Incorporating health inequality impact into economic evaluation in low- and middle-income countries: a systematic review

Figures & data

Figure 1. PRISMA study selection flow diagram.

Table 1. Summary of the included studies

Authors	Year of publication	Country	Target population	Intervention	Comparator	Type of study	Health outcomes	Modeling
Hutton et al. [24]	2010	China	Children aged 1–19 years	Nationwide hepatitis B vaccination (HBV) program	Status quo	CEA	Mortality, QALYs, HBV infections averted	Markov
Rheingans et al. [30]	2014	India	Children during the first 5 years of life	Rotavirus vaccination	Status quo	CEA	Mortality, DALYs	Included, but not detailed
Verguet et al. [15]	2015	India	People with tuberculosis	Universal public finance of tuberculosis treatment	Status quo	CEA	Lives saved	Dynamic transmission model
Campos et al. [27]	2017	Uganda	Women aged 30–49 years	Cervical cancer screening strategies	Status quo	CEA	Life years, cervical cancer cases averted	Microsimulation
Rheingans et al. [31]	2018	Pakistan	Children during the first 5 years of life	Rotavirus vaccination	Status quo	CEA	Mortality, DALYs	Included, but not detailed
Rheingans et al. [32]	2018	Laos	Children during the first 5 years of life	Rotavirus vaccination	Status quo	CEA	Mortality, DALYs	Included, but not detailed
Dawkins et al. [17]	2018	Ethiopia	Children during the first 5 years of life	Re-design rotavirus vaccination programme (pro-poor)	Status quo	CEA	Mortality, HALYs	Included, but not detailed
Chang et al. [29]	2018	41LMICs	Cohorts vaccinated in the period 2016–2030	Vaccines for ten antigens^1	Status quo	Other	Mortality	Included, but not detailed
Hangoma et al. [28]	2019	Zambia	Adult population	Excise tax on sugar sweetened beverages	Status quo (without tax)	Other	Mortality, life years, DALYs, obesity prevalence	Included, but not detailed
Arnold et al. [18]	2020	Malawi	Recipients of Essential Health Package (EHP)	Essential Health Package (EHP)	Status quo	CEA	DALYs	Not included
Love-Koh et al. [25]	2021	Brazil	General population	Community level primary care system intervention	Status quo	CEA	DALYs	Markov
Olsen et al. [26]	2021	Ethiopia	Birth cohort	Children pneumonia treatment scale-up strategies	Status quo	CEA	Mortality, life years	Markov

¹measles, hepatitis B, human papillomavirus, yellow fever, Hemophilus influenzae type b, Streptococcus pneumoniae, rotavirus, rubella, Neisseria meningitidis serogroup A, and Japanese encephalitis.

Figure 2. Methodological quality of the nine CEA studies for the listed in the Consolidated Health Economic Evaluation Reporting Standards (CHEERs) checklist.

Table 2. Characteristics used in the included studies to describe the population subgroups related to equity*

Authors (year)	Population subgroups defined by:
	Place of residence	Gender/sex	Socioeconomic status	Others
Hutton et al. (2010) [24]				Age groups
Rheingans et al. (2014) [30]	Region, states	Sex	Wealth quintile defined by household asset index
Verguet et al. (2015) [15]			Wealth quintile defined by an individual’s annual income
Campos et al. (2017) [27]				Access to cervical cancer screening
Rheingans et al. (2018) [31]	Region		Wealth quintile defined by household asset index
Rheingans et al. (2018) [32]	Region		Wealth quintile defined by national asset index
Dawkins et al. (2018) [17]			Household asset wealth quintile
Chang et al. (2018) [29]			Household income quintile
Hangoma et al. (2019) [28]		Sex
Arnold et al. (2020) [18]	Urban vs rural		Household wealth asset index
Love-Koh et al. (2021) [25]	State		A state-level indicator of socioeconomic status
Olsen et al. (2021) [26]	Region

*Other items in the Progress-PLUS criteria were not shown here as they were not included in the eligible studies (race/ethnicity/ culture/language, occupation, religion, education).

Table 3. Outcomes and methods used in the included studies for estimating the distributional effect

Authors (year)	Methodological framework				Summary of inequalityimpact	Main results	Notes
	ECEA	DCEA	MCDA	Other
Hutton et al. (2010) [24]				Subgroup analysis		Catch-up vaccination is cost-saving: it increases QALYs and saves costs compared to the status quo.
Rheingans et al. (2014) [30]				Subgroup analysis		Rotavirus vaccines are most cost-effective for the poor living in high mortality regions. Reductionsin disparities could prevent additional deaths.
Verguet et al. (2015) [15]	X					The health gains would accrue primarily to the poor.	Case study
Campos et al. (2017) [27]					Health disparity; distributional equity	A policy focusing on increasing HPV screening coverage appears to be more compatible with improving bothequity and efficiency than a focus on increasing frequency.
Rheingans et al. (2018) [31]				Subgroup analysis		Children in the poorest households would benefit more from the vaccination programme than the richest.
Rheingans et al. (2018) [32]				Subgroup analysis		Rotavirus vaccination could promote health equity.
Dawkins et al. (2018) [17]		X			Equally distributed equivalent (EDE) health	Prioritizing rural populations can thus be seen as being equitable.	Case study
Chang et al. (2018) [29]				Subgroup analysis		The poorest quintiles would gain the most from vaccine programs because they have the most to gain, in both health and economic terms.
Hangoma et al. (2019) [28]				Subgroup analysis		A sugar tax in an LMIC context like Zambia would improve health outcomes. Improvements in health outcomes are stronger in women.
Arnold et al. (2020) [18]		X			Equally distributed equivalent (EDE) health	Efforts to improve access to the EHP could be targeted to specific interventions to improve the health of the poorest fastest but that identifying these interventions is uncertain.	Case study
Love-Koh et al. (2021) [25]		X			Equally distributed equivalent (EDE) health	The intervention is likely to be cost-effective but that the inequality impacts are small and highly uncertain.	Case study
Olsen et al. (2021) [26]					Gini index	Prioritizing the intervention scale-up in the regions with the highest baseline U5MRs would reduce geographical inequalities in life expectancy.

Hutton DW, So SK, Brandeau ML. Cost-effectiveness of nationwide hepatitis B catch-up vaccination among children and adolescents in China. Hepatology. 2010;51(2):405–414.

 PubMed Web of Science ®Google Scholar

Rheingans R, Anderson J, Anderson B, et al. Estimated impact and cost-effectiveness of rotavirus vaccination in India: effects of geographic and economic disparities. Vaccine. 2014;32(Suppl 1):A140–150.

 PubMedGoogle Scholar

Verguet S, Laxminarayan R, Jamison DT. Universal public finance of tuberculosis treatment in India: an extended cost-effectiveness analysis. Health Econ. 2015;24(3):318–332.

 PubMed Web of Science ®Google Scholar

Campos NG, Tsu V, Jeronimo J, et al. To expand coverage, or increase frequency: quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings. Int J Cancer. 2017;140(6):1293–1305.

 PubMed Web of Science ®Google Scholar

Rheingans R, Anderson J, Bagamian KH, et al. Effects of geographic and economic heterogeneity on the burden of rotavirus diarrhea and the impact and cost-effectiveness of vaccination in Pakistan. Vaccine. 2018;36(51):7780–7789.

 PubMed Web of Science ®Google Scholar

Rheingans R, Anderson J, Bagamian KH, et al. Effects of geographic and economic heterogeneity on rotavirus diarrhea burden and vaccination impact and cost-effectiveness in the Lao People’s Democratic Republic. Vaccine. 2018;36(51):7868–7877.

 PubMed Web of Science ®Google Scholar

Dawkins BR, Mirelman AJ, Asaria M, et al. Distributional cost-effectiveness analysis in low- and middle-income countries: illustrative example of rotavirus vaccination in Ethiopia. Health Policy Plan. 2018;33(3):456–463.

 PubMed Web of Science ®Google Scholar

Chang AY, Riumallo-Herl C, Perales NA, et al. The equity impact vaccines May have on averting deaths and medical impoverishment in developing countries. Health Aff (Millwood). 2018;37(2):316–324.

 PubMed Web of Science ®Google Scholar

Hangoma P, Bulawayo M, Chewe M, et al. The potential health and revenue effects of a tax on sugar sweetened beverages in Zambia. BMJ Glob Health. 2020;5(4). DOI:https://doi.org/10.1136/bmjgh-2019-001968

 Google Scholar

Arnold M, Nkhoma D, Griffin S. Distributional impact of the Malawian essential health package. Health Policy Plan. 2020;35(6):646–656.

 PubMed Web of Science ®Google Scholar

Love-Koh J, Mirelman A, Suhrcke M. Equity and economic evaluation of system-level health interventions: a case study of Brazil’s family health program. Health Policy Plan. 2020.

 Google Scholar

Olsen M, Norheim OF, Memirie ST. Reducing regional health inequality: a sub-national distributional cost-effectiveness analysis of community-based treatment of childhood pneumonia in Ethiopia. Int J Equity Health. 2021;20(1):9.

 PubMed Web of Science ®Google Scholar