A review and analysis of reported global blood and marrow transplantation costs in comparison to macroeconomic factors including gross national income per capita and out-of-pocket health expenditures Free

Introduction: Despite increasing blood and marrow transplantation activity globally throughout the last few decades, regional and economic discrepancies remain. Reports highlight a positive correlation between higher transplant rates with higher gross national income (GNI) and higher transplant rates in American and European regions compared to Eastern Mediterranean and African regions. Cost reporting of blood and marrow transplantation (BMT) in each country, however, is limited and heterogenous. We compiled comprehensive data on reported BMT costs by country and transplant type and compared these costs with macroeconomic factors including GNI per capita according to the World Bank and out-of-pocket health expenditures (OOPHE) by country according to the World Health Organization (WHO) Global Health Expenditure Database (GHED) to demonstrate limitations to relying solely on gross costs to measure the affordability of BMT and suggest that OOPHE and GNI must be taken into account to determine the true cost of BMT.Methods: A literature search was performed on WHO member countries with access to BMT using key words “cost”, “marrow” “transplant” and country names. Country specific cost data was extracted by transplant type and year of publication. Currency values were converted to US dollars according to most recent available exchange rates. Median autologous, allogeneic, and overall transplant costs were calculated from reported data. The data was analyzed in comparison with GNI per capita from the World Bank and OOPHE from the WHO GHED.Results: 2,734 publications were reviewed on 84 of 194 WHO member countries which reported transplant activity to the WBMT, and 115 individual publications were identified reporting BMT transplant costs in 46 countries. Allogeneic transplant costs were more closely associated with GNI per capita than autologous (R=0.64 vs R=0.52). Countries with low GNI per capita tended to have a high ratio of transplant cost to GNI (R = 0.54, moderate). Tunisia demonstrated the highest ratio of median transplant cost to GNI of 16.82 despite having a low GNI per capita of $3,440. Norway had the highest GNI per capita within the WHO countries of $102,460, but the ratio of median transplant cost to GNI in Norway was only 0.68. OOPHE compared with transplant costs showed a similar negative correlation indicating higher OOPHE in countries with low transplant costs (R = 0.45, moderate). The United States had the highest median transplant cost of $290,791, but OOPE of only 11.10%, whereas Bangladesh had a median transplant cost of $13,500 and OOPE of 72.53%, representing a larger cost burden despite a much lower GNI. Supporting this, higher GNI per capita also demonstrated a negative correlation with OOPHE, suggesting countries with higher GNI per capita also provided greater resources for health care coverage to reduce OOPHE (R = 0.58, moderate).Discussion: These findings highlight limitations to relying solely on gross costs to measure the affordability of BMT. The ratio of cost to GNI may be a better indicator of affordability within each country as it accounts for lower incomes as a factor in the costs of treatment. However, health insurance payer systems in each country must also be considered carefully, which also significantly impact the affordability of health services. Ideally, the ratio of cost and GNI per capita should be similar across countries to ensure that the cost of BMT is relatively similar to individuals despite differences in income and purchasing power in different countries. However, this work demonstrates that is far from the current reality. Recognition of these factors may be helpful in future studies assessing access and sustainability of BMT in low-resource countries.