Cost effectiveness analysis of strategies for child health in developi
http://www.100md.com
《英国医生杂志》
1 Costs, Effectiveness, Expenditure and Priority Setting, Health Systems Financing, World Health Organization, Geneva, Switzerland, 2 JSA Consultants, Accra, Ghana, 3 Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA, 4 Initiative for Vaccine Research, World Health Organization, 5 Health Systems Financing, Evidence and Information for Policy, World Health Organization
Correspondence to: T Tan-Torres Edejer tantorrest@who.int
Objective To determine the costs and effectiveness of selected child health interventions—namely, case management of pneumonia, oral rehydration therapy, supplementation or fortification of staple foods with vitamin A or zinc, provision of supplementary food with counselling on nutrition, and immunisation against measles.
Design Cost effectiveness analysis.
Data sources Efficacy data came from published systematic reviews and before and after evaluations of programmes. For resource inputs, quantities came from literature and expert opinion, and prices from the World Health Organization Choosing Interventions that are Cost Effective (WHO-CHOICE) database
Results Cost effectiveness ratios clustered in three groups, with fortification with zinc or vitamin A as the most cost effective intervention, and provision of supplementary food and counselling on nutrition as the least cost effective. Between these were oral rehydration therapy, case management of pneumonia, vitamin A or zinc supplementation, and measles immunisation.
Conclusions On the grounds of cost effectiveness, micronutrients and measles immunisation should be provided routinely to all children, in addition to oral rehydration therapy and case management of pneumonia for those who are sick. The challenge of malnutrition is not well addressed by existing interventions.
This article is part of a series examining the cost effectiveness of strategies to achieve the millennium development goals for health
After the 1990 United Nations children's summit, 167 countries pledged to further intensify their efforts in child health and nutrition to meet a child related set of human development goals for the year 2000 (www.un.org/geninfo/bp/child.html). But by 2000, 10.6 million children were still dying yearly, most due to pneumonia, diarrhoea, and neonatal causes and, in sub-Saharan Africa, malaria as well.1 2 Malnutrition has been identified as an underlying cause in over 50% of cases,1 with zinc and vitamin A deficiencies contributing.1 3
In September 2000, 189 countries endorsed the UN millennium declaration, which set goals for human development by 2015 (www.who.int/mdg/en/). Millennium development goal 4 was specific to child health, aiming to have reduced mortality in children aged less than 5 by two thirds between 1990 and 2015. Other millennium development goals aimed at reducing poverty and malnutrition and improving access to safe water, sanitation, and air quality would also contribute to improving child health.4
Five years on, there is some, although uneven, progress, and if practice continues as usual until 2015, then many countries, particularly in sub-Saharan Africa and south Asia, will miss this goal.5 It is now incumbent on countries and the international community to reconsider if the resources currently used to improve child health are being used as effectively as possible, and what strategies would ensure that any new resources achieve the maximum benefit.
Some evidence already exists on the cost effectiveness of selected interventions aimed at improving child health in the developing world,6-8 but results have generally been based on interventions undertaken in isolation, without accounting for costs that can be shared across interventions or the impact of changing coverage on unit costs (for example, costs per child treated). In these new cost effectiveness analyses, the WHO Choosing Interventions that are Cost Effective (CHOICE) Millennium Development Goals Team standardised framework, methods, and tools9-11 are used for selected interventions for major causes of childhood morbidity and mortality. They allow combinations of interventions to be analysed at the same time and the impact of increasing coverage to be incorporated explicitly. Full details of the methods are published in the paper by Evans et al of this series.9-11
Methods
We evaluated nine single interventions, each at three levels of coverage (50%, 80%, and 95%), and various combinations thereof. The single interventions evaluated are oral rehydration therapy; case management of pneumonia; supplementation and fortification with vitamin A or zinc; provision of supplementary food during weaning, with counselling on nutrition (with and without growth monitoring and targeting); and measles immunisation. See annex A on bmj.com for a detailed description of the individual interventions.
Effectiveness
We analysed the prevented cases and deaths due to pneumonia, diarrhoea, and measles in the under 5s age group. These are converted to the number of disability adjusted life years (DALYs) averted. We obtained data on epidemiological rates by region and health state valuations primarily from the year 2000 update on burden of disease, supplemented by other published literature.12 13 Children with nutritional comorbidities have a higher risk of diarrhoea and pneumonia and dying from these diseases than do other children. We obtained relative risks from systematic reviews14-16 and we applied these to the relevant epidemiological rates for the specific subpopulations (table 1).
Table 1 Relative risks applied to epidemiological rates for specific subpopulations
For case management of pneumonia17 and supplementation with vitamin A or zinc,15-19 we obtained data on efficacy from systematic reviews with meta-analysis of numerous large community based trials in several developing countries. The estimate of effectiveness for oral rehydration therapy came from before and after evaluations of national diarrhoea control programmes in two countries. These reports were selected as being of high quality because quantitative and qualitative analyses were undertaken to isolate the impact of oral rehydration therapy from other interventions occurring at the same time.20 21 The estimate of effectiveness for provision of supplementary feeding and nutrition counselling came from a systematic review of several efficacy trials and evaluations of larger scale programmes.22 Although growth monitoring and promotion has not been shown to be effective by itself,23 we used it in this analysis for identifying children to be targeted for provision of supplementary food.
Data for vitamin A fortification came from a report on several programmes in Central America.24 In the absence of experience with national programmes on zinc fortification, we modelled its effectiveness relative to zinc supplementation at about the same level of vitamin A supplementation relative to fortification. For measles immunisation, we used an 85% seroconversion or vaccine efficacy rate.25 26 To model more realistically the attainable effectiveness outside research settings, we multiplied estimates of efficacy by an estimate of patient adherence to the therapy or, in the case of fortification, access to processed food (table 2).
Table 2 Effectiveness of interventions to improve child health
Costs
We adopted the standardised WHO ingredients approach, with separate specification of units of utilisation and costs.10 Utilisation rates and unit costs were derived from the literature, unpublished data, and expert opinion (see paper by Evans et al in this series for a description of the methods; table 3).7 27-29 All costs are summarised in international dollars ($Int), with 2000 as the base year and future costs discounted at 3%. The cost effectiveness ratios in this analysis are relatively higher than those in the literature because of the use of international dollars. International dollars are derived by dividing local currency units by an estimate of their purchasing power parity compared with a US dollar. Purchasing power parities are the rates of currency conversion that equalise the purchasing power of different currencies by eliminating the differences in price levels between countries.
Table 3 Costs of interventions to improve child health at 95% coverage in Afr-E and Sear-D
Cost effectiveness analysis
For our analysis we assumed that interventions run for 10 years, after which time managers re-evaluate their strategies. This means that costs are incurred for only 10 years. However, any improvements in health that accrue because of the activities in those 10 years are included, regardless of when they occur.
To be able to assess the cost effectiveness of the current mix of interventions, we first compared interventions with a scenario of doing nothing to improve child health from today.11 If more resources are available, the decision whether to add a new intervention or to expand the first intervention is made on the basis of the incremental cost effectiveness ratio compared with the first intervention, and this sequential comparison is continued until there are no more additional health gains. This maps out the expansion path.
We carried out a sensitivity analysis to enable reporting of results with or without 3% discounting for DALYs and with or without age weighting.
Results
Results for the full set of interventions by region are available at www.who.int/choice. Consistent with all papers in this series, we present the results for two regions, both consisting of countries with high rates of child mortality.11 Sear-D is in South East Asia and Afr-E in sub-Saharan Africa.
Costs
The highest costs at the population level are those for the provision of supplementary food and nutrition counselling, but targeting food supplementation through growth monitoring and promotion cuts costs by 40% in Sear-D and about 52% in Afr-E. Fortification programmes are the least costly, and fortification with zinc or vitamin A costs between 5% and 30% of the costs of supplementation. The total population costs for case management of pneumonia are lower than that for oral rehydration therapy because there are fewer episodes of pneumonia than there are of diarrhoea.
The proportion of patient level costs for interventions aimed at the individual range from about 80% to 99% of the total costs because most of the interventions are directed to the individual and not to the population. The bulk comes from commodities (drugs, supplementary food), outpatient visits, and hospital days. These costs increase almost linearly with increasing coverage. Because of the relatively small proportion of programme to total costs for almost all interventions except for fortification, there is limited potential to spread them across a larger number of recipients, so the unit cost of interventions is not observed to fall with increases in coverage.
Effectiveness
In general, higher population health gains are obtained from case management of pneumonia, oral rehydration therapy, and measles immunisation, followed by the nutritional interventions. Supplementation averts more DALYs than does fortification, primarily because of the limited access in some areas to processed food. Combinations of interventions produce additive or near additive gains, with the highest health gains achieved with a bundle of interventions that includes oral rehydration therapy, case management of pneumonia and diarrhoea, measles immunisation, vitamin A and zinc supplementation, the provision of supplementary feeding, and nutrition counselling.
Cost effectiveness
Tables 4 and 5 report the costs and effects of the most cost effective set of interventions in Afr-E and Sear-D, respectively. Figures 1 and 2 summarise these results. The expansion path—the bold line joining the points at the lower right of the figures—shows the interventions that would be chosen on purely cost effectiveness grounds for any level of resource availability.
Table 4 Costs, effects, and cost effectiveness ratios for most cost effective interventions in Afr-E in 2000
Table 5 Costs, effects, and cost effectiveness ratios for most cost effective interventions in Sear-D in 2000
Fig 1 Expansion path for most cost effective set of interventions to improve child health in Afr-E (WHO defined region comprising countries in sub-Saharan Africa with high child mortality)
Fig 2 Expansion path for most cost effective set of interventions to improve child health in Sear-D (WHO defined region comprising countries in South East Asia with high child mortality)
For both Sear-D and Afr-E, the expansion path starts with some form of micronutrient fortification—that is, using vitamin A or zinc, followed by measles immunisation in Afr-E and then by case management of pneumonia and oral rehydration therapy. In Sear-D, oral rehydration therapy and measles immunisation follows closely after the case management of pneumonia. A shift occurs from fortification to supplementation at higher resource levels because, even if supplementation is more costly than fortification, a greater potential exists for health gain. The cost effectiveness of the interventions included in this set is either one or two orders of magnitude lower than those of the provision of supplementary food and nutrition counselling.
Removal of age weighting and discounting for DALYs increases the health gains and makes the interventions more cost effective. It does not change the ordering in either region.
Discussion
Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet 2005;365: 1147-52.
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO, 2002.
Jones G, Steketee R, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Evans DB, Adam T, Tan-Torres Edejer T, Lim SS, Cassels A, Evans TG, et al. Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries? BMJ 2005;331: 1133-6.
World Bank. World development report 1993: investing in health. New York: Oxford University Press, 1993.
Jamison DT, Mosley WH, Measham AR, Bobadilla JL. Disease control priorities in developing countries. New York: Oxford University Press, 1993.
Gelband H, Stansfield S. The evidence base for interventions to reduce under five mortality in low and middle-income countries. www.cmhealth.org/docs/wg5_paper9.pdf. WHO Commission on Macroeconomics and Health, Working Group 5 paper 9, 2001 (accessed 12 Dec 2001).
Murray CJ, Evans DB, Acharya A, Baltussen RM. Development of WHO guidelines on generalized cost-effectiveness analysis. Health Econ 2000;9: 235-51.
World Health Organization. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: WHO, 2003.
Evans DB, Tan-Torres Edejer T, Adam T, Lim SS, for the WHO-CHOICE MDG Team. Achieving the millennium development goals for health: Methods to assess the costs and health effects of interventions for improving health in developing countries. BMJ 2005;331: 1137-40.
Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Cambridge, MA: Harvard University Press, 1996.
Perry R, Halsey N. The clinical significance of measles: a review. J Infect Dis 2004;189: S4-16.
Fishman S, Caulfield L, de Onis M, Blossner M, Hyder A, Mullany L, et al. Chapter 2. childhood and maternal underweight undernutrition. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors (vol 1). Geneva: WHO, 2004.
Rice A, West K, Fishman S, Black R. Chapter 4. Vitamin A deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors (vol 1). Geneva: WHO, 2004.
Caulfield L, Black R. Chapter 5. Zinc deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004.
Sazawal S, Black RE. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lancet 1992;340: 528-33.
Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. New York: United Nations, 1993. ACC/SCN State-of-the-Art Series. Nutrition policy discussion paper No 13.
Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000;72: 1516-22.
Victora CG, Olinto MT, Barros FC, Nobre LC. Falling diarrhoea mortality in northeastern Brazil: did ORT play a role? Health Policy Plan 1996;11: 132-41.
Miller P, Hirschhorn N. The effect of a national control of diarrheal diseases program on mortality: the case of Egypt. Soc Sci Med 1995;40: S1-30.
Caulfield L, Huffman S, Piwoz E. Interventions to improve intake of complementary foods by infants 6 to 12 months of age in developing countries: impact on growth and on the prevalence of malnutrition and potential contribution to child survival. Food Nutr Bull 1999;20: 183-99.
Pampanich R, Garner P. Growth monitoring in children. Cochrane Database Syst Rev 2000;(2): CD001443.
Mora JO, Dary O, Chinchilla D, Arroyave G. Vitamin A sugar fortification in Central America. Experience and lessons learned. Arlington, VA: MOST, US Agency for International Development Micronutrient Program, 2000.
Dilraj A, Cutts FT, de Castro JF, Wheeler JG, Brown D, Roth C, et al. Response to different measles vaccine strains given by aerosol and subcutaneous routes to schoolchildren: a randomised trial. Lancet 2000;355: 798-803.
Singh J, Datta KK. Measles vaccine efficacy in India: a review. J Commun Dis 1997;29: 47-56.
Adam T, Evans DB, Murray CJL. Econometric estimation of country-specific hospital costs. Cost Eff Resour Alloc 2003;1: 3.
Pieche S. Care seeking behaviour of caretakers of sick children (draft report). Geneva: WHO, 1998.
Horton S. Unit costs, cost-effectiveness, and financing of nutrition interventions. Washington, DC: Population and Human Resources Department, 1992. World Bank. WPS-952.
Pegurri E, Fox-Rushby JA, Damian W. The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review. Vaccine 2005;23: 1624-35.
Hutubessy R, Chisholm D, Edejer TT, WHO-CHOICE. Generalized cost-effectiveness analysis for national-level priority-setting in the health sector. Cost Eff Resour Alloc 2003;1: 8.
De Savigny D, Kasale H, Mbuya C, Reid G. Fixing health systems. Ottawa, Canada: International Development Research Centre, 2004.
United Nations. The millennium development goals report 2005. New York: United Nations, 2005: 1-43.(Tessa Tan-Torres Edejer, coordinator1, M)
Correspondence to: T Tan-Torres Edejer tantorrest@who.int
Objective To determine the costs and effectiveness of selected child health interventions—namely, case management of pneumonia, oral rehydration therapy, supplementation or fortification of staple foods with vitamin A or zinc, provision of supplementary food with counselling on nutrition, and immunisation against measles.
Design Cost effectiveness analysis.
Data sources Efficacy data came from published systematic reviews and before and after evaluations of programmes. For resource inputs, quantities came from literature and expert opinion, and prices from the World Health Organization Choosing Interventions that are Cost Effective (WHO-CHOICE) database
Results Cost effectiveness ratios clustered in three groups, with fortification with zinc or vitamin A as the most cost effective intervention, and provision of supplementary food and counselling on nutrition as the least cost effective. Between these were oral rehydration therapy, case management of pneumonia, vitamin A or zinc supplementation, and measles immunisation.
Conclusions On the grounds of cost effectiveness, micronutrients and measles immunisation should be provided routinely to all children, in addition to oral rehydration therapy and case management of pneumonia for those who are sick. The challenge of malnutrition is not well addressed by existing interventions.
This article is part of a series examining the cost effectiveness of strategies to achieve the millennium development goals for health
After the 1990 United Nations children's summit, 167 countries pledged to further intensify their efforts in child health and nutrition to meet a child related set of human development goals for the year 2000 (www.un.org/geninfo/bp/child.html). But by 2000, 10.6 million children were still dying yearly, most due to pneumonia, diarrhoea, and neonatal causes and, in sub-Saharan Africa, malaria as well.1 2 Malnutrition has been identified as an underlying cause in over 50% of cases,1 with zinc and vitamin A deficiencies contributing.1 3
In September 2000, 189 countries endorsed the UN millennium declaration, which set goals for human development by 2015 (www.who.int/mdg/en/). Millennium development goal 4 was specific to child health, aiming to have reduced mortality in children aged less than 5 by two thirds between 1990 and 2015. Other millennium development goals aimed at reducing poverty and malnutrition and improving access to safe water, sanitation, and air quality would also contribute to improving child health.4
Five years on, there is some, although uneven, progress, and if practice continues as usual until 2015, then many countries, particularly in sub-Saharan Africa and south Asia, will miss this goal.5 It is now incumbent on countries and the international community to reconsider if the resources currently used to improve child health are being used as effectively as possible, and what strategies would ensure that any new resources achieve the maximum benefit.
Some evidence already exists on the cost effectiveness of selected interventions aimed at improving child health in the developing world,6-8 but results have generally been based on interventions undertaken in isolation, without accounting for costs that can be shared across interventions or the impact of changing coverage on unit costs (for example, costs per child treated). In these new cost effectiveness analyses, the WHO Choosing Interventions that are Cost Effective (CHOICE) Millennium Development Goals Team standardised framework, methods, and tools9-11 are used for selected interventions for major causes of childhood morbidity and mortality. They allow combinations of interventions to be analysed at the same time and the impact of increasing coverage to be incorporated explicitly. Full details of the methods are published in the paper by Evans et al of this series.9-11
Methods
We evaluated nine single interventions, each at three levels of coverage (50%, 80%, and 95%), and various combinations thereof. The single interventions evaluated are oral rehydration therapy; case management of pneumonia; supplementation and fortification with vitamin A or zinc; provision of supplementary food during weaning, with counselling on nutrition (with and without growth monitoring and targeting); and measles immunisation. See annex A on bmj.com for a detailed description of the individual interventions.
Effectiveness
We analysed the prevented cases and deaths due to pneumonia, diarrhoea, and measles in the under 5s age group. These are converted to the number of disability adjusted life years (DALYs) averted. We obtained data on epidemiological rates by region and health state valuations primarily from the year 2000 update on burden of disease, supplemented by other published literature.12 13 Children with nutritional comorbidities have a higher risk of diarrhoea and pneumonia and dying from these diseases than do other children. We obtained relative risks from systematic reviews14-16 and we applied these to the relevant epidemiological rates for the specific subpopulations (table 1).
Table 1 Relative risks applied to epidemiological rates for specific subpopulations
For case management of pneumonia17 and supplementation with vitamin A or zinc,15-19 we obtained data on efficacy from systematic reviews with meta-analysis of numerous large community based trials in several developing countries. The estimate of effectiveness for oral rehydration therapy came from before and after evaluations of national diarrhoea control programmes in two countries. These reports were selected as being of high quality because quantitative and qualitative analyses were undertaken to isolate the impact of oral rehydration therapy from other interventions occurring at the same time.20 21 The estimate of effectiveness for provision of supplementary feeding and nutrition counselling came from a systematic review of several efficacy trials and evaluations of larger scale programmes.22 Although growth monitoring and promotion has not been shown to be effective by itself,23 we used it in this analysis for identifying children to be targeted for provision of supplementary food.
Data for vitamin A fortification came from a report on several programmes in Central America.24 In the absence of experience with national programmes on zinc fortification, we modelled its effectiveness relative to zinc supplementation at about the same level of vitamin A supplementation relative to fortification. For measles immunisation, we used an 85% seroconversion or vaccine efficacy rate.25 26 To model more realistically the attainable effectiveness outside research settings, we multiplied estimates of efficacy by an estimate of patient adherence to the therapy or, in the case of fortification, access to processed food (table 2).
Table 2 Effectiveness of interventions to improve child health
Costs
We adopted the standardised WHO ingredients approach, with separate specification of units of utilisation and costs.10 Utilisation rates and unit costs were derived from the literature, unpublished data, and expert opinion (see paper by Evans et al in this series for a description of the methods; table 3).7 27-29 All costs are summarised in international dollars ($Int), with 2000 as the base year and future costs discounted at 3%. The cost effectiveness ratios in this analysis are relatively higher than those in the literature because of the use of international dollars. International dollars are derived by dividing local currency units by an estimate of their purchasing power parity compared with a US dollar. Purchasing power parities are the rates of currency conversion that equalise the purchasing power of different currencies by eliminating the differences in price levels between countries.
Table 3 Costs of interventions to improve child health at 95% coverage in Afr-E and Sear-D
Cost effectiveness analysis
For our analysis we assumed that interventions run for 10 years, after which time managers re-evaluate their strategies. This means that costs are incurred for only 10 years. However, any improvements in health that accrue because of the activities in those 10 years are included, regardless of when they occur.
To be able to assess the cost effectiveness of the current mix of interventions, we first compared interventions with a scenario of doing nothing to improve child health from today.11 If more resources are available, the decision whether to add a new intervention or to expand the first intervention is made on the basis of the incremental cost effectiveness ratio compared with the first intervention, and this sequential comparison is continued until there are no more additional health gains. This maps out the expansion path.
We carried out a sensitivity analysis to enable reporting of results with or without 3% discounting for DALYs and with or without age weighting.
Results
Results for the full set of interventions by region are available at www.who.int/choice. Consistent with all papers in this series, we present the results for two regions, both consisting of countries with high rates of child mortality.11 Sear-D is in South East Asia and Afr-E in sub-Saharan Africa.
Costs
The highest costs at the population level are those for the provision of supplementary food and nutrition counselling, but targeting food supplementation through growth monitoring and promotion cuts costs by 40% in Sear-D and about 52% in Afr-E. Fortification programmes are the least costly, and fortification with zinc or vitamin A costs between 5% and 30% of the costs of supplementation. The total population costs for case management of pneumonia are lower than that for oral rehydration therapy because there are fewer episodes of pneumonia than there are of diarrhoea.
The proportion of patient level costs for interventions aimed at the individual range from about 80% to 99% of the total costs because most of the interventions are directed to the individual and not to the population. The bulk comes from commodities (drugs, supplementary food), outpatient visits, and hospital days. These costs increase almost linearly with increasing coverage. Because of the relatively small proportion of programme to total costs for almost all interventions except for fortification, there is limited potential to spread them across a larger number of recipients, so the unit cost of interventions is not observed to fall with increases in coverage.
Effectiveness
In general, higher population health gains are obtained from case management of pneumonia, oral rehydration therapy, and measles immunisation, followed by the nutritional interventions. Supplementation averts more DALYs than does fortification, primarily because of the limited access in some areas to processed food. Combinations of interventions produce additive or near additive gains, with the highest health gains achieved with a bundle of interventions that includes oral rehydration therapy, case management of pneumonia and diarrhoea, measles immunisation, vitamin A and zinc supplementation, the provision of supplementary feeding, and nutrition counselling.
Cost effectiveness
Tables 4 and 5 report the costs and effects of the most cost effective set of interventions in Afr-E and Sear-D, respectively. Figures 1 and 2 summarise these results. The expansion path—the bold line joining the points at the lower right of the figures—shows the interventions that would be chosen on purely cost effectiveness grounds for any level of resource availability.
Table 4 Costs, effects, and cost effectiveness ratios for most cost effective interventions in Afr-E in 2000
Table 5 Costs, effects, and cost effectiveness ratios for most cost effective interventions in Sear-D in 2000
Fig 1 Expansion path for most cost effective set of interventions to improve child health in Afr-E (WHO defined region comprising countries in sub-Saharan Africa with high child mortality)
Fig 2 Expansion path for most cost effective set of interventions to improve child health in Sear-D (WHO defined region comprising countries in South East Asia with high child mortality)
For both Sear-D and Afr-E, the expansion path starts with some form of micronutrient fortification—that is, using vitamin A or zinc, followed by measles immunisation in Afr-E and then by case management of pneumonia and oral rehydration therapy. In Sear-D, oral rehydration therapy and measles immunisation follows closely after the case management of pneumonia. A shift occurs from fortification to supplementation at higher resource levels because, even if supplementation is more costly than fortification, a greater potential exists for health gain. The cost effectiveness of the interventions included in this set is either one or two orders of magnitude lower than those of the provision of supplementary food and nutrition counselling.
Removal of age weighting and discounting for DALYs increases the health gains and makes the interventions more cost effective. It does not change the ordering in either region.
Discussion
Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet 2005;365: 1147-52.
Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003;361: 2226-34.
World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO, 2002.
Jones G, Steketee R, Black RE, Bhutta ZA, Morris SS, and the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003;362: 65-71.
Evans DB, Adam T, Tan-Torres Edejer T, Lim SS, Cassels A, Evans TG, et al. Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries? BMJ 2005;331: 1133-6.
World Bank. World development report 1993: investing in health. New York: Oxford University Press, 1993.
Jamison DT, Mosley WH, Measham AR, Bobadilla JL. Disease control priorities in developing countries. New York: Oxford University Press, 1993.
Gelband H, Stansfield S. The evidence base for interventions to reduce under five mortality in low and middle-income countries. www.cmhealth.org/docs/wg5_paper9.pdf. WHO Commission on Macroeconomics and Health, Working Group 5 paper 9, 2001 (accessed 12 Dec 2001).
Murray CJ, Evans DB, Acharya A, Baltussen RM. Development of WHO guidelines on generalized cost-effectiveness analysis. Health Econ 2000;9: 235-51.
World Health Organization. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: WHO, 2003.
Evans DB, Tan-Torres Edejer T, Adam T, Lim SS, for the WHO-CHOICE MDG Team. Achieving the millennium development goals for health: Methods to assess the costs and health effects of interventions for improving health in developing countries. BMJ 2005;331: 1137-40.
Murray CJL, Lopez AD. Global health statistics: a compendium of incidence, prevalence and mortality estimates for over 200 conditions. Cambridge, MA: Harvard University Press, 1996.
Perry R, Halsey N. The clinical significance of measles: a review. J Infect Dis 2004;189: S4-16.
Fishman S, Caulfield L, de Onis M, Blossner M, Hyder A, Mullany L, et al. Chapter 2. childhood and maternal underweight undernutrition. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors (vol 1). Geneva: WHO, 2004.
Rice A, West K, Fishman S, Black R. Chapter 4. Vitamin A deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors (vol 1). Geneva: WHO, 2004.
Caulfield L, Black R. Chapter 5. Zinc deficiency. In: Ezzati M, Lopez AD, Rodgers A, Murray CJL, eds. Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. Geneva: WHO, 2004.
Sazawal S, Black RE. Meta-analysis of intervention trials on case-management of pneumonia in community settings. Lancet 1992;340: 528-33.
Beaton GH, Martorell R, Aronson KJ, Edmonston B, McCabe G, Ross AC, et al. Effectiveness of vitamin A supplementation in the control of young child morbidity and mortality in developing countries. New York: United Nations, 1993. ACC/SCN State-of-the-Art Series. Nutrition policy discussion paper No 13.
Bhutta ZA, Bird SM, Black RE, Brown KH, Gardner JM, Hidayat A, et al. Therapeutic effects of oral zinc in acute and persistent diarrhea in children in developing countries: pooled analysis of randomized controlled trials. Am J Clin Nutr 2000;72: 1516-22.
Victora CG, Olinto MT, Barros FC, Nobre LC. Falling diarrhoea mortality in northeastern Brazil: did ORT play a role? Health Policy Plan 1996;11: 132-41.
Miller P, Hirschhorn N. The effect of a national control of diarrheal diseases program on mortality: the case of Egypt. Soc Sci Med 1995;40: S1-30.
Caulfield L, Huffman S, Piwoz E. Interventions to improve intake of complementary foods by infants 6 to 12 months of age in developing countries: impact on growth and on the prevalence of malnutrition and potential contribution to child survival. Food Nutr Bull 1999;20: 183-99.
Pampanich R, Garner P. Growth monitoring in children. Cochrane Database Syst Rev 2000;(2): CD001443.
Mora JO, Dary O, Chinchilla D, Arroyave G. Vitamin A sugar fortification in Central America. Experience and lessons learned. Arlington, VA: MOST, US Agency for International Development Micronutrient Program, 2000.
Dilraj A, Cutts FT, de Castro JF, Wheeler JG, Brown D, Roth C, et al. Response to different measles vaccine strains given by aerosol and subcutaneous routes to schoolchildren: a randomised trial. Lancet 2000;355: 798-803.
Singh J, Datta KK. Measles vaccine efficacy in India: a review. J Commun Dis 1997;29: 47-56.
Adam T, Evans DB, Murray CJL. Econometric estimation of country-specific hospital costs. Cost Eff Resour Alloc 2003;1: 3.
Pieche S. Care seeking behaviour of caretakers of sick children (draft report). Geneva: WHO, 1998.
Horton S. Unit costs, cost-effectiveness, and financing of nutrition interventions. Washington, DC: Population and Human Resources Department, 1992. World Bank. WPS-952.
Pegurri E, Fox-Rushby JA, Damian W. The effects and costs of expanding the coverage of immunisation services in developing countries: a systematic literature review. Vaccine 2005;23: 1624-35.
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