| 1. |
- Batura, Neha, et al.
(författare)
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Highlighting the evidence gap : how cost-effective are interventions to improve early childhood nutrition and development?
- 2015
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Ingår i: Health Policy and Planning. - : Oxford University Press. - 0268-1080 .- 1460-2237. ; 30:6, s. 813-821
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Forskningsöversikt (refereegranskat)abstract
- There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.
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| 2. |
- Beck, Simon, et al.
(författare)
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Basic income – healthy outcome? Effects on health of an Indian basic income pilot project : a cluster randomised trial
- 2015
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Ingår i: Journal of Development Effectiveness. - : Informa UK Limited. - 1943-9342 .- 1943-9407. ; 7:1, s. 111-126
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Tidskriftsartikel (refereegranskat)abstract
- This article evaluates the effects on health of a basic income (BI) pilot project in Madhya Pradesh, India, between 2011 and 2012. BI can be defined as a non-contributory, universal and unconditional cash transfer paid out on an individual basis. The project was conducted as a cluster randomised trial involving 2034 households. Three health outcomes were examined: minor illnesses and injuries, illness and injuries requiring hospitalisation, and child vaccination coverage. The data were analysed with multiple imputation, propensity score matching and weighted logistic regression. BI was seen to significantly reduce the odds of minor illnesses and injuries by 46 per cent. No effect was seen on more serious illnesses and injuries, at least not in the time scale given, nor on child vaccination coverage which was already exceptionally high. Policymakers are encouraged to consider BI as an equitable policy of social protection, though further research on its impact on health is desirable.
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| 3. |
- Colbourn, Tim, et al.
(författare)
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Cost-effectiveness and affordability of community mobilisation through women's groups and quality improvement in health facilities (MaiKhanda trial) in Malawi
- 2015
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Ingår i: Cost Effectiveness and Resource Allocation. - : BioMed Central (BMC). - 1478-7547. ; 13
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Understanding the cost-effectiveness and affordability of interventions to reduce maternal and newborn deaths is critical to persuading policymakers and donors to implement at scale. The effectiveness of community mobilisation through women's groups and health facility quality improvement, both aiming to reduce maternal and neonatal mortality, was assessed by a cluster randomised controlled trial conducted in rural Malawi in 2008-2010. In this paper, we calculate intervention cost-effectiveness and model the affordability of the interventions at scale.METHODS: Bayesian methods are used to estimate the incremental cost-effectiveness of the community and facility interventions on their own (CI, FI), and together (FICI), compared to current practice in rural Malawi. Effects are estimated with Monte Carlo simulation using the combined full probability distributions of intervention effects on stillbirths, neonatal deaths and maternal deaths. Cost data was collected prospectively from a provider perspective using an ingredients approach and disaggregated at the intervention (not cluster or individual) level. Expected Incremental Benefit, Cost-effectiveness Acceptability Curves and Expected Value of Information (EVI) were calculated using a threshold of $780 per disability-adjusted life-year (DALY) averted, the per capita gross domestic product of Malawi in 2013 international $.RESULTS: The incremental cost-effectiveness of CI, FI, and combined FICI was $79, $281, and $146 per DALY averted respectively, compared to current practice. FI is dominated by CI and FICI. Taking into account uncertainty, both CI and combined FICI are highly likely to be cost effective (probability 98% and 93%, EVI $210,423 and $598,177 respectively). Combined FICI is incrementally cost effective compared to either intervention individually (probability 60%, ICER $292, EIB $9,334,580 compared to CI). Future scenarios also found FICI to be the optimal decision. Scaling-up to the whole of Malawi, CI is of greatest value for money, potentially averting 13.0% of remaining annual DALYs from stillbirths, neonatal and maternal deaths for the equivalent of 6.8% of current annual expenditure on maternal and neonatal health in Malawi.CONCLUSIONS: Community mobilisation through women's groups is a highly cost-effective and affordable strategy to reduce maternal and neonatal mortality in Malawi. Combining community mobilisation with health facility quality improvement is more effective, more costly, but also highly cost-effective and potentially affordable in this context.
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| 4. |
- Eid Rodríguez, Daniel, et al.
(författare)
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"Cheaper and better" : Societal cost savings and budget impact of changing from systemic to intralesional pentavalent antimonials as the first-line treatment for cutaneous leishmaniasis in Bolivia
- 2019
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Ingår i: PLoS Neglected Tropical Diseases. - : Public Library of Science (PLoS). - 1935-2727 .- 1935-2735. ; 13:11
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Cutaneous leishmaniasis (CL), endemic in Bolivia, mostly affects poor people in rainforest areas. The current first-line treatment consists of systemic pentavalent antimonials (SPA) for 20 days and is paid for by the Ministry of Health (MoH). Long periods of drug shortages and a lack of safe conditions to deliver treatment are challenges to implementation. Intralesional pentavalent antimonials (ILPA) are an alternative to SPA. This study aims to compare the cost of ILPA and SPA, and to estimate the health and economic impacts of changing the first-line treatment for CL in a Bolivian endemic area.METHODS: The cost-per-patient treated was estimated for SPA and ILPA from the perspectives of the MoH and society. The quantity and unit costs of medications, staff time, transportation and loss of production were obtained through a health facility survey (N = 12), official documents and key informants. A one-way sensitivity analysis was conducted on key parameters to evaluate the robustness of the results. The annual number of patients treated and the budget impact of switching to ILPA as the first-line treatment were estimated under different scenarios of increasing treatment utilization. Costs were reported in 2017 international dollars (1 INT$ = 3.10 BOB).RESULTS: Treating CL using ILPA was associated with a cost-saving of $248 per-patient-treated from the MoH perspective, and $688 per-patient-treated from the societal perspective. Switching first-line treatment to ILPA while maintaining the current budget would allow two-and-a-half times the current number of patients to be treated. ILPA remained cost-saving compared to SPA in the sensitivity analysis.CONCLUSIONS: The results of this study support a shift to ILPA as the first-line treatment for CL in Bolivia and possibly in other South American countries.
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| 5. |
- Feldman, I., et al.
(författare)
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Effectiveness of the Salut Program : a universal health promotion intervention for parents & children
- 2016
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Ingår i: European Journal of Public Health. - : Oxford University Press. - 1101-1262 .- 1464-360X. ; 26:Suppl 1, s. -253
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Tidskriftsartikel (refereegranskat)abstract
- Background: There is a lack of evidence for the effectiveness of health promotion interventions during pregnancy and early childhood. This study aims to investigate the effectiveness of the Salut Programme, a universal health promotion intervention in a Swedish County, compared to care as usual.Methods: A register-based retrospective observational study design is used with respect to both exposures and outcomes. Outcomes of interest during pregnancy, delivery and the child’s first three years of life included: direct indications of health risks, such as birth weight, Apgar scores, hospitalization, delivery; and indicators of poor health, such as child’s and mother’s hospital visits, and parents’ number of paid days for care of sick child. We compared outcomes of interest for both parents and children during pre- (children born 2002-2004) and post- (born 2006-2008) measure periods for the intervention (n = 1891 children, n = 1599 mothers), and non-intervention groups (n = 12723 children, n = 10544 mothers). Our analysis strategy combined difference-in-difference estimation with matching. A complementary analysis was carried out on the longitudinal subsample of women who gave birth in both the pre- and post- measure periods.Results: No significant changes were found in the difference-in-difference analysis. A few significant changes were found between intervention and non-intervention groups in the longitudinal analysis; for the Apgar scores 1 and 5 minutes (p < 0.001), and hospitalization during the first three years after birth for mothers (p = 0.002).Conclusions: Adding the Salut Programme to the care as usual provided minor effects on children’s and mothers’ health, for the outcomes used in this study. However, the health outcomes may impact child public health in the long-time perspective.Key message: In this study of the effectiveness of a universal health promotion intervention, the Salut Programme, some positive impact was found on child and maternal health outcomes
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| 6. |
- Haghparast-Bidgoli, Hassan, et al.
(författare)
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Inequity in costs of seeking sexual and reproductive health services in India and Kenya
- 2015
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Ingår i: International Journal for Equity in Health. - : BioMed Central. - 1475-9276. ; 14
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Tidskriftsartikel (refereegranskat)abstract
- Objective: This study aims to assess inequity in expenditure on sexual and reproductive health (SRH) services in India and Kenya. In addition, this analysis aims to measure the extent to which payments are catastrophic and to explore coping mechanisms used to finance health spending. Methods: Data for this study were collected as a part of the situational analysis for the "Diagonal Interventions to Fast Forward Enhanced Reproductive Health" (DIFFER) project, a multi-country project with fieldwork sites in three African sites; Mombasa (Kenya), Durban (South Africa) and Tete (Mozambique), and Mysore in India. Information on access to SRH services, the direct costs of seeking care and a range of socio-economic variables were obtained through structured exit interviews with female SRH service users in Mysore (India) and Mombasa (Kenya) (n = 250). The costs of seeking care were analysed by household income quintile (as a measure of socio-economic status). The Kakwani index and quintile ratios are used as measures of inequitable spending. Catastrophic spending on SRH services was calculated using the threshold of 10 % of total household income. Results: The results showed that spending on SRH services was highly regressive in both sites, with lower income households spending a higher percentage of their income on seeking care, compared to households with a higher income. Spending on SRH as a percentage of household income ranged from 0.02 to 6.2 % and 0.03-7.5 % in India and Kenya, respectively. There was a statistically significant difference in the proportion of spending on SRH services across income quintiles in both settings. In India, the poorest households spent two times, and in Kenya ten times, more on seeking care than the least poor households. The most common coping mechanisms in India and Kenya were "receiving [money] from partner or household members" (69 %) and "using own savings or regular income" (44 %), respectively. Conclusion: Highly regressive spending on SRH services highlights the heavier burden borne by the poorest when seeking care in resource-constrained settings such as India and Kenya. The large proportion of service users, particularly in India, relying on money received from family members to finance care seeking suggests that access would be more difficult for those with weak social ties, small social networks or weak bargaining positions within the family - although this requires further study.
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| 7. |
- 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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| 8. |
- 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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| 9. |
- 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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| 10. |
- 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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