Arnab Acharya

Constraints to implementing the essential health package in Malawi.

Increasingly seen as a useful tool of health policy, Essential or Minimal Health Packages direct resources to interventions that aim to address the local burden of disease and be cost-effective. Less attention has been paid to the delivery mechanisms for such interventions. This study aimed to assess the degree to which the Essential Health Package (EHP) in Malawi was available to its population and what health system constraints impeded its full implementation. The first phase of this study comprised a survey of all facilities in three districts including interviews with all managers and clinical staff. In the second and third phase, results were discussed with District Health Management Teams and national level stakeholders, respectively, including representatives of the Ministry of Health, Central Medical Stores, donors and NGOs. The EHP in Malawi is focussing on the local burden of disease; however, key constraints to its successful implementation included a widespread shortage of staff due to vacancies but also caused by frequent trainings and meetings (only 48% of expected man days of clinical staff were available; training and meetings represented 57% of all absences in health centres). Despite the training, the percentage of health workers aware of vital diagnostic and therapeutic approaches to EHP conditions was weak. Another major constraint was shortages of vital drugs at all levels of facilities (e.g. Cotrimoxazole was sufficiently available to treat the average number of patients in only 27% of health centres). Although a few health workers noted some improvement in infrastructure and working conditions, they still considered them to be widely inadequate. In Malawi, as in similar resource poor countries, greater attention needs to be given to the health system constraints to delivering health care. Removal of these constraints should receive priority over the considerable focus on the development and implementation of essential packages of interventions.

The cost effectiveness of pneumococcal conjugate vaccine in the routine infant immunisation programme of The Gambia

Objectives  To evaluate the cost effectiveness of the use of nine‐valent pneumococcal polysaccharide conjugate vaccine in a routine infant immunisation programme based on the Pneumococcal Vaccine Trial (PVT) study in The Gambia.

An impact evaluation design for the Millennium Villages Project in Northern Ghana

This article details the design of an impact evaluation of the Millennium Villages Project in Northern Ghana. The evaluation is particularly challenging because the intervention cannot be randomised; it is clustered in a group of homogeneous communities and likely to generate spill-over effects. We propose a difference-in-differences design selecting control communities based on a propensity score and collecting five rounds of yearly data. We address a number of evaluation questions in relation to testing the breaking of the poverty trap, assessing project externalities, the role of qualitative research, cost-effectiveness and project synergies, sustainability and scalability in the presence of scale economies.

Systematic reviews of cost-effectiveness in low and middle income countries: a review of reviews

ABSTRACT We investigate whether systematic reviews of cost-effectiveness analyses of interventions in low and middle income countries are feasible and useful. To this aim, we systematically review systematic reviews of cost-effectiveness studies and systematic reviews of effectiveness studies. We find 27 systematic reviews of cost-effectiveness studies, predominantly of health interventions. We look at the methodologies employed by these reviews to summarise the results of the original studies and we look at the policy recommendations they provide. We conclude that systematic reviews of cost-effectiveness studies in developing countries are few and that their ability to provide policy recommendations is very limited. The paucity of cost-effectiveness analyses in developing countries and the difficulty to summarise the results of diverse cost-effectiveness analyses in a meaningful way are major problems. We suggest that the collection of cost data along impact evaluations and methodological development in the summary of cost-effectiveness ratios across studies constitute a more promising approach.

The economics approach to evaluation of health interventions in developing countries through randomised field trial

In the past decade economists have begun to carry out randomised field trials in social settings to examine effectiveness of developmental projects that ranged from micro-financing to vaccination in a school setting. There is strong recognition among economists that experimental design in a social setting cannot erode such problems as selective contamination and compliance. Estimation methods can be used to correct such problems. Although strongly related to the approaches long practiced in epidemiology, there are significant differences in how economists have corrected such problems as selection and heterogeneity of impact. A central theme in the economics literature is that agents can choose to participate in an intervention even in the case of randomised assignment. This paper examines illustrative interventions in social settings aimed at improving health where programmes were implemented with a randomised design. The paper is not meant to be systematic in its review, nor does it focus on any particular policy issues; we also do not attempt to provide a critique of the literature on randomised trials. Instead the paper chooses to report on a few key studies to describe how particular econometric techniques can help answer policy relevant questions from randomised trials where there might be problems such as compliance, contamination and presence of varied plausible causal explanations as to why a change might have occurred.

Cost-Effectiveness and Resource Allocation (CERA) - directions for the future.

The journal Cost-Effectiveness and Resource Allocation (CERA) is now in its seventh year, and is an excellent example of how open access publishing can improve dissemination. Now the journal is through its infancy, it is time to reflect on its orientation and to define the strategy for the years to come. Firstly, the journal will pay particular attention to stimulating and publishing studies originating from low- and middle-income countries. Second, CERA will continue to solicit contributions originating from high-income countries, but with the caveat that such studies should be of interest to the broad international readership of the journal. Third, the journal encourages submissions on methodological work from any setting, that is generalisable between low-, middle-, and high income countries. Fourth, CERA recognizes the development of national health accounts and expenditure tracking as a first step to improved resource allocation, and solicit manuscripts of this nature. Finally, CERA recognizes that cost and cost-effectiveness analysis alone may not provide sufficient information to decision makers to guide their choices on the allocation of resources, and therefore encourages submission of studies that advance the broader field of priority-setting.