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Health economics journal club: Distributional cost-effectiveness analysis in low- and middle-income countries

Health economics journal club: Distributional cost-effectiveness analysis in low- and middle-income countries cover

The Mtech Access Health Economists come together for a monthly journal club where they share subjects of interest, learn from each other’s areas of expertise, explore new techniques and share best practice. At each meeting, a different team member presents their review of a journal article or their own published research to their colleagues.

Following her presentation on ‘Distributional cost-effectiveness analysis (DCEA) in low- and middle-income countries: an illustrative example of rotavirus vaccination in Ethiopia’, Araadhna Sinha shares her experiences of presenting to the journal club.

Araadhna joined Mtech Access as an Associate Health Economist in October 2021, after completing her MSc in Health Economics at the University of York. Since joining Mtech Access, she has contributed to a number of projects, including an early cost-effectiveness model and a capacity planning tool.

How does the Health Economics journal club work at Mtech Access?

The Health Economics team meets monthly over MS Teams to discuss health economic journal papers. One person will present a topic that particularly interests them. This may be a paper they found interesting or developed themselves. After their presentation, team members can ask questions and informally discuss the topic with the presenter.

What did you present?

My journal club presentation was on the use of distributional cost-effectiveness analysis (DCEA) to model the health economic outcomes of the rotavirus vaccination programme in Ethiopia. This was my master’s dissertation topic at university. While a traditional cost-effectiveness analysis compares the total costs and health benefits of an intervention relative to a willingness-to-pay threshold, DCEA accounts for the distribution of these outcomes by income group.

I presented this topic in the context of the rotavirus vaccination programme in Ethiopia. The programme was introduced in 2013 and decreased diarrheal morbidity for children in the country. The programme reached 56% of the Ethiopian population, but coverage was concentrated in higher-income areas of the country. The cost of delivering the vaccine is higher in poorer, more rural parts of the population. My analysis questioned whether a vaccine programme that specifically targeted poorer, rural areas of Ethiopia would improve existing health inequalities in the country and whether this would affect the programme’s cost-effectiveness.

During the presentation, I displayed the methodology of DCEA and how I applied this to my chosen healthcare intervention. In essence, the cost-effectiveness of the standard vaccination programme is calculated. Then, the incremental costs and benefits of a pro-poor vaccination programme are computed in relation to the standard programme by social group. Finally, the net equity impacts are captured by calculating the equally distributed equivalent health and are compared against the net health benefits. A measure of health inequality aversion is used to assess the total health benefits that a country would be willing to sacrifice to improve health inequalities.

What do you find most interesting about this topic?

This topic was particularly interesting to me as we do not explicitly account for the health inequalities in analyses for our clients. Health inequalities feel more significant in lower-income countries like Ethiopia, where healthcare programmes’ coverage, uptake, and completion favour wealthier individuals.

However, the distribution of an intervention’s health benefits are unlikely to be equal across all socioeconomic groups in more developed markets like England. Therefore, differences in access and uptake of healthcare is still a pertinent issue. I think it’s interesting to look at whether the methodology has any place in NHS England policy development, for example.

What questions / discussion points did the presentation spark with the team at journal club?

My presentation incited discussion on the potential use and relevance of DCEA in the health economic modelling we do at Mtech Access. The group generally agreed that health inequalities are a concern when valuing healthcare interventions.

We discussed that NICE is considering incorporating inequality in their assessments and the potential for DCEA to be used to support this. However, as the discussion developed, we realised that data availability is a significant concern when conducting DCEA.

Data are required on the uptake of healthcare interventions by wealth quintile to understand the impacts on health inequality. It is unlikely that these data would be available for every health technology evaluated.

So, we concluded that it is something to acknowledge and keep in mind during health economic modelling, even if a lack of data means it cannot be formally investigated with DCEA.

What other topics have colleagues covered in journal club and what have you found most interesting?

We have discussed a wide variety of topics in the journal club. Many of my colleagues presented a previous health economic model of theirs. A few discussed papers they had published on their models, while others discussed models they had developed during their time at Mtech Access.

I particularly enjoyed my colleague Olivia Dickinson’s, presentation. She discussed a model she had developed at university and what she could now improve given her experiences at Mtech Access. I could easily relate to this since Olivia and I joined Mtech Access as graduates on the same day. Another presentation I enjoyed was Calum Jones’ discussion of a screening and treatment model, as the methods used in a screening model are very different to a standard cost-utility analysis for treatments.

How does the Health Economics journal club support your work?

Health economics is a varied field with many different model types and applications. Our journal club allows our team to discuss how they’ve incorporated these various aspects of the field in their work.

We can share knowledge and learnings from past experiences that we can use in future projects. We’ve also discussed some topics like DCEA that might not be used in our work at the moment but are worth considering during model development.

It’s interesting to think of health economics as a broader field of knowledge and the work we do.

I’ve enjoyed listening to some really insightful presentations from other team members and look forward to the ones coming up!

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