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The new Omicron variant of COVID-19 may be more transmissible and more capable of evading vaccines than older variants due to its high number of mutations. There is a real concern that it could spread rapidly throughout the world and lead to another wave of critically ill patients in low-and middle income countries (LMICs), where vaccine coverage remains low.
Given this potential bleak outlook, policy makers must decide whether to invest in advanced critical care such as mechanical ventilators, which are expensive and difficult to provide at scale, or a new and easy to scale-up package of care called Essential Emergency & Critical Care (EECC). This includes for example: monitoring basic vital signs to identify critical illness; provision of oxygen therapy and intravenous fluids; and positioning of unconscious patients to maintain a free airway.
Cost-effectiveness evidence can help answer this question by helping policymakers understand how best to allocate scarce resources to maximize population health benefits and value for money.
Today, the Center for Global Development, in collaboration with teams from Ifakara Health Institute, KEMRI Wellcome Trust Research Programme, London School of Hygiene and Tropical Medicine and Uppsala University, provide evidence on the costs of EECC and report results showing it is highly cost-effective and very good value for money in treating the critical illness of COVID-19 in low resource settings, using Tanzania as a case study.
We have compared EECC with two alternative scenarios (no critical care and typical district hospital level critical care) and used probabilistic methods due to the uncertainty in the data. Here, we share four insights from our work.
1. EECC is a low-cost solution and almost 10 times cheaper than advanced critical care for the treatment of critical patients
The Tanzanian costs per patient day of EECC for COVID-19 patients was estimated to be 10.83 and 32.84 USD for severe and critical patients respectively. This compares with our estimated 297.30 USD per patient day for treatment of critical patients with advanced critical care. Ongoing work in Kenya suggests similar costs.
The most important driver of the costs for severe and critical patients was oxygen therapy—43.8 percent and 59.9 percent respectively. Staff time also plays an important role in EECC costs (31.0 percent and 18.6 percent for severe and critically ill respectively). Continued emphasis on ensuring available staff and adequate budgets for oxygen will be an important part of EECC implementation.
2. Investing in EECC is very good value for money, and should be prioritised immediately
We find that the probability of EECC being cost-effective in Tanzania is greater than 90 percent across both a no critical care or district hospital level critical care setting, assuming that the government is willing to pay 101 USD per disability adjusted life year (DALY) averted as previous research has shown. Specifically, the cost of an additional DALY averted by EECC is estimated to lie between 10.18-70.16 USD and 8.12-52.38 USD relative to no critical care and to district hospital level critical care respectively. This is within the range of very cost-effective interventions such as emergency obstetric care or treatment of severe malaria with artemisinin-based combination therapy.
3. Investing in advanced critical care is only cost-effective if EECC is in place and providers can afford it
Assuming the same conservative willingness-to-pay threshold in Tanzania (101 USD), investment in advanced critical care is not cost-effective relative to EECC alone and therefore it is better value for money to invest in EECC before advanced critical care. When quantifying uncertainty in our analysis, we find that the probability of advanced critical care (implemented along with EECC) being cost-effective is approximately 22–28 percent for both the no critical care and district hospital level critical care settings. Some healthcare providers (such as private hospitals) may be willing and able to invest more resources in critical care than just the basics and may opt for advanced critical care. Even in these settings, our findings suggest that implementation of EECC should be the first priority given its very high value for money, and more advanced care added to the foundation of EECC for all critically ill patients.
4. We need to improve the evidence base for cost effectiveness of critical care
Both critical illness and critical care delivery are heterogeneous and clinical and economic data in care for critical illness are severely limited. Our findings are presented as probabilities and ranges due to the limited availability of data, the heterogeneity in critical care and the resulting levels of uncertainty. However, such heterogeneity should not be a barrier to the collection and analysis of clinical and economic data for research and policy purposes. One of the lowest hanging fruits would be to gather representative hospital cost data for a full positive costing exercise of care for the critically ill.
Real world evidence from hospital settings is vital for informing national health priority setting and can spark new avenues of health and economic research. For example, initiatives such as the ISARIC (International Severe Acute Respiratory and emerging Infections Consortium) partnership have enabled the rapid launch of standardised global clinical data collection from critical care facilities resulting in a large database from hundreds of hospitals globally. Unfortunately, there is an underrepresentation of data from low resourced hospitals such as district hospitals in sub-Saharan Africa. Increasing availability of these data would provide a valuable evidence base from settings where many critically ill patients are managed.
Finally, throughout the pandemic, high resource settings have led the way in assessing the effectiveness of novel interventions (e.g. dexamethasone, molnupiravir, remdesivir). The global health community must advocate for pragmatic trials and early health technology assessments in low resource settings including the assessment of the potential added value of critical care, supportive care and non-pharmacological interventions such as EECC that have the scope of preventing deaths from a wide range of causes, beyond COVID-19.
Conclusion
Several million deaths are incurred each year as a result of conditions such as COVID-19, sepsis, pneumonia, eclampsia, haemorrhage, trauma, peritonitis, asthma, and stroke which all lead to critical illness. Our results from Tanzania show that EECC is a highly cost-effective investment for providing care to critically ill COVID-19 patients. EECC can help address existing gaps in critical care provision by providing effective life-saving care of low-cost and low complexity. By prioritising EECC immediately for critically ill patients, the world can derive even greater benefits and value for money as EECC will not only help in the COVID-19 pandemic but also for other conditions that require critical care.
Find out more
To find out more information about our analysis, methods, and results, we’ll be hosting a free and open access webinar with global health stakeholders on Tuesday 7th December 2021 at 9am (EST). Here, we hope to present in-depth results and discuss ideas on the lessons learned from Tanzania on priorities for the care of critically ill patients with COVID-19.
Ahead of and during the event, please share your reactions and questions in the comments section below, on Twitter @CGDev #CGDtalks, or via email at cgdevents@cgdev.org. We look forward to your thoughts and to continuing the important conversation.
We will also be publishing all methods and results in peer reviewed scientific literature which will be announced to the public in due course.
As with any modelling study, all results should be viewed considering the assumptions made, the data used and with the caveat that these results are subject to change given any change in assumptions or data. Caution is therefore advised in interpreting our results to avoid generalisations not supported by the data.
Disclaimer
CGD blog posts reflect the views of the authors, drawing on prior research and experience in their areas of expertise. CGD is a nonpartisan, independent organization and does not take institutional positions.
