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ObjectiveTo investigate the tobacco-attributable burden on disease, medical costs, productivity losses and informal caregiving; and to estimate the health and economic gains that can be achieved if the main tobacco control measures (raising taxes on tobacco, plain packaging, advertising bans and smoke-free environments) are fully implemented in eight countries that encompass 80% of the Latin American population.DesignMarkov probabilistic microsimulation economic model of the natural history, costs and quality of life associated with the main tobacco-related diseases. Model inputs and data on labour productivity, informal caregivers’ burden and interventions’ effectiveness were obtained through literature review, surveys, civil registrations, vital statistics and hospital databases. Epidemiological and economic data from January to October 2020 were used to populate the model.FindingsIn these eight countries, smoking is responsible each year for 351 000 deaths, 2.25 million disease events, 12.2 million healthy years of life lost, US$22.8 billion in direct medical costs, US$16.2 billion in lost productivity and US$10.8 billion in caregiver costs. These economic losses represent 1.4% of countries’ aggregated gross domestic products. The full implementation and enforcement of the four strategies: taxes, plain packaging, advertising bans and smoke-free environments would avert 271 000, 78 000, 71 000 and 39 000 deaths, respectively, in the next 10 years, and result in US$63.8, US$12.3, US$11.4 and US$5.7 billions in economic gains, respectively, on top of the benefits being achieved today by the current level of implementation of these measures.ConclusionsSmoking represents a substantial burden in Latin America. The full implementation of tobacco control measures could successfully avert deaths and disability, reduce healthcare spending and caregiver and productivity losses, likely resulting in large net economic benefits.

Background: Globally, tobacco consumption continues to cause a huge burden of preventable diseases. Chile has been leading the tobacco burden ranking in the Latin American region for the last ten years; it has currently a 33. 3% prevalence of current smokers. Methods: A microsimulation economic model was developed within the framework of a multi-country project in order to estimate the burden attributable to smoking in terms of morbidity, mortality, disability-adjusted life-years (DALYs), and direct costs of care. We also modelled the impact of increasing cigarettes' taxes on this burden. Results: In Chile, 16,472 deaths were attributable to smoking in 2017, which represent around 16% of all deaths. This burden corresponds to 416,445 DALYs per year. The country's health system spends 1.15 trillion pesos annually (in Dec 2017 CLP, approx. U$D 1.8 billion) in health care treatment of illnesses caused by smoking. If the price of tobacco cigarettes was to be raised by 50%, around 13,665 deaths and 360,476 DALYs from smoking-attributable diseases would be averted in 10 years, with subsequent savings on health care costs, and increased tax revenue collection. In Chile, the tobacco tax collection does not fully cover the direct healthcare costs attributed to smoking. Conclusion: Despite a reduction observed on smoking prevalence between 2010 (40.6%) and 2017 (33.3%), this study shows that the burden of disease, and the economic toll due to smoking, remain high. As we demonstrate, a rise in the price of cigarettes could lead to a significant reduction of this burden, averting deaths and disability, and reducing healthcare spending. Fil: Castillo Riquelme, Marianela. Universidad de Chile; Chile Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Palacios, Alfredo. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina

Background: Worldwide, smoking tobacco causes 7 million deaths annually, and this toll is expected to increase, especially in low-income and middle-income countries. In Latin America, smoking is a leading risk factor for death and disability, contributes to poverty, and imposes an economic burden on health systems. Despite being one of the most effective measures to reduce smoking, tobacco taxation is underused and cigarettes are more affordable in Latin America than in other regions. Our aim was to estimate the tobacco-attributable burden on mortality, disease incidence, quality of life lost, and medical costs in 12 Latin American countries, and the expected health and economic effects of increasing tobacco taxes. Methods: In this modelling study, we developed a Markov probabilistic microsimulation economic model of the natural history, medical costs, and quality-of-life losses associated with the most common tobacco-related diseases in 12 countries in Latin America. Data inputs were obtained through a literature review, vital statistics, and hospital databases from each country: Argentina, Bolivia, Brazil, Chile, Colombia, Costa Rica, Ecuador, Honduras, Mexico, Paraguay, Peru, and Uruguay. The main outcomes of the model are life-years, quality-adjusted life-years, disease events, hospitalisations, disease incidence, disease cost, and healthy years of life lost. We estimated direct medical costs for each tobacco-related disease included in the model using a common costing methodology for each country. The disease burden was estimated as the difference in disease events, deaths, and associated costs between the results predicted by the model for current smoking prevalence and a hypothetical cohort of people in each country who had never smoked. The model estimates the health and financial effects of a price increase of cigarettes through taxes, in terms of disease and health-care costs averted, and increased tax revenues. Findings: In the 12 Latin American countries analysed, we estimated that smoking is responsible for approximately 345 000 (12%) of the total 2 860 921 adult deaths, 2·21 million disease events, 8·77 million healthy years of life lost, and $26·9 billion in direct medical costs annually. Health-care costs attributable to smoking were estimated to represent 6·9% of the health budgets of these countries, equivalent to 0·6% of their gross domestic product. Tax revenues from cigarette sales cover 36·0% of the estimated health expenditures caused by smoking. We estimated that a 50% increase in cigarette price through taxation would avert more than 300 000 deaths, 1·3 million disease events, gain 9 million healthy life-years, and save $26·7 billion in health-care costs in the next 10 years, with a total economic benefit of $43·7 billion. Interpretation: Smoking represents a substantial health and economic burden in these 12 countries of Latin America. Tobacco tax increases could successfully avert deaths and disability, reduce health-care spending, and increase tax revenues, resulting in large net economic benefits. Fil: Pichón-riviere, Andres. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Palacios, Alfredo. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Rodríguez, Belén. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Reynales Shigematsu, Luz Myriam. Instituto Nacional de Salud Pública; México Fil: Pinto, Márcia. Fundación Oswaldo Cruz; Brasil Fil: Castillo Riquelme, Marianela. Ministerio de Salud; Chile Fil: Peña Torres, Esperanza. Instituto de Evaluación Tecnológica En Salud; Colombia Fil: Osorio, Diana Isabel. Instituto de Evaluación Tecnológica en Salud; Colombia Fil: Huayanay, Leandro. Universidad Peruana Cayetano Heredia; Perú Fil: Loza Munarriz, Cesar. Universidad Peruana Cayetano Heredia; Perú Fil: Sáenz de Miera-Juárez, Belén. Universidad Autónoma de Baja California Sur; México Fil: Gallegos Rivero, Verónica. Centro Nacional de Excelencia Tecnológica en Salud; México Fil: De La Puente, Catherine. Universidad de La Frontera; Chile Fil: Navia Bueno, María del Pilar. Universidad Mayor de San Andrés; Bolivia Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Roberti, Javier Eugenio. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Virgilio, Sacha Alexis. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Parque Centenario. Centro de Investigaciones en Epidemiología y Salud Pública. Instituto de Efectividad Clínica y Sanitaria. Centro de Investigaciones en Epidemiología y Salud Pública; Argentina

Background: The increase in agricultural activity that Chile experienced in the past 20 years resulted in a boost in the use of pesticides. Despite pesticides’ productivity benefits, they caused health problems such as the increased frequency of episodes of acute poisoning, which constitutes a relevant problem in terms of occupational health. The Chilean authorities require several preventive measures at workplaces, which are not always implemented, increasing the risk of intoxications in farmers. So far in Chile, there are no studies concerning the public health care expenses associated with acute work-related pesticide intoxications. From the societal perspective, there are costs involved if the worker needs to take sick leave and families incur costs to take care of their sick members. Objectives: This study aimed to determine the costs associated with health care services used by people who suffered from work-related acute pesticide poisoning, as well as the economic costs for the families of the workers involved, and finally the costs of these episodes for the employer/industrial sector. Methods: This study considered a 3-year period (January 2009 to December 2011). Three sources of data were reviewed: reported cases at the Regional Health Authority, for the profile of the intoxications; registers of patients attended in public hospitals, for data on costs of health care services; and public information of living conditions nationwide. Results: The overall costs of a single case depend on the severity of intoxication, days of sick leave, and type of health care needed. Most cases (77%) would be ambulatory and would be assisted at an emergency room, with an average cost of US $330 per case. Those cases that might need hospitalization (23%) and, therefore, more days off work have an average cost of US $1158 per case. Taking into account the number of patients reported each year in the country, the cost per annum would be about US $185,000, but considering the underreporting of intoxications and underestimation of costs at the public insurance system fees, this amount could be six to eight times higher (US $1.1 million to US $1.4 million a year). Conclusions: This study is the first attempt to estimate costs related to this occupational and public health problem. There is an opportunity to further improve the cost-benefit balance of preventive measures that relate not only to acute poisonings but also to health problems originating from chronic and low-dose exposure to pesticides (e.g., neuropsychological impairment).

The Chilean health system has not been completely oblivious to health technology assessment (HTA). In fact, significant advances in the areas of health prioritization using criteria of disease burden, effectiveness and cost-effectiveness among others, can be acknowledged. The introduction of the reform of Explicit Health Guarantees (GES) has been an important milestone in this arena, allowing the consideration of other dimensions such as social preferences in health. However, the application of HTA encompasses the entire health system and in that sense the institutionalization of a process properly defined and extensively validated in our country, is imminent. This paper discusses the foundations on which progress must be made in institutionalizing HTA, starting from the architecture of our health care system and in light of the economic and social reality. We review some background information first, and then discuss some important considerations in our context, including information on the institutional and legal framework. It concludes with the authors' view on some key elements to consider in HTA in Chile, which does not necessarily represent the vision of the Ministry of Health.

Objetivo: Estimar los costos médicos directos atribuibles al tabaquismo en los sistemas de salud de América Latina.Métodos. Se utilizó un modelo de microsimulación para cuantificar el impacto económico en enfermedad cardiovascular y cerebrovascular, enfermedad pulmonar obstructiva crónica (EPOC), neumonía, cáncer de pulmón y otras nueve neoplasias. Se realizó una búsqueda sistemática de datos epidemiológicos y de costos de los eventos. El modelo se calibró y validó para Argentina, Bolivia, Brasil, Chile, Colombia, México y Perú, países que representan el 78% dela población de América Latina; luego se extrapolaron los resultados a nivel regional.Resultados. Cada año el tabaquismo es responsable de 33 576 millones de dólares en costos directos para el sistema de salud. Esto equivale a 0,7% del producto interno bruto (PIB) de la región y a 8,3% del presupuesto sanitario. La enfermedad cardiovascular, la EPOC y el cáncer fueron responsables de 30,3%, 26,9% y 23,7% de este gasto, respectivamente. El costo atribuible al tabaquismo varió entre 0,4% (México y Perú) y 0,9% (Chile) del PIB y entre 5,2% (Brasil) y 12,7% (Bolivia) del gasto en salud. En la región, la recaudación impositiva por la venta de cigarrillos apenas cubre 37% del gasto sanitario atribuible al tabaquismo (8,1% en Bolivia y 67,3% en Argentina).Conclusiones. El tabaquismo es responsable de una importante proporción del gasto sanitario en América Latina, y la recaudación impositiva por la venta de cigarrillos está lejos de llegara cubrirlo. La profundización de medidas como el aumento de impuestos al tabaco debería ser seriamente considerada por los países de la región. Objective: Estimate smoking-attributable direct medical costs in Latin American health systems. Methods A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America’s population; the results were then extrapolated to the regional level. Results Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region’s gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina). Conclusions Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region’s countries should seriously consider stronger measures, such as an increase in tobacco taxes. Fil: Pichón-Riviere, Andrés. Instituto de Efectividad Clínica y Sanitaria; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina Fil: Bardach, Ariel Esteban. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Augustovski, Federico Ariel. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Alcaraz, Andrea. Instituto de Efectividad Clínica y Sanitaria; Argentina Fil: Reynales Shigematsu, Luz Myriam. Instituto Nacional de Salud Pública. Centro de Investigación en Salud Poblacional. Departamento de Investigación sobre Tabaco; México Fil: Teixeira Pinto, Márcia. Fundação Oswaldo Cruz. Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente "Fernandes Figueira"; Brasil Fil: Castillo Riquelme, Marianela. Ministerio de Salud. Departamento de Economía de la Salud; Chile Fil: Peña Torres, Esperanza. Instituto de Evaluación Tecnológica en Salud ; Colombia Fil: Isabel Osorio, Diana. Instituto de Evaluación Tecnológica en Salud ; Colombia Fil: Huayanay, Leandro. Universidad Peruana Cayetano Heredia; Perú Fil: Loza Munarriz, César. Universidad Peruana Cayetano Heredia; Perú Fil: Sáenz de Miera-Juárez, Belén. Instituto Nacional de Salud Pública. Centro de Investigación en Salud Poblacional. Departamento de Investigación sobre Tabaco; México Fil: Gallegos Rivero, Verónica. Secretaría de Salud. Centro Nacional de Excelencia Tecnológica en Salud; México Fil: De La Puente, Catherine. Universidad de La Frontera; Chile Fil: Navia Bueno, María del Pilar. Universidad Mayor de San Andrés; Bolivia Fil: Caporale, Joaquín. Instituto de Efectividad Clínica y Sanitaria; Argentina

Fenómenos como el aumento progresivo del gasto en salud y el envejecimiento poblacional han obligado a los distintos países a considerar metodologías económicas que permitan obtener un mayor beneficio sanitario dentro de un contexto de recursos limitados. El presente artículo describe los componentes básicos a considerar en una evaluación de tecnología sanitaria, analiza el proceso de toma de decisión en un análisis de costo efectividad y reporta como dicha metodología ha sido implementada en América Latina y en el resto de mundo. Phenomena as the progressive increase of health expenditure and the population aging have lead many countries to consider economic methodologies in order to obtain bigger sanitary benefits in contexts of limited resources. This article describes the basic components to consider in a health technology assessment , it analyses the process of decision making with cost-effectiveness analysis and reports how this methodology has been widely implemented in Latin America and the rest of the world.

Given current lack of routine data, assessing the burden of HIV/AIDS on the public healthcare system is complex. This research aimed to collect a wide range of data that could be used to estimate this burden and the costs of meeting it. Data collection was undertaken by research doctors who were employed in a wide spectrum of facilities to compile information on patients' HIV-status, retrospective utilisation of services and unit costs of care. Key results indicated that the percentage of expenditure on HIV-related care was 26% across all facilities. HIV-positive patients had higher utilisation of services compared to other patient groups; the annual cost per patient was estimated to be R4,813 (2007/08 prices). Results should be interpreted in the light of the underlying population need and context-specific access barriers.

OBJECTIVES To evaluate treatment-seeking behaviour, financial impact and time lost due to malaria events, in southern Mozambique and eastern South Africa. METHODS In-depth household surveys (828 in Mozambique and 827 in South Africa) were analysed. An asset index was calculated using principal component analysis to allow comparison across socio-economic groups. Direct costs of seeking care and the time lost due to malaria were determined. The extent of catastrophic payments was assessed using as thresholds the traditional 10% of household income and 40% of non-food income, as recently recommended by WHO. RESULTS Poverty was highly prevalent: 70% of the South African and 95% of Mozambican households studied lived on less than $1 per capita per day. Around 97% of those with recent malaria sought healthcare, mainly in public facilities. Out-of-pocket household expenditure per malaria episode averaged $2.30 in South Africa and $6.50 in Mozambique. Analysis at the individual household level found that 32-34% of households in Mozambique, compared with 9-13% of households in South Africa, incurred catastrophic payments for malaria episodes. Results based on mean values underestimated the prevalence of catastrophic payments. Days off work/school were higher in Mozambique. CONCLUSIONS The high rate of health seeking in public health facilities seems unusual in the African context, which bodes well for high coverage with artemisinin-based combinations, even if only deployed within the public sector. However, despite no or modest charges for public sector primary healthcare, households frequently incur catastrophic expenditure on a single malaria episode.

The Chilean health system has not been completely oblivious to health technology assessment (HTA). In fact, significant advances in the areas of health prioritization using criteria of disease burden, effectiveness and cost-effectiveness among others, can be acknowledged. The introduction of the reform of Explicit Health Guarantees (GES) has been an important milestone in this arena, allowing the consideration of other dimensions such as social preferences in health. However, the application of HTA encompasses the entire health system and in that sense the institutionalization of a process properly defined and extensively validated in our country, is imminent. This paper discusses the foundations on which progress must be made in institutionalizing HTA, starting from the architecture of our health care system and in light of the economic and social reality. We review some background information first, and then discuss some important considerations in our context, including information on the institutional and legal framework. It concludes with the authors' view on some key elements to consider in HTA in Chile, which does not necessarily represent the vision of the Ministry of Health.

Phenomena as the progressive increase of health expenditure and the population aging have lead many countries to consider economic methodologies in order to obtain bigger sanitary benefits in contexts of limited resources. This article describes the basic components to consider in a health technology assessment , it analyses the process of decision making with cost-effectiveness analysis and reports how this methodology has been widely implemented in Latin America and the rest of the world.

Background The objective of this study is to report the costs of Chagas disease in Colombia, in terms of vector disease control programmes and the costs of providing care to chronic Chagas disease patients with cardiomyopathy. Methods Data were collected from Colombia in 2004. A retrospective review of costs for vector control programmes carried out in rural areas included 3,084 houses surveyed for infestation with triatomine bugs and 3,305 houses sprayed with insecticide. A total of 63 patient records from 3 different hospitals were selected for a retrospective review of resource use. Consensus methodology with local experts was used to estimate care seeking behaviour and to complement observed data on utilisation. Findings The mean cost per house per entomological survey was $4.4 (in US$ of 2004), whereas the mean cost of spraying a house with insecticide was $27. The main cost driver of spraying was the price of the insecticide, which varied greatly. Treatment of a chronic Chagas disease patient costs between $46.4 and $7,981 per year in Colombia, depending on severity and the level of care used. Combining cost and utilisation estimates the expected cost of treatment per patient-year is $1,028, whereas lifetime costs averaged $11,619 per patient. Chronic Chagas disease patients have limited access to healthcare, with an estimated 22% of patients never seeking care. Conclusion Chagas disease is a preventable condition that affects mostly poor populations living in rural areas. The mean costs of surveying houses for infestation and spraying infested houses were low in comparison to other studies and in line with treatment costs. Care seeking behaviour and the type of insurance affiliation seem to play a role in the facilities and type of care that patients use, thus raising concerns about equitable access to care. Preventing Chagas disease in Colombia would be cost-effective and could contribute to prevent inequalities in health and healthcare., Author Summary Chagas disease is one of the most important vector-transmitted diseases in Latin America. Many patients with Chagas go undiagnosed for years, and because symptoms of the chronic condition are similar to those of other cardiac conditions, the burden of the disease is not evident. This leads to underestimation of the burden that Chagas disease places on healthcare resources, which in many cases translates into inadequate prioritisation for prevention. This study assessed the cost of Chagas disease in Colombia in comparison to the cost of prevention. Measuring the cost of treatment for Chagas disease is challenging. In this study we used a method that combines retrospective review of costs for prevention activities and for treatment of chronic Chagas disease patients, and we estimated utilisation of services using experts' consensus. We found that the cost of treating Chagas disease is substantial, even though many people are not receiving appropriate care. On the other hand, we show that preventing Chagas disease transmission through insecticide spraying activities is affordable in Colombia and therefore should be conducted more systematically. This study provides the basic inputs to conduct a full economic evaluation of Chagas disease prevention.

To evaluate treatment-seeking behaviour, financial impact and time lost due to malaria events, in southern Mozambique and eastern South Africa.In-depth household surveys (828 in Mozambique and 827 in South Africa) were analysed. An asset index was calculated using principal component analysis to allow comparison across socio-economic groups. Direct costs of seeking care and the time lost due to malaria were determined. The extent of catastrophic payments was assessed using as thresholds the traditional 10% of household income and 40% of non-food income, as recently recommended by WHO.Poverty was highly prevalent: 70% of the South African and 95% of Mozambican households studied lived on less than $1 per capita per day. Around 97% of those with recent malaria sought healthcare, mainly in public facilities. Out-of-pocket household expenditure per malaria episode averaged $2.30 in South Africa and $6.50 in Mozambique. Analysis at the individual household level found that 32-34% of households in Mozambique, compared with 9-13% of households in South Africa, incurred catastrophic payments for malaria episodes. Results based on mean values underestimated the prevalence of catastrophic payments. Days off work/school were higher in Mozambique.The high rate of health seeking in public health facilities seems unusual in the African context, which bodes well for high coverage with artemisinin-based combinations, even if only deployed within the public sector. However, despite no or modest charges for public sector primary healthcare, households frequently incur catastrophic expenditure on a single malaria episode.

Few cost-effectiveness analysis (CEA) models have accounted for geographic variation in input parameters. This paper describes a deterministic discrete-time multi-state model to estimate the cost-effectiveness of vector control policies for Chagas disease, where implementation varies according to village characteristics. The model outputs include the total number of new infections, disability adjusted life years (DALYs) incurred, costs of associated healthcare, and total costs of the Ministry of Health's control policy for house surveillance and spraying. Incremental net benefits were estimated to determine Colombian villages in which it is cost-effective to implement the control policy. The robustness of these conclusions was evaluated by deterministic sensitivity analyses. The model should help provide a decision-support system to compare control policies and to allocate resources geographically.

Evidence-based reviews of published literature can be subject to several biases. Grey literature, however, can be of poor quality and expensive to access. Effective search strategies also vary by topic and are rarely known in advance. This paper complements a systematic review of the published literature on the costs and effects of expanding immunization services in developing countries. The quality of data on the effectiveness and cost-effectiveness of strategies to increase immunization coverage is shown to be similar across literatures, but the quality of information on costing is much lower in the grey literature. After excluding poorer quality studies from this review we found the quantity of available evidence almost doubled, particularly for more complex health-system interventions and cost or cost-effectiveness analyses. Interventions in the grey literature are more up to date and cover a different geographical spread. Consequently the conclusions of the published and grey literatures differ, although the number of papers is still too low to account for differences across types of interventions. We recommend that in future researchers consider using non-English keywords in their searches.

Objectives:To compare the cost-effectiveness of alternative methods of screening for retinopathy of prematurity (ROP) in the United Kingdom, including the existing method of indirect ophthalmoscopy by ophthalmologists and digital photographic screening by nurses.Methods:A decision tree model was used to compare five screening modalities for the UK population of preterm babies, using a health service perspective. Data were taken from published sources, observation at a neonatal intensive care unit (NICU), and expert judgment.Results:We estimated that use of standard digital cameras by nurses in NICUs would cost more than current methods (£371 compared with £321 per baby screened). However, a specialist nurse visiting units with a portable camera would be cheaper (£172 per baby). These estimates rely on nurses capturing and interpreting the images, with suitable training and supervision. Alternatively, nurses could capture the images then transmit them to a central unit for interpretation by ophthalmologists, although we estimate that this would be rather more expensive (£390 and £201, respectively, for NICU and visiting nurses). Sensitivity analysis was used to examine the robustness of estimates.Conclusions:It is likely that there is an opportunity to improve the efficiency of the ROP screening program. We estimate that screening by specialist nurses trained in image capture and interpretation using portable digital cameras is a cost-effective alternative to the current program of direct visualization by ophthalmologists. This option would require the development of a suitable portable machine. Direct comparative research is strongly needed to establish the accuracy of the various screening options.

Estimate smoking-attributable direct medical costs in Latin American health systems.A microsimulation model was used to quantify financial impact of cardiovascular and cerebrovascular disease, chronic obstructive pulmonary disease (COPD), pneumonia, lung cancer, and nine other neoplasms. A systematic search for epidemiological data and event costs was carried out. The model was calibrated and validated for Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, countries that account for 78% of Latin America's population; the results were then extrapolated to the regional level.Every year, smoking is responsible for 33 576 billion dollars in direct costs to health systems. This amounts to 0.7% of the region's gross domestic product (GDP) and 8.3% of its health budget. Cardiovascular disease, COPD, and cancer were responsible for 30.3%, 26.9%, and 23.7% of these expenditures, respectively. Smoking-attributable costs ranged from 0.4% (Mexico and Peru) to 0.9% (Chile) of GDP and from 5.2% (Brazil) to 12.7% (Bolivia) of health expenditures. In the region, tax revenues from cigarette sales barely cover 37% of smoking-attributable health expenditures (8.1% in Bolivia and 67.3% in Argentina).Smoking is responsible for a significant proportion of health spending in Latin America, and tax revenues from cigarette sales are far from covering it. The region's countries should seriously consider stronger measures, such as an increase in tobacco taxes.

Background Malaria in Zambia accounts for about 4 million clinical cases and 8 000 deaths annually. Artemether-lumefantrine (ACT), a relatively expensive drug, is being used as first line treatment of uncomplicated malaria. However, diagnostic capacity in Zambia is low, leading to potentially avoidable wastage of drugs due to unnecessary anti malarial treatment. Methods A cost-effectiveness evaluation of the three current alternatives to malaria diagnosis (clinical, microscopy and Rapid Diagnostic Tests- RDT) was conducted in 12 facilities from 4 districts in Zambia. The analysis was conducted along an observational study, thus reflecting practice in health facilities under routine conditions. Average and incremental cost effectiveness ratios were estimated from the providers' perspective. Effectiveness was measured in relation to malaria cases correctly diagnosed by each strategy. Results Average cost-effectiveness ratios show that RDTs were more efficient (US$ 6.5) than either microscopy (US$ 11.9) or clinical diagnosis (US$ 17.1) for malaria case correctly diagnosed. In relation to clinical diagnoses the incremental cost per case correctly diagnosed and treated was US$ 2.6 and US$ 9.6 for RDT and microscopy respectively. RDTs would be much cheaper to scale up than microscopy. The findings were robust to changes in assumptions and various parameters. Conclusion RDTs were the most cost effective method at correctly diagnosing malaria in primary health facilities in Zambia when compared to clinical and microscopy strategies. However, the treatment prescription practices of the health workers can impact on the potential that a diagnostic test has to lead to savings on antimalarials. The results of this study will serve to inform policy makers on which alternatives will be most efficient in reducing malaria misdiagnosis by taking into account both the costs and effects of each strategy.