1
|
Gunarathna SP, Wickramasinghe ND, Agampodi TC, Prasanna IR, Agampodi SB. Out-of-Pocket Expenditure for Antenatal Care Amid Free Health Care Provision: Evidence From a Large Pregnancy Cohort in Rural Sri Lanka. GLOBAL HEALTH, SCIENCE AND PRACTICE 2023; 11:e2200410. [PMID: 37903576 PMCID: PMC10615247 DOI: 10.9745/ghsp-d-22-00410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 09/29/2023] [Indexed: 11/01/2023]
Abstract
INTRODUCTION Global evidence suggests that high out-of-pocket (OOP) expenditure negatively affects health service utilization and creates an economic burden on households during pregnancy. This study aimed to estimate the magnitude and associated factors of OOP expenditure for antenatal care (ANC) in a rural Sri Lankan setting by following up with a large pregnancy cohort (The Rajarata Pregnancy Cohort [RaPCo]) in Anuradhapura District, Sri Lanka. METHODS Data were collected from July 2019 to May 2020. An interviewer-administered questionnaire was used to collect socioeconomic data and OOP expenditures in the first trimester. Self-administered questionnaires were used monthly to collect OOP expenditures in the second and third trimesters. In-depth financial information of 1,558 pregnant women was analyzed using descriptive statistics, nonparametric statistics, and a multiple linear regression model. RESULTS The majority of participants used both government and private health facilities for ANC. The mean (standard deviation [SD]) OOP expenditure per ANC visit was US$4.18 (US$4.19), and the mean (SD) OOP expenditure for total ANC was US$57.74 (US$80.96). Pregnant women who used only free government health services also spent 28% and 14% of OOP expenditure on medicines and laboratory investigations. Household income (P<.001), household expenditure (P<.1), used health care mode (P<.05), maternal morbidities (P<.05), and the number of previous pregnancies (P<.1) were the statistically significant independent predictors of OOP expenditure. OOP expenditure per visit for ANC equals half of the daily household expenditure. CONCLUSION Despite having freely available government health facilities, most pregnant women tend to use both government and private health facilities and incur higher OOP expenditure. Free government health care users also incur a direct medical OOP expenditure for medicines and laboratory investigations. Monthly household income, expenditure, used health care mode, maternal morbidities, and the number of previous pregnancies are independent predictors of OOP expenditure.
Collapse
Affiliation(s)
- Sajan Praveena Gunarathna
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka.
| | - Nuwan Darshana Wickramasinghe
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Thilini Chanchala Agampodi
- Department of Community Medicine, Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka, Saliyapura, Sri Lanka
| | - Indika Ruwan Prasanna
- Department of Economics, Faculty of Social Sciences and Humanities, Rajarata University of Sri Lanka, Mihintale, Sri Lanka
| | | |
Collapse
|
2
|
Dusingizimana T, Ramilan T, Weber JL, Iversen PO, Mugabowindekwe M, Ahishakiye J, Brough L. Predictors for achieving adequate antenatal care visits during pregnancy: a cross-sectional study in rural Northwest Rwanda. BMC Pregnancy Childbirth 2023; 23:69. [PMID: 36703102 PMCID: PMC9878946 DOI: 10.1186/s12884-023-05384-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Inadequate antenatal care (ANC) in low-income countries has been identified as a risk factor for poor pregnancy outcome. While many countries, including Rwanda, have near universal ANC coverage, a significant proportion of pregnant women do not achieve the recommended regimen of four ANC visits. The present study aimed to explore the factors associated with achieving the recommendation, with an emphasis on the distance from household to health facilities. METHODS A geo-referenced cross-sectional study was conducted in Rutsiro district, Western province of Rwanda with 360 randomly selected women. Multiple logistic regression analysis including adjusted odd ratio (aOR) were performed to identify factors associated with achieving the recommended four ANC visits. RESULTS The majority (65.3%) of women had less than four ANC visits during pregnancy. We found a significant and negative association between distance from household to health facility and achieving the recommended four ANC visits. As the distance increased by 1 km, the odds of achieving the four ANC visits decreased by 19% (aOR = 0.81, P = 0.024). The odds of achieving the recommended four ANC visits were nearly two times higher among mothers with secondary education compared with mothers with primary education or less (aOR = 1.90, P = 0.038). In addition, mothers who responded that their household members always seek health care when necessary had 1.7 times higher odds of achieving four ANC visits compared with those who responded as unable to seek health care (aOR = 1.7, P = 0.041). Furthermore, mothers from poor households had 2.1 times lower odds of achieving four ANC visits than mothers from slightly better-off households (aOR = 2.1, P = 0.028). CONCLUSIONS Findings from the present study suggest that, in Rutsiro district, travel distance to health facility, coupled with socio-economic constraints, including low education and poverty can make it difficult for pregnant women to achieve the recommended ANC regimen. Innovative strategies are needed to decrease distance by bringing ANC services closer to pregnant women and to enhance ANC seeking behaviour. Interventions should also focus on supporting women to attain at least secondary education level as well as to improve the household socioeconomic status of pregnant women, with a particular focus on women from poor households.
Collapse
Affiliation(s)
- Theogene Dusingizimana
- grid.10818.300000 0004 0620 2260Department of Food Science and Technology, College of Agriculture, Animal Sciences and Veterinary Medicine, University of Rwanda, P.O. Box 210, Musanze, Rwanda
| | - Thiagarajah Ramilan
- grid.148374.d0000 0001 0696 9806School of Agriculture and Environment, Massey University, Tennent Drive, Palmerston North, 4442 New Zealand
| | - Janet L. Weber
- grid.148374.d0000 0001 0696 9806School of Food and Advanced Technology, Massey University, Tennent Drive, Palmerston North, 4442 New Zealand
| | - Per Ole Iversen
- grid.5510.10000 0004 1936 8921Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, 0317 Norway ,grid.55325.340000 0004 0389 8485Department of Haematology, Oslo University Hospital, Oslo, 0424 Norway ,grid.11956.3a0000 0001 2214 904XDivision of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, 7505 South Africa
| | - Maurice Mugabowindekwe
- grid.5254.60000 0001 0674 042XDepartment of Geosciences and Natural Resource Management, University of Copenhagen, Copenhagen, Denmark ,grid.10818.300000 0004 0620 2260Centre for Geographic Information Systems and Remote Sensing, College of Science and Technology, University of Rwanda, P.0. Box 3900, Kigali, Rwanda
| | - Jeannine Ahishakiye
- grid.10818.300000 0004 0620 2260Human Nutrition and Dietetics Department, College of Medicine and Health Sciences, University of Rwanda, P.O. Box 3286, Kigali, Rwanda
| | - Louise Brough
- grid.148374.d0000 0001 0696 9806School of Food and Advanced Technology, Massey University, Tennent Drive, Palmerston North, 4442 New Zealand
| |
Collapse
|
3
|
Wafula ST, Nalugya A, Kananura RM, Mugambe RK, Kyangwa M, Isunju JB, Kyobe B, Ssekamatte T, Namutamba S, Namazzi G, Ekirapa EK, Musoke D, Walter F, Waiswa P. Effect of community-level intervention on antenatal care attendance: a quasi-experimental study among postpartum women in Eastern Uganda. Glob Health Action 2022; 15:2141312. [DOI: 10.1080/16549716.2022.2141312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Solomon T Wafula
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Aisha Nalugya
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Rornald M Kananura
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Richard K Mugambe
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Moses Kyangwa
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - John B Isunju
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Betty Kyobe
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Tonny Ssekamatte
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Sarah Namutamba
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Gertrude Namazzi
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth K Ekirapa
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David Musoke
- Department of Disease Control and Environmental Health, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Florian Walter
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Global Health Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
4
|
Nicol JU, Iwu-Jaja CJ, Hendricks L, Nyasulu P, Young T. The impact of faith-based organizations on maternal and child health care outcomes in Africa: taking stock of research evidence. Pan Afr Med J 2022; 43:168. [PMID: 36825129 PMCID: PMC9941616 DOI: 10.11604/pamj.2022.43.168.32983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 06/20/2022] [Indexed: 12/12/2022] Open
Abstract
This evidence synthesis aimed at assessing the effectiveness of Faith-Based Organisations (FBOs) on Maternal and Child Health (MCH) outcomes; and explore the perceptions and experiences of the users and providers of MCH services delivered by FBOs in Africa. This review considered studies from African countries only. Both reviews and primary studies focusing on MCH services provided by FBOs were considered. Quantitative, qualitative, and mixed methods reviews were included with no restriction on the date and language. Primary outcomes included maternal mortality ratio, neonatal mortality, infant mortality, child mortality, quality of care, views, experiences, and perceptions of users of FBOs. We searched up to November 2020 in the Joanna Briggs Institute (JBI) Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, PROSPERO register, PDQ-evidence, Health Systems Evidence, CINAHL, EMBASE, and PubMed. We searched references cited by similar studies that may be potentially eligible for inclusion. We then updated the search for primary studies from December 2009 - October 2020. One systematic review and six primary studies met the eligibility criteria for inclusion. Methodological quality varied. These observational and qualitative studies found that FBOs offered the following MCH services - training of healthcare workers, obstetric services, health promotion, sexual education, immunization services, and intermittent preventive therapy for malaria. Maternal and Child Health (MCH) services provided by FBO suggest a reduction in maternal morbidity and mortality. Increased uptake of maternal healthcare services, and increased satisfaction were reported by users of care. However, costs of providing these services varied across the studies and users. This review shows that FBOs play an important role in improving access and delivery of MCH services and have the potential of strengthening the health system at large. Rigorous research is needed to ascertain the effectiveness of FBO-based interventions in strengthening the health systems in Africa.
Collapse
Affiliation(s)
- Jeannine Uwimana Nicol
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa,,School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kicukiro, Kigali, Rwanda,,Corresponding author: Jeannine Uwimana Nicol, Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - Chinwe Juliana Iwu-Jaja
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lynn Hendricks
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa,,Social Research Methodology Group, Faculty of Social Sciences, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
| | - Peter Nyasulu
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Taryn Young
- Center for Evidence Based Health Care, Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| |
Collapse
|
5
|
Iacoella F, Gassmann F, Tirivayi N. Which communication technology is effective for promoting reproductive health? Television, radio, and mobile phones in sub-Saharan Africa. PLoS One 2022; 17:e0272501. [PMID: 35976900 PMCID: PMC9384982 DOI: 10.1371/journal.pone.0272501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/20/2022] [Indexed: 11/18/2022] Open
Abstract
The use of radio and television as means to spread reproductive health awareness in Sub-Saharan Africa has been extensive, and its impacts significant. More recently, other means of communication, such as mobile phones, have received the attention of researchers and policy makers as health communication tools. However, evidence on which of the two types of communication (i.e. passive communication from TV/radio, or active communication through phones) is more effective in fostering better reproductive health choices is sparse. This study aims to identify the potential influence of TV or radio ownership as opposed to cell phone ownership on contraceptive use and access to maternal healthcare. Cross-sectional, individual analysis from eleven high-maternal mortality Sub-Saharan African countries is conducted. A total of 78,000 women in union are included in the analysis. Results indicate that ownership of TV or radio is more weakly correlated to better outcomes than mobile phone ownership is. Results are stronger for lower educated women and robust across all levels of wealth. Interestingly, the study also finds that decision-making power is a relevant mediator of cell phone ownership on contraceptive use, but not on maternal healthcare access. A key takeaway from the study is that, while the role of television and radio appears to have diminished in recent years, mobile phones have become a key tool for empowerment and behavioural change among Sub-Saharan African women. Health communication policies should be designed to take into account the now prominent role of mobile phones in affecting health behaviours.
Collapse
|
6
|
Moncrieff G, Finlayson K, Cordey S, McCrimmon R, Harris C, Barreix M, Tunçalp Ö, Downe S. First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers. PLoS One 2021; 16:e0261096. [PMID: 34905561 PMCID: PMC8670688 DOI: 10.1371/journal.pone.0261096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers. Methods We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual. Findings From 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings. Conclusion Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.
Collapse
Affiliation(s)
- Gill Moncrieff
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
- * E-mail:
| | - Kenneth Finlayson
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Sarah Cordey
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| | - Rebekah McCrimmon
- School of Health and Community Studies, University of Central Lancashire, Preston, United Kingdom
| | - Catherine Harris
- Applied Health Research Hub, University of Central Lancashire, Preston, United Kingdom
| | - Maria Barreix
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Sexual and Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Soo Downe
- Research in Childbirth and Health Group, THRIVE Centre, University of Central Lancashire, Preston, United Kingdom
| |
Collapse
|
7
|
Chamani AT, Mori AT, Robberstad B. Implementing standard antenatal care interventions: health system cost at primary health facilities in Tanzania. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2021; 19:79. [PMID: 34876154 PMCID: PMC8650535 DOI: 10.1186/s12962-021-00325-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/14/2021] [Indexed: 11/29/2022] Open
Abstract
Background Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system are unknown, particularly in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania. Methods We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Costs were collected in Tanzanian shillings and converted to 2018 US$. Results The health system cost of providing ANC services at six facilities (2 health centres and 4 dispensaries) was US$185,282 under the focused model. We estimated that the cost would increase by about 90% at health centres and 97% at dispensaries to US$358,290 by introducing the standard model. Personnel cost accounted for more than one third of the total cost, and more than two additional nurses are required per facility for the standard model. The costs per pregnancy increased from about US$33 to US$63 at health centres and from about US$37 to US$72 at dispensaries. Conclusion Introduction of a standard ANC model at primary health facilities in Tanzania may double resources requirement compared to current practice. Resources availability has been one of the challenges to effective implementation of the current focused ANC model. More research is required, to consider whether the additional costs are reasonable compared to the additional value for maternal and child health. Supplementary Information The online version contains supplementary material available at 10.1186/s12962-021-00325-0.
Collapse
Affiliation(s)
- Amisa Tindamanyile Chamani
- Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway. .,Department of Pharmaceutics and Pharmacy Practice, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania.
| | - Amani Thomas Mori
- Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway.,Chr Michelsen Institute, Bergen, Norway
| | - Bjarne Robberstad
- Department of Global Public Health and Primary Care, Section for Ethics and Health Economics, University of Bergen, Bergen, Norway
| |
Collapse
|
8
|
Banke-Thomas A, Abejirinde IOO, Ayomoh FI, Banke-Thomas O, Eboreime EA, Ameh CA. e-income countries from a provider's perspective: a systematic review. BMJ Glob Health 2021; 5:bmjgh-2020-002371. [PMID: 32565428 PMCID: PMC7309188 DOI: 10.1136/bmjgh-2020-002371] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 05/09/2020] [Accepted: 05/11/2020] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider's perspective. METHODS We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$ equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings. RESULTS Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24-US$31.42); vaginal delivery (US$14.32-US$278.22); caesarean delivery (US$72.11-US$378.940; PAC (US$97.09-US$1299.21); family planning (FP) (US$0.82-US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported. CONCLUSION There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage.
Collapse
Affiliation(s)
- Aduragbemi Banke-Thomas
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | | | - Francis Ifeanyi Ayomoh
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | | | | | - Charles Anawo Ameh
- Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| |
Collapse
|
9
|
Kamali I, Barnhart DA, Nyirahabihirwe F, de la Paix Gakuru J, Uwase M, Nizeyumuremyi E, Walker S, Mazimpaka C, de Dieu Gatete J, Makuza JD, Serumondo J, Kateera F, d'Amour Ndahimana J. Initiation of hepatitis C treatment in two rural Rwandan districts: a mobile clinic approach. BMC Infect Dis 2021; 21:220. [PMID: 33632165 PMCID: PMC7908655 DOI: 10.1186/s12879-021-05920-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background To eliminate hepatitis C, Rwanda is conducting national mass screenings and providing to people with chronic hepatitis C free access to Direct Acting Antivirals (DAAs). Until 2020, prescribers trained and authorized to initiate DAA treatment were based at district hospitals, and access to DAAs remains expensive and geographically difficult for rural patients. We implemented a mobile clinic to provide DAA treatment initiation at primary-level health facilities among people with chronic hepatitis C identified through mass screening campaigns in rural Kirehe and Kayonza districts. Methods The mobile clinic team was composed of one clinician authorized to manage hepatitis, one lab technician, and one driver. Eligible patients received same-day clinical consultations, counselling, laboratory tests and DAA initiation. Using clinical databases, registers, and program records, we compared the number of patients who initiated DAA treatment before and during the mobile clinic campaign. We assessed linkage to care during the mobile clinical campaign and assessed predictors of linkage to care. We also estimated the cost per patient of providing mobile services and the reduction in out-of-pocket costs associated with accessing DAA treatment through the mobile clinic rather than the standard of care. Results Prior to the mobile clinic, only 408 patients in Kirehe and Kayonza had been initiated on DAAs over a 25-month period. Between November 2019 and January 2020, out of 661 eligible patients with hepatitis C, 429 (64.9%) were linked to care through the mobile clinic. Having a telephone number and complete address recorded at screening were strongly associated with linkage to care. The cost per patient of the mobile clinic program was 29.36 USD, excluding government-provided DAAs. Providing patients with same-day laboratory tests and clinical consultation at primary-level health facilities reduced out-of-pocket expenses by 9.88 USD. Conclusion The mobile clinic was a feasible strategy for providing rapid treatment initiation among people chronically infected by hepatitis C, identified through a mass screening campaign. Compared to the standard of care, mobile clinics reached more patients in a much shorter time. This low-cost strategy also reduced out-of-pocket expenditures among patients. However, long-term, sustainable care would require decentralization to the primary health-centre level.
Collapse
Affiliation(s)
| | - Dale A Barnhart
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda.,Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | | | | | - Mariam Uwase
- Partners In Health/Inshuti Mu Buzima, Rwinkwavu, Rwanda
| | | | | | | | | | - Jean Damascene Makuza
- Rwanda Biomedical Centre, IHDPC, Kigali, Rwanda.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | | | | |
Collapse
|
10
|
Ouédraogo CT, Vosti SA, Wessells KR, Arnold CD, Faye MT, Hess SY. Out-of-pocket costs and time spent attending antenatal care services: a case study of pregnant women in selected rural communities in Zinder, Niger. BMC Health Serv Res 2021; 21:47. [PMID: 33419448 PMCID: PMC7796614 DOI: 10.1186/s12913-020-06027-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 12/17/2020] [Indexed: 11/17/2022] Open
Abstract
Background Despite an official policy of exemption from health care costs, pregnant women in Niger still face some out-of-pocket costs (OPC) in addition to time costs when they attend antenatal care (ANC) services. We aimed to: 1) assess the OPC for pregnant woman attending ANC, 2) estimate the time spent to attend ANC and the opportunity cost of that time, and 3) assess how OPC and time spent to attend ANC affected ANC attendance. Methods Data were obtained from a quasi-experimental descriptive study carried out in the region of Zinder, Niger, which compared pre- and post-intervention cohorts of pregnant women (n = 1736 women who reported attending ANC during their current pregnancy). An ANC attendance score was developed to describe the timing of ANC attendance in regard to the WHO recommendation of attending 4 ANC sessions. OPC and time spent were evaluated separately for associations with ANC attendance using Spearman correlations. Results The mean (±SD) age of pregnant women was 25.0 ± 6.4 yr, 19.0% were ≤ 19 yr and 99.7% were in their second or third trimester of gestation at the time of the interview. Among those who were > 13 weeks and > 27 weeks of gestation, 4.0 and 74.4% had attended ANC during their first and second trimesters, respectively. The median (1st quartile (Q1), 3rd quartile (Q3)) ANC score was 0 (− 1, 0), reflecting that the majority of women failed to follow the WHO recommendation. More than half of the women (72.5%) experienced OPC related to ANC. The majority of women (> 80%) reported spending ~ 3 h for an ANC visit, including travel and waiting time. Time spent to attend ANC was not associated with ANC attendance score. Women who experienced OPC, and those who received iron folic acid (IFA) or long-lasting insecticide-treated bednets during an ANC visit, were more likely to have a higher ANC attendance score compared to those who did not. Conclusion OPC and time spent were not identified as barriers to ANC visits, and IFA and long-lasting insecticide-treated bednets distribution could be used to motivate pregnant women to attend ANC. Trial registration The NiMaNu project was registered at www.clinicaltrials.gov as NCT01832688. Registered 16 April 2013. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-020-06027-2.
Collapse
Affiliation(s)
- Césaire T Ouédraogo
- Department of Nutrition, Institute for Global Nutrition, University of California, One Shields Ave, Davis, CA, 95616, USA.
| | - Stephen A Vosti
- Department of Agricultural and Resource Economics, University of California, Davis, CA, USA
| | - K Ryan Wessells
- Department of Nutrition, Institute for Global Nutrition, University of California, One Shields Ave, Davis, CA, 95616, USA
| | - Charles D Arnold
- Department of Nutrition, Institute for Global Nutrition, University of California, One Shields Ave, Davis, CA, 95616, USA
| | | | - Sonja Y Hess
- Department of Nutrition, Institute for Global Nutrition, University of California, One Shields Ave, Davis, CA, 95616, USA
| |
Collapse
|
11
|
Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples. AIDS 2020; 34:1633-1642. [PMID: 32701577 DOI: 10.1097/qad.0000000000002584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services. DESIGN Implementation and modelling. SETTING Fifty-five government health facilities in Zambia. SUBJECTS Patients in government health facilities. INTERVENTION Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015. MAIN OUTCOME MEASURES We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year. RESULTS Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use. CONCLUSION Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.
Collapse
|
12
|
Policymaker, health provider and community perspectives on male involvement during pregnancy in southern Mozambique: a qualitative study. BMC Pregnancy Childbirth 2019; 19:384. [PMID: 31660898 PMCID: PMC6819364 DOI: 10.1186/s12884-019-2530-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 09/23/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Increasing male involvement during pregnancy is considered an important, but often overlooked intervention for improving maternal health in sub-Saharan Africa. Intervention studies aimed at improving maternal health mostly target mothers hereby ignoring the crucial role their partners play in their ability to access antenatal care (ANC) and to prevent and treat infectious diseases like HIV and malaria. Very little is known about the current level of male involvement and barriers at different levels. This study explores the attitudes and beliefs of health policymakers, health care providers and local communities regarding men's involvement in maternal health in southern Mozambique. METHODS Ten key informant interviews with stakeholders were carried out to assess their attitudes and perspectives regarding male involvement in programmes addressing maternal health, followed by 11 days of semi structured observations in health care centers. Subsequently 16 focus group discussions were conducted in the community and at provider level, followed by three in depth couple interviews. Analysis was done by applying a socio-ecological systems theory in thematic analysis. RESULTS Results show a lack of strategy and coherence at policy level to stimulate male involvement in maternal health programmes. Invitation cards for men are used as an isolated intervention in health facilities but these have not lead to the expected success. Providers have a rather passive attitude towards male involvement initiatives. In the community however, male attendance at ANC is considered important and men are willing to take a more participating role. Main barriers are the association of male attendance at ANC with being HIV infected and strong social norms and gender roles. On the one hand men are seen as caretakers of the family by providing money and making the decisions. On the other hand, men supporting their wife by showing interest in their health or sharing household tasks are seen as weak or as a manifestation of HIV seropositivity. CONCLUSION A clear strategy at policy level and a multi-level approach is needed. Gender-equitable relationships between men and women should be encouraged in all maternal health interventions and providers should be trained to involve men in ANC.
Collapse
|
13
|
Williams P, Morales K, Sridharan V, Tummala A, Marseille E. Postpartum family planning in Rwanda: a cost effectiveness analysis. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12934.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Currently, the four most commonly used postpartum family planning methods in Rwanda are injections, subdermal implants, pills, and condoms. The economic and health benefit impact of the current method selection has not yet been evaluated. Methods: To evaluate the impact of current usage rates and method types, this cost effectiveness analysis (CEA) compared the most frequently used family planning methods in Rwanda broken into two categories, longer-acting reversible contraception (LARC) (injections and subdermal implants) and shorter-acting reversible contraceptives (non-LARC) (pills and condoms). A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and was conducted from a health systems perspective. This CEA compared two service package options to provide a comparator for the two method types, thus enabling insights to differences between the two. Results: For women of reproductive age (15-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: There is an opportunity to avert unplanned pregnancies associated with increased utilization of LARC methods. The full benefits of LARC are not yet realized in Rwanda. Under the conditions presented in this study, a service package that includes LARC has the potential to be cost-saving compared with one non-LARC methods. Effective health messaging of LARC use for the postpartum population could both enhance health and reduce costs.
Collapse
|
14
|
Hussen S, Tadesse BT. Prevalence of Syphilis among Pregnant Women in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:4562385. [PMID: 31392211 PMCID: PMC6662498 DOI: 10.1155/2019/4562385] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 06/20/2019] [Accepted: 06/27/2019] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Syphilis is one of the most imperative STIs, caused by the spirochete Treponema pallidum. During pregnancy it is associated with disastrous health outcomes in the newborn. In sub-Saharan Africa, study findings on the prevalence of syphilis among pregnant women are highly dispersed and inconsistent. The aim of the current review is to conduct a systematic review and meta-analysis of syphilis in sub-Saharan Africa among pregnant women. DESIGN Systematic review and meta-analysis. DATA SOURCES Databases including MEDLINE, PubMed, Cochrane Library, Google Scholar, and HINARI and reference lists of previous prevalence studies were systematically searched for relevant literature from January 1999 to November 2018. Results were presented in forest plot, tables, and figures. Random-effects model was used for the meta-analysis. For the purpose of this review, a case of syphilis was defined as positive treponemal or nontreponemal tests among pregnant women. DATA EXTRACTION Our search gave a total of 262 citations from all searched databases. Of these, 44 studies fulfilling the inclusion criteria and comprising 175,546 subjects were finally included. RESULTS The pooled prevalence of syphilis among pregnant women in sub-Saharan Africa was 2.9% (95%CI: 2.4%-3.4%). East and Southern African regions had a higher syphilis prevalence among pregnant women (3.2%, 95% CI: 2.3%-4.2% and 3.6%, 95%CI: 2.0%-5.1%, respectively) than the sub-Saharan African pooled prevalence. The prevalence of syphilis among pregnant women in most parts of the region seemed to have decreased over the past 20 years except for the East African region. However, prevalence did not significantly differ by region and time period. CONCLUSION This review showed a high prevalence of syphilis in sub-Saharan Africa among pregnant women. The evidence suggests strengthening the screening program during pregnancy as part of the care package during antenatal care visits. Programs focusing on primary prevention of syphilis in women should also be strengthened.
Collapse
Affiliation(s)
- Siraj Hussen
- School of Laboratory Science, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| | - Birkneh Tilahun Tadesse
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
| |
Collapse
|
15
|
Musabyimana A, Lundeen T, Butrick E, Sayinzoga F, Rwabufigiri BN, Walker D, Musange SF. Before and after implementation of group antenatal care in Rwanda: a qualitative study of women's experiences. Reprod Health 2019; 16:90. [PMID: 31248425 PMCID: PMC6595554 DOI: 10.1186/s12978-019-0750-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 06/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background The Preterm Birth Initiative-Rwanda is conducting a 36-cluster randomized controlled trial of group antenatal and postnatal care. In the context of this trial, we collected qualitative data before and after implementation. The purpose was two-fold. First, to inform the design of the group care program before implementation and second, to document women’s experiences of group care at the mid-point of the trial to make ongoing programmatic adjustments and improvements. Methods We completed 8 focus group discussions among women of reproductive age before group care implementation and 6 focus group discussions among women who participated in group antenatal care and/or postnatal care at 18 health centers that introduced the model, approximately 9 months after implementation. Results Before implementation, focus group participants reported both enthusiasm for the potential for support and insight from a group of peers and concern about the risk of sharing private information with peers who may judge, mock, or gossip. After implementation, group care participants reported benefits including increased knowledge, peer support, and more satisfying relationships with providers. When asked about barriers to group care participation, none of them cited concern about privacy but instead cited lack of financial resources, lack of cooperation from a male partner, and long distances to the health center. Finally, women stated that the group care experience would be improved if all participants and providers arrived on time and remained focused on the group care visit throughout. Discussion These results are consistent with other published reports of women’s perceptions of group antenatal care, especially increased pregnancy- and parenting-related knowledge, peer support, and improved relationships with health care providers. Some results were unexpected, especially the consequences of staff allocation patterns that resulted in providers arriving late for group visits or having to leave during group visits to attend to other facility services, which diminished women’s experiences of care. Conclusion Group antenatal and postnatal care provide compelling benefits to women and families. If the model requires the addition of human resources at the health center, intensive reminder communications, and large-scale community outreach to benefit the largest number of pregnant and postnatal mothers, those additional resources required must be factored into any future decision to scale a group care model. Trial registration This trial is registered at clinicaltrials.gov as NCT03154177. Electronic supplementary material The online version of this article (10.1186/s12978-019-0750-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Angele Musabyimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Tiffany Lundeen
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA.
| | - Elizabeth Butrick
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Felix Sayinzoga
- Maternal, Child and Community Health Division, Rwanda Biomedical Center, Kigali, Rwanda
| | - Bernard Ngabo Rwabufigiri
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| | - Dilys Walker
- Institute for Global Health Sciences, University of California, San Francisco, 550 16th Street, 3rd floor, San Francisco, CA, 94158, USA
| | - Sabine F Musange
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, P.O Box 3286, Kigali, Rwanda
| |
Collapse
|
16
|
Williams P, Morales K, Sridharan V, Tummala A, Marseille E. Postpartum family planning in Rwanda: a cost effectiveness analysis. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12934.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. Women spend on average about 30 years, or three-quarters of their reproductive lives, attempting to avoid pregnancy. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Methods: This cost effectiveness analysis compared the two most frequently-used family planning methods in Rwanda, longer-acting reversible contraception (LARC), injections and subdermal implants, and shorter-acting reversible contraceptives (non-LARC), pills and condoms. Women who do not use contraception postpartum were also represented. A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and the analysis was conducted from a health systems perspective. Results: For women of reproductive age (15-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: There is an opportunity to avert unplanned pregnancies associated with the increased utilization of LARC methods. Despite the availability of LARC methods in many of Rwanda’s health facilities, the full benefits are not yet realized. LARC is cost-saving compared with non-LARC methods. Effective public health messaging campaigns and other promotion targeting current resistance to LARC use for the postpartum population could both enhance health and save public health funds.
Collapse
|
17
|
Hitimana R, Lindholm L, Mogren I, Krantz G, Nzayirambaho M, Sengoma JPS, Pulkki-Brännström AM. Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation. Health Res Policy Syst 2019; 17:36. [PMID: 30953520 PMCID: PMC6451275 DOI: 10.1186/s12961-019-0439-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 03/13/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda. METHODS Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697). RESULTS Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios. DISCUSSION Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.
Collapse
Affiliation(s)
- Regis Hitimana
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Lars Lindholm
- Department of Epidemiology and Global Health, Umeå University, SE 901 87 Umeå, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87 Umeå, Sweden
| | - Gunilla Krantz
- Department of Public Health and Community Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Manasse Nzayirambaho
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Jean-Paul Semasaka Sengoma
- School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87 Umeå, Sweden
| | | |
Collapse
|
18
|
Williams P, Morales K, Sridharan V, Tummala A, Marseille E. Postpartum family planning in Rwanda: a cost effectiveness analysis. Gates Open Res 2019. [DOI: 10.12688/gatesopenres.12934.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Globally, there is a large unmet need for family planning in the postpartum period: 90% of women in this group want family planning for birth spacing or to avoid unintended pregnancies and stop child bearing once desired family size has been reached. Women spend on average about 30 years, or three-quarters of their reproductive lives, attempting to avoid pregnancy. In total 76% of Rwandan women want family planning postpartum, yet a 26% unmet need remains. Methods: This cost effectiveness analysis compared the two most frequently-used family planning methods in Rwanda, longer-acting reversible contraception (LARC), injections and subdermal implants, and shorter-acting reversible contraceptives (non-LARC), pills and condoms. Women who do not use contraception postpartum were also represented. A time horizon of 24 months was used to reflect the World Health Organization suggested two-year spacing from birth until the next pregnancy, and the analysis was conducted from a health systems perspective. Results: For women of reproductive age (12-49 years) in Rwanda, including LARC postpartum family planning methods in the options, saves $18.73 per pregnancy averted, compared to family planning options that offer non-LARC methods exclusively. Conclusion: $2.8 million US$ per year can be saved if LARC is included as a contraceptive choice across all health centers in Rwanda; this cost savings provides the opportunity for these funds to be allocated to other high value interventions. Potential inclusion of these methods at Rwanda’s faith-based health facilities warrants further attention.
Collapse
|