1
|
Moolla A, Mdewa W, Erzse A, Hofman K, Thsehla E, Goldstein S, Kohli-Lynch C. A cost-effectiveness analysis of a South African pregnancy support grant. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002781. [PMID: 38329926 PMCID: PMC10852248 DOI: 10.1371/journal.pgph.0002781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/14/2024] [Indexed: 02/10/2024]
Abstract
Poverty among expectant mothers often results in sub-optimal maternal nutrition and inadequate antenatal care, with negative consequences on child health outcomes. South Africa has a child support grant that is available from birth to those in need. This study aims to determine whether a pregnancy support grant, administered through the extension of the child support grant, would be cost-effective compared to the existing child support grant alone. A cost-utility analysis was performed using a decision-tree model to predict the incremental costs (ZAR) and disability-adjusted life years (DALYs) averted by the pregnancy support grant over a 2-year time horizon. An ingredients-based approach to costing was completed from a governmental perspective. The primary outcome was the incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were performed. The intervention resulted in a cost saving of R13.8 billion ($930 million, 95% CI: ZAR3.91 billion - ZAR23.2 billion/ $1.57 billion - $264 million) and averted 59,000 DALYs (95% CI: -6,400-110,000), indicating that the intervention is highly cost-effective. The primary cost driver was low birthweight requiring neonatal intensive care, with a disaggregated incremental cost of R31,800 ($2,149) per pregnancy. Mortality contributed most significantly to the DALYs accrued in the comparator (0.68 DALYs). The intervention remained the dominant strategy in the sensitivity analyses. The pregnancy support grant is a highly cost-effective solution for supporting expecting mothers and ensuring healthy pregnancies. With its positive impact on child health outcomes, there is a clear imperative for government to implement this grant. By investing in this program, cost savings could be leveraged. The implementation of this grant should be given high priority in public health and social policies.
Collapse
Affiliation(s)
- Aisha Moolla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Winfrida Mdewa
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Hofman
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Evelyn Thsehla
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Ciaran Kohli-Lynch
- SAMRC/Wits Centre for Health Economics and Decision Science ‐ PRICELESS SA, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States of America
| |
Collapse
|
2
|
Erzse A, Rwafa-Ponela T, Goldstein S, Motlhatlhedi M, Watson D, Hofman KJ, Danis M, Norris SA, Ward KA, Tugendhaft A. What values drive communities' nutrition priorities in a resource constrained urban area in South Africa? BMC Public Health 2023; 23:873. [PMID: 37170249 PMCID: PMC10175056 DOI: 10.1186/s12889-023-15761-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Voices of under-resourced communities are recognised as important yet are often unheard in decisions about healthcare resource allocation. Deliberative public engagement can serve as an effective mechanism for involving communities in establishing nutrition priorities. This study sought to identify the priorities of community members of a South African township, Soweto, and describe the underlying values driving their prioritisation process, to improve nutrition in the first 1000 days of life. METHODS We engaged 54 community members (28 men and 26 women aged > 18 years) from Soweto. We conducted seven group discussions to determine how to allocate limited resources for prioritising nutrition interventions. We used a modified public engagement tool: CHAT (Choosing All Together) which presented 14 nutrition intervention options and their respective costs. Participants deliberated and collectively determined their nutritional priorities. Choices were captured quantitatively, while group discussions were audio-recorded. A thematic analysis was undertaken to identify the reasons and values associated with the selected priorities. RESULTS All groups demonstrated a preference to allocate scarce resources towards three priority interventions-school breakfast provisioning, six-months paid maternity leave, and improved food safety. All but one group selected community gardens and clubs, and five groups prioritised decreasing the price of healthy food and receiving job search assistance. Participants' allocative decisions were guided by several values implicit in their choices, such as fairness and equity, efficiency, social justice, financial resilience, relational solidarity, and human development, with a strong focus on children. Priority interventions were deemed critical to supporting children's optimal development and well-being, interrupting the intergenerational cycle of poverty and poor human development in the community. CONCLUSION Our study demonstrates how public engagement can facilitate the incorporation of community values and programmatic preferences into nutrition priority setting, enabling a responsive approach to local community needs, especially in resource constrained contexts. Findings could guide policy makers to facilitate more appropriate decisions and to improve nutrition in the first 1000 days of life.
Collapse
Affiliation(s)
- Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
| | - Teurai Rwafa-Ponela
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Susan Goldstein
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Molebogeng Motlhatlhedi
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Daniella Watson
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Karen J Hofman
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Marion Danis
- Department of Bioethics, National Institutes of Health, Bethesda, MD, USA
| | - Shane A Norris
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Kate A Ward
- SAMRC/ Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, UK
| | - Aviva Tugendhaft
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| |
Collapse
|
3
|
Desmond C, Watt K, Boua PR, Moore C, Erzse A, Sorgho H, Hofman K, Roumba T, Tinto H, Ward KA. Investing in human development and building state resilience in fragile contexts: A case study of early nutrition investments in Burkina Faso. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001737. [PMID: 36989221 DOI: 10.1371/journal.pgph.0001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/27/2023] [Indexed: 03/30/2023]
Abstract
Maternal and early malnutrition have negative health and developmental impacts over the life-course. Consequently, early nutrition support can provide significant benefits into later life, provided the later life contexts allow. This study examines the limits of siloed investments in nutrition and illustrates how ignoring life-course contextual constraints limits human development benefits and exacerbates inequality, particularly in fragile contexts. This case study focuses on Burkina Faso, a country with high rates of early malnutrition and a fragile state. We modelled the impact of scaling up 10 nutrition interventions to 80% coverage for a single year cohort on stunting, nationally and sub-nationally, using the Lives Saved Tool (LiST), and the consequent impact on earnings, without and with a complementary cash-transfer in later life. The impact on earnings was modelled utilising the well-established pathway between early nutrition, years of completed schooling and, consequent adult earnings. Productivity returns were estimated as the present value of increased income over individuals' working lives, then compared to estimates of the present value of providing the cost of nutrition interventions and cash-transfers. The cost benefit ratio at the national level for scaled nutrition alone is 1:1. Sub-nationally the worst-off region yields the lowest ratio < 0.2 for every dollar spent. The combination of nutrition and cash-transfers national cost benefit is 1:12, still with regional variation but with great improvement in the poorest region. This study shows that early nutrition support alone may not be enough to address inequality and may add to state fragility. Taking a life-course perspective when priority-setting in contexts with multiple constraints on development can help to identify interventions that maximizing returns, without worsening inequality.
Collapse
Affiliation(s)
- Chris Desmond
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Kathryn Watt
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa
| | - Palwendé R Boua
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
- Sydney Brenner Institute for Molecular Biosciences (SBIMB), University of Witwatersrand, Johannesburg, South Africa
| | - Candice Moore
- Department of International Relations, School of Social Sciences, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa
| | - Agnes Erzse
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Hermann Sorgho
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Karen Hofman
- SAMRC/ Wits Centre for Health Economics and Decision Science, PRICELESS SA, Faculty of Health Sciences, University of Witwatersrand School of Public Health, Johannesburg, South Africa
| | - Toussaint Roumba
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Halidou Tinto
- Clinical Research Unit of Nanoro (CRUN), Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Kate A Ward
- SAMRC Developmental Pathways for Health Research Unit, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa
- Global Health Research Institute, School of Human Development and Health, Faculty of Medicine, University of Southampton, United Kingdom
- Medical Research Council Lifecourse Epidemiology Centre, University of Southampton, Southampton, United Kingdom
| |
Collapse
|