Bozzani Fiammetta M, Mudzengi Don, Sumner Tom, Gomez Gabriela B, Hippner Piotr, Cardenas Vicky, Charalambous Salome, White Richard, Vassall Anna
1Department of Global Health and Development, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH UK.
2The Aurum Institute, Johannesburg, South Africa.
Cost Eff Resour Alloc. 2018 Jul 30;16:27. doi: 10.1186/s12962-018-0113-z. eCollection 2018.
Evidence on the relative costs and effects of interventions that do not consider 'real-world' constraints on implementation may be misleading. However, in many low- and middle-income countries, time and data scarcity mean that incorporating health system constraints in priority setting can be challenging.
We developed a 'proof of concept' method to empirically estimate health system constraints for inclusion in model-based economic evaluations, using intensified case-finding strategies (ICF) for tuberculosis (TB) in South Africa as an example. As part of a strategic planning process, we quantified the resources (fiscal and human) needed to scale up different ICF strategies (cough triage and WHO symptom screening). We identified and characterised three constraints through discussions with local stakeholders: (1) financial constraint: potential maximum increase in public TB financing available for new TB interventions; (2) human resource constraint: maximum current and future capacity among public sector nurses that could be dedicated to TB services; and (3) diagnostic supplies constraint: maximum ratio of Xpert MTB/RIF tests to TB notifications. We assessed the impact of these constraints on the costs of different ICF strategies.
It would not be possible to reach the target coverage of ICF (as defined by policy makers) without addressing financial, human resource and diagnostic supplies constraints. The costs of addressing human resource constraints is substantial, increasing total TB programme costs during the period 2016-2035 by between 7% and 37% compared to assuming the expansion of ICF is unconstrained, depending on the ICF strategy chosen.
Failure to include the costs of relaxing constraints may provide misleading estimates of costs, and therefore cost-effectiveness. In turn, these could impact the local relevance and credibility of analyses, thereby increasing the risk of sub-optimal investments.
关于干预措施的相对成本和效果的证据，如果没有考虑到实施过程中的“现实世界”限制，可能会产生误导。然而，在许多低收入和中等收入国家，时间和数据稀缺意味着在确定优先事项时纳入卫生系统限制可能具有挑战性。
我们开发了一种“概念验证”方法，以实证估计纳入基于模型的经济评估中的卫生系统限制，以南非常见的结核病强化病例发现策略（ICF）为例。作为战略规划过程的一部分，我们量化了扩大不同ICF策略（咳嗽分诊和世卫组织症状筛查）所需的资源（财政和人力）。我们通过与当地利益相关者的讨论确定并描述了三个限制因素：（1）财务限制：可用于新结核病干预措施的公共结核病融资的潜在最大增幅；（2）人力资源限制：公共部门护士目前和未来可专门用于结核病服务的最大能力；（3）诊断用品限制：Xpert MTB/RIF检测与结核病通报的最大比例。我们评估了这些限制对不同ICF策略成本的影响。
如果不解决财务、人力资源和诊断用品限制，就不可能达到ICF的目标覆盖范围（由政策制定者定义）。解决人力资源限制的成本很高，与假设ICF的扩大不受限制相比，2016年至2035年期间结核病项目的总成本增加了7%至37%，这取决于所选择的ICF策略。
未能纳入放宽限制的成本可能会对成本产生误导性估计，进而影响成本效益。反过来，这些可能会影响分析在当地的相关性和可信度，从而增加投资次优的风险。
