Abstract
Abstract
Background
Sexual and reproductive health (SRH) programmes and services aim to prevent complications of pregnancy and childbirth, unintended pregnancies, unsafe abortions, complications caused by sexually transmitted infections, including HIV, sexual violence and impacts from avoidable cancer.
Objective
To systematically identify published economic evaluations of SRH programmes and services, assess the methods used and analyse how costs and outcomes are estimated in these studies.
Settings
Low- and middle-income countries.
Design
Systematic review and narrative synthesis.
Methods
Eight databases were searched, including EMBASE, MEDLINE, Scopus, Health Technology Assessment, Web of Science, PsycINFO, National Health Service Economic Evaluation Database (NHS EED) and African Journals Online (AJOL) from 1998 to December 2023. The inclusion and exclusion criteria were developed using the Population, Intervention, Comparator, Outcome and Study Design framework. The review included economic evaluations alongside randomised trials and economic studies with modelling components. Study characteristics, methods and results of economic evaluations were extracted and tabulated. The quality of the studies was assessed using the Consensus Health Economic Criteria list and Philips checklists for trial-based and model-based studies, respectively. The review followed the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and the results were synthesised narratively in line with Centre for Reviews and Dissemination guidance.
Results
7575 studies were screened and categorised. 20 studies were included in the review. The studies assessed the cost-effectiveness and costs of SRH programmes and services from an individual, healthcare or societal perspective. The main SRH programme considered was contraceptive services. The main outcome measures reported were disability-adjusted life years, quality-adjusted life years, couple years of protection and pregnancies averted. Most of the studies did not indicate the costing approach used, and many of the studies evaluated direct medical costs only. Most of the study designs were model-based with significant heterogeneity between the models. The review showed that many studies did not fulfil all of the requirements for a high-quality economic evaluation. 1 out of the 20 studies reviewed considered equity.
Conclusions
The review revealed heterogeneity in approaches to evaluating the costs and outcomes of SRH programmes. These methodological limitations may have implications for their use by public health decision-makers to inform optimal decision-making.
PROSPERO registration number
CRD42023435241.
Keywords: Sexually Transmitted Disease, HEALTH ECONOMICS, Healthcare Costs, HIV & AIDS
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This review includes a robust methodology incorporating a thorough search strategy across multiple electronic databases, supplemented with hand-searching of reference lists of included studies.
The reviews focused on all potential users of sexual and reproductive health (SRH) services both adults and young people, and males and females.
Studies focusing on a wide range of SRH services and programmes, such as contraceptive services, prevention and control of sexually transmitted infections including HIV, prevention of cervical cancer and prevention of violence among adolescents and couples were included.
A limitation of this review is that it excluded studies focusing on high-risk groups (eg, female sex workers) which may mean that some relevant methodological discussions were missed.
Searching of the grey literature was not undertaken, so economic evaluations that were not published in peer-reviewed journals may have been missed.
Introduction
Sexual and reproductive health (SRH) is an important aspect of health and a fundamental human right.1 Sexual health represents a state of physical, emotional, mental and social well-being about sexuality.2 Reproductive health addresses reproductive processes, functions and systems at all stages of life and deals with the capability of an individual to reproduce and the freedom to decide if, when, and how often to do so.3 SRH services in low- and middle-income countries (LMICs) cover a wide range of health issues, including contraceptive use; maternal and newborn healthcare; prevention, diagnosis and treatment of sexually transmitted infections (STIs), including HIV4; physical and sexual violence; cervical and prostate cancer screening; as well as infertility prevention and management.5 These services aim to prevent poor SRH, such as complications of pregnancy and childbirth, unintended pregnancies, unsafe abortions, complications caused by STIs, sexual violence and avoidable cancer.6 Poor SRH affects adolescents, as well as adults, so SRH services must be available and appropriate for both of these population groups.7
Recent data suggests that SRH services are not well-established in LMICs.7 An estimated 218 million women of reproductive age (15–49 years) in LMICs have an unmet need for modern contraception, that is, they want to avoid pregnancy but cannot access a modern method (eg, oral contraceptive pills, intrauterine devices, contraceptive implants).7 Men have substantial SRH needs for contraception, prevention and treatment of HIV and other STIs, sexual dysfunction, infertility and male cancers.8 Men often experience unmet SRH needs as a result of issues such as inadequate use of SRH services, hesitancy in seeking health support (counselling) and limited access to healthcare services.9 Adolescents (10–19 years) also have substantial unmet needs in SRH care.7 For example, adolescents in LMICs have an estimated 21 million pregnancies each year, 50% of which are unplanned.7
The provision of SRH services is important to reduce mortality and morbidity in LMICs.7 Given that LMICs are resource-constrained settings, it is also important to ensure that any SRH programmes and services are effective and cost-effective. However, there is limited evidence on the cost-effectiveness of SRH programmes and services in LMICs and a lack of consideration of their methodological quality.10 11 The limited reviews that do exist have focused on specific contexts such as sexual health-related services in humanitarian crises12 and SRH and HIV interventions targeting sex workers,13 and previous studies did not comprehensively explore the cost-effectiveness of SRH programmes and services in LMICs or assess methodological quality.
Evidence on cost-effectiveness is required to support decisions around funding allocations, service planning and workforce.14 Economic evaluations relate to the costs and outcomes (inputs and outputs) of health technologies, programmes and interventions, which are compared with possible alternatives and respective costs and consequences.15 This systematic review aimed to identify economic evaluations of SRH programmes and services, assess the type of economic evaluation methods used and assess how costs and outcomes are estimated, valued and analysed in LMIC settings.
Methods
This systematic review was prospectively registered on PROSPERO (CRD42023435241) and followed the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the University of York Centre for Reviews and Dissemination (CRD).16
Search strategy
A search strategy was developed using the Population, Intervention, Comparator, Outcome and Study Design (PICOS) framework.16 The search strategy included keywords such as ‘sexual and reproductive health services’, ‘sexual health’, ‘reproductive health’, ‘HIV testing and counselling’, ‘STI management’, ‘low- and middle-income countries’, ‘economic evaluation’ and ‘costing analyses’ (online supplemental appendix 1–4).
The following eight electronic databases were searched: EMBASE, MEDLINE, Scopus, Health Technology Assessment, PsycINFO, Web of Science, National Health Service Economic Evaluation Database (NHS EED) and African Journals Online (AJOL). The choice of databases was informed by the findings of a study which stated that a combination of MEDLINE, EMBASE, Health Technology Assessment database and Scopus could generate 96% of possible relevant economic evaluation publications.17 Reference lists from included full texts were also searched as well as hand searching online. The search period was from 1998 (when WHO began developing guidance on cost-effectiveness analysis)18 to December 2023.
Inclusion and exclusion criteria
Studies were included according to the following criteria, which were developed based on the PICOS framework (see table 1). The review focused on studies that involved the general population, comprehensive SRH programmes and that were full economic evaluations. We excluded unpublished studies (ie, ‘grey’ literature) and conference abstracts as the aim was to assess methodological quality.
Table 1. PICOS framework.
| PICOS | Inclusion criteria | Exclusion criteria |
| Participants | The review included studies involving the general population aged 10 years and above.53 Participants were potential users of the SRH programmes and services. | |
| Intervention | All aspects of SRH programmes and services including contraceptive services; prevention, diagnosis and treatment of STIs, including HIV; HPV vaccination; cervical cancer screening; violence prevention; infertility prevention and management.5 | |
| Comparators | The comparators in the studies could be other interventions, usual care or no intervention. | |
| Outcomes | All outcomes associated with different types of economic evaluations (eg, cost-benefit, cost-effectiveness and cost-utility analysis) were included. The cost categories could vary depending on the economic perspective adopted (eg, individual, healthcare and societal). The outcomes of the interventions could be measured and analysed in different ways, depending on the type of economic evaluation, for example, clinical outcome measures (eg, reduced STIs and HIV infection rate), monetary benefit, quality-adjusted life years gained, disability-adjusted life years averted and life-years gained. | |
| Study design and settings | This review included economic evaluations alongside randomised controlled trials, economic studies with modelling components and observational analytical studies with economic components. The study setting was LMICs. | |
| The following were excluded from the review: conference proceedings, guidelines, abstracts, editorials, commentaries, literature reviews, letters to the editor, systematic reviews and studies published in languages other than English, and grey literatures. |
HPVhuman papillomavirusLMIClow- and middle-income countriesPICOSPopulation, Intervention, Comparator, Outcome and Study DesignSRHsexual and reproductive healthSTIsexually transmitted infection
Screening and selection of papers
EndNote V.20 referencing manager was used for the management and categorisation of the references. The strategy recommended by the CRD, University of York,19 was applied to systematically select studies. Study selection was undertaken by two independent reviewers. The two-stage categorisation process outlined by Roberts et al20 was adopted for study identification. The first stage involved categorisation of the studies based on title, abstract and keywords into one of eight categories (A to G; table 2). Studies in categories (A), (B), (C) and (D) were considered relevant to the systematic review. The second stage involved further classification of the studies in these four categories into categories 1–5 (table 2) based on a review of the full text. Full texts of studies that met the inclusion criteria classified as A(1), A(2), B(1), B(2), C(1), C(2), D(1) or D(2) in Stage II were included in the review.
Table 2. Selection of papers for review.
| Stages I | A | The study involves an economic evaluation of sexual and reproductive health (SRH) services and/or interventions in low- and middle-income countries (LMICs) based on primary and/or secondary data (eg, previously published studies or other sources) |
| B | The study discusses economic aspects of SRH services and/or interventions in LMICs and contains relevant primary and/or secondary cost or utilisation data | |
| C | The study discusses other aspects of sexual and reproductive health services and/or interventions in LMICs but is neither (A) nor (B) nor (C) nor (D) (eg, acceptability, implementation, utilisation) | |
| D | The study discusses the effectiveness of SRH services and/or interventions in LMICs and contains relevant primary and/or secondary data | |
| E | The study is a systematic review of an economic evaluation of SRH services and/or interventions in LMICs | |
| F | Complete economic evaluation, for example, cost-effectiveness analysis, cost-benefit analysis or cost-utility analysis of SRH services and/or intervention focussing on particular population groups, other than young people (eg, female sex workers) in LMICs | |
| G | The study is not relevant to the economic evaluation of sexual and reproductive health services and/or interventions in LMICs | |
| Stage II | 1 | Complete economic evaluation, for example, cost-effectiveness analysis, cost-benefit analysis or cost-utility analysis of comprehensive SRH services |
| 2 | Complete economic evaluation, for example, cost-effectiveness analysis, cost-benefit analysis or cost-utility analysis of particular services that might come under the umbrella of SRH services (eg, family planning, HIV testing) | |
| 3 | Other cost studies relating to SRH services | |
| 4 | A study describing different methods for an economic evaluation of SRH services | |
| 5 | Not relevant to the economic evaluation of SRH services |
Data extraction
A data extraction template was developed, piloted by extracting data from two studies and checked by coauthors. Relevant data were extracted on study characteristics and results, plus additional information on the methods adopted concerning the type of economic evaluation, costs, outcome measures and costing approach.
Quality assessment
The quality of included studies was assessed using the Consensus Health Economic Criteria (CHEC) list21 for trial-based studies (online supplemental table 3) and the Philips checklist22 for model-based studies (online supplemental table 4). We modified the CHEC list and Philips checklist to include an item on equity from the international decision support initiative reference case for economic evaluations, as this is particularly important in the LMIC context.23 The purpose of the quality assessment was to critically appraise the methodological quality of the economic evidence for SRH programmes and services rather than to exclude studies.
Data analysis
The findings from the included studies were tabulated (onlinesupplemental tables 1 2) to facilitate description and analysis. A narrative synthesis was undertaken in line with the University of York CRD guidance.19
Results
Identification and selection of studies
The stages of the systematic review process are shown in the PRISMA diagram (online supplemental figure 1). A total of 7574 records were obtained from the database searches and one via hand-searching. In total, 3091 duplicates were identified and removed, and the remaining 4484 studies were assessed for categorisation at Stage I. 64 studies were categorised as A to D in Stage I, and full texts for these were reviewed at Stage II and further categorised. Of these, 45 studies were excluded after full-text assessment because they did not include an outcome of interest (n=5), they were not undertaken in an LMIC (n=27), or they were other cost studies relating to SRH (n=13). 20 studies were selected for inclusion in the review.
Study characteristics
The identified studies focused on different LMICs, including South Africa (n=3),24,26 Ethiopia (n=2),27 28 Zambia (n=2),29 30 Egypt (n=1),31 Uganda (n=1),32 India (n=1),33 Mozambique (n=1),34 Bangladesh (n=1),35 Colombia (n=1),36 Mexico (n=1),37 Kenya (n=1),38 Nicaragua (n=1),39 Laos (Vientiane) (n=1)40 and multiple LMICs (n=3)41,43 (onlinesupplemental tables 1 2). The study designs included model-based evaluations (n=14),25,2729 32 trial-based economic evaluations (n=5)24 28 30 36 38 and an observational study using retrospective data (n=1).31 A wide range of SRH services and intervention programmes were considered, and these included contraceptive services (n=6),25 27 31 32 41 43 strategies for cervical cancer prevention (n=5),33 37 39 40 42 integration of contraception use into existing HIV clinics (n=2),29 38 HIV prevention (n=2),30 34 prevention of STIs (n=2),24 36 prevention of physical and sexual violence (n=2)26 28 and abortion-related care (n=1).35
Study population
The study population for most of the studies was females only (n=12).2527 32 33 36,43 Five of the studies focused on adults (males, females and couples),2428,30 34 and none of the studies targeted only males.
Study findings
A variety of results were reported in terms of cost-effectiveness across the range of programmes/services studied. Some studies reported that the programme/service was cost-effective while some could not ascertain the cost-effectiveness of the programmes/services.
Contraceptive services
Most of the studies on contraceptive services reported on the cost-effectiveness of the provision of new interventions or enhanced contraceptive programmes/services, compared with standard contraceptive programmes/services. Three studies from Ethiopia, Uganda and Indonesia on contraceptive services found the scaling up of contraceptive services interventions to a level where people have universal access to modern contraception to be highly cost-effective.27 32 41
Another study in Bangladesh and Tanzania reported that the insertion of an immediate postpartum intrauterine device (PPIUD) after the delivery of a baby was cost-effective compared with standard practice, where insertion of PPIUD is not immediate.43 In contrast, a study in South Africa could not ascertain the cost-effectiveness of the Single-size, Innovative, Low-cost Contraceptive System (SILCS) diaphragm (a new contraceptive device) over the current contraceptive devices.25
Integration of SRH services into existing HIV services
Couples’ family planning counselling with access to long-acting reversible contraception, integrated with couples’ voluntary HIV counselling and testing was compared with existing individual HIV counselling and testing and contraceptive services in Zambia.29 The study reported that the new programme averted an estimated 7165 adult HIV infections over a 5-year time horizon.
The study in Zambia assessed whether improved service delivery models increased the uptake and cost-effectiveness of HIV and SRH services.30 The study reported that integrated services were found to be more efficiently provided than vertical service provision.
A study focused on Kenya compared the integration of contraceptive services and HIV care with the non-integration of the services.38 The cost-effectiveness (cost per pregnancy averted) associated with the first year of integration of family planning into HIV care revealed a marginal cost of US$65 for each additional use of more effective family planning and US$1368 for each pregnancy averted.
Prevention of STIs including HIV
Similarly, most of the studies on the prevention of STIs found a range of sexual health services to be cost-effective. For example, a study in South Africa on syndromic management of STIs reported that providing primary care nurses with syndromic STI packages improved syndromic STI management compared with clinical patients receiving standard care. It was concluded that the intervention was cost-effective, especially in resource-limited settings.24
Another study in Mozambique, on the evaluation of HIV counselling and testing modalities found routine voluntary counselling and testing (VCT) at the centre to be cost-effective compared with door-to-door home-based testing (HBT) and outpatient provider-initiated counselling and testing (PICT).34
A study on incremental costs and estimates of single rapid diagnostic tests (RDTs) for HIV and syphilis compared with dual RDTs for HIV and syphilis in health facilities in Colombia reported lower average costs for single RDTs compared with dual RDTs.36
Cervical cancer prevention strategies
A study evaluated the incremental cost per quality-adjusted life years (QALYs) gained with the introduction of the human papillomavirus (HPV) vaccine compared with no vaccine.33 The study reported that vaccinating girls in Punjab against HPV-16 and HPV-18 would incur an incremental cost of 1827 Indian National rupees (INR) (US$28.1) per QALY gained.33 However, the incremental cost per cervical cancer case prevented and death averted was found to be INR 51 808 and INR 52 330 (US$797 and US$805), respectively.33
The study from Mexico aimed to perform a cost-effectiveness analysis of the introduction of a quadrivalent HPV vaccine into the public health system and evaluate the economic benefits of the prevention of cervical cancer.37 The strategy of using only vaccination as a preventive measure was reported as a very cost-effective strategy.37
A model-based study on the evaluation of the cost-effectiveness of HPV DNA testing and Papanicolaou-based screening for cervical cancer screening strategies was conducted in Nicaragua.39 The study revealed that HPV-Cryo every 5 years was very cost-effective using a threshold based on Nicaragua’s per capita gross domestic product.
Another study was conducted in Vientiane, Lao to determine the cost-effectiveness of screening strategies combined with a vaccination programme for 10-year-old girls for cervical cancer prevention.40 The model predicted that Visual Inspection of the cervix after Acetic acid application (VIA) screening of women aged 30–65 years old every 3 years, combined with vaccination of 10-year-old girls, was the most cost-effective option.
The last study reviewed under cervical cancer prevention strategies was conducted in three LMICs to evaluate the cost-effectiveness of screening at various start ages, intervals and frequencies.42 The study reported that screening with care HPV (cervical sampling) was the most effective and cost-effective strategy in all settings.42
Prevention of physical and sexual violence
A South African study evaluated the cost-effectiveness of interventions to prevent violence against children in LMICs.26 A decision-analytical model was developed to estimate the cost-effectiveness of the interventions. The study concluded that adding a grant linkage component to parenting support will enhance the cost-effectiveness of this intervention.
Another study from Ethiopia analysed the cost-effectiveness of a gender-transformative intervention called Unite for a Better Life (UBL).28 This intervention was designed to prevent Intimate Partner Violence (IPV) and HIV behaviours among men, women and couples by assisting participants in building skills for healthy, non-violent and equitable relationships. UBL was found to be an effective and cost-effective intervention for the prevention of IPV in LMICs.
Abortion-related care
A study from Bangladesh reported that providing early abortion services at all levels of public health facilities using manual vacuum aspiration and including contraceptive counselling services as integral components of early abortion services avert unsafe abortion and its complications.35 The study reported that the total incremental cost per case of early abortion care (menstrual regulation) was 40% of the cost of care for moderate abortion complications and 13% of the cost of care for severe complications at the tertiary care level.
Methodological considerations
Types of economic evaluations
7 of the 20 studies applied cost-effectiveness analysis for their economic evaluation,2829 31 37,39 42 5 applied cost-utility analysis,26 27 33 40 41 3 applied cost-benefit analysis,24 34 36 3 applied both cost-effectiveness and cost-utility analysis30 32 43 and the remaining 2 applied cost-effectiveness and cost-benefit analysis25 35 (online supplemental table 2).
Outcome measures
A range of outcome measures were used in the studies. Six of the cost-utility analyses reported disability-adjusted life years averted as outcome measures26 30 32 40 41 43 and two reported QALYs.29 31 Some studies used various effectiveness outcome measures reported in natural units such as couple-years of protection (n=3),29 31 43 life-years saved/year of life saved (n=3)37 39 42 and pregnancy averted (n=4).25 29 35 38 The other studies applied a monetary outcome (n=5)2425 34,36 or the number of patients treated (online supplemental table 2).
Perspective (or viewpoint)
The perspective or viewpoint of those who commissioned a programme/service or who are intended to be informed by the analysis is very important (ie, all costs and consequences that are relevant should be considered).14 These perspectives include individual, specific healthcare and/or societal perspectives.14 Nine studies applied healthcare perspectives,2426 28 31 35,37 40 43 and two studies applied healthcare and individual perspectives.25 34 Just three studies applied a broader societal perspective,33 39 42 and one study applied both a healthcare and societal perspective.32 One study applied an individual perspective,41 while four studies did not report their perspective27 29 30 38 (online supplemental table 2).
Comparators
The comparators adopted varied. For example, early abortion care (menstrual regulation) against post-abortion complication care,35 VCT against HBT and PICT,34 single RDT against dual RDT for testing HIV and Syphilis36 and HPV vaccination against no vaccination.33 Overall, 11 studies compared their intervention against the current or standard practice,24,3032 38 41 43 and 4 studies compared the strategy/arm against other strategies/arms37 39 40 42 (online supplemental table 2).
The costing approach and costs included
12 of the studies did not indicate the type of costing approach they used.24,3036 38 40 However, eight of the studies used a bottom-up costing approach.31,3537 39 43 Most of the studies focused on direct medical costs, such as buildings and salaries of the health team.27,2931 35 The study from Mozambique considered direct and indirect costs,34 and another study in Nicaragua considered direct medical and direct non-medical costs.39 Direct medical, direct non-medical (such as the cost of transportation to the healthcare facility) and indirect costs, which included loss of productivity due to the time spent accessing healthcare, were considered in the studies from Uganda and South Africa.25 32 Four studies did not fully report the costs they included in their study24 26 30 33 (online supplemental table 2).
The time horizon of the studies
15 studies stated the time horizon considered for their evaluation.25,2931 Five studies did not provide clear information on the time involved.24 30 35 36 38 The time horizon varied across the 15 studies, ranging from a lifetime to 1 year. One study gave a 100-year time horizon,40 lifetime (n=7)27 32 33 37 39 42 43 and women’s reproductive age (n=1).41 The justification for the time horizon adopted varied according to the nature of the intervention (online supplemental table 2).
Sensitivity analysis
Most of the studies conducted a sensitivity analysis (online supplemental table 2). However, five studies did not report any form of assessment of uncertainty.24 30 35 36 38 In studies where a sensitivity analysis was undertaken, the methods applied were only deterministic (n=4),26 31 37 43 only probabilistic (n=5)25 28 33 39 42 or both deterministic and probabilistic (n=6)27 29 32 34 40 41 (online supplemental table 2).
Cost-effectiveness threshold
The incremental cost-effectiveness ratio (ICER) can be compared with a decision rule called the cost-effectiveness threshold (CET). A CET is generally set so that the interventions that appear to be relatively good or very good value for money can be identified (cost-effective).44 If the ICER is below the CET, then the intervention or programme under analysis is considered cost-effective and if it is above the threshold, then the intervention or programme is regarded as not cost-effective.45 There are several types of thresholds in health-related analyses. A willingness-to-pay threshold represents an estimate of what a consumer of healthcare might be prepared to pay for the health benefit, an opportunity cost or supply-side threshold considers resource allocation and Gross Domestic Product (GDP) -based thresholds relate to the country’s GDP per capita and were previously referred to as the WHO recommended threshold.44,46
The CET adopted by some of the studies was the willingness to pay (WTP) by patients or policymakers.25,2741 Some of the studies compared the ICER with either the country’s per capita GDP (n=4)33 39 42 43 or three times the country’s per capita GDP (n=3)30 32 40 (in line with the former WHO recommendations). Several studies did not document any information regarding the cost-effectiveness threshold.2428 29 31 34,38
Equity
Only 1 of the 20 studies considered equity of service provision for individuals.27 The findings from a study conducted in Ethiopia revealed that providing universal access to modern contraceptive methods was equitable, government spending became more progressive and there was a clear reduction in unequal health outcomes because the demand for modern contraceptives in Ethiopia generated health benefits across all wealth quintiles, particularly in the poorest quintiles where financial risk protection benefit was also observed.
Model type
Two of the model-based studies29 34 focused on communicable diseases and 12 were concerned with non-communicable diseases.25,2732 33 35 37 39 Dynamic or static models were not always fully explained or justified.
Quality assessment of studies
Overall, the quality assessment revealed some limitations with the studies identified. For example, one study did not specify its discounting rate.34 An incremental analysis of alternative costs and outcomes was not performed.24 25 35 36 38 All the modelling studies except one25 did not apply the half-cycle correction to both costs and outcomes and failed to justify this omission (online supplemental table 4). Some studies did not run separate models for different subgroups and hence failed to deal with uncertainty around heterogeneity.2526 29 33,35 39 43 The uncertainties associated with model structures were also not fully assessed. One study neglected to compare their results with those of previous models,39 while four studies attempted a comparison but failed to explain the differences in their results25 35 39 42 (onlinesupplemental tables 3 4).
Discussion
This systematic review identified 20 economic evaluations of SRH services and programmes. Most of the studies focused mainly on contraception use, cervical cancer screening and prevention of STIs including HIV. Generally, many of the services and programmes were found to be cost-effective, although there was considerable diversity in the type of services considered. It was observed that there were differences in the approaches adopted by authors to evaluate the SRH services and programmes. There was heterogeneity in methods including the measurement of costs, outcomes and differences in the perspectives applied.
The cost-effectiveness threshold (which assesses value for money) adopted by some of the studies was the WTP method, where they stated that the intervention was cost-effective because the ICER was less than the WTP. Seven studies reported the WHO recommendations stating that the intervention was very cost-effective because the ICER was less than the country’s per capita GDP or the intervention was cost-effective because the ICER was less than three times the country’s per capita GDP despite concerns reported by previous studies regarding the comparison between the country’s per capita GDP and ICER of an intervention (WHO recommendations) to state whether the intervention is cost-effective or not. They regarded this recommendation as being unrealistic,46 not considering local budget constraints,44 47 unattainable48 and it may include interventions that are not affordable,49 which may result in improper allocation and wastage of the scarce healthcare resources in the LMICs. Many other studies did not report on the CET used.
Only two studies among all model-based studies on either infectious (STIs including HIV) or non-infectious (cervical cancer) diseases indicated the use of a dynamic model40 or static model,33 respectively, during their analysis.
Due to the variance in methods applied and limitations with quality, it is difficult to have an overall understanding of the cost-effectiveness of SRH services in LMICs. While local LMIC contexts might pose particular challenges and require specific approaches, it is helpful if studies try to follow established guidelines as far as possible or indicate clearly any deviations so that decision-makers are aware of any potential issues.24 25 Similar findings were reported in a scoping review of the cost-effectiveness of sexual and reproductive health and rights (SRHR) interventions in LMICs, where it was noted that the economic evaluations reviewed varied in their methodologies, SRHR intervention and comparators, cost and effectiveness data and the cost-effectiveness threshold adopted.50 However, as this was a scoping review, the authors did not assess the methodological consideration on economic evaluation of the studies they reviewed by using either the CHEC list for a trial-based study or Philips checklists for a model-based study.
This systematic review adds to the existing literature by providing detailed consideration of the methodological quality of the economic evaluation of the SRH studies reviewed, and these revealed heterogenicity and a lack of standardisation of methods in the conduct and report of economic evaluation of SRH studies.
The equity implications of implementing an intervention within a given population are important. Important equity considerations may include issues such as whether equal access is given to those in equal need or whether resources are distributed fairly to those with different levels of need.51 Equity implications should be considered at all stages of an economic evaluation, including the design, analysis and reporting stages. This is important for all types of economic evaluation. Only 1 of the 20 studies in this systematic review focused on equity,27 which is particularly important in this context. Consideration of equity issues is particularly important for public health interventions in LMIC contexts.
The quality assessment of the studies showed that a significant number of the studies did not fulfil all the requirements for a high-quality economic evaluation, and this was particularly the case for uncertainty assessment, perspective, discounting and analysis of alternative costs and outcomes. Most of the authors did not justify why they omitted certain steps in assessing uncertainty and subgroup analysis was rarely conducted to understand the differential costs and effects on various population groups. Although, there are a range of services that can be considered as SRH programmes/services, there was nonetheless considerable methodological heterogeneity in the studies reviewed. All five studies on cancer of the cervix prevention compared different strategies.33 37 39 40 42
Strengths and limitations of this review
The strengths of this review include that a robust methodology was adopted incorporating a thorough search strategy across multiple electronic databases, supplemented with hand searching of reference lists of included studies. In addition, the review focused on potential users of SRH services in terms of both adults and young people, and males and females. The review also included studies on a broad range of SRH services and programmes, such as family planning services, prevention and control of STIs including HIV, prevention of cervical cancer and prevention of violence among adolescents and couples.
The limitations of this review were that it did not include SRH services and programmes that are focused on specific groups such as female sex workers and people who require humanitarian assistance. Additional important economic evaluations specific to these groups might have been missed. Also, the wider grey literature was not searched, and hence full economic evaluations that were not published in peer-reviewed journals may have been missed. Due to resource constraints, only studies written in the English language were included, which is a further limitation. Publication bias was not formally assessed due to the lack of agreed methods in this area.52
Policy implications
The results of this systematic review show that the current economic evidence relating to SRH services in LMICs has limitations due to the wide variation in methodological approaches. This may lead to misunderstanding and misinterpretation of their methods and findings, respectively, which will result in suboptimal allocation of resources by policy decision-makers.
Future research
To improve knowledge and understanding of findings from health economic studies by public health decision-makers, and to ensure the delivery and implementation of these findings, there is a need for more robust economic evidence. Standardisation of methods for conducting and reporting economic evaluation of services and programmes is important, in terms of allowing replicability by other researchers in a range of settings. Therefore, it is suggested that future research should more closely adhere to existing guidelines for conducting and reporting economic evaluations of public health services and programmes, to ensure the fostering of high-quality programmes and services.
Conclusion
This review has observed a paucity of studies on the economic evaluation of SRH programmes/services in LMICs. It has also demonstrated limitations in the few existing economic evaluations of SRH services/programmes in an LMIC context. The review has revealed heterogeneity and a lack of replicability in the methods of existing literature on economic evaluations. Although most of the studies reported that SRH services and programmes were cost-effective, these methodological issues may limit their usefulness in informing optimal decision-making.
supplementary material
Footnotes
Funding: TWL-A’s PhD research is supported by a studentship from the Tertiary Education Trust Fund (TETFund), the Federal Government of Nigeria.
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2024-092837).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Ethics approval: Not applicable.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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