# 4. Discussion

This study has demonstrated that there are major hidden costs of HAIs in SSA. Every day, millions of Africans receive inpatient care in a healthcare facility – whether for a chronic illness or acute disease, surgical procedures or for labor and delivery and postpartum services – but in their vulnerable state an estimated 10% or more of these people become infected by a microorganism while receiving medical care, a high proportion of which are resistant to first, second- and even third-line drugs.

By quantifying the major costs associated with these infections at national level – direct healthcare costs of treatment, productivity losses for the patients, and the value of lost lives – this study shows that the economic costs exceed 1.14% of the GDP of nine countries in Eastern and Southern Africa and the direct healthcare costs exceed 7% of total health spending in these countries.

While efforts were made to select data sources that best reflect the national contexts in the countries of study, there are still some methodological weaknesses, excluded impacts and data limitations associated with a multi-country desk study that is reliant on secondary data sources.

This study adopted a standard cost-of-illness methodology (Morel et al, 2020; Shrestha et al, 2018). While previous studies have assessed the direct healthcare costs of HAIs in SSA (Aerts et al, 2022; Schäferman et al, 2020; Gidey et al; 2023; Otieku et al, 2023), none have included the indirect costs to the patient. Hence, standard economic approaches were used to value the loss of productive time due to a longer time spent away from work or home. In some instances, this loss may be incurred by a caregiver or family member– for example, a woman who has just delivered a baby is unlikely to return to work immediately, but the HAI she contracts may result in a loss of earnings or productive time for a partner or relative.

Quantifying the cost of premature death due to HAI is important, given that a significant proportion of HAIs lead to premature death, especially for AMRs when a more expensive second- or third-line drug is unavailable or unaffordable. This study used value-of-statisticallife (VSL) methodology to quantify the value of life. It did not value disability-adjusted lifeyears (DALYs) lost due to the lack of data on the age of the patient (and age at death). However, due to the lack of VSL studies in the study countries, VSL was estimated using a meta-analysis of studies from the USA and adjusted for the differences in economic development (GDP per capita) and using a conservative income-elasticity of 1.5. The latter allows for the likelihood that people have a lower willingness to pay for interventions that prevent death when their income is lower. Sensitivity analysis showed that when case fatality increased from 6.9% to 15% and when income elasticity of 1.2 was used instead of 1.5, that the total economic losses increased from US$6 billion to US$11.0 billion and US$16.4 billion, respectively.

Several quantifiable costs of HAIs - and specifically of AMR HAIs - were excluded due to lack of available data and difficulties in aggregating to the national level. These include:

- The costs of surveillance and containment programs, education programs and public health or information campaigns related to HAIs.

- Additional costs of longer-term complications of HAIs, as it was assumed that the initial cost of treatment would lead to either discharge or death. However, some patients may require long-term ICU stay, long-term care and rehabilitation, and disability benefits.

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