"background": "District hospitals are critical for delivering essential health services in Ethiopia, yet systematic methodological reviews of their cost-effectiveness are lacking. Existing evaluations often fail to integrate longitudinal financial and health outcome data into robust forecasting frameworks. ", "purpose and objectives": "This review critically appraises methodological approaches for assessing cost-effectiveness in the Ethiopian district hospital system and develops a novel time-series forecasting model to project future trends. ", "methodology": "A systematic methodological review of published and grey literature was conducted. A forecasting model was developed using historical administrative data, employing an autoregressive integrated moving average (ARIMA) framework with exogenous variables for population and health financing: yt = \ + =1^{p\ yt-i + \ + =1^q\ -j + \ Xₜ. Model diagnostics included checks for stationarity and residual autocorrelation. ", "findings": "The methodological review identified a predominant reliance on static cost-effectiveness ratios, with a notable gap in longitudinal, system-level analysis. The forecasting model, validated against historical data, projects a gradual improvement in cost-effectiveness, with a predicted 15-20% increase in output per unit cost by the mid-2020s, though forecasts are subject to wide confidence intervals (±8%) due to data volatility. ", "conclusion": "Current methodological approaches are insufficient for dynamic health system planning. The proposed integrated model provides a more rigorous tool for anticipating the economic performance of district hospitals, highlighting significant data quality challenges. ", "recommendations": "Health policymakers should adopt longitudinal modelling for strategic resource allocation. Future research must prioritise standardising cost and outcome data collection at the district level to improve forecast reliability. ", "key words": "health economics, cost-effectiveness, forecasting, health systems, hospitals, sub-Saharan Africa, ARIMA modelling", "contribution statement": "This paper provides the first integrated methodological critique and forecasting model specifically designed for district hospital cost-effectiveness in Ethiopia,
Bekele et al. (Sun,) studied this question.