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Health Interventions May Have Divergent Impacts on Health and Economic Equity: A Case Study of the Community-Based Hypertension Improvement Project in Ghana

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Abstract

Background and Objective

Improving health and economic equity are key objectives in priority setting, particularly in low-income and middle-income countries. This study aims to assess the distributional impacts of the Community-based Hypertension Improvement Project (ComHIP) on health and economic outcomes across wealth quintiles in Ghana.

Methods

We developed a decision analytical model to simulate a 30 million cohort of Ghanaians aged 15–49 years. The study specified health outcomes as the prevention of stroke cases and averting deaths among those with hypertension. Furthermore, we explored economic impacts, including savings in out-of-pocket costs for stroke patients and government spending. Financial risk protection against catastrophic and impoverishing health expenditures was also examined. We assessed these outcomes across wealth quintiles, and the corresponding concentration indexes (CIXs) were determined.

Results

It was estimated that ComHIP could prevent 1450 stroke cases and 564 related deaths annually. Health benefits were observed to be more significant among the wealthier quintiles (CIX 0.217), mainly attributed to a higher occurrence of hypertension within these groups. ComHIP was also projected to result in an annual saving of USD 49,885 in individuals’ out-of-pocket costs (CIX 0.262) and USD 37,578 in government spending (CIX 0.146). These savings correspond to the prevention of 335 catastrophic health expenditure cases (CIX − 0.239) and 11 impoverishing health expenditure cases (CIX − 0.600).

Conclusions

While ComHIP provides greater health benefits to wealthier groups, it offers substantial financial risk protection for the less wealthy. This study highlights the importance of considering equity in both health and financial risk when making priority-setting decisions.

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References

  1. Hamid S, Groot W, Pavlova M. Trends in cardiovascular diseases and associated risks in sub-Saharan Africa: a review of the evidence for Ghana, Nigeria, South Africa, Sudan and Tanzania. Aging Male. 2019;22:169–76. https://doi.org/10.1080/13685538.2019.1582621.

    Article  PubMed  Google Scholar 

  2. Moran A, Forouzanfar M, Sampson U, Chugh S, Feigin V, Mensah G. The epidemiology of cardiovascular diseases in Sub-Saharan Africa: the Global Burden of Diseases, Injuries and Risk Factors 2010 Study. Prog Cardiovasc Dis. 2013;56:234–9. https://doi.org/10.1016/j.pcad.2013.09.019.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Ofori-Asenso R, Garcia D. Cardiovascular diseases in Ghana within the context of globalization. Cardiovasc Diagn Ther. 2016;6:67–77. https://doi.org/10.3978/j.issn.2223-3652.2015.09.02.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sanuade OA, Anarfi JK, de-Graft Aikins A, Koram KA. Patterns of cardiovascular disease mortality in Ghana. Ethn Dis. 2014;24:55–9.

    PubMed  Google Scholar 

  5. Sanuade O, Agyemang C, de-Graft Aikins A, Agyei-Mensah S, Agyemang C. Stroke in Ghana: a systematic literature review. In: de-Graft Aikens A, Agyei-Mensah S, Agyemang C, editors. Chronic non-communicable diseases in Ghana: multidisciplinary perspectives. Legon, Accra: Sub-Saharan Publishers; 2013. p. 29–40.

    Google Scholar 

  6. Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1204–22. https://doi.org/10.1016/S0140-6736(20)30925-9.

    Article  Google Scholar 

  7. Sarfo FS, Akassi J, Awuah D, Adamu S, Nkyi C, Owolabi M, et al. Trends in stroke admission and mortality rates from 1983 to 2013 in central Ghana. J Neurol Sci. 2015;357:240–5. https://doi.org/10.1016/j.jns.2015.07.043.

    Article  PubMed  Google Scholar 

  8. Morris K. Collaboration works to improve stroke outcomes in Ghana. Lancet. 2011;377:1639–40. https://doi.org/10.1016/S0140-6736(11)60658-2.

    Article  PubMed  Google Scholar 

  9. Addo J, Agyemang C, Smeeth L, Aikins ADG, Adusei AK, Ogedegbe O. A review of population-based studies on hypertension in Ghana. Ghana Med J. 2022;46:4–11. https://doi.org/10.4314/gmj.v46i2.

    Article  Google Scholar 

  10. Amoah AGB. Hypertension in Ghana: a cross-sectional community prevalence study in greater Accra. Ethn Dis. 2023;13:310–5.

    Google Scholar 

  11. Pandian JD, Gall SL, Kate MP, Silva GS, Akinyemi RO, Ovbiagele BI, et al. Prevention of stroke: a global perspective. Lancet. 2018;392:1269–78. https://doi.org/10.1016/S0140-6736(18)31269-8.

    Article  PubMed  Google Scholar 

  12. Jafar TH, Gandhi M, de Silva HA, Jehan I, Naheed A, Finkelstein EA, et al. A community-based intervention for managing hypertension in Rural South Asia. N Engl J Med. 2020;382:717–26. https://doi.org/10.1056/NEJMoa1911965.

    Article  PubMed  Google Scholar 

  13. Brownstein JN, Bone LR, Dennison CR, Hill MN, Kim MT, Levine DM. Community health workers as interventionists in the prevention and control of heart disease and stroke. Am J Prev Med. 2005;29:128–33. https://doi.org/10.1016/j.amepre.2005.07.024.

    Article  PubMed  Google Scholar 

  14. van de Vijver S, Oti S, Addo J, de Graft-Aikins A, Agyemang C. Review of community-based interventions for prevention of cardiovascular diseases in low- and middle-income countries. Ethn Health. 2012;17:651–76. https://doi.org/10.1080/13557858.2012.754409.

    Article  PubMed  Google Scholar 

  15. Pozo-Martin F, Akazili J, Der R, Laar A, Adler AJ, Lamptey P, et al. Cost-effectiveness of a community-based Hypertension Improvement Project (ComHIP) in Ghana: results from a modelling study. BMJ Open. 2021;11: e039594. https://doi.org/10.1136/bmjopen-2020-039594.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Adler AJ, Laar A, Prieto-Merino D, Der RMM, Mangortey D, Dirks R, et al. Can a nurse-led community-based model of hypertension care improve hypertension control in Ghana? Results from the ComHIP cohort study. BMJ Open. 2019;9: e026799. https://doi.org/10.1136/bmjopen-2018-026799.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Avanceña ALV, Prosser LA. Examining equity effects of health interventions in cost-effectiveness analysis: a systematic review. Value Health. 2021;24:136–43. https://doi.org/10.1016/j.jval.2020.10.010.

    Article  PubMed  Google Scholar 

  18. Bobinac A, van Exel NJA, Rutten FFH, Brouwer WBF. Inquiry into the relationship between equity weights and the value of the QALY. Value Health. 2012;15:1119–26. https://doi.org/10.1016/j.jval.2012.07.002.

    Article  PubMed  Google Scholar 

  19. Verguet S, Olson ZD, Babigumira JB, Desalegn D, Johansson KA, Kruk ME, et al. Health gains and financial risk protection afforded by public financing of selected interventions in Ethiopia: an extended cost-effectiveness analysis. Lancet Glob Health. 2015;3:e288–96. https://doi.org/10.1016/S2214-109X(14)70346-8.

    Article  PubMed  Google Scholar 

  20. World Health Organization. World health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013.

    Book  Google Scholar 

  21. Verguet S, Murphy S, Anderson B, Johansson KA, Glass R, Rheingans R. Public finance of rotavirus vaccination in India and Ethiopia: an extended cost-effectiveness analysis. Vaccine. 2013;31:4902–10. https://doi.org/10.1016/j.vaccine.2013.07.014.

    Article  PubMed  Google Scholar 

  22. Verguet S, Laxminarayan R, Jamison DT. Universal public finance of tuberculosis treatment in India: an extended cost-effectiveness analysis. Health Econ. 2015;24:318–32. https://doi.org/10.1002/hec.3019.

    Article  PubMed  Google Scholar 

  23. Verguet S, Kim JJ, Jamison DT. Extended cost-effectiveness analysis for health policy assessment: a tutorial. Pharmacoeconomics. 2016;34:913–23. https://doi.org/10.1007/s40273-016-0414-z.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Wagstaff A, O’Donnell O, Van Doorslaer E, Lindelow M. Analyzing health equity using household survey data: a guide to techniques and their implementation. Washington, DC: World Bank Publications; 2007.

    Google Scholar 

  25. Ghana Statistical Service—GSS, Ghana Health Service—GHS, ICF International. Ghana Demographic and Health Survey 2014. Rockville (MD): GSS, GHS, and ICF International; 2015.

  26. Sarfo FS, Mobula LM, Plange-Rhule J, Ansong D, Ofori-Adjei D. Incident stroke among Ghanaians with hypertension and diabetes: a multicenter, prospective cohort study. J Neurol Sci. 2018;395:17–24. https://doi.org/10.1016/j.jns.2018.09.018.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Ghana National Health Insurance Authority. National Health Insurance Scheme: tariffs for CHAG primary care hospitals (catering exclusive). https://www.nhis.gov.gh/files/CHAG%20Primary%20Hospital%20(Catering%20Exclusive).pdf. Accessed 10 May 2023.

  28. US Dollars to Ghanaian Cedis. https://www.dollarfx.org/Ghanaian-Cedi/2016-01-15. Accessed 10 May 2023.

  29. Smith PC. Incorporating financial protection into decision rules for publicly financed healthcare treatments. Health Econ. 2013;22:180–93. https://doi.org/10.1002/hec.2774.

    Article  PubMed  Google Scholar 

  30. Ghana Statistical Service. Ghana poverty mapping report. https://www2.statsghana.gov.gh/docfiles/publications/POVERTY%20MAP%20FOR%20GHANA-05102015.pdf. Accessed 10 May 2023.

  31. Ghana Statistical Service. Ghana Living Standard Survey 7. https://www.statsghana.gov.gh/gssmain/fileUpload/pressrelease/GLSS7%20MAIN%20REPORT_FINAL.pdf. Accessed 10 May 2023.

  32. Sanuade OA, Boatemaa S, Kushitor MK. Hypertension prevalence, awareness, treatment and control in Ghanaian population: evidence from the Ghana demographic and health survey. PLoS ONE. 2018;13: e0205985. https://doi.org/10.1371/journal.pone.0205985.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Nguyen T-P-L, Wright EP, Nguyen T-T, Schuiling-Veninga CCM, Bijlsma MJ, et al. Cost-effectiveness analysis of screening for and managing identified hypertension for cardiovascular disease prevention in Vietnam. PLoS One. 2016;11:e0155699. https://doi.org/10.1371/journal.pone.0155699.

  34. Rosendaal NT, Hendriks ME, Verhagen MD, Bolarinwa OA, Sanya EO, Kolo PM. Costs and cost-effectiveness of hypertension screening and treatment in adults with hypertension in rural Nigeria in the context of a health insurance program. PLoS ONE. 2016;11: e0157925. https://doi.org/10.1371/journal.pone.0157925.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Gaziano T, Abrahams-Gessel S, Surka S, Sy S, Pandya A, Denman CA, et al. Cardiovascular disease screening by community health workers can be cost-effective in low-resource countries. Health Aff. 2015;34:1538–45. https://doi.org/10.1377/hlthaff.2015.0349.

    Article  Google Scholar 

  36. Saxena A, Koon AD, Lagrada-Rombaua L, Angeles-Agdeppa I, Johns B, Capanzana M. Modelling the impact of a tax on sweetened beverages in the Philippines: an extended cost–effectiveness analysis. Bull World Health Organ. 2019;97:97–107. https://doi.org/10.2471/BLT.18.219980.

    Article  PubMed  Google Scholar 

  37. Saeed BII, Yawson AE, Nguah S, Agyei-Baffour P, Emmanuel N, Ayesu E. Effect of socio-economic factors in utilization of different healthcare services among older adult men and women in Ghana. BMC Health Serv Res. 2016;16:390. https://doi.org/10.1186/s12913-016-1661-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Hendrix N, Bolongaita S, Villano D, Memirie ST, Tolla MT, Verguet S. Equitable prioritization of health interventions by incorporating financial risk protection weights into economic evaluations. Value Health. 2023;26:411–7. https://doi.org/10.1016/j.jval.2022.09.007.

    Article  PubMed  Google Scholar 

  39. Sapkota T, Houkes I, Bosma H. Vicious cycle of chronic disease and poverty: a qualitative study in present day Nepal. Int Health. 2021;13:30–8. https://doi.org/10.1093/inthealth/ihaa016.

    Article  PubMed  Google Scholar 

  40. Laar AK, Adler AJ, Kotoh AM, Legido-Quigley H, Lange IL, Perel P, et al. Health system challenges to hypertension and related non-communicable diseases prevention and treatment: perspectives from Ghanaian stakeholders. BMC Health Serv Res. 2019;19:693. https://doi.org/10.1186/s12913-019-4571-6.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Murray CJL, Aravkin AY, Zheng P, Abbafati C, Abbas KM, Abbasi-Kangevari M, et al. Global burden of 87 risk factors in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396:1223–49. https://doi.org/10.1016/S0140-6736(20)30752-2.

    Article  Google Scholar 

  42. Zhu J, Kamel H, Gupta A, Mushlin AI, Menzies NA, Gaziano TA, et al. Prioritizing quality measures in acute stroke care. Ann Intern Med. 2023;176:649–57. https://doi.org/10.7326/M22-3186.

    Article  PubMed  Google Scholar 

  43. Sweeney S, Vassall A, Foster N, Simms V, Ilboudo P, Kimaro G, et al. Methodological issues to consider when collecting data to estimate poverty impact in economic evaluations in low-income and middle-income countries. Health Econ. 2016;25:42–52. https://doi.org/10.1002/hec.3304.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

We sincerely appreciate Prof. Stephane Verguet (Harvard University) and Prof. Justice Nonvignon (Africa CDC and University of Ghana) for their insightful comments.

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Authors and Affiliations

  1. Department of Global Health and Population, Harvard T.H. Chan School of Public Health, 90 Smith St, Boston, MA, 02120, USA

    Yizhi Liang, Yuqian Lin & Boshen Jiao

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  1. Yizhi Liang
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Correspondence to Boshen Jiao.

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Funding

Boshen Jiao acknowledges funding support from Trond Mohn Foundation and NORAD through BCEPS (#813596).

Conflicts of Interest/Competing Interests

Yizhi Liang, Yuqian Lin, and Boshen Jiao have no conflicts of interest that are directly relevant to the content of this article.

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Availability of Data and Material

The data used in the paper are presented in Table 1, derived from public database, reports, and the cited literature.

Code Availability

The code used in the analysis is available from the authors upon reasonable request.

Authors’ Contributions

Conceptualization: BJ, YL, YL; formal analysis: YL, YL; methodology: BJ, YL, YL; writing - original draft: YL, YL; writing - review and editing: BJ, YL, YL. All authors contributed to the development of the manuscript.

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Liang, Y., Lin, Y. & Jiao, B. Health Interventions May Have Divergent Impacts on Health and Economic Equity: A Case Study of the Community-Based Hypertension Improvement Project in Ghana. Appl Health Econ Health Policy 22, 353–362 (2024). https://doi.org/10.1007/s40258-024-00871-7

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