Accounting for equity considerations in cost-effectiveness analysis: a systematic review of rotavirus vaccine in low- and middle-income countries

Abstract

BackgroundCost-effectiveness analysis (CEA) is frequently used as an input for guiding priority setting in health. However, CEA seldom incorporates information about trade-offs between total health gains and equity impacts of interventions. This study investigates to what extent equity considerations have been taken into account in CEA in low- and middle-income countries (LMICs), using rotavirus vaccination as a case study.MethodsSpecific equity-related indicators for vaccination were first mapped to the Guidance on Priority Setting in Health Care (GPS-Health) checklist criteria. Economic evaluations of rotavirus vaccine in LMICs identified via a systematic review of the literature were assessed to explore the extent to which equity was considered in the research objectives and analysis, and whether it was reflected in the evaluation results.ResultsThe mapping process resulted in 18 unique indicators. Under the ‘disease and intervention’ criteria, severity of illness was incorporated in 75% of the articles, age distribution of the disease in 70%, and presence of comorbidities in 5%. For the ‘social groups’ criteria, relative coverage reflecting wealth-based coverage inequality was taken into account in 30% of the articles, geographic location in 27%, household income level in 8%, and sex at birth in 5%. For the criteria of ‘protection against the financial and social effects of ill health’, age weighting was incorporated in 43% of the articles, societal perspective in 58%, caregiver’s loss of productivity in 45%, and financial risk protection in 5%. Overall, some articles incorporated the indicators in their model inputs (20%) while the majority (80%) presented results (costs, health outcomes, or incremental cost-effectiveness ratios) differentiated according to the indicators. Critically, less than a fifth (17%) of articles incorporating indicators did so due to an explicit study objective related to capturing equity considerations. Most indicators were increasingly incorporated over time, with a notable exception of age-weighting of DALYs.ConclusionIntegrating equity criteria in CEA can help policy-makers better understand the distributional impact of health interventions. This study illustrates how equity considerations are currently being incorporated within CEA of rotavirus vaccination and highlights the components of equity that have been used in studies in LMICs. Areas for further improvement are identified.Electronic supplementary materialThe online version of this article (10.1186/s12962-018-0102-2) contains supplementary material, which is available to authorized users.

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“…Four reviews focused specifically on the evaluation of or decisions on vaccines [4,21,47,55]. 19 reviews exclusively included studies or documents from high-income countries while five had an explicit focus on decision-making processes in low-and middle-income countries [10,35,52,55]. The number of criteria extracted from each publication ranged from 31 [4] to 360 [6].…”

Health Technology Assessment and priority setting for Universal Health Coverage: A qualitative study of stakeholders capacity, needs, policy areas of demand and perspectives in Nigeria

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“…Given the increase in publications, comprehensive reviews and analyses on equity consideration in economic evaluations have also been conducted, though most reviews have focused on specific methodologies of how to integrate equity concerns into economic evaluations [19][20][21]. Other reviews have been based on specific interventions or concepts, such as vaccines, operation research, and universal health coverage [9,18,22]. However, no review has comprehensively mapped the existing knowledge to date in a scoping review.…”