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Gavine A, Farre A, Lynn F, Shinwell S, Buchanan P, Marshall J, Cumming S, Wallace L, Wade A, Ahern E, Hay L, Cranwell M, McFadden A. Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-206. [PMID: 39054917 DOI: 10.3310/dgtp5702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
Background Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding. Objectives To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS. Design Evidence syntheses with stakeholder engagement. Review methods Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops. Results We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence. Limitations There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics. Conclusions 'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK. Future work Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies. Study registration This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/). Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Anna Gavine
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Albert Farre
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Fiona Lynn
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Shona Shinwell
- School of Health Sciences, University of Dundee, Dundee, UK
| | | | - Joyce Marshall
- Department of Nursing and Midwifery, University of Huddersfield, Huddersfield, UK
| | - Sara Cumming
- School of Health Sciences, University of Dundee, Dundee, UK
| | - Louise Wallace
- School of Health, Wellbeing and Social Care, The Open University, Milton Keynes, UK
| | - Angie Wade
- Population, Policy and Practice, Great Ormond Street Institute of Child Health, London, UK
| | - Elayne Ahern
- Department of Psychology, University of Limerick, Castletroy, Ireland
| | - Laura Hay
- School of Health Sciences, University of Dundee, Dundee, UK
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2
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Ahmed M, Muhoozi GKM, Atukunda P, Westerberg AC, Iversen PO, Wangen KR. Cognitive development among children in a low-income setting: Cost-effectiveness analysis of a maternal nutrition education intervention in rural Uganda. PLoS One 2023; 18:e0290379. [PMID: 37594989 PMCID: PMC10437995 DOI: 10.1371/journal.pone.0290379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 07/26/2023] [Indexed: 08/20/2023] Open
Abstract
Inadequate nutrition and insufficient stimulation in early childhood can lead to long-term deficits in cognitive and social development. Evidence for policy and decision-making regarding the cost of delivering nutrition education is lacking in low and middle-income countries (LMIC). In rural Uganda, we conducted a cluster-randomized controlled trial (RCT) examining the effect of a maternal nutrition education intervention on developmental outcomes among children aged 6-8 months. This intervention led to significantly improved cognitive scores when the children reached the age of 20-24 months. When considering the potential for this intervention's future implementation, the desired effects should be weighed against the increased costs. This study therefore aimed to assess the cost-effectiveness of this education intervention compared with current practice. Health outcome data were based on the RCT. Cost data were initially identified by reviewing publications from the RCT, while more detailed information was obtained by interviewing researchers involved in processing the intervention. This study considered a healthcare provider perspective for an 18-months' time horizon. The control group was considered as the current practice for the future large-scale implementation of this intervention. A cost-effectiveness analysis was performed, including calculations of incremental cost-effectiveness ratios (ICERs). In addition, uncertainty in the results was characterized using one-way and probabilistic sensitivity analyses. The ICER for the education intervention compared with current practice was USD ($) 16.50 per cognitive composite score gained, with an incremental cost of $265.79 and an incremental cognitive composite score of 16.11. The sensitivity analyses indicated the robustness of these results. The ICER was sensitive to changes in cognitive composite score and the cost of personnel. The education intervention can be considered cost-effective compared with the current practice. The outcome of this study, including the cost analysis, health outcome, cost-effectiveness, and sensitivity analysis, can be useful to inform policymakers and stakeholders about effective resource allocation processes in Uganda and possibly other LMIC.
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Affiliation(s)
- Montasir Ahmed
- Wolfson Institute of Population Health, Queen Mary University of London, England, United Kingdom
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
| | - Grace K. M. Muhoozi
- Department of Family Life and Consumer Studies (Home Economics), Kyambogo University, Kampala, Uganda
| | - Prudence Atukunda
- Center for Crisis Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Ane C. Westerberg
- Institute of Health Sciences, Kristiania University College, Oslo, Norway
- Division of Obstetrics and Gynecology, Oslo University Hospital, Oslo, Norway
| | - Per O. Iversen
- Department of Nutrition, University of Oslo, Oslo, Norway
- Department of Haematology, Oslo University Hospital, Oslo, Norway
- Division of Human Nutrition, Stellenbosch University, Tygerberg, South Africa
| | - Knut R. Wangen
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway
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Sanghvi TG, Homan R, Forissier T, Preware P, Kawu A, Nguyen TT, Mathisen R. The Financial Costs of Mass Media Interventions Used for Improving Breastfeeding Practices in Bangladesh, Burkina Faso, Nigeria, and Vietnam. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:16923. [PMID: 36554803 PMCID: PMC9779531 DOI: 10.3390/ijerph192416923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/11/2022] [Accepted: 12/14/2022] [Indexed: 06/17/2023]
Abstract
Breastfeeding is essential for child survival but globally less than fifty percent of infants receive adequate breastfeeding. Gaps in breastfeeding knowledge and misinformation are widespread. Mass media aims to motivate mothers and families, encourage care-seeking, improve social norms, and counteract misleading advertising. However, the costs and coverage of mass media are not well documented. Our study provides a cost-accounting of four large-scale mass media interventions and coverage obtained through mass media. We retrospectively calculated annual costs and costs per beneficiary of mass media interventions based on expenditure records in four countries. The interventions were a part of multi-component breastfeeding strategies in Bangladesh, Burkina Faso, Nigeria, and Vietnam. Annual costs ranged from 566,366 USD in Nigeria to 1,210,286 USD in Vietnam. The number of mothers of children under two years and pregnant women ranged from 685,257 to 5,566,882, and all designated recipients reached during the life of programs ranged from 1,439,040 to 11,690,453 in Burkina Faso and Bangladesh, respectively. The cost per mother varied from USD 0.13 USD in Bangladesh to 0.85 USD in Burkina Faso. Evaluations showed that mass media interventions reached high coverage and frequent exposure. This analysis documents the financial costs and budgetary needs for implementing mass media components of large-scale breastfeeding programs. It provides annual costs, cost structures, and coverage achieved through mass media interventions in four low- and middle-income countries.
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Affiliation(s)
- Tina G. Sanghvi
- Alive & Thrive Initiative, FHI Solutions, Washington, DC 20009, USA
| | - Rick Homan
- GHPR—Health Services Research, FHI 360, Durham, NC 27701, USA
| | - Thomas Forissier
- Alive & Thrive Initiative, FHI Solutions, New Delhi 110001, India
| | - Patricia Preware
- Alive & Thrive Initiative, FHI Solutions, Washington, DC 20009, USA
| | - Auwalu Kawu
- Alive & Thrive Initiative, FHI Solutions, Abuja 900271, Nigeria
| | - Tuan T. Nguyen
- Alive & Thrive East Asia Pacific, FHI Solutions/FHI 360, Hanoi 11022, Vietnam
| | - Roger Mathisen
- Alive & Thrive East Asia Pacific, FHI Solutions/FHI 360, Hanoi 11022, Vietnam
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Chekol Abebe E, Ayalew Tiruneh G, Asmare Adela G, Mengie Ayele T, Tilahun Muche Z, Behaile T/Mariam A, Tilahun Mulu A, Asmamaw Dejenie T. Levels and Determinants of Prenatal Breastfeeding Knowledge, Attitude, and Intention Among Pregnant Women: A Cross-Sectional Study in Northwest Ethiopia. Front Public Health 2022; 10:920355. [PMID: 35910888 PMCID: PMC9334898 DOI: 10.3389/fpubh.2022.920355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Pregnant women are a critical part of the community to assess various determinants of their future breastfeeding practice. This study aimed to assess the levels and determinants of breastfeeding knowledge, attitude, and intention among pregnant women. Methods A hospital-based cross-sectional study was conducted among 422 pregnant women from January 18 to February 27, 2022, at Debre Tabor Comprehensive Specialized Hospital (DTCSH) in Northwest Ethiopia. Data were collected via face-to-face interviews from participants selected by convenience sampling technique. Data analysis was made using Stata version 16.0. Multiple logistic regression analysis was used to assess the determinants of the knowledge, attitude, and intention of pregnant women, with a p-value < 0.05 considered statistically significant. Result About 57.8% of participants had adequate breastfeeding knowledge and only 46.9% had a positive attitude. Almost two-thirds (65.4%) of them had good intentions to breastfeed. Pregnant women attaining secondary education (AOR = 2.0; 95% CI: 1.31, 3.19), achieving college or university education (AOR = 3.13; 95% CI: 1.63, 7.41), being multiparous (AOR = 2.11; 95% CI: 1.33, 3.43), having four or more ANC visits (AOR:1.45; 95% CI: 1.21, 4.31), and having prior breastfeeding experience (AOR: 3.53; 95% CI: 2.22, 5.65) were significant predictors of adequate knowledge. Attending college or university education (AOR = 2.71;95% CI: 2.33, 5.13), being multiparous (AOR = 1.56; 95% CI: 1.32, 8.25), and having adequate knowledge (AOR = 2.02; 95% CI: 1.88,7.14) were determinants of a positive breastfeeding attitude. Whereas, advanced age (AOR = 1.44; 95% CI: 1.12, 5.59), adequate knowledge (AOR: 5.21; 95% CI: 1.51,8.04), and positive attitude (AOR = 2.41;95% CI:1.50, 4.27) were independent predictors of good breastfeeding intention. Conclusion The breastfeeding knowledge and attitude of pregnant women were generally suboptimal. Their overall breastfeeding intention was also unsatisfactory. This highlights the need to develop culture-specific interventions aimed at improving breastfeeding knowledge, attitudes, and intention to enhance the appropriate breastfeeding practice of their future children.
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Affiliation(s)
- Endeshaw Chekol Abebe
- Department of Biomedical Sciences, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Gebrehiwot Ayalew Tiruneh
- Department of Clinical Midwifery, College of Health Sciences>, Debre Tabor University, Debre Tabor, Ethiopia
| | - Getachew Asmare Adela
- Department of Reproductive Health and Nutrition, School of Public Health, Woliata Sodo University, Woliata Sodo, Ethiopia
| | - Teklie Mengie Ayele
- Department of Pharmacy, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Zelalem Tilahun Muche
- Department of Biomedical Sciences, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Awgichew Behaile T/Mariam
- Department of Biomedical Sciences, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Anemut Tilahun Mulu
- Department of Biomedical Sciences, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Tadesse Asmamaw Dejenie
- Department of Medical Biochemistry, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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5
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Carroll G, Safon C, Buccini G, Vilar-Compte M, Teruel G, Pérez-Escamilla R. A systematic review of costing studies for implementing and scaling-up breastfeeding interventions: what do we know and what are the gaps? Health Policy Plan 2020; 35:461-501. [PMID: 32073628 DOI: 10.1093/heapol/czaa005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/17/2022] Open
Abstract
Despite the well-established evidence that breastfeeding improves maternal and child health outcomes, global rates of exclusive breastfeeding remain low. Cost estimates can inform stakeholders about the financial resources needed to scale up interventions to ultimately improve breastfeeding outcomes in low-, middle- and high-income countries. To inform the development of comprehensive costing frameworks, this systematic review aimed to (1) identify costing studies for implementing or scaling-up breastfeeding interventions, (2) assess the quality of identified costing studies and (3) examine the availability of cost data to identify gaps that need to be addressed through future research. Peer-reviewed and grey literature were systematically searched using a combination of index terms and relevant text words related to cost and the following breastfeeding interventions: breastfeeding counselling, maternity leave, the World Health Organization International Code of Marketing of Breastmilk Substitutes, the Baby-Friendly Hospital Initiative, media promotion, workplace support and pro-breastfeeding social policies. Data were extracted after having established inter-rater reliability among the first two authors. The quality of studies was assessed using an eight-item checklist for key costing study attributes. Forty-five studies met the inclusion criteria, with the majority including costs for breastfeeding counselling and paid maternity leave. Most cost analyses included key costing study attributes; however, major weaknesses among the studies were the lack of clarity on costing perspectives and not accounting for the uncertainty of reported cost estimates. Costing methodologies varied substantially, standardized costing frameworks are needed for reliably estimating the costs of implementing and scaling-up breastfeeding interventions at local-, national- or global-levels.
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Affiliation(s)
- Grace Carroll
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
| | - Cara Safon
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA.,Department of Health Law, Policy, and Management, Boston University School of Public Health, Talbot Building, 715 Albany Street, Boston, MA 02118, USA
| | - Gabriela Buccini
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
| | - Mireya Vilar-Compte
- EQUIDE Research Institute for Equitable Development, Universidad Iberoamericana, Prolongacion Paseo de la Reforma 880, Santa Fe, Zedec Sta Fé, Álvaro Obregón, 01219 Ciudad de México, CDMX, Mexico
| | - Graciela Teruel
- EQUIDE Research Institute for Equitable Development, Universidad Iberoamericana, Prolongacion Paseo de la Reforma 880, Santa Fe, Zedec Sta Fé, Álvaro Obregón, 01219 Ciudad de México, CDMX, Mexico
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, 135 College St. Suite 200, New Haven, CT 06510, USA
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Nepal P, Schwarz R, Citrin D, Thapa A, Acharya B, Acharya Y, Aryal A, Baum A, Bhandari V, Bhatt L, Bhattarai D, Choudhury N, Dangal B, Dhimal M, Dhungana SK, Gauchan B, Halliday S, Kalaunee SP, Kunwar LB, Maru D, Nirola I, Paudel R, Raut A, Rayamazi HJ, Sapkota S, Schwarz D, Thapa P, Thapa P, Tiwari A, Tuitui R, Walter E, Maru S. Costing Analysis of a Pilot Community Health Worker Program in Rural Nepal. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:239-255. [PMID: 32606093 PMCID: PMC7326517 DOI: 10.9745/ghsp-d-19-00393] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/19/2020] [Indexed: 01/01/2023]
Abstract
Data from a retrospective costing analysis offers insights and practical considerations for policy makers and locally elected officials for designing and implementing a new community health work cadre as a mechanism to achieve SDG targets in Nepal. Community health workers (CHWs) are essential to primary health care systems and are a cost-effective strategy to achieve the Sustainable Development Goals (SDGs). Nepal is strongly committed to universal health coverage and the SDGs. In 2017, the Nepal Ministry of Health and Population partnered with the nongovernmental organization Nyaya Health Nepal to pilot a program aligned with the 2018 World Health Organization guidelines for CHWs. The program includes CHWs who: (1) receive regular financial compensation; (2) meet a minimum education level; (3) are well supervised; (4) are continuously trained; (5) are integrated into local primary health care systems; (6) use mobile health tools; (7) have consistent supply chain; (8) live in the communities they serve; and (9) provide service without point-of-care user fees. The pilot model has previously demonstrated improved institutional birth rate, antenatal care completion, and postpartum contraception utilization. Here, we performed a retrospective costing analysis from July 16, 2017 to July 15, 2018, in a catchment area population of 60,000. The average per capita annual cost is US$3.05 (range: US$1.94 to US$4.70 across 24 villages) of which 74% is personnel cost. Service delivery and administrative costs and per beneficiary costs for all services are also described. To address the current discourse among Nepali policy makers at the local and federal levels, we also present 3 alternative implementation scenarios that policy makers may consider. Given the Government of Nepal’s commitment to increase health care spending (US$51.00 per capita) to 7.0% of the 2030 gross domestic product, paired with recent health care systems decentralization leading to expanded fiscal space in municipalities, this CHW program provides a feasible opportunity to make progress toward achieving universal health coverage and the health-related SDGs. This costing analysis offers insights and practical considerations for policy makers and locally elected officials for deploying a CHW cadre as a mechanism to achieve the SDG targets.
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Affiliation(s)
| | - Ryan Schwarz
- Possible, New York, NY, USA. .,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA.,Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - David Citrin
- Possible, New York, NY, USA.,University of Washington, Department of Global Health, Seattle, WA, USA.,University of Washington, Department of Anthropology, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | - Bibhav Acharya
- Possible, New York, NY, USA.,University of California, San Francisco, Department of Psychiatry, San Francisco, CA, USA
| | - Yubraj Acharya
- Pennsylvania State University, College of Health and Human Development, Department of Health Policy and Administration, University Park, PA, USA
| | - Anu Aryal
- Nyaya Health Nepal, Kathmandu, Nepal
| | - Aaron Baum
- Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | | | | | - Nandini Choudhury
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA
| | | | | | | | - Bikash Gauchan
- Nyaya Health Nepal, Kathmandu, Nepal.,University of California, San Francisco, Health Equity Action Leadership Initiative, San Francisco, CA, USA
| | - Scott Halliday
- Possible, New York, NY, USA.,University of Washington, Department of Global Health, Seattle, WA, USA.,University of Washington, Department of Anthropology, Seattle, WA, USA.,University of Washington, Henry M. Jackson School of International Studies, Seattle, WA, USA
| | - S P Kalaunee
- Nyaya Health Nepal, Kathmandu, Nepal.,Eastern University, College of Leadership and Development, St. Davids, PA, USA
| | | | - Duncan Maru
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY, USA
| | - Isha Nirola
- Possible, New York, NY, USA.,Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | | | | | | | - Dan Schwarz
- Possible, New York, NY, USA.,Brigham and Women's Hospital, Department of Medicine, Division of Global Health Equity, Boston, MA, USA.,Harvard Medical School, Department of Medicine, Boston, MA, USA.,Beth Israel Deaconess Medical Center, Department of Medicine, Boston, MA, USA.,Ariadne Labs, Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, MA, USA
| | - Poshan Thapa
- University of New South Wales, School of Public Health and Community Medicine, Sydney, NSW, Australia
| | | | | | - Roshani Tuitui
- Nursing and Social Security Division, Dept of Health Services, Kathmandu, Nepal
| | - Eric Walter
- University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.,University of Pennsylvania, The Wharton School, Healthcare Management Department, Philadelphia, PA, USA
| | - Sheela Maru
- Possible, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Arnhold Institute for Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Health Systems Design and Global Health, New York, NY, USA.,Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology and Reproductive Science, New York, NY, USA
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7
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Engebretsen IMS, Doherty T, Horwood C, Moland KM, Dierkes J. [Development and challenges to breastfeeding in sub-Saharan Africa]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 61:937-944. [PMID: 29980806 DOI: 10.1007/s00103-018-2783-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Since there is no doubt concerning the superiority of breastfeeding compared to other forms of infant feeding, the promotion of exclusive breastfeeding up to six months and continued breastfeeding up to two years and beyond are again embraced at the highest global nutrition agenda. The latest is the United Nations decade of action on nutrition 2016-2025, building on research results and the work by the World Health Organization (WHO) over the last two decades, and extensive societal, clinical, and academic discussions in the field of breastfeeding.While the discussion was about the optimal duration of exclusive breastfeeding around the millennium shift, the focus is on the most effective measures for the promotion and protection of breastfeeding. Contemporary breastfeeding rates are well behind the goals. In sub-Saharan Africa, almost all infants are breastfed, while exclusive breastfeeding is more seldom and not sufficient. Africa, being a vast and diverse continent with a myriad of cultural practices, has had some shared attitudes ranging from the west to east regarding views on motherhood, body fluids, including milk, infant feeding, and responsible others.The region still faces high maternal HIV infection rates and high infant and child mortality rates. However, due to effective antiretroviral therapies, it is now possible and safe for women living with HIV to breastfeed their infants and to ensure them HIV-free survival. However, there is need for improvement regarding availability, compliance, and adherence to these drugs. Research gaps include the long-term effects of antiretroviral therapy on the growth, health, and development of the exposed children.
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Affiliation(s)
- Ingunn M S Engebretsen
- Centre for International Health, Department of Global Health and Primary Care, University of Bergen, Bergen, Norwegen
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Kapstadt, Südafrika.,School of Public Health, University of the Western Cape, Kapstadt, Südafrika
| | | | - Karen Marie Moland
- Centre for International Health, Department of Global Health and Primary Care, University of Bergen, Bergen, Norwegen
| | - Jutta Dierkes
- Department of Clinical Medicine, Center for Nutrition, University of Bergen, Jonas Lies vei 68, 5021, Bergen, Norwegen. .,Laboratory Medicine and Pathology, Haukeland University Hospital, Bergen, Norwegen.
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8
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Nkonki LL, Chola LL, Tugendhaft AA, Hofman KK. Modelling the cost of community interventions to reduce child mortality in South Africa using the Lives Saved Tool (LiST). BMJ Open 2017; 7:e011425. [PMID: 28851766 PMCID: PMC5577872 DOI: 10.1136/bmjopen-2016-011425] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 01/18/2017] [Accepted: 03/17/2017] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To estimate the costs and impact on reducing child mortality of scaling up interventions that can be delivered by community health workers at community level from a provider's perspective. SETTING In this study, we used the Lives Saved Tool (LiST), a module in the spectrum software. Within the spectrum software, LiST interacts with other modules, the AIDS Impact Module, Family Planning Module and Demography Projections Module (Dem Proj), to model the impact of more than 60 interventions that affect cause-specific mortality. PARTICIPANTS DemProj Based on National South African Data. INTERVENTIONS A total of nine interventions namely, breastfeeding promotion, complementary feeding, vitamin supplementation, hand washing with soap, hygienic disposal of children's stools, oral rehydration solution, oral antibiotics for the treatment of pneumonia, therapeutic feeding for wasting and treatment for moderate malnutrition. PRIMARY AND SECONDARY OUTCOME MEASURES Reducing child mortality. RESULTS A total of 9 interventions can prevent 8891 deaths by 2030. Hand washing with soap (21%) accounts for the highest number of deaths prevented, followed by therapeutic feeding (19%) and oral rehydration therapy (16%). The top 5 interventions account for 77% of all deaths prevented. At scale, an estimated cost of US$169.5 million (US$3 per capita) per year will be required in community health worker costs. CONCLUSION The use of community health workers offers enormous opportunities for saving lives. These programmes require appropriate financial investments. Findings from this study show what can be achieved if concerted effort is channelled towards the identified set of life-saving interventions.
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Affiliation(s)
- Lungiswa Ll Nkonki
- Division of Community Health, Centre for Health Systems and Services Research, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Lumbwe L Chola
- Population Health, Health Systems and Innovation, Human Science Research Council, Pretoria, South africa
| | - Aviva A Tugendhaft
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
| | - Karen K Hofman
- PRICELESS SA-MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South africa
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Seidman G, Atun R. Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries. HUMAN RESOURCES FOR HEALTH 2017; 15:29. [PMID: 28407810 PMCID: PMC5390445 DOI: 10.1186/s12960-017-0200-9] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 03/29/2017] [Indexed: 05/27/2023]
Abstract
BACKGROUND Task shifting has become an increasingly popular way to increase access to health services, especially in low-resource settings. Research has demonstrated that task shifting, including the use of community health workers (CHWs) to deliver care, can improve population health. This systematic review investigates whether task shifting in low-income and middle-income countries (LMICs) results in efficiency improvements by achieving cost savings. METHODS Using the PRISMA guidelines for systematic reviews, we searched PubMed, Embase, CINAHL, and the Health Economic Evaluation Database on March 22, 2016. We included any original peer-review articles that demonstrated cost impact of a task shifting program in an LMIC. RESULTS We identified 794 articles, of which 34 were included in our study. We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS, and additional evidence exists for the potential to achieve cost savings from activities related to malaria, NCDs, NTDs, childhood illness, and other disease areas, especially at the primary health care and community levels. CONCLUSIONS Task shifting presents a viable option for health system cost savings in LMICs. Going forward, program planners should carefully consider whether task shifting can improve population health and health systems efficiency in their countries, and researchers should investigate whether task shifting can also achieve cost savings for activities related to emerging global health priorities and health systems strengthening activities such as supply chain management or monitoring and evaluation.
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Affiliation(s)
- Gabriel Seidman
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 United States of America
| | - Rifat Atun
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115 United States of America
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10
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Nkonki L, Tugendhaft A, Hofman K. A systematic review of economic evaluations of CHW interventions aimed at improving child health outcomes. HUMAN RESOURCES FOR HEALTH 2017; 15:19. [PMID: 28245839 PMCID: PMC5331680 DOI: 10.1186/s12960-017-0192-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Accepted: 02/15/2017] [Indexed: 05/04/2023]
Abstract
Evidence of the cost-effectiveness of community health worker interventions is pertinent for decision-makers and programme planners who are turning to community services in order to strengthen health systems in the context of the momentum generated by strategies to support universal health care, the post-2015 Sustainable Development Goal agenda.We conducted a systematic review of published economic evaluation studies of community health worker interventions aimed at improving child health outcomes. Four public health and economic evaluation databases were searched for studies that met the inclusion criteria: National Health Service Economic Evaluation Database (NHS EED), Cochrane, Paediatric Economic Evaluation Database (PEED), and PubMed. The search strategy was tailored to each database.The 19 studies that met the inclusion criteria were conducted in either high income countries (HIC), low- income countries (LIC) and/or middle-income countries (MIC). The economic evaluations covered a wide range of interventions. Studies were grouped together by intended outcome or objective of each study. The data varied in quality. We found evidence of cost-effectiveness of community health worker (CHW) interventions in reducing malaria and asthma, decreasing mortality of neonates and children, improving maternal health, increasing exclusive breastfeeding and improving malnutrition, and positively impacting physical health and psychomotor development amongst children.Studies measured varied outcomes, due to the heterogeneous nature of studies included; a meta-analysis was not conducted. Outcomes included disease- or condition -specific outcomes, morbidity, mortality, and generic measures (e.g. disability-adjusted life years (DALYs)). Nonetheless, all 19 interventions were found to be either cost-effective or highly cost-effective at a threshold specific to their respective countries.There is a growing body of economic evaluation literature on cost-effectiveness of CHW interventions. However, this is largely for small scale and vertical programmes. There is a need for economic evaluations of larger and integrated CHW programmes in order to achieve the post-2015 Sustainable Development Goal agenda so that appropriate resources can be allocated to this subset of human resources for health. This is the first systematic review to assess the cost-effectiveness of community health workers in delivering child health interventions.
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Affiliation(s)
- L. Nkonki
- Centre for Health Systems and Services Revision, Division of Community Health, Faculty of Medicine and Health Sciences, Francie van Zijl Rylaan/Drive, Tygerberg, 7505 South Africa
| | - A. Tugendhaft
- PRICELESS SA, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - K. Hofman
- PRICELESS SA, MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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11
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Skordis-Worrall J, Sinha R, Kumar Ojha A, Sarangi S, Nair N, Tripathy P, Sachdev HS, Bhattacharyya S, Gope R, Rath S, Rath S, Srivastava A, Batura N, Pulkki-Brännström AM, Costello A, Copas A, Saville N, Prost A, Haghparast-Bidgoli H. Protocol for the economic evaluation of a community-based intervention to improve growth among children under two in rural India (CARING trial). BMJ Open 2016; 6:e012046. [PMID: 27807084 PMCID: PMC5128945 DOI: 10.1136/bmjopen-2016-012046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Undernutrition affects ∼165 million children globally and contributes up to 45% of all child deaths. India has the highest proportion of global undernutrition-related morbidity and mortality. This protocol describes the planned economic evaluation of a community-based intervention to improve growth in children under 2 years of age in two rural districts of eastern India. The intervention is being evaluated through a cluster-randomised controlled trial (cRCT, the CARING trial). METHODS AND ANALYSIS A cost-effectiveness and cost-utility analysis nested within a cRCT will be conducted from a societal perspective, measuring programme, provider, household and societal costs. Programme costs will be collected prospectively from project accounts using a standardised tool. These will be supplemented with time sheets and key informant interviews to inform the allocation of joint costs. Direct and indirect costs incurred by providers will be collected using key informant interviews and time use surveys. Direct and indirect household costs will be collected prospectively, using time use and consumption surveys. Incremental cost-effectiveness ratios (ICERs) will be calculated for the primary outcome measure, that is, cases of stunting prevented, and other outcomes such as cases of wasting prevented, cases of infant mortality averted, life years saved and disability-adjusted life years (DALYs) averted. Sensitivity analyses will be conducted to assess the robustness of results. ETHICS AND DISSEMINATION There is a shortage of robust evidence regarding the cost-effectiveness of strategies to improve early child growth. As this economic evaluation is nested within a large scale, cRCT, it will contribute to understanding the fiscal space for investment in early child growth, and the relative (in)efficiency of prioritising resources to this intervention over others to prevent stunting in this and other comparable contexts. The protocol has all necessary ethical approvals and the findings will be disseminated within academia and the wider policy sphere. TRIAL REGISTRATION NUMBER ISRCTN51505201; pre-results.
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Affiliation(s)
| | | | | | | | | | | | - H S Sachdev
- Sitaram Bhartia Institute of Science and Research, New Delhi, India
| | | | | | | | | | | | - Neha Batura
- University College London, Institute for Global Health, London, UK
| | - Anni-Maria Pulkki-Brännström
- University College London, Institute for Global Health, London, UK
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Anthony Costello
- University College London, Institute for Global Health, London, UK
| | - Andrew Copas
- Department of Infection and Population Health, University College London, London, UK
| | - Naomi Saville
- University College London, Institute for Global Health, London, UK
| | - Audrey Prost
- University College London, Institute for Global Health, London, UK
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12
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Lunze K, Higgins-Steele A, Simen-Kapeu A, Vesel L, Kim J, Dickson K. Innovative approaches for improving maternal and newborn health--A landscape analysis. BMC Pregnancy Childbirth 2015; 15:337. [PMID: 26679709 PMCID: PMC4683742 DOI: 10.1186/s12884-015-0784-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 12/09/2015] [Indexed: 12/31/2022] Open
Abstract
Background Essential interventions can improve maternal and newborn health (MNH) outcomes in low- and middle-income countries, but their implementation has been challenging. Innovative MNH approaches have the potential to accelerate progress and to lead to better health outcomes for women and newborns, but their added value to health systems remains incompletely understood. This study’s aim was to analyze the landscape of innovative MNH approaches and related published evidence. Methods Systematic literature review and descriptive analysis based on the MNH continuum of care framework and the World Health Organization health system building blocks, analyzing the range and nature of currently published MNH approaches that are considered innovative. We used 11 databases (MedLine, Web of Science, CINAHL, Cochrane, Popline, BLDS, ELDIS, 3ie, CAB direct, WHO Global Health Library and WHOLIS) as data source and extracted data according to our study protocol. Results Most innovative approaches in MNH are iterations of existing interventions, modified for contexts in which they had not been applied previously. Many aim at the direct organization and delivery of maternal and newborn health services or are primarily health workforce interventions. Innovative approaches also include health technologies, interventions based on community ownership and participation, and novel models of financing and policy making. Rigorous randomized trials to assess innovative MNH approaches are rare; most evaluations are smaller pilot studies. Few studies assessed intervention effects on health outcomes or focused on equity in health care delivery. Conclusions Future implementation and evaluation efforts need to assess innovations’ effects on health outcomes and provide evidence on potential for scale-up, considering cost, feasibility, appropriateness, and acceptability. Measuring equity is an important aspect to identify and target population groups at risk of service inequity. Innovative MNH interventions will need innovative implementation, evaluation and scale-up strategies for their sustainable integration into health systems. Electronic supplementary material The online version of this article (doi:10.1186/s12884-015-0784-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karsten Lunze
- Department of Medicine Boston, Boston University, Boston, MA, USA. .,Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
| | - Ariel Higgins-Steele
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,Concern Worldwide, 355 Lexington Avenue, New York, NY, 10017, USA.
| | - Aline Simen-Kapeu
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
| | - Linda Vesel
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,Concern Worldwide, 355 Lexington Avenue, New York, NY, 10017, USA.
| | - Julia Kim
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA. .,GNH Centre Bhutan, Jaffa's Commercial Building, Room 302, Thimphu, Bhutan.
| | - Kim Dickson
- Health Section, UNICEF, 3 United Nations Plaza, New York, NY, 10017, USA.
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13
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Chola L, Fadnes LT, Engebretsen IMS, Nkonki L, Nankabirwa V, Sommerfelt H, Tumwine JK, Tylleskar T, Robberstad B. Cost-Effectiveness of Peer Counselling for the Promotion of Exclusive Breastfeeding in Uganda. PLoS One 2015; 10:e0142718. [PMID: 26619338 PMCID: PMC4664391 DOI: 10.1371/journal.pone.0142718] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 10/26/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Community based breastfeeding promotion programmes have been shown to be effective in increasing breastfeeding prevalence. However, there is limited data on the cost-effectiveness of these programmes in sub-Saharan Africa. This paper evaluates the cost-effectiveness of a breastfeeding promotion intervention targeting mothers and their 0 to 6 month old children. METHODS Data were obtained from a community randomized trial conducted in Uganda between 2006-2008, and supplemented with evidence from several studies in sub-Saharan Africa. In the trial, peer counselling was offered to women in intervention clusters. In the control and intervention clusters, women could access standard health facility breastfeeding promotion services (HFP). Thus, two methods of breastfeeding promotion were compared: community based peer counselling (in addition to HFP) and standard HFP alone. A Markov model was used to calculate incremental cost-effectiveness ratios between the two strategies. The model estimated changes in breastfeeding prevalence and disability adjusted life years. Costs were estimated from a provider perspective. Uncertainty around the results was characterized using one-way sensitivity analyses and a probabilistic sensitivity analysis. FINDINGS Peer counselling more than doubled the breastfeeding prevalence as reported by mothers, but there was no observable impact on diarrhoea prevalence. Estimated incremental cost-effectiveness ratios were US$68 per month of exclusive or predominant breastfeeding and U$11,353 per disability adjusted life year (DALY) averted. The findings were robust to parameter variations in the sensitivity analyses. CONCLUSIONS Our strategy to promote community based peer counselling is unlikely to be cost-effective in reducing diarrhoea prevalence and mortality in Uganda, because its cost per DALY averted far exceeds the commonly assumed willingness-to-pay threshold of three times Uganda's GDP per capita (US$1653). However, since the intervention significantly increases prevalence of exclusive or predominant breastfeeding, it could be adopted in Uganda if benefits other than reducing the occurrence of diarrhoea are believed to be important.
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Affiliation(s)
- Lumbwe Chola
- Population Health, Health Systems and Innovation (PHHSI), Human Sciences Research Council, Pretoria, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
| | - Lars T. Fadnes
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Ingunn M. S. Engebretsen
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Lungiswa Nkonki
- Health Systems and Services Research Unit, Division of Community Health, University of Stellenbosch, Cape Town, South Africa
| | - Victoria Nankabirwa
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Box 7072, Kampala, Uganda
| | - Halvor Sommerfelt
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
- Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
| | - James K. Tumwine
- Department of Paediatrics and Child Health, School of Medicine, Makerere University, Box 7072, Kampala, Uganda
| | - Thorkild Tylleskar
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
| | - Bjarne Robberstad
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Box 7804, N-5020, Bergen, Norway
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14
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Vaughan K, Kok MC, Witter S, Dieleman M. Costs and cost-effectiveness of community health workers: evidence from a literature review. HUMAN RESOURCES FOR HEALTH 2015; 13:71. [PMID: 26329455 PMCID: PMC4557864 DOI: 10.1186/s12960-015-0070-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 08/18/2015] [Indexed: 05/20/2023]
Abstract
OBJECTIVE This study sought to synthesize and critically review evidence on costs and cost-effectiveness of community health worker (CHW) programmes in low- and middle-income countries (LMICs) to inform policy dialogue around their role in health systems. METHODS From a larger systematic review on effectiveness and factors influencing performance of close-to-community providers, complemented by a supplementary search in PubMed, we did an exploratory review of a subset of papers (32 published primary studies and 4 reviews from the period January 2003-July 2015) about the costs and cost-effectiveness of CHWs. Studies were assessed using a data extraction matrix including methodological approach and findings. RESULTS Existing evidence suggests that, compared with standard care, using CHWs in health programmes can be a cost-effective intervention in LMICs, particularly for tuberculosis, but also - although evidence is weaker - in other areas such as reproductive, maternal, newborn and child health (RMNCH) and malaria. CONCLUSION Notwithstanding important caveats about the heterogeneity of the studies and their methodological limitations, findings reinforce the hypothesis that CHWs may represent, in some settings, a cost-effective approach for the delivery of essential health services. The less conclusive evidence about the cost-effectiveness of CHWs in other areas may reflect that these areas have been evaluated less (and less rigorously) than others, rather than an actual difference in cost-effectiveness in the various service delivery areas or interventions. Methodologically, areas for further development include how to properly assess costs from a societal perspective rather than just through the lens of the cost to government and accounting for non-tangible costs and non-health benefits commonly associated with CHWs.
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Affiliation(s)
- Kelsey Vaughan
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | - Maryse C Kok
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
| | | | - Marjolein Dieleman
- Royal Tropical Institute (KIT), P.O. Box 95001, 1090 HA, Amsterdam, The Netherlands.
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Abstract
The first Millennium Development Goal (MDG 1) due in 2015 concerns poverty reduction. It has been claimed to be fulfilled on a global level, but still more than 1 billion people are living in abject poverty. There is a strong link between the economy and child survival, and only a minority of countries will have reached the MDG target for child mortality reduction by 2015. This paper discusses the relationship between poverty and child survival. It argues that a focus on equity is necessary to further reduce child mortality, through poverty reduction in absolute terms and also through targeting interventions for increased child survival to disadvantaged populations. The political will to actually achieve real change for those in greatest need is crucial but not to be taken for granted, and the distribution rather than the generation of wealth needs to be made a priority in the post-MDG era.
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Daniels K, Odendaal WA, Nkonki L, Hongoro C, Colvin CJ, Lewin S. Incentives for lay health workers to improve recruitment, retention in service and performance. Hippokratia 2014. [DOI: 10.1002/14651858.cd011201] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Karen Daniels
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
| | - Willem A Odendaal
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
| | - Lungiswa Nkonki
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Stellenbosch University; Centre for Health Systems and Services Research and Development; Cape Town South Africa
| | - Charles Hongoro
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Human Sciences Research Council; Health Systems Financing, Population Health, Health Systems and Innovation Programme; Cape Town South Africa
| | - Christopher J Colvin
- School of Public Health and Family Medicine, University of Cape Town; Centre for Infectious Disease Epidemiology and Research (CIDER); 7 Alfred St., Observatory 7925 Cape Town South Africa
| | - Simon Lewin
- Medical Research Council of South Africa; Health Systems Research Unit; PO Box 19070 Tygerberg South Africa 7505
- Norwegian Knowledge Centre for the Health Services; Global Health Unit; Box 7004 St Olavsplass Oslo Norway N-0130
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17
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Batura N, Hill Z, Haghparast-Bidgoli H, Lingam R, Colbourn T, Kim S, Sikander S, Pulkki-Brannstrom AM, Rahman A, Kirkwood B, Skordis-Worrall J. Highlighting the evidence gap: how cost-effective are interventions to improve early childhood nutrition and development? Health Policy Plan 2014; 30:813-21. [PMID: 24963156 PMCID: PMC4451167 DOI: 10.1093/heapol/czu055] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2014] [Indexed: 11/26/2022] Open
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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Affiliation(s)
- Neha Batura
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Zelee Hill
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Hassan Haghparast-Bidgoli
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Raghu Lingam
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Timothy Colbourn
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Sungwook Kim
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Siham Sikander
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Anni-Maria Pulkki-Brannstrom
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Atif Rahman
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Betty Kirkwood
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa
| | - Jolene Skordis-Worrall
- Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, University of Liverpool, Liverpool L69 3BX, UK, Department of Population Health and Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Health Economics and Systems Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and Health Economics Unit, University of Cape Town, Observatory 7925, South Africa Institute for Global Health, University College London, London WC1N 1EH, UK, Maternal and Child Health Intervention Research Group, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK, Human Development Research Foundation, Islamabad 44000, Pakistan, Epidemiology and Global Health, Umeä University, 90187 Umeå, Sweden, Institute of Psychology, Health & Society, Child Mental Health Unit, Unive
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Nkonki LL, Daviaud E, Jackson D, Chola L, Doherty T, Chopra M, Robberstad B. Costs of promoting exclusive breastfeeding at community level in three sites in South Africa. PLoS One 2014; 9:e79784. [PMID: 24427264 PMCID: PMC3888383 DOI: 10.1371/journal.pone.0079784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Accepted: 09/25/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Community-based peer support has been shown to be effective in improving exclusive breastfeeding rates in a variety of settings. METHODS We conducted a cost analysis of a community cluster randomised-controlled trial (Promise-EBF), aimed at promoting exclusive infant feeding in three sites in South Africa. The costs were considered from the perspective of health service providers. Peer supporters in this trial visited women to support exclusive infant feeding, once antenatally and four times postpartum. RESULTS The total economic cost of the Promise-EBF intervention was US$393 656, with average costs per woman and per visit of US$228 and US$52, respectively. The average costs per woman and visit in an operational 'non research' scenario were US$137 and US$32 per woman and visit, respectively. Investing in the promotion of exclusive infant feeding requires substantial financial commitment from policy makers. Extending the tasks of multi-skilled community health workers (CHWs) to include promoting exclusive infant feeding is a potential option for reducing these costs. In order to avoid efficiency losses, we recommend that the time requirements for delivering the promotion of exclusive infant feeding are considered when integrating it within the existing activities of CHWs. DISCUSSION This paper focuses on interventions for exclusive infant feeding, but its findings more generally illustrate the importance of documenting and quantifying factors that affect the feasibility and sustainability of community-based interventions, which are receiving increased focus in low income settings.
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Affiliation(s)
- Lungiswa Leonora Nkonki
- Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa
- Centre for International Health, University of Bergen, Bergen, Norway
- Division of Community Health, Faculty of Health Sciences, Stellenbosch University, South Africa
- * E-mail:
| | - Emmanuelle Daviaud
- Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa
| | - Debra Jackson
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Lumbwe Chola
- Division of Community Health, Faculty of Health Sciences, Stellenbosch University, South Africa
| | - Tanya Doherty
- Health Systems Research Unit, Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Bellville, South Africa
| | - Mickey Chopra
- UNICEF, New York, New York, United States of America
| | - Bjarne Robberstad
- Centre for International Health, University of Bergen, Bergen, Norway
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Impact of counselling on exclusive breast-feeding practices in a poor urban setting in Kenya: a randomized controlled trial. Public Health Nutr 2012; 16:1732-40. [PMID: 23039968 DOI: 10.1017/s1368980012004405] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine the impact of facility-based semi-intensive and home-based intensive counselling in improving exclusive breast-feeding (EBF) in a low-resource urban setting in Kenya. DESIGN A cluster randomized controlled trial in which nine villages were assigned on a 1:1:1 ratio, by computer, to two intervention groups and a control group. The home-based intensive counselling group (HBICG) received seven counselling sessions at home by trained peers, one prenatally and six postnatally. The facility-based semi-intensive counselling group (FBSICG) received only one counselling session prenatally. The control group (CG) received no counselling from the research team. Information on infant feeding practices was collected monthly for 6 months after delivery. The data-gathering team was blinded to the intervention allocation. The outcome was EBF prevalence at 6 months. SETTING Kibera slum, Nairobi. SUBJECTS A total of 360 HIV-negative women, 34-36 weeks pregnant, were selected from an antenatal clinic in Kibera; 120 per study group. RESULTS Of the 360 women enrolled, 265 completed the study and were included in the analysis (CG n 89; FBSICG n 87; HBICG n 89). Analysis was by intention to treat. The prevalence of EBF at 6 months was 23.6% in HBICG, 9.2% in FBSICG and 5.6% in CG. HBICG mothers had four times increased likelihood to practise EBF compared with those in the CG (adjusted relative risk = 4.01; 95% CI 2.30, 7.01; P=0.001). There was no significant difference between EBF rates in FBSICG and CG. CONCLUSIONS EBF can be promoted in low socio-economic conditions using home-based intensive counselling. One session of facility-based counselling is not sufficient to sustain EBF.
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