ABSTRACT
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.
ABSTRACT
OBJECTIVE: HIV in Nicaragua is concentrated among key populations (KPs) - men who have sex with men, female sex workers, and female transgender - in whom prevalence is 600-4,000 times higher than the general population. The United States Agency for International Development PrevenSida project is aimed at increasing healthy behavior among KPs and people with HIV and improving testing, counseling, and continuity of prevention and treatment by building capacity and improving performance of non-governmental organizations (NGOs) providing services to KPs. We evaluated the cost-effectiveness of PrevenSida's activities. METHODS: This retrospective observational evaluation used individuals in KPs covered by NGOs receiving assistance from PrevenSida from 2012 to 2014. Cost-effectiveness analysis compared PrevenSida's intervention with business-as-usual. Model inputs were generated from epidemiological modeling and PrevenSida's records. RESULTS: By 2014, 24 NGOs received grants and technical assistance from PrevenSida with 72,955 people in KPs served at $11.32/person ($9.39-$16.55/person, depending on region). The estimated incremental cost-effectiveness ratio was $50,700/HIV case averted or $2,600/Disability-adjusted Life Year (DALY) averted (95% CI: $1,000-$99,000 and $50-$5,100, respectively). CONCLUSION: PrevenSida distributed about $600,000 in grants and used $230,000 to support 24 NGOs in 2014. Cost-effectiveness from the program perspective compared to no program was slightly over half of GDP per capita per DALY averted, considered highly cost-effective by WHO criteria. Cost and efficiency varied by region, reflecting the number of people in KPs receiving services. Cost-sharing by NGOs improved cost-effectiveness from the program perspective and likely promotes sustainability. Focused interventions for KP service provision organizations can be acceptably efficient in this setting.
ABSTRACT
There is little evidence to direct health systems toward providing efficient interventions to address medical errors, defined as an unintended act of omission or commission or one not executed as intended that may or may not cause harm to the patient but does not achieve its intended outcome. We believe that lack of guidance on what is the most efficient way to reduce medical errors and improve the quality of health-care limits the scale-up of health system improvement interventions. Challenges to economic evaluation of these interventions include defining and implementing improvement interventions in different settings with high fidelity, capturing all of the positive and negative effects of the intervention, using process measures of effectiveness rather than health outcomes, and determining the full cost of the intervention and all economic consequences of its effects. However, health system improvement interventions should be treated similarly to individual medical interventions and undergo rigorous economic evaluation to provide actionable evidence to guide policy-makers in decisions of resource allocation for improvement activities among other competing demands for health-care resources.
