ABSTRACT
BACKGROUND: Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity. METHODS: We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed. RESULTS: In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique's annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country's annual average for out-of-pocket health expenditures. CONCLUSION: Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
ABSTRACT
BACKGROUND: Most low- and middle-income countries have limited access to cost data that meets the needs of health policy-makers and researchers in health intervention areas including HIV, tuberculosis, and immunization. Unit cost repositories (UCRs)-searchable databases that systematically codify evidence from costing studies-have been developed to reduce the effort required to access and use existing costing information. These repositories serve as public resources and standard references, which can improve the consistency and quality of resource needs projections used for strategic planning and resource mobilization. UCRs also enable analysis of cost determinants and more informed imputation of missing cost data. This report examines our experiences developing and using seven UCRs (two global, five country-level) for cost projection and research purposes. DISCUSSION: We identify advances, challenges, enablers, and lessons learned that might inform future work related to UCRs. Our lessons learned include: (1) UCRs do not replace the need for costing expertise; (2) tradeoffs are required between the degree of data complexity and the useability of the UCR; (3) streamlining data extraction makes populating the UCR with new data easier; (4) immediate reporting and planning needs often drive stakeholder interest in cost data; (5) developing and maintaining UCRs requires dedicated staff time; (6) matching decision-maker needs with appropriate cost data can be challenging; (7) UCRs must have data quality control systems; (8) data in UCRs can become obsolete; and (9) there is often a time lag between the identification of a cost and its inclusion in UCRs. CONCLUSIONS: UCRs have the potential to be a valuable public good if kept up-to-date with active quality control and adequate support available to end-users. Global UCR collaboration networks and greater control by local stakeholders over global UCRs may increase active, sustained use of global repositories and yield higher quality results for strategic planning and resource mobilization.
