Intersectoral action: Including local economic considerations in health guidelines
Authors: Amanda S. Brand1, Celeste E. Naude1, Tamara Kredo2,3
1. Centre for Evidence-based Healthcare, Division of Epidemiology and Biostatistics, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
2. Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
3. Division of Clinical Pharmacology, Department of Medicine and Division of Biostatistics and Epidemiology, Department of Global Health, Stellenbosch University, Stellenbosch, South Africa
Evidence-based decision-making in healthcare
Evidence-based decision-making (EBDM) in healthcare is of critical importance, with the Agency for Healthcare Research and Quality stating that it can lead to improved health outcomes and higher-quality healthcare. The World Health Organization (WHO) guide for evidence-informed decision-making describes EBDM as health care decisions that are informed by the best available research evidence, but also other criteria such as the setting where the health intervention is implemented; public opinion; how the intervention affects equity; how practical the intervention is to implement; and how acceptable, sustainable, and affordable the intervention is to the interested parties.
Health guidelines to support evidence-based decision-making
Health guidelines often support EBDM for individuals or groups of people and health systems. The WHO guide for evidence-informed decision-making defines these as ‘systematically developed statements that recommend a particular course of action … with one or more evidence syntheses contributing to the assessment of effectiveness, values and preferences, and other factors‘. Such guidelines are often informed by research evidence on factors or criteria that are important to the interested parties. To improve trust in this process, it is important that the evidence translated into guideline decisions is conducted and reported in a transparent way. To ensure this, a structured framework such as the GRADE Evidence-to-Decision (EtD) framework is often used.
Organisations such as the WHO develop health guidelines to enable EBDM at the international level. However, many countries or regions decide to produce their own guidelines. The belief that guidelines should be developed in, and for, the context in which they will be used was identified by Schünemann and colleagues as an important reason why different countries or regions decided to produce their own specific guidelines.
Importantly, costs are often a central determining factor in whether a specific healthcare intervention is recommended, and these may vary considerably across different countries. For example, Sohn and colleagues described a healthcare reminder sent by short messaging service (SMS) in a lower-middle-income country as an intervention requiring large initial costs to modify telecommunications infrastructure, to ensure that the reminder service could be implemented. These authors concluded that costs would be different in a country with a different telecommunication system. Therefore, an intervention that may be considered good value for money in one country may not be considered cost-effective in another.
A further complication in directly using costs that were not determined for a specific setting is that so-called ‘perspectives‘ may be different. The cost of an intervention can be estimated based on a ‘provider perspective‘, considering only direct medical costs for the healthcare sector, or from the wider ‘societal perspective’, considering the costs for the whole society by including direct non-medical costs and indirect costs. These differences in perspectives—or in the costs they include—in different settings may also result in varied interpretations about whether an intervention is good value for money.
Developing context-specific guidelines
Even though the production of evidence-based guidelines for specific settings often makes sense, limitations on appropriate infrastructure, human capacity and funding may constrain the ability of countries or regions to do so. To optimise resource use, Schünemann and colleagues outline three choices that guideline developers have in such situations:
1. adopt an existing guideline recommendation as-is;
2. adapt an existing recommendation to their context; or
3. develop a new recommendation based on available evidence syntheses.
The Centre for Evidence-based Health Care at Stellenbosch University is a partner in the Global Evidence – Local Adaptation (GELA) project, a 3-year project coordinated by the South African Medical Research Council along with other partners from the Norwegian University of Science and Technology, Western Norway University of Applied Science, University of Calabar Teaching Hospital (Nigeria), Kamuzu University of Health Sciences (Malawi), Cochrane and the MAGIC Evidence Ecosystem Foundation (Norway).
The project, funded by the European and Developing Countries Clinical Trials Partnership (EDCTP), aims to use global research to develop locally relevant health guidelines for priority topics in the field of newborn and child health in Malawi, Nigeria and South Africa. These priority topics were identified in consultation with interested parties (advocacy groups, academics, clinicians and policymakers) in each country. These interested parties provided insights into areas of clinical practice where EBDM requires guidance on specific interventions.
Within GELA, interested parties in Malawi identified a gap in guidance around the best approach to feed critically ill babies and children in this country. The best way to ensure healthcare workers practice proper hand hygiene and whether to provide oral iron supplementation preventatively to young children were also identified as gaps in Nigeria and South Africa, respectively.
In this blog, we share an approach for including cost and resource considerations when adapting guidelines or producing new guidelines for local contexts in sub-Saharan Africa.
What was needed?
No international guidelines on the prioritised topic in each country contained economic evidence that could be used directly in these settings. To produce locally relevant health guidelines in Malawi, Nigeria and South Africa, the GELA team needed to produce, among others, country-specific economic evidence to help guideline developers make decisions about:
- how large the costs of the intervention are;
- where appropriate, whether the intervention is cost-effective (what is the relative efficiency, or health gains, of the intervention relative to its cost); and
- how certain we are about costs and cost-effectiveness.
These decisions would be used to populate the resource domains of the GRADE EtD framework, thereby incorporating specific economic evidence into country-specific guidelines, according to guidance by Xie and colleagues.
This was done in cases where existing guideline recommendations were being adapted or new guideline recommendations were being developed for those countries.
What did we do?
The GELA health economics team identified potential resources needed and costs that would be incurred by the health sector in each country should the intervention of interest be recommended. In consultation with the relevant country-level institutions (the South Africa National Departments of Health, the Malawian Ministry of Health, and the Nigerian Federal Ministry of Health), we further refined this identification process. We also worked with the institutions in each country to calculate country-specific costings for each intervention, often gaining valuable insights into country-level pricing agreements and logistical considerations that are not readily available in the literature. In some cases, these costs were used for further analysis, such as formal assessment of cost-effectiveness or the impact on the national health budget.
What were the challenges and how did we approach these?
In Malawi, disability-weighted effectiveness evidence was required to estimate cost-effectiveness in this setting. However, we encountered challenges in finding representative condition-specific disability weights to calculate the effectiveness of the intervention in this country. As a result, we had to estimate proportions of condition-specific sub-populations in the Malawian health system to which we could map disability weights in order to conduct a cost-effectiveness analysis.
In Nigeria, a lack of effectiveness evidence on patient-important outcomes was such that we could not directly relate it to local cost implications. As a result, the economic evidence for an intervention in Nigeria had to be restricted to a costing without determining cost-effectiveness or impact on the national budget.
For the South African setting, we had to find a way of translating changes in clinical effectiveness from meta-analyses into estimated changes in overall disease burden to determine cost-effectiveness. To do so, we first had to model shifts in disease state using the current proportion of children in sub-Saharan Africa currently affected by anaemia.
Key messages
The incorporation of economic considerations into the development of health guidelines can help ensure that clinical practice is affordable within the countries’ health systems. In most cases, consultation with local departmental health representatives is essential in producing accurate and relevant economic evidence for health guidelines.
Methodological challenges are often present when producing fit-for-purpose economic evidence for health guidelines to support EBDM in specific settings, and these need to be addressed on a case-by-case basis. Novel approaches to conducting economic analyses may be required to ensure that local guideline development incorporates local economic considerations as far as possible.
References
Agency for Healthcare Research and Quality. (n.d.). Evidence-based decision-making. U.S. Department of Health and Human Services. https://www.ahrq.gov/prevention/chronic-care/decision/index.html
Schünemann, H. J., Wiercioch, W., Brożek, J., Etxeandia-Ikobaltzeta, I., Mustafa, R. A., Manja, V., Brignardello-Petersen, R., Neumann, I., Falavigna, M., Alhazzani, W., Santesso, N., Zhang, Y., Meerpohl, J. J., Morgan, R. L., Rochwerg, B., Darzi, A., Rojas, M. X., Carrasco-Labra, A., Adi, Y.,... Akl, E. A. (2017). GRADE Evidence to Decision (EtD) frameworks for adoption, adaptation, and de novo development of trustworthy recommendations: GRADE-ADOLOPMENT. Journal of Clinical Epidemiology, 81, 101–110. https://doi.org/10.1016/j.jclinepi.2016.09.009
Sohn, H., Tucker, A., Ferguson, O., Gomes, I., & Dowdy, D. (2020). Costing the implementation of public health interventions in resource-limited settings: A conceptual framework. Implementation Science, 15, Article 86. https://doi.org/10.1186/s13012-020-01047-2
World Health Organization. (2022). Evidence, policy, impact: WHO guide for evidence-informed decision-making. WHO. https://www.who.int/publications/i/item/9789240039872
Xie, F., Shemilt, I., Vale, L., Alonso-Coello, P., Shamliyan, T., & Schünemann, H. J. (2023). GRADE guidance 23: Considering cost-effectiveness evidence in moving from evidence to health-related recommendations. Journal of Clinical Epidemiology, 162, 135-144. https://doi.org/10.1016/j.jclinepi.2023.08.001
To link to this article - DOI: https://doi.org/10.70253/PPSZ5721
Co-publication declaration
This blog has not been published elsewhere. However, the approach to identifying country-specific priority topics has been published here, and individual projects to produce economic evidence described here are being prepared for publication in academic journals.
Conflict of interest
Amanda Brand is a member of the World EBHC Day 2024 Steering Committee
Disclaimer
The views expressed in this World EBHC Day Blog, as well as any errors or omissions, are the sole responsibility of the author and do not represent the views of the World EBHC Day Steering Committee, Official Partners or Sponsors; nor does it imply endorsement by the aforementioned parties.
