| 1. |
- Batura, Neha, et al.
(author)
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Collecting and analysing cost data for complex public health trials : reflections on practice
- 2014
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In: Global Health Action. - : CoAction Publishing. - 1654-9716 .- 1654-9880. ; 7, s. 23257-
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Journal article (peer-reviewed)abstract
- BACKGROUND: Current guidelines for the conduct of cost-effectiveness analysis (CEA) are mainly applicable to facility-based interventions in high-income settings. Differences in the unit of analysis and the high cost of data collection can make these guidelines challenging to follow within public health trials in low- and middle- income settings.OBJECTIVE: This paper reflects on the challenges experienced within our own work and proposes solutions that may be useful to others attempting to collect, analyse, and compare cost data between public health research sites in low- and middle- income countries.DESIGN: We describe the generally accepted methods (norms) for collecting and analysing cost data in a single-site trial from the provider perspective. We then describe our own experience applying these methods within eight comparable cluster randomised, controlled, trials. We describe the strategies used to maximise adherence to the norm, highlight ways in which we deviated from the norm, and reflect on the learning and limitations that resulted.RESULTS: When the expenses incurred by a number of small research sites are used to estimate the cost-effectiveness of delivering an intervention on a national scale, then deciding which expenses constitute 'start-up' costs will be a nontrivial decision that may differ among sites. Similarly, the decision to include or exclude research or monitoring and evaluation costs can have a significant impact on the findings. We separated out research costs and argued that monitoring and evaluation costs should be reported as part of the total trial cost. The human resource constraints that we experienced are also likely to be common to other trials. As we did not have an economist in each site, we collaborated with key personnel at each site who were trained to use a standardised cost collection tool. This approach both accommodated our resource constraints and served as a knowledge sharing and capacity building process within the research teams.CONCLUSIONS: Given the practical reality of conducting randomised, controlled trials of public health interventions in low- and middle- income countries, it is not always possible to adhere to prescribed guidelines for the analysis of cost effectiveness. Compromises are frequently required as researchers seek a pragmatic balance between rigor and feasibility. There is no single solution to this tension but researchers are encouraged to be mindful of the limitations that accompany compromise, whilst being reassured that meaningful analyses can still be conducted with the resulting data.
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| 2. |
- Batura, Neha, et al.
(author)
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Highlighting the evidence gap : how cost-effective are interventions to improve early childhood nutrition and development?
- 2015
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In: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 30:6, s. 813-821
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Research review (peer-reviewed)abstract
- There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.
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| 3. |
- Berner-Rodoreda, Astrid, et al.
(author)
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Where is the 'global' in the European Union's Health Research and Innovation Agenda?
- 2019
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In: BMJ Global Health. - : BMJ. - 2059-7908. ; 4:5
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Journal article (peer-reviewed)abstract
- Global Health has not featured as prominently in the European Union (EU) research agenda in recent years as it did in the first decade of the new millennium, and participation of low-income and middle-income countries (LMICs) in EU health research has declined substantially. The Horizon Europe Research and Innovation Framework adopted by the European Parliament in April 2019 for the period 2021-2027 will serve as an important funding instrument for health research, yet the proposed health research budget to be finalised towards the end of 2019 was reduced from 10% in the current framework, Horizon 2020, to 8% in Horizon Europe. Our analysis takes the evolvement of Horizon Europe from the initial framework of June 2018 to the framework agreed on in April 2019 into account. It shows that despite some improvements in terms of Global Health and reference to the Sustainable Development Goals, European industrial competitiveness continues to play a paramount role, with Global Health research needs and relevant health research for LMICs being only partially addressed. We argue that the globally interconnected nature of health and the transdisciplinary nature of health research need to be fully taken into account and acted on in the new European Research and Innovation Framework. A facilitated global research collaboration through Horizon Europe could ensure that Global Health innovations and solutions benefit all parts of the world including EU countries.
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| 4. |
- Colbourn, Tim, et al.
(author)
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Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi
- 2015
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In: Cost Effectiveness and Resource Allocation. - : BioMed Central (BMC). - 1478-7547. ; 13
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Journal article (peer-reviewed)abstract
- BACKGROUND: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.METHODS: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.RESULTS: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.CONCLUSIONS: Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.
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| 5. |
- Dickin, Sarah, et al.
(author)
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Implementation of the Afya conditional cash transfer intervention to retain women in the continuum of care : a mixed-methods process evaluation
- 2022
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In: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 12:9
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Journal article (peer-reviewed)abstract
- Objectives: We report the results of a mixed-methods process evaluation that aimed to provide insight on the Afya conditional cash transfer (CCT) intervention fidelity and acceptability.Intervention, setting and participants: The Afya CCT intervention aimed to retain women in the continuum of maternal healthcare including antenatal care (ANC), delivery at facility and postnatal care (PNC) in Siaya County, Kenya. The cash transfers were delivered using an electronic card reader system at health facilities. It was evaluated in a trial that randomised 48 health facilities to intervention or control, and which found modest increases in attendance for ANC and immunisation appointments, but little effect on delivery at facility and PNC visits.Design: A mixed-methods process evaluation was conducted. We used the Afya electronic portal with recorded visits and payments, and reports on use of the electronic card reader system from each healthcare facility to assess fidelity. Focus group interviews with participants (N=5) and one-on-one interviews with participants (N=10) and healthcare staff (N=15) were conducted to assess the acceptability of the intervention. Data analyses were conducted using descriptive statistics and qualitative content analysis, as appropriate.Results: Delivery of the Afya CCT intervention was negatively affected by problems with the electronic card reader system and a decrease in adherence to its use over the intervention period by healthcare staff, resulting in low implementation fidelity. Acceptability of cash transfers in the form of mobile transfers was high for participants. Initially, the intervention was acceptable to healthcare staff, especially with respect to improvements in attaining facility targets for ANC visits. However, acceptability was negatively affected by significant delays linked to the card reader system.Conclusions: The findings highlight operational challenges in delivering the Afya CCT intervention using the Afya electronic card reader system, and the need for greater technology readiness before further scale-up.
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| 6. |
- Fottrell, Edward, et al.
(author)
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The effect of increased coverage of participatory women's groups on neonatal mortality in Bangladesh : A cluster randomized trial
- 2013
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In: JAMA pediatrics. - : American Medical Association. - 2168-6211 .- 2168-6203. ; 167:9, s. 816-25
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Journal article (peer-reviewed)abstract
- IMPORTANCE: Community-based interventions can reduce neonatal mortality when health systems are weak. Population coverage of target groups may be an important determinant of their effect on behavior and mortality. A women's group trial at coverage of 1 group per 1414 population in rural Bangladesh showed no effect on neonatal mortality, despite a similar intervention having a significant effect on neonatal and maternal death in comparable settings.OBJECTIVE: To assess the effect of a participatory women's group intervention with higher population coverage on neonatal mortality in Bangladesh.DESIGN: A cluster randomized controlled trial in 9 intervention and 9 control clusters.SETTING: Rural Bangladesh.PARTICIPANTS: Women permanently residing in 18 unions in 3 districts and accounting for 19 301 births during the final 24 months of the intervention.INTERVENTIONS: Women's groups at a coverage of 1 per 309 population that proceed through a participatory learning and action cycle in which they prioritize issues that affected maternal and neonatal health and design and implement strategies to address these issues.MAIN OUTCOMES AND MEASURES: Neonatal mortality rate.RESULTS: Analysis included 19 301 births during the final 24 months of the intervention. More than one-third of newly pregnant women joined the groups. The neonatal mortality rate was significantly lower in the intervention arm (21.3 neonatal deaths per 1000 live births vs 30.1 per 1000 in control areas), a reduction in neonatal mortality of 38% (risk ratio, 0.62 [95% CI, 0.43-0.89]) when adjusted for socioeconomic factors. The cost-effectiveness was US $220 to $393 per year of life lost averted. Cause-specific mortality rates suggest reduced deaths due to infections and those associated with prematurity/low birth weight. Improvements were seen in hygienic home delivery practices, newborn thermal care, and breastfeeding practices.CONCLUSIONS AND RELEVANCE: Women's group community mobilization, delivered at adequate population coverage, is a highly cost-effective approach to improve newborn survival and health behavior indicators in rural Bangladesh.TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN01805825.
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| 7. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Do economic evaluation studies inform effective healthcare resource allocation in Iran? A critical review of the literature.
- 2014
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In: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 12:Jul 11
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Research review (peer-reviewed)abstract
- To aid informed health sector decision-making, data from sufficient high quality economic evaluations must be available to policy makers. To date, no known study has analysed the quantity and quality of available Iranian economic evaluation studies. This study aimed to assess the quantity, quality and targeting of economic evaluation studies conducted in the Iranian context. The study systematically reviewed full economic evaluation studies (n = 30) published between 1999 and 2012 in international and local journals. The findings of the review indicate that although the literature on economic evaluation in Iran is growing, these evaluations were of poor quality and suffer from several major methodological flaws. Furthermore, the review reveals that economic evaluation studies have not addressed the major health problems in Iran. While the availability of evidence is no guarantee that it will be used to aid decision-making, the absence of evidence will certainly preclude its use. Considering the deficiencies in the data identified by this review, current economic evaluations cannot be a useful source of information for decision makers in Iran. To improve the quality and overall usefulness of economic evaluations we would recommend; 1) developing clear national guidelines for the conduct of economic evaluations, 2) highlighting priority areas where information from such studies would be most useful and 3) training researchers and policy makers in the calculation and use of economic evaluation data.
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| 8. |
- Haghparast-Bidgoli, Hassan, et al.
(author)
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Inequity in costs of seeking sexual and reproductive health services in India and Kenya
- 2015
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In: International Journal for Equity in Health. - : BioMed Central. - 1475-9276. ; 14
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Journal article (peer-reviewed)abstract
- Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.
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| 9. |
- Kim, Sung, et al.
(author)
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Comparing the cost effectiveness of harm reduction strategies : a case study of the Ukraine
- 2014
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In: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 12
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Journal article (peer-reviewed)abstract
- BackgroundHarm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study.MethodsA Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars.ResultsThe Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55].The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies.ConclusionsDespite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.
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| 10. |
- Kim, Sung Wook, et al.
(author)
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Socio-economic inequity in HIV testing in Malawi
- 2016
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In: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 9, s. 1-15
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Journal article (peer-reviewed)abstract
- BACKGROUND: Human immunodeficiency virus (HIV) is a significant contributor to Malawi's burden of disease. Despite a number of studies describing socio-economic differences in HIV prevalence, there is a paucity of evidence on socio-economic inequity in HIV testing in Malawi.OBJECTIVE: To assess horizontal inequity (HI) in HIV testing in Malawi.DESIGN: Data from the Demographic and Health Surveys (DHSs) 2004 and 2010 in Malawi are used for the analysis. The sample size for DHS 2004 was 14,571 (women =11,362 and men=3,209), and for DHS 2010 it was 29,830 (women=22,716 and men=7,114). The concentration index is used to quantify the amount of socio-economic-related inequality in HIV testing. The inequality is a primary method in this study. Corrected need, a further adjustment of the standard decomposition index, was calculated. Standard HI was compared with corrected need-adjusted inequity. Variables used to measure health need include symptoms of sexually transmitted infections. Non-need variables include wealth, education, literacy and marital status.RESULTS: Between 2004 and 2010, the proportion of the population ever tested for HIV increased from 15 to 75% among women and from 16 to 54% among men. The need for HIV testing among men was concentrated among the relatively wealthy in 2004, but the need was more equitably distributed in 2010. Standard HI was 0.152 in 2004 and 0.008 in 2010 among women, and 0.186 in 2004 and 0.04 in 2010 among men. Rural-urban inequity also fell in this period, but HIV testing remained pro-rich among rural men (HI 0.041). The main social contributors to inequity in HIV testing were wealth in 2004 and education in 2010.CONCLUSIONS: Inequity in HIV testing in Malawi decreased between 2004 and 2010. This may be due to the increased support to HIV testing by global donors over this period.
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