Participatory learning and action cycles with women’s groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability

Abstract

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.

Economic evaluation of participatory women’s groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India

“…The incremental cost-effectiveness ratio of $INT41 is substantially lower than India’s GDP per capita (ranging from 0.3% to 7% of GDP). FLAG’s ICER is 85% lower than that found in a smaller-scale efficacy trial of women’s groups facilitated by ASHAs conducted in Jharkhand and Odisha (ICER of 2017 INT$ 274 or US$83), and 70% lower than in another smaller trial of women’s groups supported by salaried facilitators in the same states (ICER of 2016 INT$ 135) [13] [12]. Similarly, FLAG’s ICER is also substantially lower than those reported for small scale efficacy trials of women’s groups in Nepal, Bangladesh, and Malawi[12] (Table S2).…”

“…In FLAG, there was one women’s group per c. 1000 population compared to one per c.500 population in previous trials in India. Finally, the results also potentially reflect economies of scale (See Figure S1); the intervention area covered 1.6 million livebirths at a very low unit cost (cost per livebirths) (INT$ 9.4 compared with average unit cost of INT$ 203, range: 2016 INT$ 61-537)[12] in smaller scale trials of women’s groups (Table S2). As Figure S2 illustrates, unit costs decreased with the increased scale of the intervention, which is in line with conclusion from scale up of SHGs in India, in general [38].…”

“…A similar conclusion can be drawn by comparing FLAG results with two small (JEEViKA-MC) [36] and large (Parivartan) scale [37] implementation studies of Self-help groups (SHGs) with maternal and child health components. The Parivartan programme [37] [12] in smaller scale trials of women's groups (Table S2). As Figure S2 illustrates, unit costs decreased with the increased scale of the intervention, which is in line with conclusion from scale up of SHGs in India, in general [38].…”

Effectiveness of participatory women’s groups scaled up by the public health system to improve birth outcomes in Jharkhand, eastern India: a pragmatic cluster non-randomised controlled trial

“…The intervention covered 1.6 million live births at a cost of INT$9.4 per live birth compared with average cost per live birth of INT$203 (range: 2016 INT$61-INT$537) in efficacy trials. 46 Our study benefited from a large sample size, low attrition levels and conservative statistical methods. It also *Model 1: cluster-level analysis adjusted for baseline differences in the outcome only.…”

“…The intervention covered 1.6 million live births at a cost of INT$9.4 per live birth compared with average cost per live birth of INT$203 (range: 2016 INT$61–INT$537) in efficacy trials. 46 …”