title: GDP Matters: Cost Effectiveness of Cochlear Implantation and Deaf Education in Sub-Saharan Africa.
abstract: OBJECTIVE
  Cochlear implantation and deaf education are cost effective in Sub-Saharan Africa.
  
  
  BACKGROUND
  Cost effectiveness of pediatric cochlear implantation has been well established in developed countries but is unknown in low resource settings, where access to the technology has traditionally been limited. With incidence of severe-to-profound congenital sensorineural hearing loss 5 to 6 times higher in low/middle-income countries than the United States and Europe, developing cost-effective management strategies in these settings is critical.
  
  
  METHODS
  Costs were obtained from experts in Nigeria, South Africa, Kenya, Rwanda, Uganda, and Malawi using known costs and published data, with estimation when necessary. A disability adjusted life years (DALY) model was applied using 3% discounting and 10-year length of analysis. Sensitivity analysis was performed to evaluate the effect of device cost, professional salaries, annual number of implants, and probability of device failure. Cost effectiveness was determined using the WHO standard of cost-effectiveness ratio/gross domestic product per capita (CER/GDP) less than 3.
  
  
  RESULTS
  Cochlear implantation was cost effective in South Africa and Nigeria, with CER/GDP of 1.03 and 2.05, respectively. Deaf education was cost effective in all countries investigated, with CER/GDP ranging from 0.55 to 1.56. The most influential factor in the sensitivity analysis was device cost, with the cost-effective threshold reached in all countries using discounted device costs that varied directly with GDP.
  
  
  CONCLUSIONS
  Cochlear implantation and deaf education are equally cost effective in lower-middle and upper-middle income economies of Nigeria and South Africa. Device cost may have greater impact in the emerging economies of Kenya, Uganda, Rwanda, and Malawi.
authors.affiliation: *Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine; †Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, U.S.A.; ‡Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, U.S.A.; §Department of Otorhinolaryngology-Head and Neck Surgery, University of the Free State, Bloemfontein, South Africa; ∥Department of Surgery, University of Nairobi, Nairobi, Kenya; ¶Mbarara University of Science and Technology, Mbarara, Uganda; **University of Rwanda College of Medicine and Health Sciences, Kigali, Rwanda; ††Department of ENT, University of Abuja and the University of Abuja Teaching Hospital, Abuja, Nigeria; ‡‡Department of Surgery, University of Malawi College of Medicine, Blantyre, Malawi; and §§Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, U.S.A.
authors.forename: Susan D
authors.initials: SD
authors.lastname: Emmett
authors.forename: Debara L
authors.initials: DL
authors.lastname: Tucci
authors.forename: Magteld
authors.initials: M
authors.lastname: Smith
authors.forename: Isaac M
authors.initials: IM
authors.lastname: Macharia
authors.forename: Serah N
authors.initials: SN
authors.lastname: Ndegwa
authors.forename: Doreen
authors.initials: D
authors.lastname: Nakku
authors.forename: Kaitesi B
authors.initials: KB
authors.lastname: Mukara
authors.forename: Mukara B
authors.initials: MB
authors.lastname: Kaitesi
authors.forename: Titus S
authors.initials: TS
authors.lastname: Ibekwe
authors.forename: Wakisa
authors.initials: W
authors.lastname: Mulwafu
authors.forename: Wenfeng
authors.initials: W
authors.lastname: Gong
authors.forename: Howard W
authors.initials: HW
authors.lastname: Francis
authors.forename: James E
authors.initials: JE
authors.lastname: Saunders
mesh_terms: D017954:Africa South of the Sahara / Q000453:epidemiology; D002675:Child, Preschool; D019929:Cochlear Implantation / Q000191:economics*; D003054:Cochlear Implants / Q000191:economics; D003362:Cost-Benefit Analysis; D003638:Deafness / Q000191:economics* / Q000534:rehabilitation*; D004493:Education / Q000191:economics*; D004868:Equipment Failure / Q000191:economics; D006319:Hearing Loss, Sensorineural / Q000628:therapy; D006801:Humans; D007223:Infant; D019057:Quality-Adjusted Life Years