| 1. |
- 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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| 2. |
- 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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| 3. |
- 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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| 4. |
- 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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| 5. |
- 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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