, with 26 articles meeting the inclusion criteria. Articles were categorised into four subgroups: (i) population screening, (ii) opportunistic screening, (iii) targeted, and (iv) mixed methods of screening. Most of the studies screened adults ≥65 years of age. Most studies were performed from a 'health care payer perspective' and almost all studies used 'not screening' as a comparator. Almost all screening methods assessed were found to be cost-effective in comparison to 'not screening'. The reporting quality varied between 58% to 89%. The majority of the studies were found to be of limited usefulness for health policy makers, as none of the studies made any clear statements about policy change or implementation direction.

CONCLUSION

All approaches of AF screening were found to be cost-effective compared with no screening, while opportunistic screening was found to be the optimal approach in some studies. However, screening for AF in asymptomatic individuals is context specific and likely to be cost-effective depending on the population screened, screening approach, frequency, and the duration of screening.

Cost-effectiveness of increased contraceptive coverage using family planning benefits cards compared with the standard of care for young women in Uganda

BACKGROUND

Uganda has a high population growth rate of 3%, partly due to limited access to and low usage of contraception. This study assessed the cost-effectiveness of the family planning benefits cards (FPBC) program compared to standard of care (SOC). The FPBC program was initiated to increase access to modern contraception among young women in slums in Kampala, Uganda.

METHODS

We developed a decision-analytic model (decision tree) and parameterized it using primary intervention data together with previously published data. In the base case, a sexually active woman from an urban slum, aged 18 to 30 years, was modelled over a one-year time horizon from both the modified societal and provider perspectives. The main model outcomes included the probability of unintended conception, costs, and incremental cost-effectiveness ratio (ICER) in terms of cost per unwanted pregnancy averted. Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the modelling results. All costs were reported in 2022 US dollars, and analyses were conducted in Microsoft Excel.

RESULTS

In the base case analysis, the FPBC was superior to the SOC in outcomes. The probability of conception was lower in the FPBC than in the SOC (0.20 vs. 0.44). The average societal and provider costs were higher in the FPBC than in the SOC, i.e., $195 vs. $164 and $193 vs. $163, respectively. The ICER comparing the FPBC to the SOC was $125 per percentage reduction in the probability of unwanted conception from the societal perspective and $121 from the provider perspective. The results were robust to sensitivity analyses.

CONCLUSION

Given Uganda's GDP per capita of $1046 in 2022, the FPBC is highly cost-effective compared to the SOC in reducing unintended pregnancies among young women in low-income settings. It can even get cheaper in the long run due to the low marginal costs of deploying additional FPBCs.

TRIAL REGISTRATION

MUREC1/7 No. 10/05-17. Registered on July 19, 2017.

Economic evaluation of COVID-19 vaccination: A systematic review

Background

Safe and effective vaccination is considered to be the most critical strategy to fight coronavirus disease 2019 (COVID-19), leading to individual and herd immunity protection. We aimed to systematically review the economic evaluation of COVID-19 vaccination globally.

Methods

We performed a systematic search to identify relevant studies in two major databases (MEDLINE/PubMed and EBSCO) published until September 8, 2022. After deduplication, two researchers independently screened the study titles and abstracts according to pre-determined inclusion and exclusion criteria. The remaining full-text studies were assessed for eligibility. We assessed their quality of reporting using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist and summarized and narratively presented the results.

Results

We identified 25 studies that assessed the economic evaluation of COVID-19 vaccination worldwide by considering several input parameters, including vaccine cost, vaccine efficacy, utility value, and the size of the targeted population. All studies suggested that COVID-19 vaccination was a cost-effective or cost-saving intervention for mitigating coronavirus transmission and its effect in many countries within certain conditions. Most studies reported vaccine efficacy values ranging from 65% to 75%.

Conclusions

Given the favorable cost-effectiveness profile of COVID-19 vaccines and disparities in affordability across countries, considering prioritization has become paramount. This review provides comprehensive insights into the economic evaluation of COVID-19 vaccination that will be useful to policymakers, particularly in highlighting preventive measures and preparedness plans for the next possible pandemic.

Family planning interventions in Jordan: A scoping review

BACKGROUND

Despite all efforts in Jordan to increase the demand and use of family planning services, many challenges have likely influenced fertility and contraceptive use outcomes. Improving accessibility and availability of family planning services and interventions to married women and their spouse is essential to improve pregnancy outcomes.

OBJECTIVES

This study reviewed the gray and peer-reviewed literature published between January 2010 and June 2022 that described family planning interventions implemented in Jordan and highlighted the gaps identified in the literature.

ELIGIBILITY CRITERIA

For inclusion, primary studies that included information regarding family planning interventions implemented in Jordan were retained.

SOURCES OF EVIDENCE

PubMed database was searched between 2010 till June 2022, as well as bibliographies of the retrieved literature were screened for the relevant literature.

CHARTING METHODS

Information extracted from the interventions included author, publication year, study design and purpose, intervention name, aim of the intervention, population descriptor and sample size of the intervention, and impact of the intervention.

RESULTS

A total of 10 studies that met the inclusion criteria were reviewed. The studies described/assessed 10 different interventions including communication interventions, child preparation programs, evidence-based educational program, counseling interventions, pharmacist booklet on effective use of oral contraceptive pills and Village Health Center project. Five family planning interventions targeted women and five targeted health care providers. Three interventions targeted men, two targeted religious leaders, and two targeted community health committees. Many of the interventions suffered from a lack of a robust methodological framework.

CONCLUSION

This scoping review showed that there is scarce information on the implementation of High Impact Practices in Family Planning in Jordan. The review identified a lack of robust evidence on the impact and effectiveness of family planning interventions on the access to and use of family planning services and methods. There is a need for developing, implementing, and evaluating family planning interventions that elicit a positive environment and encourage the use of family planning services.

Cost-effectiveness of antenatal corticosteroids and tocolytic agents in the management of preterm birth: A systematic review

BACKGROUND

Preterm birth is a leading cause of neonatal mortality and morbidity, and imposes high health and societal costs. Antenatal corticosteroids (ACS) to accelerate fetal lung maturation are commonly used in conjunction with tocolytics for arresting preterm labour in women at risk of imminent preterm birth.

METHODS

We conducted a systematic review on the cost-effectiveness of ACS and/or tocolytics as part of preterm birth management. We systematically searched MEDLINE and Embase (December 2021), as well as a maternal health economic evidence repository collated from NHS Economic Evaluation Database, EconLit, PubMed, Embase, CINAHL and PsycInfo, with no date cutoff. Eligible studies were economic evaluations of ACS and/or tocolytics for preterm birth. Two reviewers independently screened citations, extracted data on cost-effectiveness and assessed study quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement.

FINDINGS

35 studies were included: 11 studies on ACS, eight on tocolytics to facilitate ACS administration, 12 on acute and maintenance tocolysis, and four studies on a combination of ACS and tocolytics. ACS was cost-effective prior to 34 weeks' gestation, but economic evidence on ACS use at 34-<37 weeks was conflicting. No single tocolytic was identified as the most cost-effective. Studies disagreed on whether ACS and tocolytic in combination were cost-saving when compared to no intervention.

INTERPRETATION

ACS use prior to 34 weeks' gestation appears cost-effective. Further studies are required to identify what (if any) tocolytic option is most cost-effective for facilitating ACS administration, and the economic consequences of ACS use in the late preterm period.

FUNDING

UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), a cosponsored programme executed by WHO.

Impact of social protection on gender equality in low- and middle-income countries: A systematic review of reviews

Background

More than half of the global population is not effectively covered by any type of social protection benefit and women's coverage lags behind. Most girls and boys living in low-resource settings have no effective social protection coverage. Interest in these essential programmes in low and middle-income settings is rising and in the context of the COVID-19 pandemic the value of social protection for all has been undoubtedly confirmed. However, evidence on whether the impact of different social protection programmes (social assistance, social insurance and social care services and labour market programmes) differs by gender has not been consistently analysed. Evidence is needed on the structural and contextual factors that determine differential impacts. Questions remain as to whether programme outcomes vary according to intervention implementation and design.

Objectives

This systematic review aims to collect, appraise, and synthesise the evidence from available systematic reviews on the differential gender impacts of social protection programmes in low and middle-income countries. It answers the following questions: 1.What is known from systematic reviews on the gender-differentiated impacts of social protection programmes in low and middle-income countries?2.What is known from systematic reviews about the factors that determine these gender-differentiated impacts?3.What is known from existing systematic reviews about design and implementation features of social protection programmes and their association with gender outcomes?

Search Methods

We searched for published and grey literature from 19 bibliographic databases and libraries. The search techniques used were subject searching, reference list checking, citation searching and expert consultations. All searches were conducted between 10 February and 1 March 2021 to retrieve systematic reviews published within the last 10 years with no language restrictions.

Selection Criteria

We included systematic reviews that synthesised evidence from qualitative, quantitative or mixed-methods studies and analysed the outcomes of social protection programmes on women, men, girls, and boys with no age restrictions. The reviews included investigated one or more types of social protection programmes in low and middle-income countries. We included systematic reviews that investigated the effects of social protection interventions on any outcomes within any of the following six core outcome areas of gender equality: economic security and empowerment, health, education, mental health and psychosocial wellbeing, safety and protection and voice and agency.

Data Collection and Analysis

A total of 6265 records were identified. After removing duplicates, 5250 records were screened independently and simultaneously by two reviewers based on title and abstract and 298 full texts were assessed for eligibility. Another 48 records, identified through the initial scoping exercise, consultations with experts and citation searching, were also screened. The review includes 70 high to moderate quality systematic reviews, representing a total of 3289 studies from 121 countries. We extracted data on the following areas of interest: population, intervention, methodology, quality appraisal, and findings for each research question. We also extracted the pooled effect sizes of gender equality outcomes of meta-analyses. The methodological quality of the included systematic reviews was assessed, and framework synthesis was used as the synthesis method. To estimate the degree of overlap, we created citation matrices and calculated the corrected covered area.

Main Results

Most reviews examined more than one type of social protection programme. The majority investigated social assistance programmes (77%, N = 54), 40% (N = 28) examined labour market programmes, 11% (N = 8) focused on social insurance interventions and 9% (N = 6) analysed social care interventions. Health was the most researched (e.g., maternal health; 70%, N = 49) outcome area, followed by economic security and empowerment (e.g., savings; 39%, N = 27) and education (e.g., school enrolment and attendance; 24%, N = 17). Five key findings were consistent across intervention and outcomes areas: (1) Although pre-existing gender differences should be considered, social protection programmes tend to report higher impacts on women and girls in comparison to men and boys; (2) Women are more likely to save, invest and share the benefits of social protection but lack of family support is a key barrier to their participation and retention in programmes; (3) Social protection programmes with explicit objectives tend to demonstrate higher effects in comparison to social protection programmes without broad objectives; (4) While no reviews point to negative impacts of social protection programmes on women or men, adverse and unintended outcomes have been attributed to design and implementation features. However, there are no one-size-fits-all approaches to design and implementation of social protection programmes and these features need to be gender-responsive and adapted; and (5) Direct investment in individuals and families' needs to be accompanied by efforts to strengthen health, education, and child protection systems. Social assistance programmes may increase labour participation, savings, investments, the utilisation of health care services and contraception use among women, school enrolment among boys and girls and school attendance among girls. They reduce unintended pregnancies among young women, risky sexual behaviour, and symptoms of sexually transmitted infections among women. Social insurance programmes increase the utilisation of sexual, reproductive, and maternal health services, and knowledge of reproductive health; improve changes in attitudes towards family planning; increase rates of inclusive and early initiation of breastfeeding and decrease poor physical wellbeing among mothers. Labour market programmes increase labour participation among women receiving benefits, savings, ownership of assets, and earning capacity among young women. They improve knowledge and attitudes towards sexually transmitted infections, increase self-reported condom use among boys and girls, increase child nutrition and overall household dietary intake, improve subjective wellbeing among women. Evidence on the impact of social care programmes on gender equality outcomes is needed.

Authors' Conclusions

Although effectiveness gaps remain, current programmatic interests are not matched by a rigorous evidence base demonstrating how to appropriately design and implement social protection interventions. Advancing current knowledge of gender-responsive social protection entails moving beyond effectiveness studies to test packages or combinations of design and implementation features that determine the impact of these interventions on gender equality. Systematic reviews investigating the impact of social care programmes, old age pensions and parental leave on gender equality outcomes in low and middle-income settings are needed. Voice and agency and mental health and psychosocial wellbeing remain under-researched gender equality outcome areas.

Procurement Practice of Program Drugs and Its Challenges at the Ethiopian Pharmaceuticals Supply Agency: A Mixed Methods Study

Background

Effective drug procurement guarantees the sustainable supply of products for health and eliminates excessive costs. However, there is limited information on the area of pharmaceutical procurement practice in Ethiopia. Thus, this study aimed at assessing the procurement practices of program drugs and its challenges at the Ethiopian Pharmaceuticals Supply Agency.

Methods

A cross-sectional study accompanied by qualitative assessment was conducted between February 21 and April 20/2020 to examine the procurement practice of the Ethiopian pharmaceutical supply agency. The quantitative data were gathered by reviewing documents and electronic records. Mean forecast error, price paid to international price reference, number of emergency orders placed, and lead time variability were the measurements used to assess the procurement practice. A statistical package for the social sciences version 23 was used to analyze the data. The results were then summarized using tables and texts. The qualitative data were collated through face-to-face in-depth interviews to explore the challenges behind the procurement practice. And the data were analyzed manually using the thematic analysis technique.

Results

The agency had its own procurement list which defines the items to be procured. The overall mean forecast error in the 2018/19 budget year was 27.8%. Of the 70 program commodities included in the study, 52 (74.3%) items had a mean price less than the international price reference. Three of the 14 orders (21.4%) placed in the aforementioned year were emergency purchases made through direct procurement. The mean lead time for the suppliers of the agency was 137.3 days. Poor data quality from service delivery points, staff capacity constraints, communication problems, and policy issues became the major challenges to implement an effective procurement system in the agency.

Conclusion

The procurement practice at the agency has strong side. However, it was not without weaknesses. Using a procurement list is a worthwhile practice. Despite this, much remains to improve lead times and forecasting accuracy.

Evidence on scaling in health and social care: protocol for a living umbrella review

BACKGROUND

There is a growing interest in scaling effective health innovations to promote equitable access to high-quality health services worldwide. However, multiple challenges persist in scaling innovations. In this study, we aim to summarize the scaling evidence in the health and social care literature and identify current knowledge gaps.

METHODS

We will conduct a living umbrella review according to the Joanna Briggs Institute Reviewers' Manual. We will consider all knowledge syntheses addressing scaling in health or social care (e.g., any setting, any clinical area) and conducted in a systematic way. We will search the following electronic databases: MEDLINE (Ovid), Embase, PsychINFO (Ovid), CINAHL (EBSCO), Web of Science, The Cochrane Library, Sociological Abstract (Proquest), Academic Search Premier (EBSCO), and Proquest Dissertations & Theses Global, from inception. Furthermore, we will conduct searches of the grey literature. No restriction regarding date or language will be applied. Each phase of the review will be processed by two independent reviewers. We will develop a data extraction form on Covidence. We will assess the methodological quality of the included reviews using AMSTAR2 and the risk of bias using ROBIS. Results will be presented in tabular form and accompanied by a narrative synthesis covering the traditional themes of scaling science that emerge from the analysis, such as coverage, range, and sustainability, as well as themes less covered in the literature, including reporting guidance, models, tools, barriers, and/or facilitators to scaling innovations, evidence regarding application in high-income or low-income countries, and end-user engagement. We will disseminate the findings via publications and through relevant networks.

DISCUSSION

The findings of the umbrella review will facilitate access to scaling evidence in the literature and help strengthen the science of scaling for researchers, policy makers, and program managers. Finally, this work will highlight important knowledge gaps and help prioritize future research questions.

SYSTEMATIC REVIEW REGISTRATION

This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on November 11, 2020 (registration number: CRD42020183774 ).

Providing universal access to modern contraceptive methods: An extended cost-effectiveness analysis of meeting the demand for modern contraception in Ethiopia

Despite recent advances in access to and use of modern contraception in Ethiopia, further improvement is needed, particularly among poorer women. This extended cost-effectiveness analysis investigated the health outcomes, their distribution, and financial risk protection associated with meeting the demand for modern contraception for all Ethiopian women. We developed five Markov models with wealth quintile-specific input data to investigate the effects of meeting this demand and followed a hypothetical cohort of 1,252,000 women through their reproductive lives from ages 15-49 years. The health outcomes are reported in quality-adjusted life years (QALYs) gained and in intermediate health outcomes, such as the total number of induced abortions, unintended pregnancies, and pregnancy-related deaths averted. The economic effect of meeting the demand for modern contraception was assessed by estimating the financial risk protection benefits in terms of averted out-of-pocket payments and the reduction in the number of cases of catastrophic health expenditure by quintile. Meeting the demand for modern contraception was deemed highly cost effective, with an incremental cost-effectiveness ratio of $96.60/QALY gained per woman. A total of 676,300 QALYs were gained, and approximately 1,900,000 unintended pregnancies, 250,000 induced abortions, and 9000 pregnancy-related deaths were averted over the 35-year period. Most of these gains were achieved among low-income groups. When the demand for modern contraception was met, almost 40,000 cases of catastrophic health expenditure were averted in the poorest quintile. The total governmental cost was higher in all quintiles when the demand for modern contraception was met compared to the baseline scenario, with the largest percentage increase in governmental spending in the poorest quintiles. Meeting the demand for modern contraception fulfills the priority-setting criteria established by the Ethiopian Ministry of Health and makes the Ethiopian health care system more equitable.

Cost-Effectiveness of Contraceptive Use in Indonesia after the Implementation of the National Health Insurance System

Since 2014, Indonesia has initiated to implement a national health insurance system, which included both of short- (SARC) and long-acting reversible contraceptive (LARC) into the benefit package. The aim of this study was to analyze the cost-effectiveness of contraceptive use in Indonesia after the implementation of the national health insurance in 2014-2017. A decision tree model was developed to analyze the cost-effectiveness of contraceptive use in Indonesia in 2014-2017 by comparing two strategies of pregnancy prevention: contraceptive and non-contraceptive. For contraceptive strategy, we took into account SARC and LARC. In a comparison with non-contraceptive, we calculated that the incremental cost-effectiveness ratio (ICER) of SARC would be $5.18, $4.80 and $3.76 per pregnancy averted for injection, condom, and pill, respectively. For LARC, we calculated that the ICER would be $1.67 and $0.84 for implant and intrauterine device (IUD), respectively, compared with non-contraceptive. In general, the cost-effectiveness value of LARC ($1.25) was much better than SARC ($4.58). The cost of contraceptive was considered to be the most influential parameter affecting both the ICER of SARC and LARC. In conclusion, the use of LARC in Indonesia was considered to be more cost-effective than SARC since the implementation of national health insurance system. In particular, IUD yielded the greatest cost-effectiveness value, compared with other methods.

Development of a pharmacoeconomic registry: an example using hormonal contraceptives

BACKGROUND

Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives.

METHODS

An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry.

RESULTS

The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files.

CONCLUSION

This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.

Impact of home-based family planning counselling and referral on modern contraceptive use in Karachi, Pakistan: a retrospective, cross-sectional matched control study

OBJECTIVES

To assess: (1) the impact of a reproductive health program on modern contraceptive use from baseline to program close; (2) the sustained impact from baseline to follow-up 36 months later; and (3) the exposure-adjusted impact at program close and follow-up.

DESIGN

Retrospective, cross-sectional matched control study.

SETTING

Karachi, Pakistan.

PARTICIPANTS

2561 married women aged 16-49 years.

INTERVENTIONS

The Willows Program, a community-based family planning counselling and referral program implemented from 2013 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was community-level modern contraceptive prevalence rate (mCPR), measured for January 2013 (baseline), June 2015 (program close) and at follow-up 36 months later. A secondary outcome was exposure-adjusted mCPR (among women reporting a family planning home visit) at program close and at follow-up.

RESULTS

There was no significant effect on community-level mCPR at program close (2.4 percentage point increase in intervention over comparison; 95% CI -2.2 to 7.0) or at follow-up (1.9 percentage point decrease; 95% CI -6.7 to 2.8). Only 18% of women in the intervention area reported receiving a family planning visit in the preceding 5 years. Among those reporting a visit, we observed a significant 10.3 percentage point increase (95% CI 4.6 to 15.9) from baseline to close, and a non-significant 2.0 percentage point increase (95% CI -3.8 to 7.8) from baseline to follow-up, relative to matched women in the comparison area. The cost per new modern method user was US$1089, while the cost per user-year during the intervention period was US$455.

CONCLUSIONS

The program had a positive short-term effect on women who received a family planning visit; however, this effect was not sustained. Program coverage was low and did not significantly increase community-level family planning use. Findings highlight the need to increase community coverage of high-quality counselling and contextually relevant interventions for family planning demand generation.

Family Planning in Zambia: An Investment Pillar for Economic Development

Family planning represents a 'best buy' in global efforts to achieve sustainable development and attain improvements in sexual and reproductive health. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Drawing from the Zambian context, including a review of current policy solutions, we present a case for making investments in voluntary family planning (FP), underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia - and other low- and middle-income countries - can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population.

A Mobile Phone-Based Support Intervention to Increase Use of Postabortion Family Planning in Cambodia: Cost-Effectiveness Evaluation

BACKGROUND

Despite progress over the last decade, there is a continuing unmet need for contraception in Cambodia. Interventions delivered by mobile phone could help increase uptake and continuation of contraception, particularly among hard-to-reach populations, by providing interactive personalized support inexpensively wherever the person is located and whenever needed.

OBJECTIVE

The objective of this study was to evaluate the cost-effectiveness of mobile phone-based support added to standard postabortion family planning care in Cambodia, according to the results of the MOTIF (MObile Technology for Improved Family planning) trial.

METHODS

A model was created to estimate the costs and effects of the intervention versus standard care. We adopted a societal perspective when estimating costs, including direct and indirect costs for users. The incremental cost-effectiveness ratio was calculated for the base case, as well as a deterministic and probabilistic sensitivity analysis, which we compared against a range of likely cost-effectiveness thresholds.

RESULTS

The incremental cost of mobile phone-based support was estimated to be an additional US $8160.49 per 1000 clients, leading to an estimated 518 couple-years of protection (CYPs) gained per 1000 clients and 99 disability-adjusted life-years (DALYs) averted. The incremental cost-effectiveness ratio was US $15.75 per additional CYP and US $82.57 per DALY averted. The model was most sensitive to personnel and mobile service costs. Assuming a range of cost-effectiveness thresholds from US $58 to US $176 for Cambodia, the probability of the intervention being cost-effective ranged from 11% to 95%.

CONCLUSIONS

This study demonstrates that the cost-effectiveness of the intervention delivered by mobile phone assessed in the MOTIF trial lies within the estimated range of the cost-effectiveness threshold for Cambodia. When assessing value in interventions to improve the uptake and adherence of family planning services, the use of interactive mobile phone messaging and counselling for women who have had an abortion should be considered as an option by policy makers.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01823861; https://clinicaltrials.gov/ct2/show/NCT01823861.

Family Planning in Zambia: An Investment Pillar for Economic Development

Family planning represents a ‘best buy’ in global efforts to achieve sustainable development and attain improvements in sexual and reproductive health. Ensuring access is amongst key transformative strategies that underpin health and sustainable development. It confers fertility choices on women and couples within a human rights framework. By meeting contraceptive needs of all women, significant public health impact and development gains accrue. At the same time, governments face the complex challenge of allocating finite resources to competing priorities, each of which presents known and unknown challenges and opportunities. As such, there is a need to carefully consider the estimated costs and benefits for each proposed investment in health, education, social welfare, and security. Zambia has experienced a slow but steady increase in contraceptive prevalence, with slight decline in total fertility rate (TFR), over the past 20 years. Increasing voluntary modern contraceptive use among women offers opportunities to reduce unintended pregnancy while effectively harnessing the demographic dividend in order to bolster socioeconomic outcomes for households and communities. Drawing from the Zambian context, we present a case for making investments in voluntary family planning (FP), underpinned by a human rights framework, as a pillar for accelerating development and socio-economic advancement. Through multilevel interventions aimed at averting unintended pregnancies, Zambia – and other low- and middle-income countries – can reduce their age dependency ratios and harness economic growth opportunities awarded by the demographic dividend while improving the health and quality of life of the population.

Cost-Effectiveness of Scaling Up Modern Family Planning Interventions in Low- and Middle-Income Countries: An Economic Modeling Analysis in Indonesia and Uganda

OBJECTIVES

The aim was to estimate the long-term cost-effectiveness of improved family planning interventions to reduce the unmet need in low- and middle-income countries, with Indonesia and Uganda as reference cases.

METHODS

The analysis was performed using a Markov decision analytic model, where current situation and several scenarios to reduce the unmet need were incorporated as the comparative strategies. Country-specific evidence was synthesized from the demographic and health survey and published studies. The model simulated the sexual and reproductive health experience of women in the reproductive age range over a time horizon of women's reproductive years, from the healthcare payer perspective. Modeled outcomes included clinical events, costs and incremental cost-effectiveness ratios (ICERs) expressed as cost per disability-adjusted life year (DALY) averted. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on modeled outcomes.

RESULTS

In the hypothetical cohort of 100,000 women, scenarios to reduce the unmet need for family planning would result in savings within a range of US$230,600-US$895,100 and US$564,400-US$1,865,900 in Indonesia and Uganda, respectively. The interventions would avert an estimated 1859-3780 and 3705-12,230 DALYs in Indonesia and Uganda, respectively. The results of our analysis indicate that scaling up family planning dominates the current situation in all scenarios in both countries, with lower costs and fewer DALYs. These results were robust in sensitivity analyses.

CONCLUSION

Scaling up family planning interventions could improve women's health outcomes substantially and be cost-effective or even cost saving across a range of scenarios compared to the current situation.

Logistics management information system performance for program drugs in public health facilities of East Wollega Zone, Oromia regional state, Ethiopia

Background

Proper logistics management information system in the supply chain improves health outcomes by maintaining accurate and timely information. The purpose of this study was to determine program drugs logistics management information system performance in public health facilities of East Wollega Zone, Oromia Regional State.

Methods

A facility-based descriptive cross-sectional study design complemented with a qualitative method was conducted from April 01 to May 30, 2017. The quantitative data were gathered through reviewing logistics tools, a physical count of the selected program drugs, and interview of the pharmacy staffs. The evaluation of data quality was done on 134 RRFs and 805 bin-cards. A statistical package for social science version 20 was used to analyze the quantitative data. A chi-square test was performed to determine the association between dependent and independent variables. For the qualitative method, 11 face to face in-depth interviews were carried out, and the data were analyzed using thematic analysis technique.

Results

Twenty three selected public health facilities were included in the study of which 39% of them had an automated recording system. Concerning the data quality, 65% of RRFs and 79.1% of bin-cards were accurately filled, and 97.8% of the reports were found to be complete. Sixty-nine percent of the facilities had timely submitted their report to the higher level and the reporting rate of the facilities was determined to be 97%. A significant association was observed between RRF data accuracy and type of profession, X² (4, N = 134) =35.0, P = 0.040, trainings, X² (2, N = 134) =37.12, P = 0.001, e-LMIS, X² (2, N = 134) = 38.67, P = 0.03, educational status, X² (2,N = 134) = 90.38, P = 0.012, & supervision, X² (2, N = 134) = 94.03,P < 0.001. Shortage of skilled human resources and poor commitment of the staffs were identified to be the major bottlenecks of logistics management information system performances.

Conclusions

The facilities’ report submission rates were promising yet the quality of the reports need improvement. Poor data quality was more likely because of weak supportive supervision and the information system being managed by non-pharmacy professionals.

Cost-Effectiveness of a Family Planning Voucher Program in Rural Pakistan

Introduction

This study reports on the effectiveness and efficiency from the program funder’s perspective of the Suraj Social Franchise (SSF) voucher program in which private health-care providers in remote rural areas were identified, trained, upgraded, and certified to deliver family planning services to underserved women of reproductive age in 29 districts of Sindh and 3 districts of Punjab province, Pakistan between October 2013 and June 2016.

Method

A decision tree compared the cost of implementing SSF to the program funder and its effects of providing additional couple years of protection (CYPs) to targeted women, compared to business-as-usual. Costs included vouchers given to women to receive a free contraceptive method of their choice from the SSF provider. The vouchers were then reimbursed to the SSF provider by the program.

Results

A total of 168,206 married women of reproductive age (MWRA) received SSF vouchers between October 2013 and June 2016, costing $3,278,000 ($19.50/recipient). The average effectiveness of the program per voucher recipient was an additional 1.66 CYPs, giving an incremental cost-effectiveness of the program of $4.28 per CYP compared to not having the program (95% CI: $3.62–5.31).

Conclusion

The result compares favorably to other interventions with similar objectives and appears affordable for the Pakistan national health-care system. It is therefore recommended to help address the unmet need for contraception among MWRA in these areas of Pakistan and is worthy of trial implementation in the country more widely.

A systematic review of health economic evaluation in adjuvant breast radiotherapy: Quality counted by numbers

BACKGROUND

Evolving practice in adjuvant breast radiotherapy inevitably impacts healthcare budgets. This is reflected in a rise of health economic evaluations (HEE) in this domain. The available HEE literature was analysed qualitatively and quantitatively, using available instruments.

METHODS

HEEs published between 1/1/2000 and 31/10/2016 were retrieved through a systematic search in Medline, Cochrane and Embase. A quality-assessment using CHEERS (Consolidated Health Economic Evaluation Reporting Standards) was translated into a quantitative score and compared with Tufts Medical Centre CEA registry and Quality of Health Economic Studies (QHES) results.

RESULTS

Twenty cost-effectiveness analyses (CEA) and thirteen cost comparisons (CC) were analysed. In qualitative evaluation, valuation or justification of data sources, population heterogeneity and discussion on generalizability, in addition to declaration on funding, were often absent or incomplete. After quantification, the average CHEERS-scores were 74% (CI 66.9-81.1%) and 75.6% (CI 70.7-80.5%) for CEAs and CCs respectively. CEA-scores did not differ significantly from Tufts and QHES-scores.

CONCLUSION

Quantitative CHEERS evaluation is feasible and yields comparable results to validated instruments. HEE in adjuvant breast radiotherapy is of acceptable quality, however, further efforts are needed to improve comprehensive reporting of all data, indispensable for assessing relevance, reliability and generalizability of results.