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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

 

Research

Tim Colbourn1*, Anni-Maria Pulkki-Brännström15, Bejoy Nambiar1, Sungwook Kim1, Austin Bondo2, Lumbani Banda2, Charles Makwenda2, Neha Batura1, Hassan Haghparast-Bidgoli1, Rachael Hunter3, Anthony Costello1, Gianluca Baio4 and Jolene Skordis-Worrall1

  • *
    Corresponding author: Tim Colbourn t.colbourn@ucl.ac.uk

Author Affiliations

1 UCL Institute for Global Health, 30 Guilford Street, London WC1N 1EH, UK

2 Parent and Child Health Initiative (PACHI), Amina House, Western Wing – Second Floor, Capital City, Lilongwe 3, Malawi

3 Research Department of Primary Care Population Health, UCL Priment Clinical Trials Unit, Royal Free Campus, London NW3 2PF, UK

4 Department of Statistical Science, University College London, 1-19 Torrington Place, London WC1E 6BT, UK

5 Epidemiology and Global Health, Umeå University, Umeå, 901 87, Sweden

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Cost Effectiveness and Resource Allocation 2015, $article.volume.volumeNumber:1 
doi:10.1186/s12962-014-0028-2

Published: 10 January 2015

Abstract (provisional)

BackgroundUnderstanding 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.MethodsBayesian 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 $.ResultsThe 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.ConclusionsCommunity 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.