Wilson-Barthes Marta, Braitstein Paula, DeLong Allison, Ayuku David, Atwoli Lukoye, Sang Edwin, Galárraga Omar
Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA.
Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
MDM Policy Pract. 2022 Dec 22;7(2):23814683221143782. doi: 10.1177/23814683221143782. eCollection 2022 Jul-Dec.
Strengthening family-based care is a key policy response to the more than 15 million orphaned and separated children who have lost 1 or both parents in sub-Saharan Africa. This analysis estimated the cost-effectiveness of family-based care environments for preventing HIV and death in this population. We developed a time-homogeneous Markov model to simulate the incremental cost per disability-adjusted life year (DALY) averted by supporting family-based environments caring for orphaned and separated children in western Kenya. Model parameters were based on data from the longitudinal OSCAR's Health and Well-Being Project and published literature. We used a societal perspective, annual cycle length, and 3% discount rate. Incremental cost-effectiveness ratios were simulated over 5- to 15-y horizons, comparing family-based settings to street-based "self-care." Parameter uncertainty was addressed via deterministic and probabilistic sensitivity analyses. Under base-case assumptions, family-based environments prevented 422 HIV infections and 298 deaths in a simulated cohort of 1,000 individuals over 10 y. Compared with street-based self-care, family-based care had an incremental cost of $2,528 per DALY averted (95% confidence interval [CI]: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413). The probability of family-based care being highly cost-effective was >80% at a willingness-to-pay (WTP) threshold of $2,250/DALY averted. Households receiving government cash transfers had minimally higher cost-effectiveness ratios than households without cash transfers but were still cost-effective at a WTP threshold of twice Kenya's GDP per capita. Compared with the status quo of street-based self-care, family-based environments offer a cost-effective approach for preventing HIV and death among orphaned children in lower-middle income countries. Decision makers should consider increasing resources to these environments in tandem with social protection programs.
UNICEF and more than 200 other international organizations endorsed efforts to redirect services toward family-based care as part of the 2019 UN Resolution on the Rights of the Child; yet this study is one of the first to quantify the cost-effectiveness of family-based care environments serving some of the world's most vulnerable children.This health economic modeling analysis found that family-based environments would prevent 422 HIV infections and 298 deaths in a cohort of 1,000 orphaned and separated children over a 10-y time horizon.Compared with street-based "self-care," family-based care resulted in an incremental cost of $2,528 per DALY averted (95% CI: 1,798, 2,599) and $2,355 per quality-adjusted life year gained (95% CI: 1,667, 2,413) after 10 y.Annual per-child expenditures for children living in family-based care environments in sub-Saharan Africa could potentially be increased by at least 25% and remain highly cost-effective.
加强以家庭为基础的照护是针对撒哈拉以南非洲地区超过1500万失去单亲或双亲的孤儿和与家人离散儿童的一项关键政策应对措施。本分析评估了以家庭为基础的照护环境对于预防该人群感染艾滋病毒和死亡的成本效益。我们构建了一个时间齐次马尔可夫模型，以模拟通过支持肯尼亚西部为孤儿和与家人离散儿童提供照护的家庭环境，每避免一个伤残调整生命年（DALY）所产生的增量成本。模型参数基于纵向的奥斯卡健康与福祉项目的数据及已发表文献。我们采用社会视角、年度周期长度和3%的贴现率。在5至15年的时间范围内模拟增量成本效益比，将基于家庭的环境与街头“自我照护”进行比较。通过确定性和概率性敏感性分析来处理参数不确定性。在基线假设下，在一个10年的模拟队列中，基于家庭的环境在1000名个体中预防了422例艾滋病毒感染和298例死亡。与街头自我照护相比，基于家庭的照护每避免一个DALY的增量成本为2528美元（95%置信区间[CI]：1798，2599），每获得一个质量调整生命年的增量成本为2355美元（95%CI：1667，2413）。在每避免一个DALY支付意愿（WTP）阈值为2250美元时，基于家庭的照护具有高成本效益的概率>80%。接受政府现金转移的家庭与没有现金转移的家庭相比，成本效益比略高，但在WTP阈值为肯尼亚人均国内生产总值两倍时仍具有成本效益。与街头自我照护的现状相比，基于家庭的环境为中低收入国家的孤儿预防艾滋病毒感染和死亡提供了一种具有成本效益的方法。决策者应考虑在增加社会保护项目的同时，增加对这些环境的资源投入。
联合国儿童基金会和其他200多个国际组织认可将服务转向以家庭为基础的照护的努力，这是2019年联合国儿童权利决议的一部分；然而，本研究是首批量化为世界上一些最脆弱儿童提供照护的家庭环境成本效益的研究之一。这项健康经济模型分析发现，在10年的时间范围内，基于家庭的环境将在1000名孤儿和与家人离散儿童的队列中预防422例艾滋病毒感染和298例死亡。与街头“自我照护”相比，10年后基于家庭的照护每避免一个DALY的增量成本为2528美元（95%CI：1798，2599），每获得一个质量调整生命年的增量成本为2355美元（95%CI：1667，2413）。撒哈拉以南非洲地区生活在基于家庭照护环境中的儿童的年度人均支出可能至少增加25%，并且仍具有高成本效益。
