Community-Based Interventions for Newborns in Ethiopia (COMBINE): Cost-effectiveness analysis

Abstract

About 87 000 neonates die annually in Ethiopia, with slower progress than for child deaths and 85% of births are at home. As part of a multi-country, standardized economic evaluation, we examine the incremental benefit and costs of providing management of possible serious bacterial infection (PSBI) for newborns at health posts in Ethiopia by Health Extension Workers (HEWs), linked to improved implementation of existing policy for community-based newborn care (Health Extension Programme). The government, with Save the Children/Saving Newborn Lives and John Snow, Inc., undertook a cluster randomized trial. Both trial arms involved improved implementation of the Health Extension Programme. The intervention arm received additional equipment, support and supervision for HEWs to identify and treat PSBI. In 2012, ∼95% of mothers in the study area received at least one pregnancy or postnatal visit in each arm, an average of 5.2 contacts per mother in the intervention arm (4.9 in control). Of all visits, 79% were conducted by volunteer community health workers. HEWs spent around 9% of their time on the programme. The financial cost per mother and newborn was $34 (in 2015 USD) in the intervention arm ($27 in control), economic costs of $37 and $30, respectively. Adding PSBI management at community level was estimated to reduce neonatal mortality after day 1 by 17%, translating to a cost per DALY averted of $223 or 47% of the GDP per capita, a highly cost-effective intervention by WHO thresholds. In a routine situation, the intervention programme cost would represent 0.3% of public health expenditure per capita and 0.5% with additional monthly supervision meetings. A platform wide approach to improved supervision including a dedicated transport budget may be more sustainable than a programme-specific approach. In this context, strengthening the existing HEW package is cost-effective and also avoids costly transfers to health centres/hospitals.

Implementation of the WHO guideline on treatment of young infants with signs of possible serious bacterial infection when hospital referral is not feasible in rural Zaria, Nigeria: Challenges and solutions

“…[5][6][7][8][9][28][29] Experience from Ethiopia also showed that implementing neonatal PSBI management within the existing government health structure through Health Extension Workers at community level was feasible and cost effective. [30]Its inclusion in the intervention areas reduced the post day 1 neonatal deaths by 17% compared to control areas. Also in a similar setting in Nepal, a community-based pilot called-Morang Innovative Neonatal Intervention (MINI) progamme, implemented withing the existing government health infrastructure, showed that Community Health Workers were able to assess and identify possible infections in young infants and delivered appropriate treatment with antibiotics.…”

“…The is similar to experience from Nepal who reported no adverse event throughout the course of the MINI programme. [30] Scale-up and implementation of PSBI treatment guideline requires government commitment and motivation of the health facility staff. If that commitment is not there in the shape of human and financial resources, this will not happen.…”

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas

“…The questionnaire tools for baseline and endline surveys were adapted from the team's own, and others' previous work on the Integrated Management of Childhood Illness [28], iCCM [29], and CBNC [30]. The questionnaire instrument included modules regarding household, health posts and health centres, HEWs, health centre staff, WDA members, an observation and re-examination of the HEW assessing sick children, and district contextual factors (Table 2) [see additional files [1][2][3][4][5][6][7][8][9].…”

“…This category of health workers is reportedly able to correctly manage multiple child illnesses through the integrated community case management (iCCM) activities that the government initiated in 2010 [5]. If appropriately trained and supported, this cadre can also treat severe infections of the newborn in a costeffective way within the Community-Based Newborn Care (CBNC) program that has been running since 2014 [6]. Although nearly all the HEWs throughout the country have been trained, relatively few sick newborns have been identified and treated [7].…”

The cost of the training and supervision of community health workers to improve exclusive breastfeeding amongst mothers in a cluster randomised controlled trial in South Africa

“…Community health workers (CHWs) have the potential to address the barriers encountered by women and children in accessing maternal and child health (MCH) services, particularly in underserved rural areas where the shortage of professional health workers is most profound [1]. CHWs can increase coverage of maternal and child services in African settings, leading to improved maternal and child health outcomes [2,3]. In 2010, the South African government proposed to re-engineer the provision of primary health care by focusing on a small number of key priorities, including the training and deployment of a generalist CHW that would become a recognised cadre within the national health system [4].…”