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Are low and middle-income countries prioritising high-value healthcare interventions?
  1. Ashley A Leech1,2,
  2. David D Kim2,
  3. Joshua T Cohen2,
  4. Peter J Neumann2
  1. 1Department of Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
  2. 2Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts, USA
  1. Correspondence to Dr Ashley A Leech; ashley.leech{at}


Introduction Since resources are finite, investing in services that produce the highest health gain ‘return on investment’ is critical. We assessed the extent to which low and middle-income countries (LMIC) have included cost-saving interventions in their national strategic health plans.

Methods We used the Tufts Medical Center Global Health Cost-Effectiveness Analysis Registry, an open-source database of English-language cost-per-disability-adjusted life year (DALY) studies, to identify analyses published in the last 10 years (2008–2017) of cost-saving health interventions in LMICs. To assess whether countries prioritised cost-saving interventions within their latest national health strategic plans, we identified 10 countries, all in sub-Saharan Africa, with the highest measures on the global burden of disease scale and reviewed their national health priority plans.

Results We identified 392 studies (63%) targeting LMICs that reported 3315 cost-per-DALY ratios, of which 207 ratios (6%) represented interventions reported to be cost saving. Over half (53%) of these targeted sub-Saharan Africa. For the 10 countries we investigated in sub-Saharan Africa, 58% (79/137) of cost-saving interventions correspond with priorities identified in country plans. Alignment ranged from 95% (21/22 prioritised cost-saving ratios) in South Africa to 17% (2/12 prioritised cost-saving ratios) in Cameroon. Human papillomavirus vaccination was a noted priority in 70% (7/10) of national health prioritisation plans, while 40% (4/10) of countries explicitly included prenatal serological screening for syphilis. HIV prevention and treatment were stated priorities in most country health plans, whereas 40% (2/5) of countries principally outlined efforts for lymphatic filariasis. From our sample of 45 unique interventions, 36% of interventions (16/45) included costs associated directly with the implementation of the intervention.

Conclusion Our findings indicate substantial variation across country and disease area in incorporating economic evidence into national health priority plans in a sample of sub-Saharan African countries. To make health economic data more salient, the authors of cost-effectiveness analyses must do more to reflect implementation costs and other factors that could limit healthcare delivery.

  • health economics
  • health policy

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  • Handling editor Seye Abimbola

  • Contributors AAL is the guarantor of the article. All authors meet the four ICMJE criteria for authorship and worked collaboratively to contribute to the conceptual design, review and final approval of the published version. To prepare this manuscript, the authors systematically reviewed the Tufts Medical Center Global Health Cost-Effectiveness Analysis (GHCEA) Registry, a repository of English-language cost-per-DALY averted studies indexed in PubMed.

  • Funding The Bill and Melinda Gates Foundation.

  • Competing interests JTC has grants for work conducted on behalf of Amgen, Biogen and Janssen Pharmaceuticals and has lectured on the use of simulation for Pfizer. JTC has also consulted for AbbVie, Precision Health Economics, Sage Therapeutics and Sarepta. PN has held one-time roles on the advisory boards on health economics topics for Avexis, AbbVie, Research Triangle Institute, Merck, Genentech, Bluebird Bio and Novo Nordisk. PN serves on the advisory board for the Congressional Budget Office and has consulted for Precision Health Economics.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information

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