Unit Cost Estimates Research Articles

Recurrent costs in primary health care in Ethiopia: facility and disease specific unit costs and their components in government primary hospitals and health centers

BackgroundContinued investment, especially from domestic financing, is needed for Ethiopia to achieve universal health coverage and a sustainable health system over time. Understanding costs of providing health services will assist the government to mobilize adequate resources for health, and to understand future costs of changes in quality of care, service provision scope, and potential decline in external resources. This study assessed costs per unit of service output, “unit costs”, for government primary hospitals and health centers, and disease-specific services within each facility.MethodsQuantitative and qualitative data were collected from 25 primary hospitals and 47 health centers across eight of the eleven regions of Ethiopia for 2013/14, and 2014/15 and 2015/16 but only for primary hospitals, and supplemented by other related health and financial institutions records. A top-down costing approach was used to estimate unit costs for each facility by department – inpatient, outpatient, maternal and child health, and delivery. A mixed-method approach was used for the disease-specific unit costs exempt from fees.ResultsHealth center median unit cost was 146 Ethiopian birr (ETB) (17 PPP$, 2012), the Delivery department had the highest median unit cost (647 ETB; 76 PPP$, 2012) and Outpatient department (OPD) had the lowest (124 ETB; 14 PPP$, 2012). Primary hospital median unit cost was 339 ETB (40 PPP$, 2012), with Inpatient department having the highest median unit cost (1288 ETB; 151 PPP$, 2012), while OPD was the lowest (252 ETB; 29 PPP$, 2012). Drugs and pharmaceutical supplies accounted for most of the costs for both facilities. Among the exempted services offered, tuberculosis and antiretroviral treatment are the costliest with median unit costs from 1091 to 1536 ETB (128–180 PPP$, 2012), with drugs and supplies accounting for almost 90% of the costs.ConclusionsHigh unit costs of service provision could be indicative of underutilization of the primary health care system, coupled with inefficiencies associated with organization and delivery of health services. Data from this study are being used to assess efficiency and productivity among primary care facilities, facilitate premium setting for health insurance, and improve budgeting and allocating health resources for a more sustainable and effective primary health care system.

A Systematic Review of Methodological Variation in Healthcare Provider Perspective Tuberculosis Costing Papers Conducted in Low- and Middle-Income Settings, Using An Intervention-Standardised Unit Cost Typology.

BackgroundThere is a need for easily accessible tuberculosis unit cost data, as well as an understanding of the variability of methods used and reporting standards of that data.ObjectiveThe aim of this systematic review was to descriptively review papers reporting tuberculosis unit costs from a healthcare provider perspective looking at methodological variation; to assess quality using a study quality rating system and machine learning to investigate the indicators of reporting quality; and to identify the data gaps to inform standardised tuberculosis unit cost collection and consistent principles for reporting going forward.MethodsWe searched grey and published literature in five sources and eight databases, respectively, using search terms linked to cost, tuberculosis and tuberculosis health services including tuberculosis treatment and prevention. For inclusion, the papers needed to contain empirical unit cost estimates for tuberculosis interventions from low- and middle-income countries, with reference years between 1990 and 2018. A total of 21,691 papers were found and screened in a phased manner. Data were extracted from the eligible papers into a detailed Microsoft Excel tool, extensively cleaned and analysed with R software (R Project, Vienna, Austria) using the user interface of RStudio. A study quality rating was applied to the reviewed papers based on the inclusion or omission of a selection of variables and their relative importance. Following this, machine learning using a recursive partitioning method was utilised to construct a classification tree to assess the reporting quality.ResultsThis systematic review included 103 provider perspective papers with 627 unit costs (costs not presented here) for tuberculosis interventions among a total of 140 variables. The interventions covered were active, passive and intensified case finding; tuberculosis treatment; above-service costs; and tuberculosis prevention. Passive case finding is the detection of tuberculosis cases where individuals self-identify at health facilities; active case finding is detection of cases of those not in health facilities, such as through outreach; and intensified case finding is detection of cases in high-risk populations. There was heterogeneity in some of the reported methods used such cost allocation, amortisation and the use of top-down, bottom-up or mixed approaches to the costing. Uncertainty checking through sensitivity analysis was only reported on by half of the papers (54%), while purposive and convenience sampling was reported by 72% of papers. Machine learning indicated that reporting on ‘Intervention’ (in particular), ‘Urbanicity’ and ‘Site Sampling’, were the most likely indicators of quality of reporting. The largest data gap identified was for tuberculosis vaccination cost data, the Bacillus Calmette–Guérin (BCG) vaccine in particular. There is a gap in available unit costs for 12 of 30 high tuberculosis burden countries, as well as for the interventions of above-service costs, tuberculosis prevention, and active and intensified case finding.ConclusionVariability in the methods and reporting used makes comparison difficult and makes it hard for decision makers to know which unit costs they can trust. The study quality rating system used in this review as well as the classification tree enable focus on specific reporting aspects that should improve variability and increase confidence in unit costs. Researchers should endeavour to be explicit and transparent in how they cost interventions following the principles as laid out in the Global Health Cost Consortium’s Reference Case for Estimating the Costs of Global Health Services and Interventions, which in turn will lead to repeatability, comparability and enhanced learning from others.Electronic supplementary materialThe online version of this article (10.1007/s40273-020-00910-w) contains supplementary material, which is available to authorized users.

Using Cost Evidence for Price Setting: Experience from a Large National Public Insurance Scheme of India

Background: In 2018, the Government of India launched Ayushman Bharat – Pradhan Mantri Jan Aarogya Yojana (AB - PMJAY), a large tax-funded health insurance scheme. Provider payment rates for the AB-PMJAY health benefit packages (HBPs) were determined through consultative process and review of existing publicly financed health insurance (PFHI) schemes. In this paper, we present findings of the Costing of Health Services in India (CHSI) study and the process of price revision in 2019. Methods: Reference costs were generated from first phase of CHSI study which sampled 11 tertiary public hospitals from 11 Indian states. Economic costs were estimated using mixed (top-down & bottom-up) micro-costing methods. Based on stakeholder consultations, the cost of HBPs were analysed with different combinations of fixed and variable costs. The HBP cost was compared with AB-PMJAY prices of 2018 and 2019 and the budgetary impact was estimated. Finding: Only 13% of the HBPs in 2018, were close to (± 10%) to the actual cost of providing care. More than one-third (42%) of the HBPs had price less than 50% of the cost. After revision of prices in 2019, the latter decreased to 20%. The evidence-informed revision of HBP prices is estimated to increase claims amount by 200 million (0·7%). Interpretation: Strategic purchasing and price-setting of HBPs require creation of systems of evidence generation on the cost of providing services. Further, research is recommended to develop a cost-function for unit cost estimation with changes in time, region, prices, skill-mix and other factors. Funding Department of Health Research. Funding Statement: The study is funded by Department of Health Research (DHR), Ministry of Health & Family Welfare, Government of India. Declaration of Interests: The authors declare no conflict of interest. Ethics Approval Statement: The present study was approved by the Institutional Ethics Committee (IEC) vide letter no. PGI/IEC/2018/00125A and Institutional Collaborative Committee (ICC) vide letter no. 79/30-Edu-13/111273 of Postgraduate Institute of Medical Education & Research, Chandigarh, India.

Investigating the economics of the power sector under high penetration of variable renewable energies

In recent years, several studies have been published focusing on the economics of the power sector under the high penetration of variable renewable energy (VRE) following the rapid expansion of VRE capacities worldwide. However, detailed analyses of the fluctuations in meteorological conditions have hitherto been scarce, despite the expectation that VRE output will be significantly affected by them. To fill this gap, we investigated the economic likelihood of achieving a zero-emission power system in Japan by 2050, using multi-annual meteorological data from 1990 to 2017. We used a detailed linear programming optimization model, as well as a method that uses cumulative residual loads (CRL), which proved to be useful for estimating required energy storage capacities and for understanding the complex substitution of power generation and storage technologies. The estimated unit cost for a 100% renewable electricity system depends heavily on meteorological conditions, standing at 20.9 JPY/kWh with a standard deviation of 1.2 JPY/kWh, which declines to 18.3 JPY/kWh with a standard deviation of 0.6 JPY/kWh for a system with hydrogen storage. The calculations indicate that the required storage capacity is determined mainly by the duration of “windless and sunless” periods, or “dark doldrums”, and the greatest risk under high VRE penetrations is the possibility of supply disruption during such periods. The results also highlight the considerable value of “firm capacities”, such as thermal and nuclear power generation, under a high share of VRE, although it should be noted that the profitability of these capacities may differ significantly from current situations, with large VRE outputs with negligible marginal costs.

Unit Cost Analysis for Health Academic and Operational Purposes

Background: Unit cost estimation is one of the key planning tasks of organisation in order to allocate resources to each activity properly. Therefore, this study was conducted applying top-down costing approach, for academic unit cost estimation.
 Objective: To estimate the unit costs using top-down allocation costing approach for academic and operational purposes of the Department of Clinical Epidemiology and Biostatistics (CEB) at Faculty of Medicine, Ramathibodi Hospital, Mahidol University.
 Methods: A cross-sectional study of the cost of CEB in fiscal year 2018 was retrieved. Direct and indirect costs were allocated to CEB based on 3 main missions (education, research, and academic services) considering staffs’ activities and time spent for each mission. Three cost per unit of measures (cost per student, cost per publication, and cost per research consultation) were estimated accordingly to these 3 main missions.
 Results: In the fiscal year 2018, direct and indirect costs were ฿15 178 761 and ฿737 496, respectively. As for staffs’ time spent for each mission activity, CEB mission costs were ฿6 807 282 for education (฿3 914 187 and ฿2 893 095 for MSc and PhD, respectively), ฿5 912 895 for research, and ฿2 186 280 for academic services.
 Conclusions: Unit cost should be estimated properly to minimise and optimally allocate resources to each activity. This study should be useful for other departments as a guideline for their cost management and resource planning.

Estimating the Unit Costs of Healthcare Service Delivery in India: Addressing Information Gaps for Price Setting and Health Technology Assessment.

BackgroundIndia’s flagship National Health insurance programme (AB-PMJAY) requires accurate cost information for evidence-based decision-making, strategic purchasing of health services and setting reimbursement rates. To address the challenge of limited health service cost data, this study used econometric methods to identify determinants of cost and estimate unit costs for each Indian state.MethodsUsing data from 81 facilities in six states, models were developed for inpatient and outpatient services at primary and secondary level public health facilities. A best-fit unit cost function was identified using guided stepwise regression and combined with data on health service infrastructure and utilisation to predict state-level unit costs.ResultsHealth service utilisation had the greatest influence on unit cost, while number of beds, facility level and the state were also good predictors. For district hospitals, predicted cost per inpatient admission ranged from 1028 (313–3429) Indian Rupees (INR) to 4499 (1451–14,159) INR and cost per outpatient visit ranged from 91 (44–196) INR to 657 (339–1337) INR, across the states. For community healthcare centres and primary healthcare centres, cost per admission ranged from 412 (148–1151) INR to 3677 (1359–10,055) INR and cost per outpatient visit ranged from 96 (50–187) INR to 429 (217–844) INR.ConclusionThis is the first time cost estimates for inpatient admissions and outpatient visits for all states have been estimated using standardised data. The model demonstrates the usefulness of such an approach in the Indian context to help inform health technology assessment, budgeting and forecasting, as well as differential pricing, and could be applied to similar country contexts where cost data are limited.Electronic supplementary materialThe online version of this article (10.1007/s40258-020-00566-9) contains supplementary material, which is available to authorized users.

Economic Cost of Absentee and Dropout Students in Public Schools of Nepal

High absenteeism and dropout rates in school are considered one of the major stumbling blocks in achieving educational goals in developing countries. Absentees and dropouts impose a large resource cost on the educational system and the society. The study examines the economic cost of absentee and dropout students in public schools of Nepal. Using data from public schools in a rural municipality in Nepal, the study estimates the unit cost of absentee and dropout students by level. Cost of human resource, stationery, utility and fixed costs of building and furniture were the components for estimating unit costs. The findings reveal that the unit cost of students was equivalent to U.S. $295, 130 and 143 for primary, lower-secondary, and secondary levels respectively, and an average of U.S. $189 overall. The resource loss due to dropout was around 28, 12, and 11 percent of the total resource spent for primary, lower secondary and secondary levels respectively with an average of around 16 percent. The combined resource loss from dropouts and absentees were found to be 39, 23 and 20 percent for the different levels. On average, 26 percent of the public-school resource was lost due to dropouts and absentees. The main causes of dropout and absenteeism were the lack of interest, motivation of parents and the children to attend the school. The study suggests the need for more comprehensive and in depth study for effective policy formulation to address this problem.

The costs of home-based HIV testing and counselling in sub-Saharan Africa and its association with testing yield: a literature review

More than 14.5 of the 36.7 million people living with HIV globally do not know their HIV status, making comprehensive testing interventions a critical step in ending the HIV/AIDS epidemic. Home-based testing and counselling (HBTC) involves small teams of community health workers with basic training going from door-to-door and offering services in people’s homes. HBTC is effective in reaching individuals that are unlikely to test otherwise, but there is conflicting evidence on its costs and little insight into why estimates are different. We undertook a comparative review of existing costing studies of HBTC in sub-Saharan Africa. Yield or positivity rate, the number of persons tested positive among all tested, is an important metric to judge the efficacy of a testing campaign. We conducted descriptive analyses to test whether unit costs are associated with yield. Studies varied in size with a maximum of 264 953 and a minimum of 494 persons tested. The average “cost per person tested” across 14 studies was $22.8 (SD $14.5) with a minimum of $6 and a maximum of $55.4, and the average “cost per person tested HIV-positive’ across 12 studies was $439.4 (SD $399.7) with a minimum of $66.2 and a maximum of $800.9. Correlations between unit cost estimates and yield were not statistically significant. Existant estimates of the costs of HBTC are conflicting, and it is likely that differences in the setting, design and implementation of the studies are responsible for the discrepancies. This makes it difficult to reliably estimate the costs and cost-effectiveness of HBTC.

Smart cascades: using cost analysis to improve HIV care and treatment interventions to achieve global 95–95–95 goals

Background: HIV programmes are achieving significant scale, even as external financing plateaus. Maximising achievement from identification to viral suppression is key to epidemic control and reaching global 95-95-95 goals. Cost and technical efficiency analyses can help programs understand why losses occur along the cascade, which tactics prevent losses, and additional investments required for cost-efficient solutions.Methodology: The PEPFAR- and USAID-funded Health Policy Plus (HP+) project identified cascade failure points and interventions needed in six countries (Ghana, Indonesia, Kyrgyz Republic, Kenya, Tajikistan, Tanzania). Methods included secondary data analysis and expert interviews. HP+ estimated unit costs and effectiveness of tactics to model future costs and cascade outcomes across scenarios. Conclusions across countries are synthesised for overall best practices.Results: In Ghana, Indonesia, Tajikistan, and the Kyrgyz Republic, HIV identification strategies need to evolve to counter diminishing testing yields. Higher-yield testing modes may have higher costs per person tested, yet lower costs per person identified compared to previous strategies. In Kenya, investments in linkage and retention require additional funding, and will reduce the need for expensive loss-to-follow-up activities. In Tanzania, differentiated antiretroviral therapy can improve patient management while reducing facility-level costs.Conclusion: Results from diverse settings suggest that cost-efficiency analyses aimed at smart cascades will help countries identify and resolve reasons for poor outcomes. The analyses are predicated on contextual exploration of how interventions are linked, and should inform prioritisation and investment strategies. While improving the cascade often has incremental costs, it may be cost-efficient versus the long-term cost of poor outcomes.

Techno-economic analysis of solar trigeneration system

In this work, a techno-economic analysis of concentrated photovoltaic/thermal collector (CPVT) driven desalination and cooling plant is presented. The system comprises of a CPVT collector, a humidification-dehumidification (HDH) desalination unit and vapour compression refrigeration (VCR) unit. The CPVT collector having 10 m2 aperture area and a triple junction PV panel placed at the receiver supplies required hot water to the HDH desalination system. Chilled water generated from 0.5 hp compressor operated VCR unit is supplied to the dehumidifier of HDH desalination. The process of cooling and dehumidification using chilled water result in increased desalination yield and resulting air is suitable for air conditioning purpose. The work is aimed to evaluate the annual performance of the trigeneration plant and to estimate the unit cost of fresh water and payback period. The annual performance of the plant is evaluated for the typical metrological year data for the location of Vellore, India. Results show that the annual desalination, electricity and cooling output are 4.2 m3/yr and 3.46 MWh/yr and 0.788 MWh/yr respectively. The daily average desalination and cooling output are 11.12 L/day and 2.47 kWh/day respectively. The annual electricity consumption of the solar cogeneration plant is 6570 kWh/yr. The estimated unit cost of fresh water is ¹10/L. By considering the interest rate of 9 % and total life time of the plant as 20 years, the payback period is estimated to be 6.5 years.

The Unit and Scale-Up Cost of Postabortion Care in Tanzania.

Based on research conducted in 2017, we estimated the cost to the Tanzanian health care system of providing postabortion care (PAC). PAC is an integrated service package that addresses the curative and preventive needs of women experiencing complications from abortion. PAC services include treating complications of miscarriage and incomplete abortion, providing voluntary family planning counseling and services, and engaging the community to reduce future unintended pregnancies and repeat abortions. Thirty-one public and private health facilities, representing 3 levels of health care, were selected for data collection from key care providers and administrators in 3 regions. We gathered data on the direct costs of PAC startup (i.e., training and capital costs), as well as the recurrent costs of medicines, supplies, hospitalization, and personnel, and the indirect costs of PAC provision. We also gathered data to estimate PAC clients' out-of-pocket expenses. Estimates of the average cost per client (i.e., unit cost) were calculated for treatment of routine and severe abortion complications, treatment at different levels of health care, postabortion contraception, and various available treatment methods. We found that the unit cost of PAC training per provider was US$163.43. The total unit cost was $72.91. The unit recurrent cost of treating routine complications, which included 81% of the cases in our sample, was $36.23. The cost of treating incomplete abortion through manual vacuum aspiration was $22.63, while the cost of treatment with misoprostol was $18.74. The average cost of providing voluntary postabortion family planning was $11.56. We estimated an average client out-of-pocket expenditure on PAC of $22.96. We applied our unit cost estimates to those on PAC utilization and provision and unmet need for PAC that were derived from research conducted in Tanzania in 2013-2016, and we estimated an annual national cost of PAC of $4,170,476. We estimated the cost of providing PAC for all women who have abortion complications, including those who do not access PAC, at $10,426,299. Investing more resources in voluntary family planning and PAC treatment of routine complications at the primary level would likely reduce health system costs.

Optimization of a novel solar-based multi-generation system for waste heat recovery in a cement plant

Abstract This article presents a novel renewable-based multi-generation energy system. The system is based on a double effect absorption chiller, an ejector refrigeration cycle, a proton exchange membrane electrolyzer, an amine-based CO2 capture system, an organic Rankine cycle, and a heater. The proposed integrated system is fueled by a biomass combustor, a photovoltaic thermal solar panels, and a waste heat recovery from a cement plant located in Abyek, Iran. This innovative configuration of energy system can produce electricity, cooling, heating, and hydrogen in summer and winter modes, in addition to removing CO2 from the flue gas of the cement plant. The system is analyzed in energetic, exergetic and thermoeconomic terms. The performance of the system is investigated parametrically by examining the effect of variation of selected key parameters. To perform comprehensive modeling, the system is assessed thermoeconomically through estimating unit cost of each product and total cost rate of the product. Finally, single and multi-objective optimizations are performed by an evolutionary algorithm and illustrated on a Pareto frontier in order to achieve the optimum scheme of the multi-generation system regarding technical and economic viewpoints. According to the results, the studied integrated system produces 17.4 MW and 18.4 MW electricity in summer and winter, 4.1 MW heating power, 1.2 MW cooling power, 5.8 kg/h and 11.3 kg/h hydrogen in summer and winter. Moreover, the system captures 234.1 kg/s CO2 with 90% removal factor from the cement plant. The result of the optimization indicates in winter product cost rate of the Combined Cooling, Heating and Power (CCHP) subsection can reduce 24%. However, in summer for a 0.47% increase in product cost rate, the exergy efficiency is capable of increase by 39%.

Estimated unit cost of the slaves in the second half of the 18th century

Previous surveys based on historical documents on the price of slaves from Africa have contributedgreatly to accounting literature. However, most of these studies usually focus on the sale price of slaves in the colonies or on slave purchase prices in Africa. Therefore, no work has been observed in the literature relating to the effective or estimated unit cost of slaves, taking into account the total cost of all phases of the slave trade. This study aims to bring to the literature of accounting history an approach on the estimated unit cost of slaves basedon estimated total cost of all costing phases of captive transportation from Angola to Pernambuco. This approach was found in a historical document dated November 12, 1758, written by the governor of the captaincy of Pernambuco - Luis Diogo Lobo da Silva. This document was written in fulfillment of the orders of the king of Portugal, D. José I, in order to prepare a list of ships capable of transporting slaves from Africa and the details ofnecessary provisions for the slaves, who would be sent from Angola to Pernambuco. Luis Diogo Lobo da Silva was governor of the captaincy of Pernambuco from 1756 to 1763, and he was recognized for his qualities as a good colonial administrator and for adopting good management practices in his work.

Performance analysis of a fabricated line focusing concentrated solar distillation system

A line focusing concentrated solar distillation unit was developed and its techno-economic analysis was carried out using batch flow, continuous flow without and with tracking mechanisms. Physical quality parameters of feed and distilled water samples, water temperature at different points, performance analysis and estimated production of developed unit were examined. The examined quality parameters of distilled water were well below permissible limits. The water temperature inside the concentrated tube was in the range of 107.0˚C to 109.0˚C. The quantity of distilled water was observed to be inversely proportional to the amount of total dissolved solids in the water samples. The measured average daily and estimated lifetime yield from the developed unit during batch flow was 4.0 and 13,621.0 liters, for continuous flow without tracking 5.1 and 19,689.0 liters, and with tracking mechanism 5.7 and 21,758.0 liters, respectively. The continuous flow with tracking mechanism was found as best method for the production of distilled water. The total life cycle cost of the project was estimated to be PKR 62,144.00. The estimated unit cost of the distilled water per liter would be PKR 6.06 for continuous flow with tracking and PKR 9.69 for batch flow technique. ©2019. CBIORE-IJRED. All rights reserved

PCV41 HEALTHCARE RESOURCE UTILIZATION AND ACUTE COSTS IN FRENCH PATIENTS WITH CORONARY ARTERY DISEASE AND PERIPHERAL ARTERY DISEASE

We aimed to describe healthcare resource utilization (HCRU) and acute costs (3 month) of the most relevant outcomes in French patients with coronary artery disease (CAD) and peripheral artery disease (PAD) using real world data. The objective of this study was to describe acute costs for CAD or PAD patients from the SHI (National French health insurance) perspective. This study applied a retrospective cohort design, and using the Echantillon Generaliste de Beneficiaires (EGB) claims database. Patients with an ICD-10 code or long-term disease health insurance status for CAD or PAD were included, and required to be CAD and PAD free 18 months prior to index diagnosis and also free of Atrial Fibrillation (AF) or Venous Thromboembolism Event (VTE) or cancer at baseline. Study period was from 1st January 2010 through 31st December 2015. Unit cost estimates per cardiovascular (CV) events or complications of CAD or PAD are limited to direct costs and can be considered either from a societal or a payer perspective as those events are fully covered in France (LTD status). A total of 10,526 CAD or PAD patients were included in the study. The costs of hospital stay represented the major part of the total cost estimates (about 80 to 90%). Amputation (19.305€), VTE (13.809€), hemorrhagic stroke (13.717€) and CABG/PCI (12.584€) accrued the highest costs in the acute phase. Total average costs in the month before death of a patient were 3.478€. Outpatient care cost estimates were more uncertain as they were not necessarily linked to the event itself. Rehabilitation costs (not documented in EGB) were not included in those estimates leading probably to an underestimation of costs especially for stroke. In France acute costs for the national health insurance system are high in patients with CAD and PAD.

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation

ObjectivesHigh-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.MethodsTwo health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).ResultsIncremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.DiscussionImplementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

A marginal cost analysis of a Big Brothers Big Sisters of America youth mentoring program: New evidence using statistical analysis

The objective of this study was to evaluate the cost of serving one additional youth in the Big Brothers Big Sisters of America (BBBS) program. We used a marginal cost approach which offers a significant improvement over previous methods based on average total cost estimates. The data consisted of eight years of monthly records from January 2008 to August 2015 obtained from program administrators at one BBBS site in the Mid-Atlantic. Results show that the BBBS marginal cost to serve one additional youth was $80 per mentor-month of BBBS mentoring (irrespective of program type). The cost to offer services for the average match duration of 19 months per marginal added youth was $1503. The marginal costs per treated program participant in school-based versus community-based programs were $1199 and $3301, respectively. Marginal cost estimates are in the range of youth mentoring programs with significant returns on investment but are substantially higher than prior BBBS unit cost estimates reported using less robust estimation methods. This cost analysis can better inform policy makers and donors on the cost of expanding the scale of local BBBS programs as well as suggest opportunities for cost savings.

Heterogeneity of cost estimates in health economic evaluation research. A systematic review of stress urinary incontinence studies

Introduction and hypothesisThere is increased demand for an international overview of cost estimates and insight into the variation affecting these estimates. Understanding of these costs is useful for cost-effectiveness analysis (CEA) research into new treatment modalities and for clinical guideline development.MethodsA systematic search was conducted in Ovid MEDLINE & other non-indexed materials and Ovid Embase for articles published between 1995 and 2017. The National Health Service Economic Evaluation Database (NHS-EED) filter and the McMaster sensitive therapy filter were combined with a bespoke search strategy for stress urinary incontinence (SUI). We extracted unit cost estimates, assessed variability and methodology, and determined transferability.ResultsWe included 37 studies in this review. Four hundred and eighty-two cost estimates from 13 countries worldwide were extracted. Descriptive analysis shows that hospital stay in gynecology ranged between €82 and €1,292 per day. Costs of gynecological consultation range from €30 in France to €158 in Sweden. In the UK, costs are estimated at €228 per hour. Costs of a tension-free vaginal tape (TVT) device range from €431 in Finland to €994 in Canada. TVT surgery per minute costs €25 in France and €82 in Sweden. Total costs of TVT range from €1,224 in Ireland to €5,809 for inpatient care in France. Variation was explored.ConclusionsHeterogeneity was observed in cost estimates for all units at all levels of health care. CEAs of SUI interventions cannot be interpreted without bias when the base of these analyses—namely costs—cannot be compared and generalized.

Economic Analysis of Delivering Postpartum Intrauterine Contraceptive Device Services in India.

Introduction:We estimated the unit costs for implementing postpartum intrauterine contraceptive device (PPIUCD) services from the perspective of both health system and development agencies.Methodology:Seven districts from two Indian states, i.e., Uttarakhand (UK) and Madhya Pradesh (MP), were selected to study the cost of PPIUCD service. Data on costs incurred both by health system and development agencies for PPIUCD service were collected. Unit costs were estimated for providing PPIUCD and IUCD services by state and district level of care in public health-care system. We also estimated unit cost per couple-year protected (CYP) by the level of the health facility.Results:We found that the unit cost per PPIUCD insertion including all costs, i.e., for service delivery and program support, was INR 522 ($8.7) and INR 502 ($8.4) in MP and UK, respectively. Similarly, the unit costs per interval IUCD insertion were INR 287 ($4.8) in UK and INR 281 ($4.7) in MP. Development partners have a share of >50% in overall costs. From a health system's perspective, PPIUCD and interval IUCD cost per CYP at the level of district hospital were INR 440 ($7.3) and INR 449 ($7.5), respectively.Conclusions:In India, PPIUCD, being a low-cost procedure, should be considered as a primary strategy targeted toward pregnancy spacing over other contraceptory methods.

Funding and services needed to achieve universal health coverage: applications of global, regional, and national estimates of utilisation of outpatient visits and inpatient admissions from 1990 to 2016, and unit costs from 1995 to 2016

SummaryBackgroundTo inform plans to achieve universal health coverage (UHC), we estimated utilisation and unit cost of outpatient visits and inpatient admissions, did a decomposition analysis of utilisation, and estimated additional services and funds needed to meet a UHC standard for utilisation.MethodsWe collated 1175 country-years of outpatient data on utilisation from 130 countries and 2068 country-years of inpatient data from 128 countries. We did meta-regression analyses of annual visits and admissions per capita by sex, age, location, and year with DisMod-MR, a Bayesian meta-regression tool. We decomposed changes in total number of services from 1990 to 2016. We used data from 795 National Health Accounts to estimate shares of outpatient and inpatient services in total health expenditure by location and year and estimated unit costs as expenditure divided by utilisation. We identified standards of utilisation per disability-adjusted life-year and estimated additional services and funds needed.FindingsIn 2016, the global age-standardised outpatient utilisation rate was 5·42 visits (95% uncertainty interval [UI] 4·88–5·99) per capita and the inpatient utilisation rate was 0·10 admissions (0·09–0·11) per capita. Globally, 39·35 billion (95% UI 35·38–43·58) visits and 0·71 billion (0·65–0·77) admissions were provided in 2016. Of the 58·65% increase in visits since 1990, population growth accounted for 42·95%, population ageing for 8·09%, and higher utilisation rates for 7·63%; results for the 67·96% increase in admissions were 44·33% from population growth, 9·99% from population ageing, and 13·55% from increases in utilisation rates. 2016 unit cost estimates (in 2017 international dollars [I$]) ranged from I$2 to I$478 for visits and from I$87 to I$22 543 for admissions. The annual cost of 8·20 billion (6·24–9·95) additional visits and 0·28 billion (0·25–0·30) admissions in low-income and lower-middle income countries in 2016 was I$503·12 billion (404·35–605·98) or US$158·10 billion (126·58–189·67).InterpretationUHC plans can be based on utilisation and unit costs of current health systems and guided by standards of utilisation of outpatient visits and inpatient admissions that achieve the highest coverage of personal health services at the lowest cost.FundingBill & Melinda Gates Foundation.