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1.  Maternal and perinatal mortality by place of delivery in sub-Saharan Africa: a meta-analysis of population-based cohort studies 
BMC Public Health  2014;14(1):1014.
Background
Facility-based delivery has gained traction as a key strategy for reducing maternal and perinatal mortality in developing countries. However, robust evidence of impact of place of delivery on maternal and perinatal mortality is lacking. We aimed to estimate the risk of maternal and perinatal mortality by place of delivery in sub-Saharan Africa.
Methods
We conducted a systematic review of population-based cohort studies reporting on risk of maternal or perinatal mortality at the individual level by place of delivery in sub-Saharan Africa. Newcastle-Ottawa Scale was used to assess study quality. Outcomes were summarized in pooled analyses using fixed and random effects models. We calculated attributable risk percentage reduction in mortality to estimate exposure effect. We report mortality ratios, crude odds ratios and associated 95% confidence intervals.
Results
We found 9 population-based cohort studies: 6 reporting on perinatal and 3 on maternal mortality. The mean study quality score was 10 out of 15 points. Control for confounders varied between the studies. A total of 36,772 pregnancy episodes were included in the analyses. Overall, perinatal mortality is 21% higher for home compared to facility-based deliveries, but the difference is only significant when produced with a fixed effects model (OR 1.21, 95% CI: 1.02-1.46) and not when produced by a random effects model (OR 1.21, 95% CI: 0.79-1.84). Under best settings, up to 14 perinatal deaths might be averted per 1000 births if the women delivered at facilities instead of homes. We found significantly increased risk of maternal mortality for facility-based compared to home deliveries (OR 2.29, 95% CI: 1.58-3.31), precluding estimates of attributable risk fraction.
Conclusion
Evaluating the impact of facility-based delivery strategy on maternal and perinatal mortality using population-based studies is complicated by selection bias and poor control of confounders. Studies that pool data at an individual level may overcome some of these problems and provide better estimates of relative effectiveness of place of delivery in the region.
Electronic supplementary material
The online version of this article (doi:10.1186/1471-2458-14-1014) contains supplementary material, which is available to authorized users.
doi:10.1186/1471-2458-14-1014
PMCID: PMC4194414  PMID: 25263746
Maternal and perinatal mortality risk; Place of delivery; Sub-Saharan Africa
3.  Cost-effectiveness of dihydroartemisinin-piperaquine compared with artemether-lumefantrine for treating uncomplicated malaria in children at a district hospital in Tanzania 
Malaria Journal  2014;13(1):363.
Background
Dihydroartemisinin-piperaquine (DhP) is highly recommended for the treatment of uncomplicated malaria. This study aims to compare the costs, health benefits and cost-effectiveness of DhP and artemether-lumefantrine (AL) alongside “do-nothing” as a baseline comparator in order to consider the appropriateness of DhP as a first-line anti-malarial drug for children in Tanzania.
Methods
A cost-effectiveness analysis was performed using a Markov decision model, from a provider’s perspective. The study used cost data from Tanzania and secondary effectiveness data from a review of articles from sub-Saharan Africa. Probabilistic sensitivity analysis was used to incorporate uncertainties in the model parameters. In addition, sensitivity analyses were used to test plausible variations of key parameters and the key assumptions were tested in scenario analyses.
Results
The model predicts that DhP is more cost-effective than AL, with an incremental cost-effectiveness ratio (ICER) of US$ 12.40 per DALY averted. This result relies on the assumption that compliance to treatment with DhP is higher than that with AL due to its relatively simple once-a-day dosage regimen. When compliance was assumed to be identical for the two drugs, AL was more cost-effective than DhP with an ICER of US$ 12.54 per DALY averted. DhP is, however, slightly more likely to be cost-effective compared to a willingness-to-pay threshold of US$ 150 per DALY averted.
Conclusion
Dihydroartemisinin-piperaquine is a very cost-effective anti-malarial drug. The findings support its use as an alternative first-line drug for treatment of uncomplicated malaria in children in Tanzania and other sub-Saharan African countries with similar healthcare infrastructures and epidemiology of malaria.
Electronic supplementary material
The online version of this article (doi:10.1186/1475-2875-13-363) contains supplementary material, which is available to authorized users.
doi:10.1186/1475-2875-13-363
PMCID: PMC4171550  PMID: 25223864
Tanzania; Dihydroartemisinin-piperaquine; Artemether-lumefantrine; Malaria; Cost-effectiveness; Markov model; Disability adjusted life years
4.  Costs of Promoting Exclusive Breastfeeding at Community Level in Three Sites in South Africa 
PLoS ONE  2014;9(1):e79784.
Background
Community-based peer support has been shown to be effective in improving exclusive breastfeeding rates in a variety of settings.
Methods
We conducted a cost analysis of a community cluster randomised-controlled trial (Promise-EBF), aimed at promoting exclusive infant feeding in three sites in South Africa. The costs were considered from the perspective of health service providers. Peer supporters in this trial visited women to support exclusive infant feeding, once antenatally and four times postpartum.
Results
The total economic cost of the Promise-EBF intervention was US$393 656, with average costs per woman and per visit of US$228 and US$52, respectively. The average costs per woman and visit in an operational ‘non research’ scenario were US$137 and US$32 per woman and visit, respectively. Investing in the promotion of exclusive infant feeding requires substantial financial commitment from policy makers. Extending the tasks of multi-skilled community health workers (CHWs) to include promoting exclusive infant feeding is a potential option for reducing these costs. In order to avoid efficiency losses, we recommend that the time requirements for delivering the promotion of exclusive infant feeding are considered when integrating it within the existing activities of CHWs.
Discussion
This paper focuses on interventions for exclusive infant feeding, but its findings more generally illustrate the importance of documenting and quantifying factors that affect the feasibility and sustainability of community-based interventions, which are receiving increased focus in low income settings.
doi:10.1371/journal.pone.0079784
PMCID: PMC3888383  PMID: 24427264
5.  The Role of Evidence in the Decision-Making Process of Selecting Essential Medicines in Developing Countries: The Case of Tanzania 
PLoS ONE  2014;9(1):e84824.
Background
Insufficient access to essential medicines is a major health challenge in developing countries. Despite the importance of Standard Treatment Guidelines and National Essential Medicine Lists in facilitating access to medicines, little is known about how they are updated. This study aims to describe the process of updating the Standard Treatment Guidelines and National Essential Medicine List in Tanzania and further examines the criteria and the underlying evidence used in decision-making.
Methods
This is a qualitative study in which data were collected by in-depth interviews and document reviews. Interviews were conducted with 18 key informants who were involved in updating the Standard Treatment Guidelines and National Essential Medicine List. We used a thematic content approach to analyse the data.
Findings
The Standard Treatment Guidelines and National Essential Medicine List was updated by committees of experts who were recruited mostly from referral hospitals and the Ministry of Health and Social Welfare. Efficacy, safety, availability and affordability were the most frequently utilised criteria in decision-making, although these were largely based on experience rather than evidence. In addition, recommendations from international guidelines and medicine promotions also influenced decision-making. Cost-effectiveness, despite being an important criterion for formulary decisions, was not utilised.
Conclusions
Recent decisions about the selection of essential medicines in Tanzania were made by committees of experts who largely used experience and discretionary judgement, leaving evidence with only a limited role in decision-making process. There may be several reasons for the current limited use of evidence in decision-making, but one hypothesis that remains to be explored is whether training experts in evidence-based decision-making would lead to a better and more explicit use of evidence.
doi:10.1371/journal.pone.0084824
PMCID: PMC3885598  PMID: 24416293
6.  Pharmacoeconomics and its implication on priority-setting for essential medicines in Tanzania: a systematic review 
Background
Due to escalating treatment costs, pharmacoeconomic analysis has been assigned a key role in the quest for increased efficiency in resource allocation for drug therapies in high-income countries. The extent to which pharmacoeconomic analysis is employed in the same role in low-income countries is less well established. This systematic review identifies and briefly describes pharmacoeconomic studies which have been conducted in Tanzania and further assesses their influence in the selection of essential medicines.
Methods
Pubmed, Embase, Cinahl and Cochrane databases were searched using “economic evaluation”, “cost-effectiveness analysis”, “cost-benefit analysis” AND “Tanzania” as search terms. We also scanned reference lists and searched in Google to identify other relevant articles. Only articles reporting full economic evaluations about drug therapies and vaccines conducted in Tanzania were included. The national essential medicine list and other relevant policy documents related to the identified articles were screened for information regarding the use of economic evaluation as a criterion for medicine selection.
Results
Twelve pharmacoeconomic studies which met our inclusion criteria were identified. Seven studies were on HIV/AIDS, malaria and diarrhoea, the three highest ranked diseases on the disease burden in Tanzania. Six studies were on preventive and treatment interventions targeting pregnant women and children under the age of five years. The national essential medicine list and the other identified policy documents do not state the use of economic evaluation as one of the criteria which has influenced the listing of the drugs.
Conclusion
Country specific pharmacoeconomic analyses are too scarce and inconsistently used to have had a significant influence on the selection of essential medicines in Tanzania. More studies are required to fill the existing gap and to explore whether decision-makers have the ability to interpret and utilise pharmacoeconomic evidence. Relevant health authorities in Tanzania should also consider how to apply pharmacoeconomic analyses more consistently in the future priority-setting decisions for selection of essential medicines.
doi:10.1186/1472-6947-12-110
PMCID: PMC3472274  PMID: 23016739
Tanzania; Essential medicines; Pharmacoeconomics; Cost-effectiveness; Priority-setting; National essential medicine list; Decision-making; Disease burden; Low-income countries
7.  Cost of individual peer counselling for the promotion of exclusive breastfeeding in Uganda 
Background
Exclusive breastfeeding (EBF) for 6 months is the recommended form of infant feeding. Support of mothers through individual peer counselling has been proved to be effective in increasing exclusive breastfeeding prevalence. We present a costing study of an individual peer support intervention in Uganda, whose objective was to raise exclusive breastfeeding rates at 3 months of age.
Methods
We costed the peer support intervention, which was offered to 406 breastfeeding mothers in Uganda. The average number of counselling visits was about 6 per woman. Annual financial and economic costs were collected in 2005-2008. Estimates were made of total project costs, average costs per mother counselled and average costs per peer counselling visit. Alternative intervention packages were explored in the sensitivity analysis. We also estimated the resources required to fund the scale up to district level, of a breastfeeding intervention programme within a public health sector model.
Results
Annual project costs were estimated to be US$56,308. The largest cost component was peer supporter supervision, which accounted for over 50% of total project costs. The cost per mother counselled was US$139 and the cost per visit was US$26. The cost per week of EBF was estimated to be US$15 at 12 weeks post partum. We estimated that implementing an alternative package modelled on routine public health sector programmes can potentially reduce costs by over 60%. Based on the calculated average costs and annual births, scaling up modelled costs to district level would cost the public sector an additional US$1,813,000.
Conclusion
Exclusive breastfeeding promotion in sub-Saharan Africa is feasible and can be implemented at a sustainable cost. The results of this study can be incorporated in cost effectiveness analyses of exclusive breastfeeding promotion programmes in sub-Saharan Africa.
doi:10.1186/1478-7547-9-11
PMCID: PMC3135543  PMID: 21714877
8.  Explaining household socio-economic related child health inequalities using multiple methods in three diverse settings in South Africa 
Background
Despite free healthcare to pregnant women and children under the age of six, access to healthcare has failed to secure better child health outcomes amongst all children of the country. There is growing evidence of socioeconomic gradient on child health outcomes
Methods
The objectives of this study were to measure inequalities in child mortality, HIV transmission and vaccination coverage within a cohort of infants in South Africa. We also used the decomposition technique to identify the factors that contribute to the inequalities in these three child health outcomes. We used data from a prospective cohort study of mother-child pairs in three sites in South African. A relative index of household socio-economic status was developed using principal component analysis. This paper uses the concentration index to summarise inequalities in child mortality, HIV transmission and vaccination coverage.
Results
We observed disparities in the availability of infrastructure between least poor and most poor families, and inequalities in all measured child health outcomes. Overall, 75 (8.5%) infants died between birth and 36 weeks. Infant mortality and HIV transmission was higher among the poorest families within the sample. Immunisation coverage was higher among the least poor. The inequalities were mainly due to the area of residence and socio-economic position.
Conclusion
This study provides evidence that socio-economic inequalities are highly prevalent within the relatively poor black population. Poor socio-economic position exposes infants to ill health. In addition, the use of immunisation services was lower in the poor households. These inequalities need to be explicitly addressed in future programme planning to improve child health for all South Africans.
doi:10.1186/1475-9276-10-13
PMCID: PMC3086829  PMID: 21463530
9.  The health related quality of life of people living with HIV/AIDS in sub-Saharan Africa - a literature review and focus group study 
Background
While health outcomes of HIV/AIDS treatments in terms of increased longevity has been the subject of much research, there appears to be very limited research on the improved health related quality of life (HRQL) that can be applied in cost-utility analyses in Africa south of the Sahara (SSA). Most of the literature that does exist present HRQL measured by disease specific instruments, but such data is of little use as input to economic evaluations.
Methods
A systematic review of the literature on HRQL weights for people living with HIV/AIDS in Africa was performed, and the findings are presented and interpreted. We also use focus group discussions in panels of clinical AIDS experts to test the preference based on a generic descriptive system EQ-5D. We contrast quality of life with and without antiretroviral treatment (ART), and with and without treatment failure.
Results
In only four papers were the HRQL weights for HIV/AIDS in sub-Saharan Africa estimated with generic preference based methodologies that can be directly applied in economic evaluation. A total of eight studies were based on generic health profiles. While such 'health profiles' are not preference based, the scores could potentially be transformed into health state utilities. Most of the available literature (20 papers) utilized disease specific instrument, which are not applicable for economic evaluation.
The focus group discussions revealed that HRQL weights are strongly correlated to disease stage. Furthermore, clinical experts consistently report that ART has a strong positive impact on the HRQL of patients, although this effect appears to rebound in cases of drug resistance.
Conclusions
EQ-5D appears to be an appropriate tool for measuring and valuing HRQL of HIV/AIDS in Africa. More empirical research is needed on various methodological aspects in order to obtain valid and reliable HRQL weights in economic evaluations of HIV/AIDS prevention and treatment interventions.
doi:10.1186/1478-7547-8-5
PMCID: PMC2861016  PMID: 20398367
10.  Further benefits by early start of HIV treatment in low income countries: Survival estimates of early versus deferred antiretroviral therapy 
Background
International HIV guidelines have recently shifted from a medium-late to an early-start treatment strategy. As a consequence, more people will be eligible to Highly Active Antiretroviral Therapy (HAART). We estimate mean life years gained using different treatment indications in low income countries.
Methods
We carried out a systematic search to identify relevant studies on the treatment effect of HAART. Outcome from identified observational studies were combined in a pooled-analyses and we apply these data in a Markov life cycle model based on a hypothetical Tanzanian HIV population. Survival for three different HIV populations with and without any treatment is estimated. The number of patients included in our pooled-analysis is 35 047.
Results
Providing HAART early when CD4 is 200-350 cells/μl is likely to be the best outcome strategy with an expected net benefit of 14.5 life years per patient. The model predicts diminishing treatment benefits for patients starting treatment when CD4 counts are lower. Patients starting treatment at CD4 50-199 and <50 cells/μl have expected net health benefits of 7.6 and 7.3 life years. Without treatment, HIV patients with CD4 counts 200-350; 50-199 and < 50 cells/μl can expect to live 4.8; 2.0 and 0.7 life years respectively.
Conclusions
This study demonstrates that HIV patients live longer with early start strategies in low income countries. Since low income countries have many constraints to full coverage of HAART, this study provides input to a more transparent debate regarding where to draw explicit eligibility criteria during further scale up of HAART.
doi:10.1186/1742-6405-7-3
PMCID: PMC2836271  PMID: 20180966
11.  Estimating average inpatient and outpatient costs and childhood pneumonia and diarrhoea treatment costs in an urban health centre in Zambia 
Background
Millions of children die every year in developing countries, from preventable diseases such as pneumonia and diarrhoea, owing to low levels of investment in child health. Investment efforts are hampered by a general lack of adequate information that is necessary for priority setting in this sector. This paper measures the health system costs of providing inpatient and outpatient services, and also the costs associated with treating pneumonia and diarrhoea in under-five children at a health centre in Zambia.
Methods
Annual economic and financial cost data were collected in 2005-2006. Data were summarized in a Microsoft excel spreadsheet to obtain total department costs and average disease treatment costs.
Results
The total annual cost of operating the health centre was US$1,731,661 of which US$1 284 306 and US$447,355 were patient care and overhead departments costs, respectively. The average cost of providing out-patient services was US$3 per visit, while the cost of in-patient treatment was US$18 per bed day. The cost of providing dental services was highest at US$20 per visit, and the cost of VCT services was lowest, with US$1 per visit. The cost per out-patient visit for under-five pneumonia was US$48, while the cost per bed day was US$215. The cost per outpatient visit attributed to under-five diarrhoea was US$26, and the cost per bed day was US$78.
Conclusion
In the face of insufficient data, a cost analysis exercise is a difficult but feasible undertaking. The study findings are useful and applicable in similar settings, and can be used in cost effectiveness analyses of health interventions.
doi:10.1186/1478-7547-7-16
PMCID: PMC2770026  PMID: 19845966
12.  Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia 
Background
As the resource implications of expanding anti-retroviral therapy (ART) are likely to be large, there is a need to explore its cost-effectiveness. So far, there is no such information available from Ethiopia.
Objective
To assess the cost-effectiveness of ART for routine clinical practice in a district hospital setting in Ethiopia.
Methods
We estimated the unit cost of HIV-related care from the 2004/5 fiscal year expenditure of Arba Minch Hospital in southern Ethiopia. We estimated outpatient and inpatient service use from HIV-infected patients who received care and treatment at the hospital between January 2003 and March 2006. We measured the health effect as life years gained (LYG) for patients receiving ART compared with those not receiving such treatment. The study adopted a health care provider perspective and included both direct and overhead costs. We used Markov model to estimate the lifetime costs, health benefits and cost-effectiveness of ART.
Findings
ART yielded an undiscounted 9.4 years expected survival, and resulted in 7.1 extra LYG compared to patients not receiving ART. The lifetime incremental cost is US$2,215 and the undiscounted incremental cost per LYG is US$314. When discounted at 3%, the additional LYG decreases to 5.5 years and the incremental cost per LYG increases to US$325.
Conclusion
The undiscounted and discounted incremental costs per LYG from introducing ART were less than the per capita GDP threshold at the base year. Thus, ART could be regarded as cost-effective in a district hospital setting in Ethiopia.
doi:10.1186/1478-7547-7-13
PMCID: PMC2724492  PMID: 19615069
13.  Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia 
Background
Little is known about the costs of HIV care in Ethiopia.
Objective
To estimate the average per person year (PPY) cost of care for HIV patients with and without anti-retroviral therapy (ART) in a district hospital.
Methods
Data on costs and utilization of HIV-related services were taken from Arba Minch Hospital (AMH) in southern Ethiopia. Mean annual outpatient and inpatient costs and corresponding 95% confidence intervals (CI) were calculated. We adopted a district hospital perspective and focused on hospital costs.
Findings
PPY average (95% CI) costs under ART were US$235.44 (US$218.11–252.78) and US$29.44 (US$24.30–34.58) for outpatient and inpatient care, respectively. Estimates for the non-ART condition were US$38.12 (US$34.36–41.88) and US$80.88 (US$63.66–98.11) for outpatient and inpatient care, respectively. The major cost driver under the ART scheme was cost of ART drugs, whereas it was inpatient care and treatment in the non-ART scheme.
Conclusion
The cost profile of ART at a district hospital level may be useful in the planning and budgeting of implementing ART programs in Ethiopia. Further studies that focus on patient costs are warranted to capture all patterns of service use and relevant costs. Economic evaluations combining cost estimates with clinical outcomes would be useful for ranking of ART services.
doi:10.1186/1478-7547-7-6
PMCID: PMC2672061  PMID: 19364399
14.  Cost-effectiveness of medical interventions to prevent cardiovascular disease in a sub-Saharan African country – the case of Tanzania 
Background
There is a high and rising prevalence of cardiovascular risk in sub-Saharan Africa, a development typical for countries in epidemiological transition. Contrary to recommendations in treatment guidelines, medical interventions to prevent cardiovascular disease are implemented only on a limited scale in these settings. There is a widespread concern that such treatment is not cost-effective compared to alternative health interventions. The main objectives of this article are therefore to calculate costs-, effects and cost-effectiveness of fourteen medical interventions of primary prevention of cardiovascular disease in Tanzania, including Acetylsalicylic acid, a diuretic drug (Hydrochlorothiazide), a β-blocker (Atenolol), a calcium channel blocker (Nifedepine), a statin (Lovastatin) and various combinations of these.
Methods
Effect sizes were derived from systematic reviews or meta-analyses, and calculated as Disability Adjusted Life Years (DALYs). Data on drug costs were calibrated to a Tanzanian setting. Other recurrent and capital costs were derived from previous studies and reviewed by local experts. Expected lifetime costs and health outcomes were calculated using a life-cycle model. Probabilistic cost-effectiveness analysis was performed using Monte Carlo simulation, and results presented as cost-effectiveness acceptability curves and frontiers. The potential impacts of uncertainty in value laden single parameters were explored in one-way sensitivity analyses.
Results
The incremental cost-effectiveness ratios for the fourteen interventions and four different levels of risk (totally 56 alternative interventions) ranged from about USD 85 per DALY to about USD 4589 per DALY saved. Hydrochlorothiazide as monotherapy is the drug yielding the most favorable cost-effectiveness ratio, although not significantly lower than when it is combined in duo-therapy with Aspirin or a β-blocker, in triple-therapy with Aspirin and a β-blocker, or than Aspirin given as mono-therapy.
Conclusion
Preventive cardiology is not cost-effective for any patient group in this setting until willingness to pay exceeds USD 85 per DALY. At this level of willingness to pay, the optimal intervention is Hydrochlorothiazide to patients with very high cardiovascular risk. As willingness to pay for health increase further, it becomes optimal to provide this treatment also to patients with lower cardiovascular risk, and to substitute to more sophisticated interventions.
doi:10.1186/1478-7547-5-3
PMCID: PMC1808049  PMID: 17316431
15.  Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania 
Background
Identifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania.
Methods
Two alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in US $ using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated.
Results
The total cost of treating a patient with conventional health facility based DOT and community based DOT were $ 145 and $ 94 respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about $ 43 to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at $ 128 per patient successfully treated compared to $ 203 for a patient successfully treated with health facility based DOT.
Conclusion
Community based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.
doi:10.1186/1478-7547-3-6
PMCID: PMC1180840  PMID: 16018806

Results 1-15 (15)