Global health systems strengthening: FIGO's strategic view on reducing maternal and newborn mortality worldwide

OBJECTIVE

To demonstrate that successful health systems strengthening (HSS) projects have addressed disparities and inequities in maternal and perinatal care in low-income countries.

METHODS

A comprehensive literature review covered the period between 1980 and 2022, focusing on successful HSS interventions within health systems' seven core components that improved maternal and perinatal care.

RESULTS

The findings highlight the importance of integrating quality interventions into robust health systems, as this has been shown to reduce maternal and newborn mortality. However, several challenges, including service delivery gaps, poor data use, and funding deficits, continue to hinder the delivery of quality care. To improve maternal and newborn health outcomes, a comprehensive HSS strategy is essential, which should include infrastructure enhancement, workforce skill development, access to essential medicines, and active community engagement.

CONCLUSION

Effective health systems, leadership, and community engagement are crucial for a comprehensive HSS approach to catalyze progress toward universal health coverage and global improvements in maternal and newborn health.

Service delivery interventions to improve maternal and newborn health in low- and middle-income countries: scoping review of quality improvement, implementation research and health system strengthening approaches

INTRODUCTION

This review explores the characteristics of service delivery-related interventions to improve maternal and newborn health (MNH) in low-and middle-income countries (LMICs) over the last two decades, comparing three common framings of these interventions, namely, quality improvement (QI), implementation science/research (IS/IR), and health system strengthening (HSS).

METHODS

The review followed the staged scoping review methodology proposed by Levac et al. (2010). We developed and piloted a systematic search strategy, limited to English language peer-reviewed articles published on LMICs between 2000 and March 2022. Analysis was conducted in two-quantitative and qualitative-phases. In the quantitative phase, we counted the year of publication, country(-ies) of origin, and the presence of the terms 'quality improvement', 'health system strengthening' or 'implementation science'/ 'implementation research' in titles, abstracts and key words. From this analysis, a subset of papers referred to as 'archetypes' (terms appearing in two or more of titles, abstract and key words) was analysed qualitatively, to draw out key concepts/theories and underlying mechanisms of change associated with each approach.

RESULTS

The searches from different databases resulted in a total of 3,323 hits. After removal of duplicates and screening, a total of 231 relevant articles remained for data extraction. These were distributed across the globe; more than half (n = 134) were published since 2017. Fifty-five (55) articles representing archetypes of the approach (30 QI, 16 IS/IR, 9 HSS) were analysed qualitatively. As anticipated, we identified distinct patterns in each approach. QI archetypes tended towards defined process interventions (most typically, plan-do-study-act cycles); IS/IR archetypes reported a wide variety of interventions, but had in common evaluation methodologies and explanatory theories; and HSS archetypes adopted systemic perspectives. Despite their distinctiveness, there was also overlap and fluidity between approaches, with papers often referencing more than one approach. Recognising the complexity of improving MNH services, there was an increased orientation towards participatory, context-specific designs in all three approaches.

CONCLUSIONS

Programmes to improve MNH outcomes will benefit from a better appreciation of the distinctiveness and relatedness of different approaches to service delivery strengthening, how these have evolved and how they can be combined.

Infertility services integrated within the maternal health department of a public hospital in a low-income country, Rwanda

Objective

To describe the initiation, integration, and costs of reduced-cost infertility services within the maternal health department of a public hospital in a low-income country.

Design

Retrospective review of the clinical and laboratory components of patients undergoing in vitro fertilization (IVF) treatment in Rwanda from 2018 to 2020.

Setting

Academic tertiary referral hospital in Rwanda.

Patients

Patients seeking infertility services beyond the primary gynecological options.

Interventions

The national government furnished facilities and personnel, and the Rwanda Infertility Initiative, an international nongovernmental organization, provided training, equipment, and materials. The incidence of retrieval, fertilization, embryo cleavage, transfer, and conception (observed until ultrasound verification of intrauterine pregnancy with fetal heartbeat) were analyzed. Cost calculations used the government-issued tariff specifying insurers' payments and patients' copayments with projected delivery rates using early literature.

Main Outcome Measures

Assessment of functional clinical and laboratory infertility services and costs.

Results

A total of 207 IVF cycles were initiated, 60 of which led to transfer of ≥1 high-grade embryo and 5 to ongoing pregnancies. The projected average cost per cycle was 1,521 USD. Using optimistic and conservative assumptions, the estimated costs per delivery for women <35 years were 4,540 and 5,156 USD, respectively.

Conclusions

Reduced-cost infertility services were initiated and integrated within a maternal health department of a public hospital in a low-income country. This integration required commitment, collaboration, leadership, and a universal health financing system. Low-income countries, such as Rwanda, might consider infertility treatment and IVF for younger patients as part of an equitable and affordable health care benefit.

Economic evaluations of maternal health interventions: a scoping review

Background   Evidence on the affordability and cost-effectiveness of interventions is critical to decision-making for clinical practice guidelines and development of national health policies. This study aimed to develop a repository of primary economic evaluations to support global maternal health guideline development and provide insights into the body of research conducted in this field. Methods   A scoping review was conducted to identify and map available economic evaluations of maternal health interventions. We searched six databases (NHS Economic Evaluation Database, EconLit, PubMed, Embase, CINAHL and PsycInfo) on 20 November 2020 with no date, setting or language restrictions. Two authors assessed eligibility and extracted data independently. Included studies were categorised by subpopulation of women, level of care, intervention type, mechanism, and period, economic evaluation type and perspective, and whether the intervention is currently recommended by the World Health Organization. Frequency analysis was used to determine prevalence of parameters. Results   In total 923 studies conducted in 72 countries were included. Most studies were conducted in high-income country settings (71.8%). Over half pertained to a general population of pregnant women, with the remainder focused on specific subgroups, such as women with preterm birth (6.2%) or those undergoing caesarean section (5.5%). The most common interventions of interest related to non-obstetric infections (23.9%), labour and childbirth care (17.0%), and obstetric complications (15.7%). Few studies addressed the major causes of maternal deaths globally. Over a third (36.5%) of studies were cost-utility analyses, 1.4% were cost-benefit analyses and the remainder were cost-effectiveness analyses. Conclusions   This review provides a navigable, consolidated resource of economic evaluations in maternal health. We identified a clear evidence gap regarding economic evaluations of maternal health interventions in low- and middle-income countries. Future economic research should focus on interventions to address major drivers of maternal morbidity and mortality in these settings.

Impact of Solar Light and Electricity on the Quality and Timeliness of Maternity Care: A Stepped-Wedge Cluster-Randomized Trial in Uganda

Lack of access to reliable energy is a major neglected health system challenge to maternal and child health. We found that installing a solar energy system intervention in rural Ugandan maternity facilities led to modest increases in the quality of maternity care and reductions in delays in care.

Background:

We evaluated the impact of solar light installation in Ugandan maternity facilities on implementation processes, reliability of light, and quality of intrapartum care.

Methods:

We conducted a stepped-wedge cluster-randomized trial of the We Care Solar Suitcase, a complete solar electric system providing lighting and power for charging phones and small medical devices, in 30 rural Ugandan maternity facilities with unreliable lighting. Facilities were randomly assigned to receive the intervention in the first or second sequence in a 1:1 ratio. We collected data from June 2018 to April 2019. The intervention was installed in September 2018 (first sequence) and in December 2018 (second sequence). The primary effectiveness outcomes were a 20-item and a 36-item index of quality of intrapartum care, a 6-item index of delays in care provision, and the percentage of deliveries with bright light, satisfactory light, and adequate light.

Results:

We observed 1,118 births across 30 facilities. The intervention was successfully installed in 100% of facilities. After installation, the intervention was used in 83% of nighttime deliveries. Before the intervention, providers on average performed 42% of essential care actions and accumulated 76 minutes of delays during nighttime deliveries. After installation, quality increased by 4 percentage points (95% confidence interval [CI]=1,8) and delays in care decreased by 10 minutes (95% CI=−16,−3), with the largest impacts on infection control, prevention of postpartum hemorrhage, and newborn care practices. One year after the end of the trial, 90% of facilities had LED lights in operation and 60% of facilities had all components in operation.

Conclusions:

Reliable light is an important driver of timely and adequate health care. Policy makers should invest in renewable energy systems for health facilities; however, even when reliable lighting is present, quality of care may remain low without a broader approach to quality improvements.

Cost-effectiveness analysis of a large-scale crèche intervention to prevent child drowning in rural Bangladesh

Background

Drowning is the leading cause of death among children 12–59 months old in rural Bangladesh. This study evaluated the cost-effectiveness of a large-scale crèche (daycare) intervention in preventing child drowning.

Methods

The cost of the crèches intervention was evaluated using an ingredients-based approach and monthly expenditure data collected prospectively throughout the study period from two agencies implementing the intervention in different study areas. The estimate of the effectiveness of the crèches intervention was based on a previous study. The study evaluated the cost-effectiveness from both a program and societal perspective.

Results

From the program perspective the annual operating cost of a crèche was $416.35 (95% CI: $221 to $576), the annual cost per child was $16 (95% CI: $8 to $23), and the incremental-cost-effectiveness ratio (ICER) per life saved with the crèches was $17,008 (95% CI: $8817 to $24,619). From the societal perspective (including parents time valued) the ICER per life saved was − $166,833 (95% CI: − $197,421 to − $141,341)—meaning crèches generated net economic benefits per child enrolled. Based on the ICER per disability-adjusted-life years averted from the societal perspective (excluding parents time), $1978, the crèche intervention was cost-effective even when the societal economic benefits were ignored.

Conclusions

Based on the evidence, the crèche intervention has great potential for generating net societal economic gains by reducing child drowning at a program cost that is reasonable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40621-021-00351-9.

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.

e-income countries from a provider's perspective: a systematic review

INTRODUCTION

Maternal health services are effective in reducing the morbidity and mortality associated with pregnancy and childbirth. We conducted a systematic review on costs of maternal health services in low-income and middle-income countries from the provider's perspective.

METHODS

We searched multiple peer-reviewed databases (including African Journal Online, CINAHL Plus, EconLit, Popline, PubMed, Scopus and Web of Science) and grey literature for relevant articles published from year 2000. Articles meeting our inclusion criteria were selected with quality assessment done using relevant cost-focused criteria of the Consolidated Health Economic Evaluation Reporting Standards checklist. For comparability, disaggregated costs data were inflated to 2019 US$ equivalents. Costs and cost drivers were systematically compared. Where heterogeneity was observed, narrative synthesis was used to summarise findings.

RESULTS

Twenty-two studies were included, with most studies costing vaginal and/or caesarean delivery (11 studies), antenatal care (ANC) (9) and postabortion care (PAC) (8). Postnatal care (PNC) has been least costed (2). Studies used different methods for data collection and analysis. Quality of peer-reviewed studies was assessed average to high while all grey literature studies were assessed as low quality. Following inflation, estimated provision cost per service varied (ANC (US$7.24-US$31.42); vaginal delivery (US$14.32-US$278.22); caesarean delivery (US$72.11-US$378.940; PAC (US$97.09-US$1299.21); family planning (FP) (US$0.82-US$5.27); PNC (US$5.04)). These ranges could be explained by intercountry variations, variations in provider type (public/private), facility type (primary/secondary) and care complexity (simple/complicated). Personnel cost was mostly reported as the major driver for provision of ANC, skilled birth attendance and FP. Economies of scale in service provision were reported.

CONCLUSION

There is a cost savings case for task-shifting and encouraging women to use lower level facilities for uncomplicated services. Going forward, consensus regarding cost component definitions and methodologies for costing maternal health services will significantly help to improve the usefulness of cost analyses in supporting policymaking towards achieving Universal Health Coverage.

Increasing utilisation of skilled attendants at birth in sub-Saharan Africa: A systematic review of interventions

BACKGROUND

Maternal mortality is a critical global public health concern, especially in low- and middle-income countries in sub-Saharan Africa. Although maternal mortality rates have declined by approximately 39% in sub-Saharan Africa over the last decade, maternal deaths during pregnancy and in childbirth remain high. Interventions to improve mothers' use of skilled birth attendants may decrease maternal mortality in sub-Saharan African countries.

OBJECTIVES

This systematic literature review examines components of and evaluates the effectiveness of interventions to increase use of skilled birth attendants in sub-Saharan Africa.

METHODS

Guided by the PRISMA model for systematic reviews, the PubMed, Web of Science, and CIHNAL databases were searched for studies from years 2003 through June 2020.

RESULTS

The 28 articles included in this review reported on interventions incorporating community health workers, phone or text messages, implementation of community-level initiatives, free health care, cash incentives, an international multi-disciplinary volunteer team, and a group home for pregnant women, which improved use of skilled birth attendants to varying degrees. Only one study reported improved outcomes with the use of community health workers. All of the interventions using text messages increased hospital utilization for births.

CONCLUSIONS

Interventions implemented in sub-Saharan Africa hold promise for improving maternal health. Multi-level interventions that involve community members and local leaders can help address the multi-faceted issue of poor maternal health outcomes and mortality. Interventions should focus on capacity building and on training and mentoring of formally-trained health care providers and community health workers in order to expand access.

Scoping review protocol of service delivery-related interventions to improve maternal and newborn health in low-income and middle-income countries

INTRODUCTION

This review will explore the characteristics of service delivery-related interventions to improve maternal and newborn health in low-income and middle-income countries, comparing three common framing approaches of these interventions (referred to as archetypes), namely, quality improvement (QI), health system strengthening (HSS) and implementation science (IS), over the last 20 years.

METHODS AND ANALYSIS

This study will review the literature on health service interventions from 2000 to 2020. This will be achieved by searching for English peer-reviewed articles in the following electronic databases EBSCOhost, PubMed, Web of Science, MASCOT/Wotro Map of Maternal Health Research and Google scholar. We will develop a systematic search strategy using a combination of keywords and Boolean operators AND/OR. Eligibility screening and data extraction will be conducted by two independent reviewers, and disagreements resolved by a third independent reviewer. Analyses will be conducted in two steps, a quantitative and a qualitative phase. The quantitative phase will provide a descriptive profile of papers, including the category (QI, HSS, IS, mixed or other) of papers. In the follow-up qualitative phase, all three reviewers will independently code for key concepts in a subset of papers, jointly selected as representing each archetype, and analysed in batches until concept saturation is achieved.

ETHICS AND DISSEMINATION

This review does not require ethical approval. The results will be published as an article in a peer-reviewed journal and presented to stakeholders involved in implementing health system interventions in maternal and newborn.

Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya

INTRODUCTION

Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya.

METHODS

We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses.

RESULTS

We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars).

CONCLUSIONS

This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.

Estimates of aid for reproductive, maternal, newborn, and child health: findings from application of the Muskoka2 method, 2002-17

Background

Four methods have previously been used to track aid for reproductive, maternal, newborn, and child health (RMNCH). At a meeting of donors and stakeholders in May, 2018, a single, agreed method was requested to produce accurate, predictable, transparent, and up-to-date estimates that could be used for analyses from both donor and recipient perspectives. Muskoka2 was developed to meet these needs. We describe Muskoka2 and present estimates of levels and trends in aid for RMNCH in 2002–17, with a focus on the latest estimates for 2017.

Methods

Muskoka2 is an automated algorithm that generates disaggregated estimates of aid for reproductive health, maternal and newborn health, and child health at the global, donor, and recipient-country levels. We applied Muskoka2 to the Organisation for Economic Co-operation and Development's Creditor Reporting System (CRS) aid activities database to generate estimates of RMNCH disbursements in 2002–17. The percentage of disbursements that benefit RMNCH was determined using CRS purpose codes for all donors except Gavi, the Vaccine Alliance; the UN Population Fund; and UNICEF; for which fixed percentages of aid were considered to benefit RMNCH. We analysed funding by donor for the 20 largest donors, by recipient-country income group, and by recipient for the 16 countries with the greatest RMNCH need, defined as the countries with the worst levels in 2015 on each of seven health indicators.

Findings

After 3 years of stagnation, reported aid for RMNCH reached $15·9 billion in 2017, the highest amount ever reported. Among donors reporting in both 2016 and 2017, aid increased by 10% ($1·4 billion) to $15·4 billion between 2016 and 2017. Child health received almost half of RMNCH disbursements in 2017 (46%, $7·4 billion), followed by reproductive health (34%, $5·4 billion), and maternal and newborn health (19%, $3·1 billion). The USA ($5·8 billion) and the UK ($1·6 billion) were the largest bilateral donors, disbursing 46% of all RMNCH funding in 2017 (including shares of their core contributions to multilaterals). The Global Fund and Gavi were the largest multilateral donors, disbursing $1·7 billion and $1·5 billion, respectively, for RMNCH from their core budgets. The proportion of aid for RMNCH received by low-income countries increased from 31% in 2002 to 52% in 2017. Nigeria received 7% ($1·1 billion) of all aid for RMNCH in 2017, followed by Ethiopia (6%, $876 million), Kenya (5%, $754 million), and Tanzania (5%, $751 million).

Interpretation

Muskoka2 retains the speed, transparency, and donor buy-in of the G8's previous Muskoka approach and incorporates eight innovations to improve precision. Although aid for RMNCH increased in 2017, low-income and middle-income countries still experience substantial funding gaps and threats to future funding. Maternal and newborn health receives considerably less funding than reproductive health or child health, which is a persistent issue requiring urgent attention.

Funding

Bill & Melinda Gates Foundation; Partnership for Maternal, Newborn & Child Health.

The future of cystic fibrosis care: a global perspective

The past six decades have seen remarkable improvements in health outcomes for people with cystic fibrosis, which was once a fatal disease of infants and young children. However, although life expectancy for people with cystic fibrosis has increased substantially, the disease continues to limit survival and quality of life, and results in a large burden of care for people with cystic fibrosis and their families. Furthermore, epidemiological studies in the past two decades have shown that cystic fibrosis occurs and is more frequent than was previously thought in populations of non-European descent, and the disease is now recognised in many regions of the world. The Lancet Respiratory Medicine Commission on the future of cystic fibrosis care was established at a time of great change in the clinical care of people with the disease, with a growing population of adult patients, widespread genetic testing supporting the diagnosis of cystic fibrosis, and the development of therapies targeting defects in the cystic fibrosis transmembrane conductance regulator (CFTR), which are likely to affect the natural trajectory of the disease. The aim of the Commission was to bring to the attention of patients, health-care professionals, researchers, funders, service providers, and policy makers the various challenges associated with the changing landscape of cystic fibrosis care and the opportunities available for progress, providing a blueprint for the future of cystic fibrosis care. The discovery of the CFTR gene in the late 1980s triggered a surge of basic research that enhanced understanding of the pathophysiology and the genotype-phenotype relationships of this clinically variable disease. Until recently, available treatments could only control symptoms and restrict the complications of cystic fibrosis, but advances in CFTR modulator therapies to address the basic defect of cystic fibrosis have been remarkable and the field is evolving rapidly. However, CFTR modulators approved for use to date are highly expensive, which has prompted questions about the affordability of new treatments and served to emphasise the considerable gap in health outcomes for patients with cystic fibrosis between high-income countries, and low-income and middle-income countries (LMICs). Advances in clinical care have been multifaceted and include earlier diagnosis through the implementation of newborn screening programmes, formalised airway clearance therapy, and reduced malnutrition through the use of effective pancreatic enzyme replacement and a high-energy, high-protein diet. Centre-based care has become the norm in high-income countries, allowing patients to benefit from the skills of expert members of multidisciplinary teams. Pharmacological interventions to address respiratory manifestations now include drugs that target airway mucus and airway surface liquid hydration, and antimicrobial therapies such as antibiotic eradication treatment in early-stage infections and protocols for maintenance therapy of chronic infections. Despite the recent breakthrough with CFTR modulators for cystic fibrosis, the development of novel mucolytic, anti-inflammatory, and anti-infective therapies is likely to remain important, especially for patients with more advanced stages of lung disease. As the median age of patients with cystic fibrosis increases, with a rapid increase in the population of adults living with the disease, complications of cystic fibrosis are becoming increasingly common. Steps need to be taken to ensure that enough highly qualified professionals are present in cystic fibrosis centres to meet the needs of ageing patients, and new technologies need to be adopted to support communication between patients and health-care providers. In considering the future of cystic fibrosis care, the Commission focused on five key areas, which are discussed in this report: the changing epidemiology of cystic fibrosis (section 1); future challenges of clinical care and its delivery (section 2); the building of cystic fibrosis care globally (section 3); novel therapeutics (section 4); and patient engagement (section 5). In panel 1, we summarise key messages of the Commission. The challenges faced by all stakeholders in building and developing cystic fibrosis care globally are substantial, but many opportunities exist for improved care and health outcomes for patients in countries with established cystic fibrosis care programmes, and in LMICs where integrated multidisciplinary care is not available and resources are lacking at present. A concerted effort is needed to ensure that all patients with cystic fibrosis have access to high-quality health care in the future.

Cost-effectiveness of results-based financing, Zambia: a cluster randomized trial

Objective

To evaluate the cost-effectiveness of results-based financing and input-based financing to increase use and quality of maternal and child health services in rural areas of Zambia.

Methods

In a cluster-randomized trial from April 2012 to June 2014, 30 districts were allocated to three groups: results-based financing (increased funding tied to performance on pre-agreed indicators), input-based financing (increased funding not tied to performance) or control (no additional funding), serving populations of 1.33, 1.26 and 1.40 million people, respectively. We assessed incremental financial costs for programme implementation and verification, consumables and supervision. We evaluated coverage and quality effectiveness of maternal and child health services before and after the trial, using data from household and facility surveys, and converted these to quality-adjusted life years (QALYs) gained.

Findings

Coverage and quality of care increased significantly more in results-based financing than control districts: difference in differences for coverage were 12.8% for institutional deliveries, 8.2% postnatal care, 19.5% injectable contraceptives, 3.0% intermittent preventive treatment in pregnancy and 6.1% to 29.4% vaccinations. In input-based financing districts, coverage increased significantly more versus the control for institutional deliveries (17.5%) and postnatal care (13.2%). Compared with control districts, 641 more lives were saved (lower-upper bounds: 580-700) in results-based financing districts and 362 lives (lower-upper bounds: 293-430) in input-based financing districts. The corresponding incremental cost-effectiveness ratios were 809 United States dollars (US$) and US$ 413 per QALY gained, respectively.

Conclusion

Compared with the control, both results-based financing and input-based financing were cost-effective in Zambia.