A Systematic Review of Randomised Field Trials for Cost-Effectiveness Methodologies in Tanzanian District Hospital Systems

{ "background": "District hospital systems in Tanzania face significant resource constraints, necessitating robust evidence on the cost-effectiveness of health interventions. Randomised field trials (RFTs) are a key source of such evidence, yet the methodological rigour and reporting of their economic evaluations within these settings have not been systematically appraised.", "purpose and objectives": "This systematic review aims to critically evaluate the methodologies employed in randomised field trials measuring cost-effectiveness within Tanzanian district hospital systems, identifying prevalent practices, strengths, and methodological limitations.", "methodology": "A systematic search of multiple electronic databases was conducted following a pre-registered protocol. Eligible studies were RFTs incorporating a full economic evaluation (cost-effectiveness, cost-utility, or cost-benefit analysis) conducted within the defined hospital systems. Screening, data extraction, and quality assessment were performed in duplicate. Methodological appraisal focused on design, costing perspective, sensitivity analysis, and handling of uncertainty. A common statistical model for estimating incremental cost-effectiveness ratios is $ICER = (C1 - C0)/(E1 - E0)$, where C and E denote costs and effects for intervention (1) and comparator (0).", "findings": "Of the screened records, a small proportion (under 15%) of RFTs included a full economic evaluation component. A dominant theme was the frequent omission of detailed sensitivity analyses; only a minority adequately characterised uncertainty using cost-effectiveness acceptability curves or confidence intervals. The precision of cost-difference estimates was often limited, with few studies reporting robust standard errors to account for clustered trial design.", "conclusion": "The integration of comprehensive economic evaluations within RFTs in this context is inconsistent. Common methodological shortcomings reduce the reliability and generalisability of cost-effectiveness evidence for policy-making.", "recommendations": "Future RFTs should incorporate economic evaluation by design, adhere to consolidated health economic evaluation reporting standards, and employ analytical methods that properly account for clustering and sampling uncertainty. Capacity building in health economics methodology is