| 21. |
- Hitimana, Regis, et al.
(författare)
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Cost of antenatal care for the health sector and for households in Rwanda
- 2018
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Ingår i: BMC Health Services Research. - : Springer Science and Business Media LLC. - 1472-6963. ; 18
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Tidskriftsartikel (refereegranskat)abstract
- Background: Rwanda has made tremendous progress in reduction of maternal mortality in the last twenty years. Antenatal care is believed to have played a role in that progress. In late 2016, the World Health Organization published new antenatal care guidelines recommending an increase from four visits during pregnancy to eight contacts with skilled personnel, among other changes. There is ongoing debate regarding the cost implications and potential outcomes countries can expect, if they make that shift. For Rwanda, a necessary starting point is to understand the cost of current antenatal care practice, which, according to our knowledge, has not been documented so far.Methods: Cost information was collected from Kigali City and Northern province of Rwanda through two cross-sectional surveys: a household-based survey among women who had delivered a year before the interview (N = 922) and a health facility survey in three public, two faith-based, and one private health facility. A micro costing approach was used to collect health facility data. Household costs included time and transport. Results are reported in 2015 USD.Results: The societal cost (household + health facility) of antenatal care for the four visits according to current Rwandan guidelines was estimated at $160 in the private health facility and $44 in public and faith-based health facilities. The first visit had the highest cost ($75 in private and $21 in public and faith-based health facilities) compared to the three other visits. Drugs and consumables were the main input category accounting for 54% of the total cost in the private health facility and for 73% in the public and faith-based health facilities.Conclusions: The unit cost of providing antenatal care services is considerably lower in public than in private health facilities. The household cost represents a small proportion of the total, ranging between 3% and 7%; however, it is meaningful for low-income families. There is a need to do profound equity analysis regarding the accessibility and use of antenatal care services, and to consider ways to reduce households’ time cost as a possible barrier to the use of antenatal care.
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| 22. |
- Hitimana, Regis, 1982-
(författare)
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Health economic evaluation for evidence-informed decisions in low-resource settings : the case of Antenatal care policy in Rwanda
- 2018
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Introduction: The general aim of this thesis is to contribute to the use of health economic evidence for informed health care decisions in low-resource settings, using antenatal care (ANC) policy in Rwanda as a case study. Despite impressive and sustained progress over the last 15 years, Rwanda’s maternal mortality ratio is still among the highest in the world. Persistent gaps in health care during pregnancy make ANC a good candidate among interventions that can, if improved, contribute to better health and well-being of mothers and newborns in Rwanda.Methods: Data used in this thesis were gathered from primary and secondary data collections. The primary data sources included a cross-sectional household survey (N=922) and a health facility survey (N=6) conducted in Kigali city and the Northern Province, as well as expert elicitation with Rwandan specialists (N=8). Health-related quality of life (HRQoL) for women during the first-year post-partum was measured using the EQ-5D-3L instrument. The association between HRQoL and adequacy of ANC utilization and socioeconomic and demographic predictors was tested through bivariate and linear regression analyses (Paper I). The costs of current ANC practices in Rwanda for both the health sector and households were estimated through analysis of primary data (Paper II). Incremental cost associated with the implementation of the 2016 World Health Organization (WHO) ANC recommendations compared to current practice in Rwanda was estimated through simulation of attendance and adaptation of the unit cost estimates (Paper III). Incremental health outcomes of the 2016 WHO ANC recommendations were estimated as life-years saved from perinatal and maternal mortality reduction obtained from the expert elicitation (Paper III). Lastly, a systematic review of the evidence base for the cost and cost-effectiveness of routine ultrasound during pregnancy was conducted (Paper IV). The review included 606 studies published between January 1999 and April 2018 and retrieved from PubMed, Scopus, and the Cochrane database.Results: Sixty one percent of women had not adequately attended ANC according to the Rwandan guidelines during their last pregnancy; either attending late or fewer than four times. Adequate utilization of ANC was significantly associated with better HRQoL after delivery measured using EQ-VAS, as were good social support and household wealth. The most prevalent health problems were anxiety or depression and pain or discomfort. The first ANC visit accounted for about half the societal cost of ANC, which was $44 per woman (2015 USD) in public/faith-based facilities and $160 in the surveyed private facility. Implementing the 2016 WHO recommendations in Rwanda would have an incremental national annual cost between $5.8 million and $11 million across different attendance scenarios. The estimated reduction in perinatal mortality would be between 22.5% and 55%, while maternal mortality reduction would range from 7% to 52.5%. Out of six combinations of attendance and health outcome scenarios, four were below the GDP-based cost-effectiveness threshold. Out of the 606 studies on cost and cost-effectiveness of ultrasound during pregnancy retrieved from the databases, only nine reached the data extraction stage. Routine ultrasound screening was reported to be a cost-effective intervention for screening pregnant women for cervical length, for vasa previa, and congenital heart disease, and cost-saving when used for screening for fetal malformations.Conclusions: The use of health economic evidence in decision making for low-income countries should be promoted. It is currently among the least used types of evidence, yet there is a huge potential of gaining many QALYs given persistent and avoidable morbidity and mortality. In this thesis, ANC policy in Rwanda was used as a case to contribute to evidence informed decision-making using health economic evaluation methods. Low-income countries, particularly those that that still have a high burden of maternal and perinatal mortality should consider implementing the 2016 WHO ANC recommendations.
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| 23. |
- Hitimana, Regis, et al.
(författare)
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Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study
- 2018
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Ingår i: Journal of Health Population and Nutrition. - : Springer Science and Business Media LLC. - 1606-0997 .- 2072-1315. ; 37
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Tidskriftsartikel (refereegranskat)abstract
- Background: Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (113 months) after delivery and socio-economic and demographic factors were explored in Rwanda. Methods: In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors. Results: Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL. Conclusions: ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.
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| 24. |
- Hitimana, Regis, et al.
(författare)
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Health related quality of life determinants for Rwandan women after delivery
- 2017
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Ingår i: European Journal of Public Health. - : OXFORD UNIV PRESS. - 1101-1262 .- 1464-360X. ; 27:Suppl_3, s. 436-
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Tidskriftsartikel (övrigt vetenskapligt/konstnärligt)abstract
- Health related quality of life determinants for Rwandan women after delivery. Does Antenatal care utilization matter? Maternal health conditions are still a major problem in most low-income countries. The postpartum health status and the effect of antenatal care utilization on health are relatively under researched. This study aims at (1) assessing whether receipt of antenatal care according to Rwandan guidelines is associated with mother’s health-related quality of life (HRQoL) and (2) exploring determinants associated with mother’s HRQoL in the first year (1-13 months) after delivery in Rwanda. In 2014 a cross-sectional survey was conducted on 922 women from Kigali City and Northern province of Rwanda, who gave birth in the period of 1–13 months prior to survey. The study population was randomly selected and interviewed using a questionnaire. HRQoL was measured using EQ-5D-3L. Average values of HRQoL were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care on HRQoL was tested in two multivariable linear regression models - with EQ-5D weights and the Visual Analogue Scale score as outcomes respectively - with ANC adequacy and socio-demographic and psychosocial variables as predictors. Mean HRQoL was 0.92 using EQ-5D and 69.58 using EQ-VAS. Fifteen per cent reported moderate pain/discomfort and 1% reported extreme pain/discomfort, 16% reported being moderately anxious/depressed and 3% reported being extremely anxious/depressed. Having more than one child and being cohabitant or single/not married was associated with significantly lower HRQoL, while having good social support and belonging to the highest wealth quintile was associated with higher HRQoL. Antenatal care utilization was not associated with HRQoL among postpartum mothers. Policy makers should address the social determinants of health, and promote social networks among women. There is a need to assess the quality of Antenatal care in Rwanda.Key messages:Health related quality of life among postpartum mothers is high. Pain or discomfort and anxiety of depression are most prevalent problems.Antenatal care utilization was not associated with HRQoL among postpartum mothers. Rather social determinants of health are important in determining mother's HRQoL
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| 25. |
- Hitimana, Regis, et al.
(författare)
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Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation
- 2019
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Ingår i: Health Research Policy and Systems. - : Springer Science and Business Media LLC. - 1478-4505. ; 17
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Tidskriftsartikel (refereegranskat)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.
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| 26. |
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| 27. |
- Häggström, Jenny, et al.
(författare)
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Is the Salut Programme an effective and cost-effective universal health promotion intervention for parents and their children? : a register-based retrospective observational study
- 2017
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Ingår i: BMJ Open. - : BMJ Publishing Group Ltd. - 2044-6055. ; 7:9
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: This study investigates the effectiveness and cost-effectiveness of the Salut Programme, a universal health promotion intervention, compared with care-as-usual, over the periods of pregnancy, delivery and the child's first 2 years of life.METHOD: We adopted a register-based retrospective observational design using existing data sources with respect to both exposures and outcomes. Health outcomes and costs were compared between geographical areas that received care-as-usual (non-Salut area) and areas where the programme was implemented (Salut area). We included mothers and their children from both the Salut and non-Salut areas if: (1) the child was born 2002-2004 (premeasure period) or (2) the child was born 2006-2008 (postmeasure period). The effectiveness study adopted two strategies: (1) a matched difference-in-difference analysis using data from all participants and (2) a longitudinal analysis restricted to mothers who had given birth twice, that is, both in the premeasure and postmeasure periods. The economic evaluation was performed from a healthcare and a limited societal perspective. Outcomes were clustered during pregnancy, delivery and birth and the child's first 2 years.RESULTS: Difference-in-difference analyses did not yield any significant effect on the outcomes. Longitudinal analyses resulted in significant positive improvement in Apgar scores, reflecting the newborn's physical condition, with more children having a normal Apgar score (1 min +3%, 5 min +1%). The cost of the programme was international dollar (INT$)308/child. From both costing perspectives, the programme yielded higher effects and lower costs than care-as-usual, being thus cost-saving (probability of around 50%).CONCLUSIONS: Our findings suggest that the Salut Programme is an effective universal intervention to improve maternal and child health, and it may be good value for money; however, there is large uncertainty around the cost estimates.
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| 28. |
- Kim, Sung, et al.
(författare)
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Comparing the cost effectiveness of harm reduction strategies : a case study of the Ukraine
- 2014
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Ingår i: Cost Effectiveness and Resource Allocation. - : Springer Science and Business Media LLC. - 1478-7547. ; 12
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundHarm reduction strategies commonly include needle and syringe programmes (NSP), opioid substitution therapy (OST) and interventions combining these two strategies. Despite the proven effectiveness of harm-reduction strategies in reducing human immunodeficiency virus (HIV) infection among injecting drug users (IDUs), no study has compared the cost-effectiveness of these interventions, nor the incremental cost effectiveness of combined therapy. Using data from the Global Fund, this study compares the cost-effectiveness of harm reduction strategies in Eastern Europe and Central Asia, using the Ukraine as a case study.MethodsA Markov Monte Carlo simulation is carried out using parameters from the literature and cost data from the Global Fund. Effectiveness is presented as both QALYs and infections averted. Costs are measured in 2011 US dollars.ResultsThe Markov Monte Carlo simulation estimates the cost-effectiveness ratio per infection averted as $487.4 [95% CI: 488.47-486.35] in NSP and $1145.9 [95% CI: 1143.39-1148.43] in OST. Combined intervention is more costly but more effective than the alternative strategies with a cost effectiveness ratio of $851.6[95% CI: 849.82-853.55].The ICER of the combined strategy is $1086.9/QALY [95% CI: 1077.76:1096.24] compared with NSP, and $461.0/infection averted [95% CI: 452.98:469.04] compared with OST. These results are consistent with previous studies.ConclusionsDespite the inherent limitations of retrospective data, this study provides evidence that harm-reduction interventions are a cost-effective way to reduce HIV prevalence. More research on into cost effectiveness in different settings, and the availability of fiscal space for government uptake of programmes, is required.
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| 29. |
- Kim, Sung Wook, et al.
(författare)
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Socio-economic inequity in HIV testing in Malawi
- 2016
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Ingår i: Global Health Action. - : Informa UK Limited. - 1654-9716 .- 1654-9880. ; 9, s. 1-15
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Human immunodeficiency virus (HIV) is a significant contributor to Malawi's burden of disease. Despite a number of studies describing socio-economic differences in HIV prevalence, there is a paucity of evidence on socio-economic inequity in HIV testing in Malawi.OBJECTIVE: To assess horizontal inequity (HI) in HIV testing in Malawi.DESIGN: Data from the Demographic and Health Surveys (DHSs) 2004 and 2010 in Malawi are used for the analysis. The sample size for DHS 2004 was 14,571 (women =11,362 and men=3,209), and for DHS 2010 it was 29,830 (women=22,716 and men=7,114). The concentration index is used to quantify the amount of socio-economic-related inequality in HIV testing. The inequality is a primary method in this study. Corrected need, a further adjustment of the standard decomposition index, was calculated. Standard HI was compared with corrected need-adjusted inequity. Variables used to measure health need include symptoms of sexually transmitted infections. Non-need variables include wealth, education, literacy and marital status.RESULTS: Between 2004 and 2010, the proportion of the population ever tested for HIV increased from 15 to 75% among women and from 16 to 54% among men. The need for HIV testing among men was concentrated among the relatively wealthy in 2004, but the need was more equitably distributed in 2010. Standard HI was 0.152 in 2004 and 0.008 in 2010 among women, and 0.186 in 2004 and 0.04 in 2010 among men. Rural-urban inequity also fell in this period, but HIV testing remained pro-rich among rural men (HI 0.041). The main social contributors to inequity in HIV testing were wealth in 2004 and education in 2010.CONCLUSIONS: Inequity in HIV testing in Malawi decreased between 2004 and 2010. This may be due to the increased support to HIV testing by global donors over this period.
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| 30. |
- Lewycka, Sonia, et al.
(författare)
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Effect of women's groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana) : a factorial, cluster-randomised controlled trial
- 2013
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Ingår i: The Lancet. - : Elsevier. - 0140-6736 .- 1474-547X. ; 381:9879, s. 1721-35
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Women's groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.METHODS: We did a 2×2 factorial, cluster-randomised trial in 185,888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women's group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.FINDINGS: We monitored outcomes of 26,262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women's group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0.93, 0.64-1.35) and MMR (0.54, 0.28-1.04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0.85, 0.59-1.22) and MMR (0.48, 0.26-0.91). Because of the interaction between the two interventions, a stratified analysis was done. For women's groups, in adjusted analyses, MMR fell by 74% (0.26, 0.10-0.70), and NMR by 41% (0.59, 0.40-0.86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1.09, 0.40-2.98, and 1.38, 0.75-2.54). Factorial analysis for the peer counselling intervention for years 1-3 showed a fall in IMR of 18% (0.82, 0.67-1.00) and an improvement in EBF rates (2.42, 1.48-3.96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0.64, 0.48-0.85) but no effect on EBF (1.18, 0.63-2.25) in areas without women's groups, and in areas with women's groups there was no effect on IMR (1.05, 0.82-1.36) and an increase in EBF (5.02, 2.67-9.44). The cost of women's groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.INTERPRETATION: Community mobilisation through women's groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.
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