ADDIS ABABA UNIVERSITY

SCHOOL OF PHARMACY
DEPARTMENT OF HEALTH SUPPLY CHAIN
MANAGEMENT

By SARON ALEMAYEHU KASSAYE

GSR/6199/14

SUBMTTED TO ESKINDER ESHETU ALI (Phd)

Nov , 2022
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 An analysis of the study "A cost-effectiveness analysis of maternal
and newborn health interventions in Ethiopia" using the
Consolidated Health Economic Evaluation Reporting Standards
(CHEERS) criterion.

Citation : Memirie, S.T., Tolla, M.T., Desalegn, D., Hailemariam, M., Norheim, O.F.,
Verguet, S. and Johansson, K.A. (2019). A cost-effectiveness analysis of maternal and
neonatal health interventions in Ethiopia. Health Policy and Planning, 34(4), pp.289–297.
doi:10.1093/heapol/czz034.

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I. Introduction
The Consolidated Health Economic Evaluation Reporting Standards (CHEERS)
statement from ISPOR aims to maximize the reporting of health economic evaluations
by offering suggestions in the form of a checklist. Recently, researchers and editors of
biomedical journals recognized the necessity for modern reporting guidelines for
economic evaluations. The CHEERS statement makes an effort to streamline and
modernize earlier efforts into a single practical reporting standard. In light of the
CHEERS guideline, this review aims to assess the reporting quality of the publication
"A cost-effectiveness analysis of maternal and neonatal health interventions in
Ethiopia".
II. Summary

The study analyzed 13 case management and preventive MNH interventions to

determine the cost-effectiveness of selected MNH interventions in an Ethiopian
setting. A static life table model was used to estimate the health impact of a 20%
increase in intervention coverage over the baseline. The health outcome measure was
disability-adjusted life years (DALYs), and the costs were expressed in 2018 US
dollars. When available, analyses were based on local epidemiological, demographic,
and cost data. According to the findings, 12 of the 13 interventions included in the
analysis were highly cost-effective. The most cost-effective interventions for
newborns were neonatal resuscitation (institutional), kangaroo mother care, and
management of newborn sepsis with injectable antibiotics, with incremental cost-
effectiveness ratios of US$7, US$8, and US$17 per DALY averted, respectively.
Calcium supplementation for pre-eclampsia and eclampsia prevention was the least
cost-effective, costing about US$3100 per DALY.
III. Critique
Title and Abstract
The study title is precise and describes the content of the report using the specific
term "cost effectiveness," which helps identify the article as an economic evaluation
and simplifies the process of cataloguing and indexing terms to indexers. In those
respects, the study's title complies with CHEERS recommendations, but it neglects to
clearly indicate the intervention compared, which is baseline service.
The study's abstract section included the standard objectives, setting, methods, results,
and key words, and it also seemed to contain information that was consistent with the

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article's body. However, the abstract was not written in a structured abstract format,
and it also omitted key details for an ideal economic evaluation, such as the study's
target population, perspective, and sensitivity analysis results, all of which are crucial
for the interpretation of the research and have an impact on how it is applied. The
study's limitations and primary source of funding were also not disclosed, which
caused the paper to be below par.
Introduction
The introduction section of the article provides a clear and broad overview of the
topic of interest, as well as the significance of conducting the study to assist
policymakers in making health policy or practice decisions, justifying its relevance
and indicating for whom the study was specifically conducted. However, the research
question is not clearly stated, and vital information such as study population details,
the specific intervention of interest, and the relevant comparator are excluded, failing
to comply with the CHEERS recommendation in this regard.
Methods- General
Target population
On "Table 1," the study clearly identified the target population, with their respective
characteristics meeting the CHEERS recommendation.
Setting and location
Aside from the general description of the Country name, a clear and detailed
description of the location, setting, or other relevant aspects of the system in which
the intervention is provided, such as the health care setting, is missing from the
method section, making it difficult for readers to assess the generalizability and
transferability of the study in their specific setting.
Study perspective
The method section describes the study's perspective, indicating that costs are
estimated from the provider's perspective and that only direct medical costs borne by
the provider at the point of service delivery were included, as well as how they relate
to the costs being evaluated. The study perspective was found to be as per CHEERS.
Comparators
The interventions or strategies being compared, baseline coverage, and why it is.
Time horizon
CHEERS recommends that an economic evaluation study state the time horizon(s)
over which costs and consequences are being evaluated, as well as provide reasons

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why that time horizon is appropriate; however, the method section makes no mention
of the time horizon.
Discount rate
According to CHEERS, the choice of discount rate(s) used for costs and outcomes, as
well as why it was chosen, should be reported. The study stated that the discount rate
for the outcome was 3%, but neither the reason for that specific rate nor the guideline
used to choose the rate was provided. Furthermore, the cost discount rate was not
specified, so it is unclear whether the same rate as the outcome or 0% was used.
CHEERS recommends that, while a short time horizon may not necessitate the use of
discount rates for economic evaluations, analysts report this rate as 0% for clarity.
The time horizon is also not clearly indicated in this study, making it difficult to
assume a 0% discount rate.
Methods—Outcomes
Choice of outcomes
The article described what outcomes were used as the measure(s) of benefit in the
economic evaluation (DALY) and their relevance for the type of analysis performed,
according to CHEERS.
Measurement of effectiveness
As per the recommendation the measurement of effectiveness was described in detail
and stepwise manner along with the tools and source of data used .
Measurement and valuation of preference-based outcomes
The study used the Lives Saved Tool (LiST) to combine national inputs on age-
specific population size, disease incidence, prevalence, and mortality to be able to
calculate the number of maternal and neonatal lives saved for a given set of
interventions at a specified increase in coverage. Once the number of deaths
prevented by each intervention was estimated, the disability-adjusted life years
(DALYs) averted were also computed, based on the life table for Ethiopia adjusted by
health state valuations from the World Health Organization cost-effectiveness and
strategic planning (WHOCHOICE) data for the African region. Therefore, it can be
concluded that the article describes the measurement and valuation of preference-
based outcomes in detail, including the calculation formula used accordingly to
CHEERS.
Methods—Costs
Estimating resource use and costs

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The study outlined the types of cost included and excluded from perspective and type
of cost point of view. Moreover the different sources of data used to estimate cost
including WHO-CHOICE and directly collecting from health facilities were
described. Again as per the CHEERS recommendation method and approaches used
to calculate cost together with adjustments were pointed out.
Currency, price date, and conversion.
As recommended the study report the dates (year) of the estimated resource quantities
and unit costs and the currency used is clearly reported. However the way of
expressing currency as described by the convention in ISO 4217 (e.g., USD for US
dollars and ARS for Argentinian pesos) were not used in this study.
Methods—Model-Based Economic Evaluations
Choice of model
The study doesn’t mention anything more than what specific model is used. It failed
to explain why the specified model was selected and provide a figure to justify the
model structure is strongly recommended. The CHEERS recommendation require
description of the reason for selecting a model and also evidence based justification
for working with the selected model however this article was found not complying
with this recommendation.
Model assumptions
There is no assumption related with the model used .
Analytical Methods
Analytic methods
The article described the analytical method supporting the evaluation and also the
uncertainty analysis performed including probabilistic and one way analysis. However
the analysis method were not detailed enough and also approaches used to handle
cases as missing data were not described as the recommendation of CHEERS.
Results
Study parameters
The result section of the study presented a tabulated listing of each of the clinical and
economic parameters required to calculate overall costs and consequences and their
associated values.
Incremental costs and outcomes

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The study reported values for the main categories of estimated costs, outcomes of
interest and incremental cost-effectiveness ratios (ICERs) for each intervention as per
the recommendation of CHEERS.
Characterizing uncertainty
Model-based economic evaluation
The study shows the substantial uncertainty that resides within the cost-effectiveness
estimates along with the effects on the results of uncertainty standing from the result
of uncertainty analysis performed. The results of probabilistic and deterministic
analysis (one way) were presented using a table and figure (scatter plot) as
recommended. The one way analysis was conducted under multiple scenarios,
including undiscounted health benefits, 75% adherence to treatment, double cost and
50% effectiveness.
Discussion
Study findings, limitations, generalizability, and fit with current knowledge
Key study findings were reported in the discussion part, however certain fundamental
information, such as perspective and the primary area of uncertainty, were not
addressed. Additionally, it was not stated how the main finding supported the
conclusions drawn. The study's limitations were also thoroughly explored, and as
suggested by CHEERS, the findings' generalizability and fit with existing information
were also described.
Source of funding and support
Source of funding was describe but the role of the funder in the identification, design,
conduct, and reporting of the analysis was not mentioned as recommended.
Conflicts of interest
The study confirmed there was no conflict of interest.
IV. Conclusion
This review revealed that the study was set up as an abstract, introduction, method,
result, and discussion, and that, out of the 24 CHEERS items, the title, three general
method items (target population, study perspective, and comparator), all method
outcome items, and the result were completely consistent with the recommendation.