RESUMEN
Community-based maternal and newborn care with home visits by community health workers (CHWs) are recommended by WHO to complement facility-based care. As part of multi-country economic and systems analyses, we aimed to compare the content and financial costs associated with equipping CHWs or 'home visit kits' from seven studies in Bolivia, Ethiopia, Ghana, Malawi, South Africa, Tanzania and Uganda. We estimated the equivalent annual costs (EACs) of home visit kits per CHW in constant 2015 USD. We estimated EAC at scale in a population of 100 000 assuming four home visits per mother during the pregnancy and postnatal period. All seven packages were designed for health promotion; six included clinical assessments and one included curative care. The items used by CHWs differed between countries, even for the same task. The EAC per home visit kit ranged from $15 in Tanzania to $116 in South Africa. For health promotion and preventive care, between 82 and 100% of the cost of CHW commodities did not vary with the number of home visits conducted; however, in Ethiopia, the majority of EAC associated with curative care varied with the number of visits conducted. The EAC of equipping CHWs to meet the needs of 95% of expectant mothers in a catchment area of 100 000 people was highest in Bolivia, $40 260 for 633 CHWs, due to mothers being in hard-to-reach areas with CHW conducting few visits per year per, and lowest in Tanzania ($2693 for 172 CHWs), due to the greater number of CHW visits per week and lower EAC of items. To inform and ensure sustainable implementation at scale, national discussions regarding the cadre of CHWs and their workload should also consider carefully the composition and cost of equipping CHWs to carry out their work effectively and efficiently.
Asunto(s)
Servicios de Salud del Niño/economía , Agentes Comunitarios de Salud/economía , Equipos y Suministros/economía , Servicios de Salud Materna/economía , África , Bolivia , Servicios de Salud del Niño/organización & administración , Servicios de Salud Comunitaria/economía , Agentes Comunitarios de Salud/organización & administración , Femenino , Promoción de la Salud , Visita Domiciliaria/economía , Humanos , Recién Nacido , Servicios de Salud Materna/organización & administración , EmbarazoRESUMEN
Home visits for pregnancy and postnatal care were endorsed by the WHO and partners as a complementary strategy to facility-based care to reduce newborn and maternal mortality. This article aims to synthesise findings and implications from the economic analyses of community-based maternal and newborn care (CBMNC) evaluations in seven countries. The evaluations included five cluster randomized trials (Ethiopia, Ghana, South Africa, Tanzania, Uganda) and programmatic before/after assessments (Bolivia, Malawi). The economic analyses were undertaken using a standardized, comparable methodology the 'Cost of Integrated Newborn Care' Tool, developed by the South African Medical Research Council, with Saving Newborn Lives and a network of African economists. The main driver of costs is the number of community health workers (CHWs), determined by their time availability, as fixed costs per CHW (equipment, training, salary/stipend, supervision and management), independent from the level of activity (number of mothers visited) represented over 96% of economic and financial costs in five of the countries. Unpaid volunteers are not necessarily a cheap option. An integrated programme with multi-purpose paid workers usually has lower costs per visit but requires innovative management, including supervision to ensure that coverage, or quality of care are not compromised since these workers have many other responsibilities apart from maternal and newborn health. If CHWs reach 95% of pregnant women in a standardized 100 000 population, the additional financial cost in all cases would be under USD1 per capita. In five of the six countries, the programme would be highly cost-effective (cost per DALY averted < GDP/capita) by WHO threshold even if they only achieved a reduction of 1 neonatal death per 1000 live births. These results contribute useful information for implementation planning and sustainability of CBMNC programmes.
Asunto(s)
Servicios de Salud del Niño/economía , Agentes Comunitarios de Salud/economía , Análisis Costo-Beneficio , Visita Domiciliaria/economía , Servicios de Salud Materna/economía , África , Bolivia , Servicios de Salud del Niño/organización & administración , Servicios de Salud Comunitaria/economía , Servicios de Salud Comunitaria/organización & administración , Agentes Comunitarios de Salud/organización & administración , Femenino , Humanos , Lactante , Recién Nacido , Servicios de Salud Materna/organización & administración , EmbarazoRESUMEN
BACKGROUND: Achievement of global health goals will require assessment of progress not only nationally but also for population subgroups. We aimed to assess how the magnitude of socioeconomic inequalities in health changes in relation to different rates of national progress in coverage of interventions for the health of mothers and children. METHODS: We assessed coverage in low-income and middle-income countries for which two Demographic Health Surveys or Multiple Indicator Cluster Surveys were available. We calculated changes in overall coverage of skilled birth attendants, measles vaccination, and a composite coverage index, and examined coverage of a newly introduced intervention, use of insecticide-treated bednets by children. We stratified coverage data according to asset-based wealth quintiles, and calculated relative and absolute indices of inequality. We adjusted correlation analyses for time between surveys and baseline coverage levels. FINDINGS: We included 35 countries with surveys done an average of 9·1 years apart. Pro-rich inequalities were very prevalent. We noted increased coverage of skilled birth attendants, measles vaccination, and the composite index in most countries from the first to the second survey, while inequalities were reduced. Rapid changes in overall coverage were associated with improved equity. These findings were not due to a capping effect associated with limited scope for improvement in rich households. For use of insecticide-treated bednets, coverage was high for the richest households, but countries making rapid progress did almost as well in reaching the poorest groups. National increases in coverage were primarily driven by how rapidly coverage increased in the poorest quintiles. INTERPRETATION: Equity should be accounted for when planning the scaling up of interventions and assessing national progress. FUNDING: Bill & Melinda Gates Foundation; World Bank; Governments of Australia, Brazil, Canada, Norway, Sweden, and UK.