Adapting Economic Evaluation Methods to Shifting Global Health Priorities: Assessing the Value of Health System Inputs

OBJECTIVES

We highlight the importance of undertaking value assessments for health system inputs if allocative efficiency is to be achieve with health sector resources, with a focus on low- and middle-income countries. However, methodological challenges complicated the application of current economic evaluation techniques to health system input investments.

METHODS

We undertake a review of the literature to examine how assessments of investments in health system inputs have been considered to date, highlighting several studies that have suggested ways to address the methodological issues. Additionally, we surveyed how empirical economic evaluations of health system inputs have approached these issues. Finally, we highlight the steps required to move toward a comprehensive standardized framework for undertaking economic evaluations to make value assessments for investments in health systems.

RESULTS

Although the methodological challenges have been illustrated, a comprehensive framework for value assessments of health system inputs, guiding the evidence required, does not exist. The applied literature of economic evaluations of health system inputs has largely ignored the issues, likely resulting in inaccurate assessments of cost-effectiveness.

CONCLUSIONS

A majority of health sector budgets are spent on health system inputs, facilitating the provision of healthcare interventions. Although economic evaluation methods are a key component in priority setting for healthcare interventions, such methods are less commonly applied to decision making for investments in health system inputs. Given the growing agenda for investments in health systems, a framework will be increasingly required to guide governments and development partners in prioritizing investments in scarce health sector budgets.

Community-level integration of health services and community health workers' agency in Malawi

Despite a large literature on integration of health services, there is a dearth of scholarship assessing service integration in its totality at the community level. Similarly, across the wide evidence base on community health workers (CHWs), there is little that analyses the ways in which they interact with both formal and informal structures and how these interactions shape their agency and ultimately the delivery of integrated services. A better understanding of agency in the work of CHWs would help health systems, policy makers and practitioners to better design and support the delivery of community-level integrated health packages to improve health outcomes. In this study, we explored the agency of CHWs in Malawi known as Health Surveillance Assistants (HSAs). We used qualitative methods: participant observation, in-depth interviews, and focus group discussions between July and October 2018. Overall, the ethnographic study utilised actors-centred frameworks (structuration theory and street-level bureaucracy). The study findings unravel the complexities involving HSAs' agency shaped by health system structures (staffing, infrastructure, drugs, and supplies) and informal structures (community relations, local power structures, gendered-household relations) which narrowed or widened their discretionary decision-making space. The flexibility of HSAs was a distinctive feature in their work, but they developed other coping mechanisms: task shifting, teamwork, creative community engagement, and referrals to deliver integrated maternal and child health services. HSAs' unique position as community-based providers meant they needed to consider diverse factors that constrained or facilitated their work. Overall, we argue that HSAs need to be fully involved in the design of community-level integrated health programmes. There should be a consideration to address both informal and formal structures that together shape agency. Additionally, CHWs' flexibility and agency to make locally informed decisions must be protected and maintained because it enhances their ability to deliver essential health services.

Economic evaluation and health systems strengthening: a review of the literature

Health systems strengthening (HSS) is firmly on the global health and development agenda. While a growing evidence base seeks to understand the effectiveness of HSS, there is limited evidence regarding cost and cost-effectiveness. Without such evidence, it is hard to argue that HSS represents value for money and the level of investment needed cannot be quantified. This paper seeks to review the literature regarding the economic evaluation of HSS from low- and middle-income country (LMIC) settings, and to contribute towards the development of methods for the economic evaluation of HSS. A systematic search for literature was conducted in PubMed, Scopus and the Health Systems Evidence database. MeSH terms related to economic evaluation were combined with key words related to the concept of HSS. Of the 204 records retrieved, 52 were retained for full text review and 33 were included. Of these, 67% were published between January 2015 and June 2019. While many HSS interventions have system wide impacts, most studies (71%) investigated these impacts using a disease-specific lens (e.g. the impact of quality of care improvements on uptake of facility deliveries). HSS investments were categorized, with the majority being investments in platform efficiency (e.g. quality of care), followed by simultaneous investment in platform efficiency and platform capacity (e.g. quality of care and task shifting). This review identified a growing body of work seeking to undertake and/or conceptualize the economic evaluation of HSS in low- and middle-income countries. The majority assess HSS interventions using a disease-specific or programmatic lens, treating HSS in a similar manner to the economic evaluation of medicines and diagnostics. While this approach misses potential economies of scope from HSS investments, it allows for a preliminary understanding of relative value for money. Future research is needed to complement the emerging evidence base.

Evaluating implementation strategies for essential newborn care interventions in low- and low middle-income countries: a systematic review

Neonatal mortality remains a significant health problem in low-income settings. Low-cost essential newborn care (ENC) interventions with proven efficacy and cost-effectiveness exist but have not reached high coverage (≥90%). Little is known about the strategies used to implement these interventions or how they relate to improved coverage. We conducted a systematic review of implementation strategies and implementation outcomes for ENC in low- and low middle-income countries capturing evidence from five medical and global health databases from 1990 to 2018. We included studies of implementation of delayed cord clamping, immediate drying, skin-to-skin contact (SSC) and/or early initiation of breastfeeding implemented in the first hour (facility-based studies) or the 1st day (community-based studies) of life. Implementation strategies and outcomes were categorized according to published frameworks: Expert Recommendations for Implementing Change and Outcomes for Implementation Research. The relationship between implementation strategies and outcomes was evaluated using standardized mean differences and correlation coefficients. Forty-three papers met inclusion criteria. Interventions included community-based care/health promotion and facility-based support and health care provider training. Included studies used 3-31 implementation strategies, though the consistency with which strategies were applied was variable. Conduct educational meetings was the most frequently used strategy. Included studies reported 1-4 implementation outcomes with coverage reported most frequently. Heterogeneity was high and no statistically significant association was found between the number of implementation strategies used and coverage of ENC. This review highlights several challenges in learning from implementation of ENC in low- and low middle-income countries, particularly poor description of interventions and implementation outcomes. We recommend use of UK Medical Research Council guidelines (2015) for process evaluations and checklists for reporting implementation studies. Improved reporting of implementation research in this setting is necessary to learn how to improve service delivery and outcomes and thereby reduce neonatal mortality.

An evidence-based policy brief: improving the quality of postnatal care in mothers 48 hours after childbirth

Introduction

Malawi is experiencing slow progress in postnatal care of mothers within the first 48 hours after childbirth. Malawi Demographic and Health Survey (MDHS) 2015–16 reported a slow progress in postnatal care of mothers in the first 48 hours at 42% from 41% in 2010 despite a high number of institutional births. This is a critical period as a large proportion of maternal deaths occur during this period, currently at 439 per 100,000 live births. During postnatal care the mother is given important information to assist in caring for herself and her baby. The lack of well documented guidelines and funding to employ more midwives to manage mothers in postnatal ward contributes to poor quality of postnatal care.

Methods

This is an evidence-based policy brief that was prepared to inform policy makers, health workers, clients, community and other stakeholders to consider the available evidence about the impact of the suggested options in order to improve postnatal care.

Results

Several factors that contribute to low utilization of postnatal care among mothers after childbirth were identified. Factors included lack of clear guidelines on postnatal care, shortage of skilled health workers and inadequate resources.

Conclusion

Implementation of the identified policy options may improve postnatal care.

Home visits by community health workers for pregnant mothers and newborns: coverage plateau in Malawi

BACKGROUND

Home visits by community health workers (CHWs) during pregnancy and soon after delivery are recommended to improve newborn survival. However, as the roles of CHWs expand, there are concerns regarding the capacity of community health systems to deliver high effective coverage of home visits. The WHO's Rapid Access Expansion (RAcE) program supported the Malawi Ministry of Health to align their Community-Based Maternal and Newborn Care (CBMNC) package with the latest WHO guidelines and to implement and evaluate the feasibility and coverage of home visits in Ntcheu district.

METHODS

A population-based survey of 150 households in Ntcheu district was conducted in July-August 2016 after approximately 10 months of CBMNC implementation. Thirty clusters were selected proportional-to-size using the most recent census. In selected clusters, five households with mothers of children under six months of age were randomly selected for interview. The Health Surveillance Assistants (HSAs) providing community-based services to the same clusters were purposively selected for a structured interview and register review.

RESULTS

Less than one third of pregnant women (30.7%; 95% confidence interval CI = 21.7%-41.5%) received a home visit during pregnancy and only 20.7% (95% CI = 13.0%-29.4%) received the recommended two visits. Coverage of postnatal visits was even lower: 11.4% (95%CI = 6.8%-18.5%) of mothers and newborns received a visit within three days of delivery and 20.7% (95%CI = 12.7%-32.0%) received a visit within the first eight days. Reaching newborns soon after delivery requires timely participation of the family and/or health facility staff to notify the HSA - yet only 42.9% (95% CI = 33.4%-52.9%) of mothers reported that the HSA was informed of the delivery. Coverage of postnatal home visits among those who informed the HSA was significantly higher than among those in which the HSA was not informed (46.7% compared to 1.3%; P = 0.00). Most HSAs had the necessary equipment and supplies and were active in CBMNC: 83.9% (95% CI = 70.2%-97.6%) of HSAs had pregnancy home visits and 77.4% (95% CI = 61.8%-93.0%) had postnatal home visits documented in their registers for the previous three months.

CONCLUSIONS

We found low coverage of home visits during pregnancy and soon after delivery in a well-supported program delivery environment. Most HSAs were conducting home visits, but not at the level needed to reach high coverage. These findings were similar to previous studies, calling into question the feasibility of the current visitation schedule. It is time to re-align the CBMNC package with what the existing platform can deliver and identify strategies to better support HSAs to implement home visits to those who would benefit most.

Overview, methods and results of multi-country community-based maternal and newborn care economic analysis

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.

Multi-country analysis of the cost of community health workers kits and commodities for community-based maternal and newborn care

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.