Economic evaluations of health system strengthening activities in low-income and middle-income country settings : a methodological systematic review

Hendrix, Nathaniel and Kwete, Xiaoxiao and Bolongaita, Sarah and Megiddo, Itamar and Memirie, Solomon Tessema and Mirkuzie, Alemnesh H and Nonvignon, Justice and Verguet, Stéphane (2022) Economic evaluations of health system strengthening activities in low-income and middle-income country settings : a methodological systematic review. BMJ Global Health, 7 (3). e007392. ISSN 2059-7908 (

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Objective -- Health system strengthening (HSS) activities should accompany disease-targeting interventions in low/middle-income countries (LMICs). Economic evaluations provide information on how these types of investment might best be balanced but can be challenging. We conducted a systematic review to evaluate how researchers address these economic evaluation challenges. Methods -- We identified studies about economic evaluation of HSS activities in LMICs using a two-stage approach. First, we conducted a broad search to identify areas where economic evaluations of HSS activities were being conducted. Next, we selected specific interventions for more targeted literature review. We extracted study characteristics using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Finally, we summarised authors’ modelling decisions using a framework that examines how models are developed to emphasise generalisability, precision, or realism. Findings -- Our searches produced 1978 studies, out of which we included 36. Most studies used data from prospective trials and calculated cost-effectiveness directly from these trial inputs, rather than using simulation methods. As a group, these studies primarily emphasised precision and realism over generalisability, meaning that their results were best suited to specific settings. Conclusions -- The number of included studies was small. Our findings suggest that most economic evaluations of HSS do not leverage methods like sensitivity analyses or inputs from literature review that would produce more generalisable (but potentially less precise) results. More research into how decision-makers would use economic evaluations to define the expansion path to strengthening health systems would allow for conceptualising impactful work on the economic value of HSS.


Hendrix, Nathaniel, Kwete, Xiaoxiao, Bolongaita, Sarah, Megiddo, Itamar ORCID logoORCID:, Memirie, Solomon Tessema, Mirkuzie, Alemnesh H, Nonvignon, Justice and Verguet, Stéphane;