"background": "District hospital systems in sub-Saharan Africa face persistent challenges in delivering cost-effective care. Robust evidence on their economic efficiency is limited, with few studies employing rigorous experimental designs to isolate causal effects on cost and health outcomes. ", "purpose and objectives": "This study aimed to appraise the methodology of a randomised field trial designed to measure the cost-effectiveness of a systemic intervention in district hospitals, and to present its primary empirical findings. ", "methodology": "A pragmatic, parallel-group randomised controlled trial was conducted across 24 district hospitals. Hospitals were randomised to implement an integrated systems intervention or continue standard care. Cost-effectiveness was assessed from a health system perspective over a 12-month period, using disability-adjusted life years (DALYs) averted as the primary outcome. The analysis employed a generalised linear model: \ (ECost{i) = \0 + \1 Ti + \2 Xi + \, where Ti indicates treatment assignment and Xᵢ a vector of baseline covariates. Uncertainty was characterised using 95% confidence intervals derived from non-parametric bootstrapping. ", "findings": "The intervention group demonstrated a mean reduction in cost per DALY averted of 15% (95% CI: 8% to 21%) compared to the control group. The methodological appraisal confirmed the trial successfully maintained allocation concealment and achieved high fidelity in implementation, though attrition in follow-up cost data presented analytical challenges. ", "conclusion": "The randomised field trial proved to be a methodologically robust approach for generating high-quality evidence on the cost-effectiveness of systemic interventions in a real-world hospital setting. ", "recommendations": "Future health systems research should prioritise experimental designs where feasible. Investment is needed in routine health information and financial systems to improve the precision of cost data collection in such trials. ", "key words": "cost-effectiveness analysis, health systems research, randomised controlled trial, district hospitals, sub-Saharan Africa, economic evaluation",
Kwame Kumi Asare (Mon,) studied this question.