Laurens Niëns and colleagues estimate the impoverishing effects of four medicines in 16 low- and middle-income countries using the impoverishment method as a metric of affordability and show that medicine purchases could impoverish large numbers of people.

Abstractobjective Breast cancer control in Ghana is characterised by low awareness, late-stage treatment and poor survival. In settings with severely constrained health resources, there is a need to spend money wisely. To achieve this and to guide policy makers in their selection of interventions, this study systematically compares costs and effects of breast cancer control interventions in Ghana.methods We used a mathematical model to estimate costs and health effects of breast cancer interventions in Ghana from the healthcare perspective. Analyses were based on the WHO-CHOICE method, with health effects expressed in disability-adjusted life years (DALYs), costs in 2009 US dollars (US$) and cost-effectiveness ratios (CERs) in US$ per DALY averted. Analyses were based on local demographic, epidemiological and economic data, to the extent these data were available.results Biennial screening by clinical breast examination (CBE) of women aged 40-69 years, in combination with treatment of all stages, seems the most cost-effective intervention (costing $1299 per DALY averted). The intervention is also economically attractive according to international standards on cost-effectiveness. Mass media awareness raising (MAR) is the second best option (costing $1364 per DALY averted). Mammography screening of women of aged 40-69 years (costing $12 908 per DALY averted) cannot be considered cost-effective.conclusions Both CBE screening and MAR seem economically attractive interventions. Given the uncertainty about the effectiveness of these interventions, only their phased introduction, carefully monitored and evaluated, is warranted. Moreover, their implementation is only meaningful if the capacity of basic cancer diagnostic, referral and treatment and possibly palliative services is simultaneously improved.

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The issue of affordability of health care services remains high on the (health) policy agenda. Determining whether health care services are affordable is complex, however, as the concept 'affordability' is inherently normative. With a focus on measuring affordability in low- and middle-income countries, we discuss different methods used to operationalize this concept. Using the example of medicine purchases in Indonesia, we show the choice of method and threshold to have a significant impact on outcomes. We argue it is important to further standardize methods and appropriate threshold use in applied research to increase comparability of results and to facilitate sound assessments of affordability.

International collaborations like the Breast Health Global Initiative (BHGI) can help low and middle income countries (LMCs) to establish or improve breast cancer control programs by providing evidence-based, resource-stratified guidelines for the management and control of breast cancer. The Problem Solving Working Group of the BHGI 2010 Global Summit met to develop a consensus statement on problem-solving strategies addressing breast cancer in LMCs. To better assess breast cancer burden in poorly studied populations, countries require accurate statistics regarding breast cancer incidence and mortality. To better identify health care system strengths and weaknesses, countries require reasonable indicators of true health system quality and capacity. Using qualitative and quantitative research methods, countries should formulate cancer control strategies to identify both system inefficiencies and patient barriers. Patient navigation programs linked to public advocacy efforts feed and strengthen functional early detection and treatment programs. Cost-effectiveness research and implementation science are tools that can guide and expand successful pilot programs.