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Health care quality improvement (QI) initiatives are being implemented by a number of low- and middle-income countries. However, there is concern that these policies may not reduce, or may even worsen, inequities in access to high-quality care. Few studies have examined the distributional impact of QI programmes. We study the Ideal Clinic Realization and Maintenance program implemented in health facilities in South Africa, assessing whether the effects of the program are sensitive to previous quality performance. Implementing difference-in-difference-in-difference and changes-in-changes approaches we estimate the effect of the program on quality across the distribution of past facility quality performance. We find that the largest gains are realized by facilities with higher baseline quality, meaning this policy may have led to a worsening of pre-existing inequity in health care quality. Our study highlights that the full consequences of QI programmes cannot be gauged solely from examination of the mean impact., (© 2024 The Author(s). Health Economics published by John Wiley & Sons Ltd.)

Background: COVID-19 vaccines were rolled out in South Africa beginning in February 2021. In this study we retrospectively assessed the cost-effectiveness of the vaccination programme in its first two years of implementation., Method: We modelled the costs, expressed in 2021 US$, and health outcomes of the COVID-19 vaccination programme compared to a no vaccination programme scenario. The study was conducted from a public payer's perspective over two time-horizons - nine months (February to November 2021) and twenty-four months (February 2021 to January 2023). Health outcomes were estimated from a disease transmission model parameterised with data on COVID-19-related hospitalisations and deaths and were converted to disability adjusted life years (DALYs). Deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted to assess parameter uncertainty., Results: Incremental cost-effectiveness ratio (ICER) was estimated at US$1600 per DALY averted during the first study time horizon. The corresponding ICER for the second study period was estimated at US$1300 per DALY averted. When 85% of all excess deaths during these periods were included in the analysis, ICERs in the first and second study periods were estimated at US$1070 and US$660 per DALY averted, respectively. In the PSA, almost 100% of simulations fell below the estimated opportunity cost-based cost-effectiveness threshold for South Africa (US$2300 DALYs averted). COVID-19 vaccination programme cost per dose had the greatest impact on the ICERs., Conclusion: Our findings suggest that South Africa's COVID-19 vaccination programme represented good value for money in the first two years of rollout., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: The COVID-19 vaccination programme in South Africa was rolled out in February 2021 via five delivery channels- hospitals, primary healthcare (PHC), fixed, temporary, and mobile outreach channels. In this study, we estimated the financial and economic costs of the COVID-19 vaccination programme in the first year of roll out from February 2021 to January 2022 and one month prior, in one district of South Africa, the West Rand district., Methods: Financial and economic costs were estimated from a public payer's perspective using top-down and ingredient-based costing approaches. Data were collected on costs incurred at the national level and from the West Rand district. Total cost and cost per COVID-19 vaccine dose were estimated for each of the five delivery channels implemented in the district. In addition, we estimated vaccine delivery costs which we defined as total cost exclusive of vaccine procurement costs., Results: Total financial and economic costs were estimated at US$8.5 million and US$12 million, respectively; with a corresponding cost per dose of US$15.31 (financial) and US$21.85 (economic). The two biggest total cost drivers were vaccine procurement which contributed 73% and 51% to total financial and economic costs respectively, and staff time which contributed 10% and 36% to total financial and economic costs, respectively. Total vaccine delivery costs were estimated at US$2.1 million (financial) and US$5.7 million (economic); and the corresponding cost per dose at US$3.84 (financial) and US$10.38 (economic). Vaccine delivery cost per dose (financial/economic) was estimated at US$2.93/12.84 and US$2.45/5.99 in hospitals and PHCs, respectively, and at US$7.34/20.29, US$3.96/11.89 and US$24.81/28.76 in fixed, temporary and mobile outreach sites, respectively. Staff time was the biggest economic cost driver for vaccine delivery in PHCs and hospitals while per diems and staff time were the biggest economic cost drivers for vaccine delivery in the three outreach delivery channels., Conclusion: This study offers insights for budgeting and planning of COVID-19 vaccine delivery in South Africa's public healthcare system. It also provides input for cost-effectiveness analyses to guide future strategies for maximizing vaccination coverage in the country., (© 2024. The Author(s).)

Background: There are variations in the numbers of pancreatic cancer deaths reported annually in South Africa (SA). Since pancreatic cancer deaths in SA from 1997 to 2016, the number of cases has hugely increased, and reached 23 581 in both sexes. Sex differences are likely to contribute to the variations in the strength of associations between the risk factors and pancreatic cancer mortality., Objective: To identify factors associated with an increased risk of pancreatic cancer mortality in SA., Methods: A matched case-control study with 1:1 matching was conducted using data collected by Statistics SA from 1997 to 2016. Controls were randomly selected to be as similar as possible to the cases, and matched by age, sex and year of death. Conditional logistic regression was used to identify factors associated with pancreatic cancer mortality., Results: This case-control study comprised a final selection of 23 581 cases (12 171 males and 11 410 females) and 23 581 controls (12 171 males and 11 410 females). A significantly increased risk of pancreatic cancer mortality was observed among males who were managers (odds ratio (OR) 2.99; 95% confidence interval (CI) 1.36 - 6.60; p=0.006) and craft and related trade workers (OR 1.89; 95% CI 1.14 - 3.14; p=0.013). Elevated risks of pancreatic cancer mortality were also found among females who were managers (OR 6.13; 95% CI 1.32 - 28.52; p=0.021), professionals (OR 2.12; 95% CI 1.24 - 3.63; p=0.006), clerical support workers (OR 3.78; 95% CI 1.79 - 7.98; p=0.001) and elementary occupation workers (OR 1.41; 95% CI 0.99 - 2.00; p=0.059). Smoking was significantly associated with pancreatic cancer mortality in females (OR 1.36; 95% CI 1.02 - 1.82; p=0.039). Working in several occupations was associated with an increased risk of pancreatic cancer mortality in males (OR 1.31; 95% CI 1.01 - 1.71; p=0.045) and females (OR 1.66; 95% CI 1.30 - 2.12; p<0.001)., Conclusion: Smoking and certain occupations increased the risk of pancreatic cancer mortality. Further research is needed to evaluate the associations between other extrinsic and intrinsic factors and pancreatic cancer mortality.

Background: Upon the addition of the numbers corresponding to various cancer anatomical locations in the report published by Statistics South Africa (StatsSA), the absolute number and proportion of deaths due to all cancers increased from 36 726 (8.0%) in 2013 to 40 460 (8.5%) in 2015. These high figures suggest that malignant neoplasms were in fact the second-most frequent cause of death in South Africa (SA) in 2013, and moved to the first rank in 2015., Objectives: To support the initiative aimed at reducing cancer mortality in SA. To this purpose, we assessed trends in cancer mortality rates among males and females in SA from 1997 to 2016 to better understand the increasing threat of cancer mortality in SA., Methods: The general mortality data for the period 1997 - 2016, as captured from death certificates in SA, was retrieved from StatsSA. Agestandardised mortality rates (ASMR) for each year were computed using the world standard population structure proposed by Segi as the reference population. The adjusted rates were reported per 100 000 population per year. The years of potential productive life lost (YPPLL) due to cancer deaths were calculated for each age group and gender., Results: There were 681  689 total cancer deaths from 1997 to 2016, with 51.1% males and 48.9% females. Males had higher mortality rates than females. The ASMR ranged from 105.0 to 129.2 and 67.9 to 88.3 per 100 000 population per year among males and females, respectively. In 2004, the cancer mortality rate increased significantly among males (129.2 per 100 000 population), which was 1.5 times higher than in females (88.3 per 100 000 population). Among males, cancer of the lung had the highest YPPLL (394 779.3), followed by oesophageal (253 989.4) and liver (207 911.0). The YPPLL for cancer of the cervix (647 855.5) ranked first, followed by breast (483 863.6) and lung (146 304.6) in females., Conclusion: Cancer mortality rates have increased since 1997, regardless of gender. Overall, there was a decline in YPPLL for cancer in the young population, while it increased in the adult population. A significant reduction in cancer deaths could be achieved by broadly applying effective interventions.

Introduction: The mortality data in South Africa (SA) have not been widely used to estimate the patterns of deaths attributed to cancer over a spectrum of relevant subgroups. There is no research in SA providing patterns and atlases of cancer deaths in age and sex groups per district per year. This study presents age-sex-specific geographical patterns of cancer mortality at the district level in SA and their temporal evolutions from 1997 to 2016., Methods: Individual mortality level data provided by Statistics South Africa were grouped by three age groups (0-14, 15-64, and 65+), sex (male and female), and aggregated at each of the 52 districts. The proportionate mortality ratios (PMRs) for cancer were calculated per 100 residents. The atlases showing the distribution of cancer mortality were plotted using ArcGIS. Spatial analyses were conducted through Moran's I test., Results: There was an increase in PMRs for cancer in the age groups 15-64 and 65+ years from 2006 to 2016. Ranges were 2.83 (95% CI: 2.77-2.89) -4.16 (95% CI: 4.08-4.24) among men aged 15-64 years and 2.99 (95% CI: 2.93-3.06) -5.19 (95% CI: 5.09-5.28) among women in this age group. The PMRs in men and women aged 65+ years were 2.47 (95% CI: 2.42-2.53) -4.06 (95% CI: 3.98-4.14), and 2.33 (95% CI: 2.27-2.38) -4.19 (95% CI: 4.11-4.28). There were considerable geographical variations and similarities in the patterns of cancer mortality. For the age group 15-64 years, the ranges were 1.18 (95% CI: 0.78-1.71) -8.71 (95% CI: 7.18-10.47), p  < 0.0001 in men and 1.35 (95% CI: 0.92-1.92) -10.83 (95% CI: 8.84-13.14), p  < 0.0001 in women in 2016. There were higher PMRs among women in the Western Cape, Northern Cape, North West, and Gauteng compared to other areas. Similar patterns were also observed among men in these provinces, except in North West and Gauteng., Conclusion: The identification of geographical and temporal distributions of cancer mortality provided evidence of periods and districts with similar and divergent patterns. This will contribute to understanding the past, present, future trends and formulating interventions at a local level., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Nhleko, Edoka and Musenge.)

Shigellosis is a leading cause of diarrhea and dysentery in young children from low to middle-income countries and adults experiencing traveler's diarrhea worldwide. In addition to acute illness, infection by Shigella bacteria is associated with stunted growth among children, which has been linked to detrimental long-term health, developmental, and economic outcomes. On March 24 and 29, 2021, PATH convened an expert panel to discuss the potential impact of Shigella vaccines on these long-term outcomes. Based on current empirical evidence, this discussion focused on whether Shigella vaccines could potentially alleviate the long-term burden associated with Shigella infections. Also, the experts provided recommendations about how to best model the burden, health and vaccine impact, and economic consequences of Shigella infections. This international multidisciplinary panel included 13 scientists, physicians, and economists from multiple relevant specialties. According to the panel, while the relationship between Shigella infections and childhood growth deficits is complex, this relationship likely exists. Vaccine probe studies are the crucial next step to determine whether vaccination could ameliorate Shigella infection - related long-term impacts. Infants should be vaccinated during their first year of life to maximize their protection from severe acute health outcomes and ideally reduce stunting risk and subsequent negative long-term developmental and health impacts. With vaccine schedule crowding, targeted or combination vaccination approaches would likely increase vaccine uptake in high-burden areas. Shigella impact and economic assessment models should include a wider range of linear growth outcomes. Also, these models should produce a spectrum of results-ones addressing immediate benefits for usual health care decision-makers and others that include broader health impacts, providing a more comprehensive picture of vaccination benefits. While many of the underlying mechanisms of this relationship need better characterization, the remaining gaps can be best addressed by collecting data post-vaccine introduction or through large trials., Competing Interests: Dr. Kotloff receives funding from Institut Pasteur to conduct Shigella vaccine clinical trials. Dr. Lanata is a member of the World Health Organization (WHO) COVID-19 vaccine effectiveness working group and WHO Product Development Advisory Group. All other authors have no competing interests to declare., (© 2022 The Authors.)

Background: Influenza accounts for a substantial number of deaths and hospitalisations annually in South Africa. To address this disease burden, the South African National Department of Health introduced a trivalent inactivated influenza vaccination programme in 2010., Methods: We adapted and populated the WHO Seasonal Influenza Immunization Costing Tool (WHO SIICT) with country-specific data to estimate the cost of the influenza vaccination programme in South Africa. Data were obtained through key-informant interviews at different levels of the health system and through a review of existing secondary data sources. Costs were estimated from a public provider perspective and expressed in 2018 prices. We conducted scenario analyses to assess the impact of different levels of programme expansion and the use of quadrivalent vaccines on total programme costs., Results: Total financial and economic costs were estimated at approximately USD 2.93 million and USD 7.91 million, respectively, while financial and economic cost per person immunised was estimated at USD 3.29 and USD 8.88, respectively. Expanding the programme by 5% and 10% increased economic cost per person immunised to USD 9.36 and USD 9.52 in the two scenarios, respectively. Finally, replacing trivalent inactivated influenza vaccine (TIV) with quadrivalent vaccine increased financial and economic costs to USD 4.89 and USD 10.48 per person immunised, respectively., Conclusion: We adapted the WHO SIICT and provide estimates of the total costs of the seasonal influenza vaccination programme in South Africa. These estimates provide a basis for planning future programme expansion and may serve as inputs for cost-effectiveness analyses of seasonal influenza vaccination programmes., (© 2022 The Authors. Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background: Coronavirus disease 2019 (COVID-19) has had a devastating impact globally, with severe health and economic consequences. To prepare health systems to deal with the pandemic, epidemiological and cost projection models are required to inform budgets and efficient allocation of resources. This study estimates daily inpatient care costs of COVID-19 in South Africa, an important input into cost projection and economic evaluation models., Methods: We adopted a micro-costing approach, which involved the identification, measurement and valuation of resources used in the clinical management of COVID-19. We considered only direct medical costs for an episode of hospitalisation from the South African public health system perspective. Resource quantities and unit costs were obtained from various sources. Inpatient costs per patient day was estimated for consumables, capital equipment and human resources for three levels of inpatient care - general wards, high care wards and intensive care units (ICUs)., Results: Average daily costs per patient increased with the level of care. The highest average daily cost was estimated for ICU admissions - 271 USD to 306 USD (financial costs) and ~800 USD to 830 USD (economic costs, excluding facility fee) depending on the need for invasive vs. non-invasive ventilation (NIV). Conversely, the lowest cost was estimated for general ward-based care - 62 USD to 79 USD (financial costs) and 119 USD to 278 USD (economic costs, excluding facility fees) depending on the need for supplemental oxygen. In high care wards, total cost was estimated at 156 USD, financial costs and 277 USD, economic costs (excluding facility fees). Probabilistic sensitivity analyses suggest our costs estimates are robust to uncertainty in cost inputs., Conclusion: Our estimates of inpatient costs are useful for informing budgeting and planning processes and cost-effectiveness analysis in the South African context. However, these estimates can be adapted to inform policy decisions in other context., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Background: When healthcare budgets are exogenous, cost-effectiveness thresholds (CETs) used to inform funding decisions should represent the health opportunity cost (HOC) of such funding decisions, but HOC-based CET estimates have not been available until recently. In recent years, empirical HOC-based CETs for multiple countries have been published, but the use of these CETs in the cost-effectiveness analysis (CEA) literature has not been investigated. Analysis of the use of HOC-based CETs by researchers undertaking CEAs in countries with different decision-making contexts will provide valuable insights to further understand barriers and facilitators to the acceptance and use of HOC-based CETs., Objectives: We aimed to identify the CET values used to interpret the results of CEAs published in the scientific literature before and after the publication of jurisdiction-specific empirical HOC-based CETs in four countries., Methods: We undertook a scoping review of CEAs published in Spain, Australia, the Netherlands and South Africa between 2016 (2014 in Spain) and 2020. CETs used before and after publication of HOC estimates were recorded. We conducted logit regressions exploring factors explaining the use of HOC values in identified studies and linear models exploring the association of the reported CET value with study characteristics and results., Results: 1171 studies were included in this review (870 CEAs and 301 study protocols). HOC values were cited in 28% of CEAs in Spain and in 11% of studies conducted in Australia, but they were not referred to in CEAs undertaken in the Netherlands and South Africa. Regression analyses on Spanish and Australian studies indicate that more recent studies, studies without a conflict of interest and studies estimating an incremental cost-effectiveness ratio (ICER) below the HOC value were more likely to use the HOC as a threshold reference. In addition, we found a small but significant impact indicating that for every dollar increase in the estimated ICER, the reported CET increased by US$0.015. Based on the findings of our review, we discuss the potential factors that might explain the lack of adoption of HOC-based CETs in the empirical CEA literature., Conclusions: The adoption of HOC-based CETs by identified published CEAs has been uneven across the four analysed countries, most likely due to underlying differences in their decision-making processes. Our results also reinforce a previous finding indicating that CETs might be endogenously selected to fit authors' conclusions., (© 2021. The Author(s).)

Primary healthcare systems are central to achieving universal healthcare coverage. However, in many low- and middle-income country settings, primary care quality is challenged by inadequate facility infrastructure and equipment, limited human resources, and poor provider process. We study the effects of a recent large-scale quality improvement policy in South Africa, the Ideal Clinics Realization and Maintenance Program (ICRMP). The ICRMP introduced a set of standards for facilities and a quality improvement process involving manuals, district-based support, and external assessment. Exploiting differential prioritization of facilities for the ICRMP's quality improvement process, we apply differences-in-differences methods to identify the effects of the program's efforts on standards scores and primary care quality indicators over the first 12 months of implementation. We find large and statistically significant increases in standards scores, but mixed effects on care outcomes-a small magnitude improvement in early antenatal care usage, null effects on childhood immunization and cervical cancer screening, and small negative effect of human immunodeficiency virus (HIV) care. While the ICRMP process has led to significant improvements in facilities' satisfaction of the program's standards, we were unable to detect meaningful change in care quality indicators., (© 2021 The Authors. Health Economics published by John Wiley & Sons Ltd.)

Background: In 2016, South Africa announced an intention to levy a tax on sugar-sweetened beverages (SSBs). In 2018, the country implemented an SSB tax of approximately 10%, known as the Health Promotion Levy (HPL). We aimed to assess changes in the purchases of beverages before and after the HPL announcement and implementation., Methods: We used Kantar Europanel data on monthly household purchases between January, 2014, and March, 2019, among a sample of South African households (n=113 653 household-month observations) from all nine provinces to obtain per-capita sugar, calories, and volume from taxable and non-taxable beverages purchased before and after the HPL announcement and implementation. We describe survey-weighted means for each period, and regression-controlled predictions of outcomes and counterfactuals based on pre-HPL announcement trends, with bootstrapped 95% CIs, and stratify results by socioeconomic status., Findings: Mean sugar from taxable beverage purchases fell from 16·25 g/capita per day (95% CI 15·80-16·70) to 14·26 (13·85-14·67) from the pre-HPL announcement to post-announcement period, and then to 10·63 g/capita per day (10·22-11·04) in the year after implementation. Mean volumes of taxable beverage purchases fell from 518·99 mL/capita per day (506·90-531·08) to 492·16 (481·28-503·04) from pre-announcement to post announcement, and then to 443·39 mL/capita per day (430·10-456·56) after implementation. Across these time periods, there was a small increase in the purchases of non-taxable beverages, from 283·45 mL/capita per day (273·34-293·56) pre-announcement to 312·94 (296·29-329·29) post implementation. When compared with pre-announcement counterfactual trends, reductions in taxable beverage purchase outcomes were significantly larger than the unadjusted survey-weighted observed reductions. Households with lower socioeconomic status purchased larger amounts of taxable beverages in the pre-announcement period than did households with higher socioeconomic status, but demonstrated bigger reductions after the tax was implemented., Interpretation: The announcement and introduction of South Africa's HPL were followed by reductions in the sugar, calories, and volume of beverage purchases., Funding: Bloomberg Philanthropies, International Development Research Centre, South African Medical Research Council, and the US National Institutes of Health., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Background: Dexamethasone and remdesivir have the potential to reduce coronavirus disease 2019 (COVID)-related mortality or recovery time, but their cost-effectiveness in countries with limited intensive care resources is unknown., Methods: We projected intensive care unit (ICU) needs and capacity from August 2020 to January 2021 using the South African National COVID-19 Epi Model. We assessed the cost-effectiveness of (1) administration of dexamethasone to ventilated patients and remdesivir to nonventilated patients, (2) dexamethasone alone to both nonventilated and ventilated patients, (3) remdesivir to nonventilated patients only, and (4) dexamethasone to ventilated patients only, all relative to a scenario of standard care. We estimated costs from the health care system perspective in 2020 US dollars, deaths averted, and the incremental cost-effectiveness ratios of each scenario., Results: Remdesivir for nonventilated patients and dexamethasone for ventilated patients was estimated to result in 408 (uncertainty range, 229-1891) deaths averted (assuming no efficacy [uncertainty range, 0%-70%] of remdesivir) compared with standard care and to save $15 million. This result was driven by the efficacy of dexamethasone and the reduction of ICU-time required for patients treated with remdesivir. The scenario of dexamethasone alone for nonventilated and ventilated patients requires an additional $159 000 and averts 689 [uncertainty range, 330-1118] deaths, resulting in $231 per death averted, relative to standard care., Conclusions: The use of remdesivir for nonventilated patients and dexamethasone for ventilated patients is likely to be cost-saving compared with standard care by reducing ICU days. Further efforts to improve recovery time with remdesivir and dexamethasone in ICUs could save lives and costs in South Africa., (© The Author(s) 2021. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

Background: Seasonal influenza imposes a significant health and economic burden in South Africa, particularly in populations vulnerable to severe consequences of influenza. This study assesses the cost-effectiveness of South Africa's seasonal influenza vaccination strategy, which involves vaccinating vulnerable populations with trivalent inactivated influenza vaccine (TIV) during routine facility visits. Vulnerable populations included in our analysis are persons aged ≥ 65 years; pregnant women; persons living with HIV/AIDS (PLWHA), persons of any age with underlying medical conditions (UMC) and children aged 6-59 months., Method: We employed the World Health Organisation's (WHO) Cost Effectiveness Tool for Seasonal Influenza Vaccination (CETSIV), a decision tree model, to evaluate the 2018 seasonal influenza vaccination campaign from a public healthcare provider and societal perspective. CETSIV was populated with existing country-specific demographic, epidemiologic and coverage data to estimate incremental cost-effectiveness ratios (ICERs) by comparing costs and benefits of the influenza vaccination programme to no vaccination., Results: The highest number of clinical events (influenza cases, outpatient visits, hospitalisation and deaths) were averted in PLWHA and persons with other UMCs. Using a cost-effectiveness threshold of US$ 3400 per quality-adjusted life year (QALY), our findings suggest that the vaccination programme is cost-effective for all vulnerable populations except for children aged 6-59 months. ICERs ranged from ~US$ 1 750 /QALY in PLWHA to ~US$ 7500/QALY in children. In probabilistic sensitivity analyses, the vaccination programme was cost-effective in pregnant women, PLWHA, persons with UMCs and persons aged ≥65 years in >80% of simulations. These findings were robust to changes in many model inputs but were most sensitive to uncertainty in estimates of influenza-associated illness burden., Conclusion: South Africa's seasonal influenza vaccination strategy of opportunistically targeting vulnerable populations during routine visits is cost-effective. A budget impact analysis will be useful for supporting future expansions of the programme., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020. Published by Elsevier Ltd.)

Public payers around the world are increasingly using cost-effectiveness thresholds (CETs) to assess the value-for-money of an intervention and make coverage decisions. However, there is still much confusion about the meaning and uses of the CET, how it should be calculated, and what constitutes an adequate evidence base for its formulation. One widely referenced and used threshold in the last decade has been the 1-3 GDP per capita, which is often attributed to the Commission on Macroeconomics and  WHO guidelines on Choosing Interventions that are Cost Effective (WHO-CHOICE). For many reasons, however, this threshold has been widely criticised; which has led experts across the world, including the WHO, to discourage its use. This has left a vacuum for policy-makers and technical staff at a time when countries are wanting to move towards Universal Health Coverage . This article seeks to address this gap by offering five practical options for decision-makers in low- and middle-income countries that can be used instead of the 1-3 GDP rule, to combine existing evidence with fair decision-rules or develop locally relevant CETs. It builds on existing literature as well as an engagement with a group of experts and decision-makers working in low, middle and high income countries., Competing Interests: No competing interests were disclosed., (Copyright: © 2020 Chi YL et al.)

Background: Data on influenza economic burden in risk groups for severe influenza are important to guide targeted influenza immunization, especially in resource-limited settings. However, this information is limited in low- and middle-income countries., Methods: We estimated the cost (from a health system and societal perspective) and years of life lost (YLL) for influenza-associated illness in South Africa during 2013-2015 among (i) children aged 6-59 months, (ii) individuals aged 5-64 years with HIV, pulmonary tuberculosis (PTB) and selected underlying medical conditions (UMC), separately, (iii) pregnant women and (iv) individuals aged ≥65 years, using publicly available data and data collected through laboratory-confirmed influenza surveillance and costing studies. All costs were expressed in 2015 prices using the South Africa all-items Consumer Price Index., Results: During 2013-2015, the mean annual cost of influenza-associated illness among the selected risk groups accounted for 52.1% ($140.9/$270.5 million) of the total influenza-associated illness cost (for the entire population of South Africa), 45.2% ($52.2/$115.5 million) of non-medically attended illness costs, 43.3% ($46.7/$107.9 million) of medically-attended mild illness costs and 89.3% ($42.0/$47.1 million) of medically-attended severe illness costs. The YLL among the selected risk groups accounted for 86.0% (262,069 /304,867 years) of the total YLL due to influenza-associated death., Conclusion: In South Africa, individuals in risk groups for severe influenza accounted for approximately half of the total influenza-associated illness cost but most of the cost of influenza-associated medically attended severe illness and YLL. This study provides the foundation for future studies on the cost-effectiveness of influenza immunization among risk groups., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background South Africa recently experienced a first peak in COVID-19 cases and mortality. Dexamethasone and remdesivir both have the potential to reduce COVID-related mortality, but their cost-effectiveness in a resource-limited setting with scant intensive care resources is unknown. Methods We projected intensive care unit (ICU) needs and capacity from August 2020 to January 2021 using the South African National COVID-19 Epi Model. We assessed cost-effectiveness of 1) administration of dexamethasone to ventilated patients and remdesivir to non-ventilated patients, 2) dexamethasone alone to both non-ventilated and ventilated patients, 3) remdesivir to non-ventilated patients only, and 4) dexamethasone to ventilated patients only; all relative to a scenario of standard care. We estimated costs from the healthcare system perspective in 2020 USD, deaths averted, and the incremental cost effectiveness ratios of each scenario. Results Remdesivir for non-ventilated patients and dexamethasone for ventilated patients was estimated to result in 1,111 deaths averted (assuming a 0-30% efficacy of remdesivir) compared to standard care, and save $11.5 million. The result was driven by the efficacy of the drugs, and the reduction of ICU-time required for patients treated with remdesivir. The scenario of dexamethasone alone to ventilated and non-ventilated patients requires additional $159,000 and averts 1,146 deaths, resulting in $139 per death averted, relative to standard care. Conclusions The use of dexamethasone for ventilated and remdesivir for non-ventilated patients is likely to be cost-saving compared to standard care. Given the economic and health benefits of both drugs, efforts to ensure access to these medications is paramount.

Background : age structured mathematical models have been used to evaluate the impact of rubella-containing vaccine (RCV) introduction into existing measles vaccination programs in several countries. South Africa has a well-established measles vaccination program and is considering RCV introduction. This study aimed to provide a comparison of different scenarios and their relative costs within the context of congenital rubella syndrome (CRS) reduction or elimination. Methods : we used a previously published age-structured deterministic discrete time rubella transmission model. We obtained estimates of vaccine costs from the South African medicines price registry and the World Health Organization. We simulated RCV introduction and extracted estimates of rubella incidence, CRS incidence and effective reproductive number over 30 years. Results : compared to scenarios without mass campaigns, scenarios including mass campaigns resulted in more rapid elimination of rubella and congenital rubella syndrome (CRS). Routine vaccination at 12 months of age coupled with vaccination of nine-year-old children was associated with the lowest RCV cost per CRS case averted for a similar percentage CRS reduction. Conclusion : At 80% RCV coverage, all vaccine introduction scenarios would achieve rubella and CRS elimination in South Africa. Any RCV introduction strategy should consider a combination of routine vaccination in the primary immunization series and additional vaccination of older children.

Background: Data on influenza burden in risk groups for severe influenza are important to guide targeted influenza immunization, especially in resource limited settings. However, this information is limited overall and in particular in low- and middle-income countries. We sought to assess the mean annual national burden of medically and non-medically attended influenza-associated mild, severe-non-fatal and fatal illness among potential target groups for influenza immunization in South Africa during 2013-2015., Methods: We used published mean national annual estimates of mild, severe-non-fatal, and fatal influenza-associated illness in South Africa during 2013-2015 and estimated the number of such illnesses occurring among the following risk groups: (i) children aged 6-59 months; (ii) individuals aged 5-64 years with HIV, and/or pulmonary tuberculosis (PTB), and/or selected underlying medical conditions (UMC); (iii) pregnant women; and (iv) individuals aged ≥65 years. We also estimated the number of individuals among the same risk groups in the population., Results: During 2013-2015, individuals in the selected risk groups accounted for 45.3% (24,569,328/54,086,144) of the population and 43.5% (4,614,763/10,598,138), 86.8% (111,245/128,173) and 94.5% (10,903/11,536) of the mean annual estimated number of influenza-associated mild, severe-non-fatal and fatal illness episodes, respectively. The rates of influenza-associated illness were highest in children aged 6-59 months (23,983 per 100,000 population) for mild illness, in pregnant women (930 per 100,000 population) for severe-non-fatal illness and in individuals aged ≥65 years (138 per 100,000 population) for fatal illness., Conclusion: Influenza immunization of the selected risk groups has the potential to prevent a substantial number of influenza-associated severe illness. Nonetheless, because of the high number of individuals at risk, South Africa, due to financial resources constrains, may need to further prioritize interventions among risk populations. Cost-burden and cost-effectiveness estimates may assist with further prioritization., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

A growing number of jurisdictions are introducing taxes on sugar-sweetened beverages (SSBs) in efforts to reduce sugar intake, obesity, and associated metabolic conditions. A key dimension of the impact of such taxes is how they induce changes in the prices of the taxed beverages and their un-taxed substitutes. At present these taxes have typically been based solely on volume. More recently, however, due to the potential to target the source of SSBs' health harms and to incentivize product reformulation, SSB taxes are being levied based on sugar content. In April of 2018 South Africa implemented such a tax, the Health Promotion Levy (HPL), at a rate of 0.021 ZAR (approximately 0.15 US cents) for each gram of sugar over an initial threshold of 4 g/100 ml. Drawing on a dataset of price observations (N = 71, 677) collected in South Africa between January 2013 and March 2019, we study changes in beverage prices following the introduction of the HPL. We find null price increases among un-taxed beverages and find significant price increases for carbonates, the largest taxed product category. However, within carbonates we find similar increases in price for low- and high-sugar brands, despite the underlying difference in tax liability. In addition, while we find evidence of product reformulation, we find significant price increases among the brands that reduced their sugar content. While the findings are broadly consistent with the price changes of volume-based SSB taxes, future considerations of price effects of sugar-based SSB taxes need to account for the opportunity for intra-firm heterogeneity in price response among large multi-product firms., (Copyright © 2019 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Economic burden estimates are essential to guide policy-making for influenza vaccination, especially in resource-limited settings., Methods: We estimated the cost, absenteeism, and years of life lost (YLL) of medically and non-medically attended influenza-associated mild and severe respiratory, circulatory and non-respiratory/non-circulatory illness in South Africa during 2013-2015 using a modified version of the World Health Organization (WHO) worksheet based tool for estimating the economic burden of seasonal influenza. Additionally, we restricted the analysis to influenza-associated severe acute respiratory illness (SARI) and influenza-like illness (ILI; subsets of all-respiratory illnesses) as suggested in the WHO manual., Results: The estimated mean annual cost of influenza-associated illness was $270.5 million, of which $111.3 million (41%) were government-incurred costs, 40.7 million (15%) were out-of-pocket expenses, and $118.4 million (44%) were indirect costs. The cost of influenza-associated medically attended mild illness ($107.9 million) was 2.3 times higher than that of severe illness ($47.1 million). Influenza-associated respiratory illness costs ($251.4 million) accounted for 93% of the total cost. Estimated absenteeism and YLL were 13.2 million days and 304 867 years, respectively. Among patients with influenza-associated WHO-defined ILI or SARI, the costs ($95.3 million), absenteeism (4.5 million days), and YLL (65 697) were 35%, 34%, and 21% of the total economic and health burden of influenza., Conclusion: The economic burden of influenza-associated illness was substantial from both a government and a societal perspective. Models that limit estimates to those obtained from patients with WHO-defined ILI or SARI substantially underestimated the total economic and health burden of influenza-associated illness., (© 2019 The Authors. Influenza and Other Respiratory Viruses Published by John Wiley & Sons Ltd.)

Objectives: Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments., Methods: A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses., Results: The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as -R578 and -R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses., Conclusions: Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa., (Copyright © 2019 ISPOR–The professional society for health economics and outcomes research. Published by Elsevier Inc. All rights reserved.)

Background: At the end of the eleven-year conflict in Sierra Leone, a wide range of policies were implemented to address both demand- and supply-side constraints within the healthcare system, which had collapsed during the conflict. This study examines the extent to which households' exposure to financial risks associated with seeking healthcare evolved in post-conflict Sierra Leone., Method: This study uses the 2003 and 2011 cross-sections of the Sierra Leone Integrated Household Survey to examine changes in catastrophic health expenditure between 2003 and 2011. An Oaxaca-Blinder decomposition approach is used to quantify the extent to which changes in catastrophic health expenditure are attributable to changes in the distribution of determinants (distributional effect) and to changes in the impact of these determinants on the probability of incurring catastrophic health expenditure (coefficient effect)., Results: The incidence of catastrophic health expenditure decreased significantly by 18% from approximately 50% in 2003 t0 32% in 2011. The decomposition analysis shows that this decrease represents net effects attributable to the distributional and coefficient effects of three determinants of catastrophic health expenditure - ill-health, the region in which households reside and the type of health facility used. A decrease in the incidence of ill-health and changes in the regional location of households contributed to a decrease in catastrophic health expenditure. The distributional effect of health facility types observed as an increase in the use of public health facilities, and a decrease in the use of services in facilities owned by non-governmental organizations (NGOs) also contributed to a decrease in the incidence of catastrophic health expenditure. However, the coefficient effect of public health facilities and NGO-owned facilities suggests that substantial exposure to financial risk remained for households utilizing both types of health facilities in 2011., Conclusion: The findings support the need to continue expanding current demand-side policies in Sierra Leone to reduce the financial risk of exposure to ill health.

Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting. Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 and 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation. Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect. Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected., (Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Achieving sustainable universal health coverage depends partly on fair priority-setting processes that ensure countries spend scarce resources wisely. While general health economics capacity-strengthening initiatives exist in Africa, less attention has been paid to developing the capacity of individuals, institutions and networks to apply economic evaluation in support of health technology assessment and effective priority-setting., Objective: On the basis of international  lessons, to identify how research organisations and partnerships could contribute to capacity strengthening for health technology assessment and priority-setting in Africa., Methods: A rapid scan was conducted of international formal and grey literature and lessons extracted from the deliberations of two international and regional workshops relating to capacity-building for health technology assessment. 'Capacity' was defined in broad terms, including a conducive political environment, strong public institutional capacity to drive priority-setting, effective networking between experts, strong research organisations and skilled researchers., Results: Effective priority-setting requires more than high quality economic research. Researchers have to engage with an array of stakeholders, network closely other research organisations, build partnerships with different levels of government and train the future generation of researchers and policy-makers. In low- and middle-income countries where there are seldom government units or agencies dedicated to health technology assessment, they also have to support the development of an effective priority-setting process that is sensitive to societal and government needs and priorities., Conclusions: Research organisations have an important role to play in contributing to the development of health technology assessment and priority-setting capacity. In Africa, where there are resource and capacity challenges, effective partnerships between local and international researchers, and with key government stakeholders, can leverage existing skills and knowledge to generate a critical mass of individuals and institutions. These would help to meet the priority-setting needs of African countries and contribute to sustainable universal health coverage.

This study evaluates the impact of Sierra Leone's 2010 Free Health Care Initiative (FHCI). It uses two nationally representative surveys to identify the impact of the policy on utilisation of maternal care services by pregnant women and recent mothers as well as the impact on curative health care services and out-of-pocket payments for consultation and prescription in children under the age of 5 years. A Regression Discontinuity Design (RDD) is applied in the case of young children and a before-after estimation approach, adjusted for time trends in the case of expectant and recent mothers. Our results suggest that children affected by the FHCI have a lower probability of incurring any health expenditure in public, non-governmental and missionary health facilities. However, a proportion of eligible children are observed to incur some health expenditure in participating facilities with no impact of the policy on the level of out-of-pocket health expenditure. Similarly, no impact is observed with the utilisation of services in these facilities. Utilisation of informal care is observed to be higher among non-eligible children while in expectant and recent mothers, we find substantial but possibly transient increases in the use of key maternal health care services in public facilities following the implementation of the FHCI. The diminishing impact on utilisation mirrors experience in other countries that have implemented free health care initiatives and demonstrates the need for greater domestic and international efforts to ensure that resources are sufficient to meet increasing demand and monitor the long run impact of these policies.

Objective: To assess the cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya., Methods: Incremental cost-effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. Life years gained were estimated based on coverage of reproductive, maternal, neonatal and child health services. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. For Indonesia, coverage of health service interventions was estimated from routine data. We used the Lives Saved Tool to estimate the number of lives saved from changes in reproductive, maternal, neonatal and child health-service coverage. Gross domestic product per capita was used as the reference willingness-to-pay threshold value., Findings: The estimated incremental cost per life year gained was 82 international dollars ($)in Kenya, $999 in Ethiopia and $3396 in Indonesia. The results were most sensitive to uncertainty in the estimates of life-years gained. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective., Conclusion: Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. Community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.

To achieve universal health coverage (UHC), a range of health-financing reforms, including removal of user fees and the expansion of social health insurance, have been implemented in many countries. While the focus of much research and discussion on UHC has been on the impact of health-financing reforms on population coverage, health-service utilization and out-of-pocket payments, the implications of such reforms for the distribution and performance of the health workforce have often been overlooked. Shortages and geographical imbalances in the distribution of skilled health workers persist in many low- and middle-income countries, posing a threat to achieving UHC. This paper suggests that there are risks associated with health-financing reforms, for the geographical distribution and performance of the health workforce. These risks require greater attention if poor and rural populations are to benefit from expanded financial protection.