WHO recommends participatory learning and action cycles with women’s groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61–$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women’s groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
Background This study aimed to investigate the health and economic outcomes of a universal early intervention for parents and children, the Salut Programme, from birth to when the child completed five years of age. Methods This study adopted a retrospective observational design using routinely collected register data with respect to both exposures and outcomes from a county in northern Sweden. Areas that received care-as-usual (non-Salut area) were compared to areas where the Programme was implemented after 2006 (Salut area) in terms of: i) health outcomes, healthcare resource use and related costs around pregnancy, delivery and birth, and ii) healthcare resource use and related costs, as well as costs related to care of sick child. Costs were estimated for inpatient care and specialised outpatient care for mothers and children. Two analyses were conducted: a matched difference-in difference analysis using the total sample and an analysis including a longitudinal subsample. Results The longitudinal analysis on mothers who had given birth in both the pre- and post-measure periods showed that those that had been exposed to the Salut Programme, had on average 6% (95% CI 3-9%) more full-term pregnancies and 2% (95% CI 0.03-3%) more babies born within normal weight range, compared to mothers who had only care-as-usual. Savings were incurred in terms of outpatient care related costs for children of mothers in the Salut area ($826). The difference-in-difference analysis using the total sample did not result in any significant differences in health outcomes or cumulative resource use over time. Conclusions The Salut Programme achieved health gains at a reasonable cost for children and parents, and may lead to lower usage of outpatient care. Other indicators point towards positive effects but the small sample size may have led to underestimation of true differences. The current findings support the continuous investment in this early childhood programme. Key messages • The Salut Programme improves the health of children and parents at a low cost. • The Salut Programme as a health promotion early intervention is value for money and should be included in the local policy investment agenda.
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