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Abstract：
BACKGROUND: Cost-effectiveness analysis (CEA) is a standard tool for evaluating health programs and informing decisions about resource allocation and prioritization. Most CEAs evaluating health interventions in low- and middle-income countries adopt a health sector perspective, accounting for resources funded by international donors and country governments, while often excluding out-of-pocket expenditures and time costs borne by program beneficiaries. Even when patients\' costs are included, a companion analysis focused on the patient perspective is rarely performed. We view this as a missed opportunity.
METHODS: We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.
RESULTS: In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique\'s annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country\'s annual average for out-of-pocket health expenditures.
CONCLUSIONS: Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
METHODS: We developed methods for assessing intervention affordability and evaluating whether optimal interventions from the health sector perspective also represent efficient and affordable options for patients. We mapped the five different patterns that a comparison of the perspective results can yield into a practical framework, and we provided guidance for researchers and decision-makers on how to use results from multiple perspectives. To illustrate the methodology, we conducted a CEA of six HIV treatment delivery models in Mozambique. We conducted a Monte Carlo microsimulation with probabilistic sensitivity analysis from both patient and health sector perspectives, generating incremental cost-effectiveness ratios for the treatment approaches. We also calculated annualized patient costs for the treatment approaches, comparing the costs with an affordability threshold. We then compared the cost-effectiveness and affordability results from the two perspectives using the framework we developed.
RESULTS: In this case, the two perspectives did not produce a shared optimal approach for HIV treatment at the willingness-to-pay threshold of 0.3 × Mozambique\'s annual GDP per capita per DALY averted. However, the clinical 6-month antiretroviral drug distribution strategy, which is optimal from the health sector perspective, is efficient and affordable from the patient perspective. All treatment approaches, except clinical 1-month distributions of antiretroviral drugs which were standard before Covid-19, had an annual cost to patients less than the country\'s annual average for out-of-pocket health expenditures.
CONCLUSIONS: Including a patient perspective in CEAs and explicitly considering affordability offers decision-makers additional insights either by confirming that the optimal strategy from the health sector perspective is also efficient and affordable from the patient perspective or by identifying incongruencies in value or affordability that could affect patient participation.
摘要：
背景：成本效益分析（CEA）是用于评估卫生计划并告知有关资源分配和优先次序的决策的标准工具。大多数评估低收入和中等收入国家卫生干预措施的CEA都采用卫生部门的观点，核算由国际捐助者和国家政府资助的资源，同时通常不包括由计划受益人承担的自付支出和时间成本。即使包括患者费用，很少进行针对患者观点的伴随分析.我们认为这是一个错失的机会。
方法：我们开发了评估干预措施可负担性的方法，并评估从卫生部门角度来看的最佳干预措施是否也代表了患者的有效和可负担的选择。我们将比较透视结果可以产生的五种不同模式映射到一个实用的框架中，我们为研究人员和决策者提供了如何从多个角度使用结果的指导。为了说明方法论，我们在莫桑比克进行了6种HIV治疗模式的CEA.我们从患者和卫生部门的角度进行了蒙特卡洛微观模拟，并进行了概率敏感性分析。为治疗方法产生增量成本效益比。我们还计算了治疗方法的年度患者成本，将成本与负担能力阈值进行比较。然后，我们使用我们开发的框架从两个角度比较了成本效益和可负担性结果。
结果：在这种情况下，这两种观点并没有产生一个共同的艾滋病毒治疗的最佳方法，在支付意愿阈值0.3×莫桑比克人均每年国内生产总值避免DALY。然而,临床6个月抗逆转录病毒药物分配策略，从卫生部门的角度来看，这是最优的，从患者的角度来看是有效和负担得起的。所有的治疗方法,除了在Covid-19之前标准的抗逆转录病毒药物的临床1个月分布外，患者的年度费用低于该国自付医疗支出的年度平均水平。
结论：在CEA中纳入患者观点并明确考虑可负担性为决策者提供了额外的见解，无论是通过确认从卫生部门角度来看的最佳策略也是有效和可负担的，还是通过确定可能影响患者参与的价值或可负担性的不一致。
方法：我们开发了评估干预措施可负担性的方法，并评估从卫生部门角度来看的最佳干预措施是否也代表了患者的有效和可负担的选择。我们将比较透视结果可以产生的五种不同模式映射到一个实用的框架中，我们为研究人员和决策者提供了如何从多个角度使用结果的指导。为了说明方法论，我们在莫桑比克进行了6种HIV治疗模式的CEA.我们从患者和卫生部门的角度进行了蒙特卡洛微观模拟，并进行了概率敏感性分析。为治疗方法产生增量成本效益比。我们还计算了治疗方法的年度患者成本，将成本与负担能力阈值进行比较。然后，我们使用我们开发的框架从两个角度比较了成本效益和可负担性结果。
结果：在这种情况下，这两种观点并没有产生一个共同的艾滋病毒治疗的最佳方法，在支付意愿阈值0.3×莫桑比克人均每年国内生产总值避免DALY。然而,临床6个月抗逆转录病毒药物分配策略，从卫生部门的角度来看，这是最优的，从患者的角度来看是有效和负担得起的。所有的治疗方法,除了在Covid-19之前标准的抗逆转录病毒药物的临床1个月分布外，患者的年度费用低于该国自付医疗支出的年度平均水平。
结论：在CEA中纳入患者观点并明确考虑可负担性为决策者提供了额外的见解，无论是通过确认从卫生部门角度来看的最佳策略也是有效和可负担的，还是通过确定可能影响患者参与的价值或可负担性的不一致。
