Topic: Systems-based Practice M aternal and neonatal mortality rates remain high in many low-income and middle-income countries. To attain the Millennium Development Goals 4 and 5, different approaches to improve birth outcomes have been tried, including community-based interventions. Effects on survival have been heterogeneous and uncertain. This systematic review and meta-analysis of randomized controlled trials (RCTs) was done to assess the effects of women's groups practicing participatory learning and action on birth outcomes in low-resource settings.Seven databases and citations from reference lists were searched for RCTs carried out in Bangladesh, India, Malawi, and Nepal. Inclusion criteria for studies in the systematic review included: RCT, the intervention contained the stages of a participatory learning and action cycle, most participants were aged 15-49 years, and outcomes reported included maternal mortality, neonatal mortality, and stillbirths. The participatory learning and action cycle had 4 phases: (1) identify and prioritize problems during pregnancy, delivery, and postpartum; (2) plan;(3) implement locally feasible strategies to address the priority problems; and (4) assess the activities. Subgroup analyses were carried out to identify population-level predictors of effect. Incremental cost-effectiveness ratios were used for trials in which significant effects on the neonatal mortality rate were reported. Cost-effectiveness was expressed as the incremental cost per neonatal death averted and life-year saved.Seven RCTs performed between 1999 and 2011 that included a total of 119,428 births met the inclusion criteria. Group facilitators in the participatory programs were local women who were not health workers; they coordinated 9-13 group meetings per month after receiving 7-11 days of training in maternal and newborn health and participatory facilitation techniques. Exposure to women's groups was associated with 37% and 23% reductions in maternal and neonatal mortality, respectively. No association was found between participatory learning programs and a reduction in stillbirths. The proportion of pregnant women participating in the groups was linearly associated with reductions in both maternal and neonatal mortality, but no evidence of associations was found between the effects of the intervention and background mortality or institutional delivery rates. In studies in which Z30% of pregnant women participated in women's groups, a 55% reduction in maternal mortality and a 33% reduction in neonatal morality was observed. The women's participatory learning and action groups had strong effects on clean delivery practices for home deliveries and noticeable effects on breastfeeding. Women's groups were a highly cost-effective intervention as determined by World Health Organization standards. The intervention could save an estimated 283,000 newborns and 41,100 mothers per year if implemented in rural areas of 74 countdown countries (those countries targeted for attaining Millennium Goals by 2015).Wome...
Cash-based interventions (CBIs) increasingly are being used to deliver humanitarian assistance and there is growing interest in the cost-effectiveness of cash transfers for preventing undernutrition in emergency contexts. The objectives of this study were to assess the costs, cost-efficiency and cost-effectiveness in achieving nutrition outcomes of three CBIs in southern Pakistan: a ‘double cash’ (DC) transfer, a ‘standard cash’ (SC) transfer and a ‘fresh food voucher’ (FFV) transfer. Cash and FFVs were provided to poor households with children aged 6–48 months for 6 months in 2015. The SC and FFV interventions provided $14 monthly and the DC provided $28 monthly. Cost data were collected via institutional accounting records, interviews, programme observation, document review and household survey. Cost-effectiveness was assessed as cost per case of wasting, stunting and disability-adjusted life year (DALY) averted. Beneficiary costs were higher for the cash groups than the voucher group. Net total cost transfer ratios (TCTRs) were estimated as 1.82 for DC, 2.82 for SC and 2.73 for FFV. Yet, despite the higher operational costs, the FFV TCTR was lower than the SC TCTR when incorporating the participation cost to households, demonstrating the relevance of including beneficiary costs in cost-efficiency estimations. The DC intervention achieved a reduction in wasting, at $4865 per case averted; neither the SC nor the FFV interventions reduced wasting. The cost per case of stunting averted was $1290 for DC, $882 for SC and $883 for FFV. The cost per DALY averted was $641 for DC, $434 for SC and $563 for FFV without discounting or age weighting. These interventions are highly cost-effective by international thresholds. While it is debatable whether these resource requirements represent a feasible or sustainable investment given low health expenditures in Pakistan, these findings may provide justification for continuing Pakistan’s investment in national social safety nets.
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 $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women’s groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations.
BackgroundHuman resources are a major cost driver in childhood pneumonia case management. Introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in Malawi can lead to savings on staff time and salaries due to reductions in pneumonia cases requiring admission. Reliable estimates of human resource costs are vital for use in economic evaluations of PCV-13 introduction.MethodsTwenty-eight severe and twenty-four very severe pneumonia inpatients under the age of five were tracked from admission to discharge by paediatric ward staff using self-administered timesheets at Mchinji District Hospital between June and August 2012. All activities performed and the time spent on each activity were recorded. A monetary value was assigned to the time by allocating a corresponding percentage of the health workers’ salary. All costs are reported in 2012 US$.ResultsA total of 1,017 entries, grouped according to 22 different activity labels, were recorded during the observation period. On average, 99 min (standard deviation, SD = 46) were spent on each admission: 93 (SD = 38) for severe and 106 (SD = 55) for very severe cases. Approximately 40 % of activities involved monitoring and stabilization, including administering non-drug therapies such as oxygen. A further 35 % of the time was spent on injecting antibiotics. Nurses provided 60 % of the total time spent on pneumonia admissions, clinicians 25 % and support staff 15 %. Human resource costs were approximately US$ 2 per bed-day and, on average, US$ 29.5 per severe pneumonia admission and US$ 37.7 per very severe admission.ConclusionsSelf-reporting was successfully used in this context to generate reliable estimates of human resource time and costs of childhood pneumonia treatment. Assuming vaccine efficacy of 41 % and 90 % coverage, PCV-13 introduction in Malawi can save over US$ 2 million per year in staff costs alone.
IntroductionThe aim of this evaluation is to understand whether introducing stabilisation rooms equipped with pulse oximetry and oxygen systems to frontline health facilities in Ikorodu, Lagos State, alongside healthcare worker (HCW) training improves the quality of care for children with pneumonia aged 0–59 months. We will explore to what extent, how, for whom and in what contexts the intervention works.Methods and analysisQuasi-experimental time-series impact evaluation with embedded mixed-methods process and economic evaluation. Setting: seven government primary care facilities, seven private health facilities, two government secondary care facilities. Target population: children aged 0–59 months with clinically diagnosed pneumonia and/or suspected or confirmed COVID-19. Intervention: ‘stabilisation rooms’ within participating primary care facilities in Ikorodu local government area, designed to allow for short-term oxygen delivery for children with hypoxaemia prior to transfer to hospital, alongside HCW training on integrated management of childhood illness, pulse oximetry and oxygen therapy, immunisation and nutrition. Secondary facilities will also receive training and equipment for oxygen and pulse oximetry to ensure minimum standard of care is available for referred children. Primary outcome: correct management of hypoxaemic pneumonia including administration of oxygen therapy, referral and presentation to hospital. Secondary outcome: 14-day pneumonia case fatality rate. Evaluation period: August 2020 to September 2022.Ethics and disseminationEthical approval from University of Ibadan, Lagos State and University College London. Ongoing engagement with government and other key stakeholders during the project. Local dissemination events will be held with the State Ministry of Health at the end of the project (December 2022). We will publish the main impact results, process evaluation and economic evaluation results as open-access academic publications in international journals.Trial registration numberACTRN12621001071819; Registered on the Australian and New Zealand Clinical Trials Registry.
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