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Nuwamanya E, Babigumira JB, Svensson M. Cost-effectiveness of increased contraceptive coverage using family planning benefits cards compared with the standard of care for young women in Uganda. Contracept Reprod Med 2023; 8:21. [PMID: 36782307 PMCID: PMC9926799 DOI: 10.1186/s40834-022-00206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 12/04/2022] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Uganda has a high population growth rate of 3%, partly due to limited access to and low usage of contraception. This study assessed the cost-effectiveness of the family planning benefits cards (FPBC) program compared to standard of care (SOC). The FPBC program was initiated to increase access to modern contraception among young women in slums in Kampala, Uganda. METHODS We developed a decision-analytic model (decision tree) and parameterized it using primary intervention data together with previously published data. In the base case, a sexually active woman from an urban slum, aged 18 to 30 years, was modelled over a one-year time horizon from both the modified societal and provider perspectives. The main model outcomes included the probability of unintended conception, costs, and incremental cost-effectiveness ratio (ICER) in terms of cost per unwanted pregnancy averted. Both deterministic and probabilistic sensitivity analyses were conducted to assess the robustness of the modelling results. All costs were reported in 2022 US dollars, and analyses were conducted in Microsoft Excel. RESULTS In the base case analysis, the FPBC was superior to the SOC in outcomes. The probability of conception was lower in the FPBC than in the SOC (0.20 vs. 0.44). The average societal and provider costs were higher in the FPBC than in the SOC, i.e., $195 vs. $164 and $193 vs. $163, respectively. The ICER comparing the FPBC to the SOC was $125 per percentage reduction in the probability of unwanted conception from the societal perspective and $121 from the provider perspective. The results were robust to sensitivity analyses. CONCLUSION Given Uganda's GDP per capita of $1046 in 2022, the FPBC is highly cost-effective compared to the SOC in reducing unintended pregnancies among young women in low-income settings. It can even get cheaper in the long run due to the low marginal costs of deploying additional FPBCs. TRIAL REGISTRATION MUREC1/7 No. 10/05-17. Registered on July 19, 2017.
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Affiliation(s)
- Elly Nuwamanya
- Infectious Diseases Institute, College of Health Sciences, Makerere University, P. O Box 22418, Kampala, 40530, Uganda. .,GHE Consulting, P.O Box 27011, Kampala, Uganda. .,Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530, Gothenburg, Sweden.
| | | | - Mikael Svensson
- grid.8761.80000 0000 9919 9582Department of Community Medicine and Public Health, Sahlgrenska Academy, University of Gothenburg, P. O Box 414, 40530 Gothenburg, Sweden
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Enden MR, Tolla MT, Norheim OF. Providing universal access to modern contraceptive methods: An extended cost-effectiveness analysis of meeting the demand for modern contraception in Ethiopia. Soc Sci Med 2021; 281:114076. [PMID: 34116422 DOI: 10.1016/j.socscimed.2021.114076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/15/2021] [Accepted: 05/20/2021] [Indexed: 11/18/2022]
Abstract
Despite recent advances in access to and use of modern contraception in Ethiopia, further improvement is needed, particularly among poorer women. This extended cost-effectiveness analysis investigated the health outcomes, their distribution, and financial risk protection associated with meeting the demand for modern contraception for all Ethiopian women. We developed five Markov models with wealth quintile-specific input data to investigate the effects of meeting this demand and followed a hypothetical cohort of 1,252,000 women through their reproductive lives from ages 15-49 years. The health outcomes are reported in quality-adjusted life years (QALYs) gained and in intermediate health outcomes, such as the total number of induced abortions, unintended pregnancies, and pregnancy-related deaths averted. The economic effect of meeting the demand for modern contraception was assessed by estimating the financial risk protection benefits in terms of averted out-of-pocket payments and the reduction in the number of cases of catastrophic health expenditure by quintile. Meeting the demand for modern contraception was deemed highly cost effective, with an incremental cost-effectiveness ratio of $96.60/QALY gained per woman. A total of 676,300 QALYs were gained, and approximately 1,900,000 unintended pregnancies, 250,000 induced abortions, and 9000 pregnancy-related deaths were averted over the 35-year period. Most of these gains were achieved among low-income groups. When the demand for modern contraception was met, almost 40,000 cases of catastrophic health expenditure were averted in the poorest quintile. The total governmental cost was higher in all quintiles when the demand for modern contraception was met compared to the baseline scenario, with the largest percentage increase in governmental spending in the poorest quintiles. Meeting the demand for modern contraception fulfills the priority-setting criteria established by the Ethiopian Ministry of Health and makes the Ethiopian health care system more equitable.
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Affiliation(s)
- M R Enden
- Bergen Centre for Ethics and Priority Setting, Institute of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5009, Bergen, Norway.
| | - M T Tolla
- Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Ave, Boston, MA, 02115, United States.
| | - O F Norheim
- Bergen Centre for Ethics and Priority Setting, Institute of Global Public Health and Primary Care, University of Bergen, Årstadveien 21, 5009, Bergen, Norway; Harvard T.H. Chan School of Public Health, Harvard University, 677 Huntington Ave, Boston, MA, 02115, United States.
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Wagner GJ, Wanyenze RK, Beyeza-Kashesya J, Gwokyalya V, Hurley E, Mindry D, Finocchario-Kessler S, Nanfuka M, Tebeka MG, Saya U, Booth M, Ghosh-Dastidar B, Linnemayr S, Staggs VS, Goggin K. "Our Choice" improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches. Implement Sci 2021; 16:41. [PMID: 33858462 PMCID: PMC8048255 DOI: 10.1186/s13012-021-01109-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Safer conception counseling (SCC) to promote the use of safer conception methods (SCM) is not yet part of routine family planning or HIV care. Guidelines for the use of SCM have been published, but to date there are no published controlled evaluations of SCC. Furthermore, it is unknown whether standard methods commonly used in resource constrained settings to integrate new services would be sufficient, or if enhanced training and supervision would result in a more efficacious approach to implementing SCC. Methods In a hybrid, cluster randomized controlled trial, six HIV clinics were randomly assigned to implement the SCC intervention Our Choice using either a high (SCC1) or low intensity (SCC2) approach (differentiated by amount of training and supervision), or existing family planning services (usual care). Three hundred eighty-nine HIV clients considering childbearing with an HIV-negative partner enrolled. The primary outcome was self-reported use of appropriate reproductive method (SCM if trying to conceive; modern contraceptives if not) over 12 months or until pregnancy. Results The combined intervention groups used appropriate reproductive methods more than usual care [20.8% vs. 6.9%; adjusted OR (95% CI)=10.63 (2.79, 40.49)], and SCC1 reported a higher rate than SCC2 [27.1% vs. 14.6%; OR (95% CI)=4.50 (1.44, 14.01)]. Among those trying to conceive, the intervention arms reported greater accurate use of SCM compared to usual care [24.1% vs. 0%; OR (95% CI)=91.84 (4.94, 1709.0)], and SCC1 performed better than SCC2 [34.6% vs. 11.5%; OR (95% CI)=6.43 (1.90, 21.73)]. The arms did not vary on modern contraception use among those not trying to conceive. A cost of $631 per person was estimated to obtain accurate use of SCM in SCC1, compared to $1014 in SCC2. Conclusions More intensive provider training and more frequent supervision leads to greater adoption of complex SCM behaviors and is more cost-effective than the standard low intensity implementation approach. Trial registration Clinicaltrials.gov, NCT03167879; date registered May 23, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01109-z.
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Affiliation(s)
- Glenn J Wagner
- RAND Corporation, 1776 Main St., Santa Monica, CA, 91105, USA.
| | - Rhoda K Wanyenze
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jolly Beyeza-Kashesya
- Department of Reproductive Medicine, Mulago Specialised Women and Neonatal Hospital, Kampala, Uganda
| | - Violet Gwokyalya
- Department of Disease Control and Environmental Health, Makerere University School of Public Health, Kampala, Uganda
| | - Emily Hurley
- Children's Mercy Research Institute, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Deborah Mindry
- University of California Global Health Institute, Center for Women's Health and Empowerment, 1234 Sunny Oaks Circle, Altadena, CA, 91001, USA
| | - Sarah Finocchario-Kessler
- Department of Family Medicine & Community Health, University of Kansas Medical Center, Kansas City, KS, 66160, USA
| | | | - Mahlet G Tebeka
- Pardee RAND Graduate School, 1776 Main St., Santa Monica, CA, 91105, USA
| | - Uzaib Saya
- Pardee RAND Graduate School, 1776 Main St., Santa Monica, CA, 91105, USA
| | - Marika Booth
- RAND Corporation, 1776 Main St., Santa Monica, CA, 91105, USA
| | | | | | - Vincent S Staggs
- Children's Mercy Research Institute, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Kathy Goggin
- Children's Mercy Research Institute, Children's Mercy Kansas City, University of Missouri - Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA
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4
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White A, Srinivasan M, Wingate LM, Peasah S, Fleming M. Development of a pharmacoeconomic registry: an example using hormonal contraceptives. HEALTH ECONOMICS REVIEW 2021; 11:10. [PMID: 33745016 PMCID: PMC7981865 DOI: 10.1186/s13561-021-00309-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/12/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Disease-specific registries, documenting costs and probabilities from pharmacoeconomic studies along with health state utility values from quality-of-life studies could serve as a resource to guide researchers in evaluating the published literature and in the conduct of future economic evaluations for their own research. Registries cataloging economic evaluations currently exist, however they are restricted by the type of economic evaluations they include. There is a need for intervention-specific registries, that document all types of complete and partial economic evaluations and auxiliary information such as quality of life studies. The objective of this study is to describe the development of a pharmacoeconomic registry and provide best practices using an example of hormonal contraceptives. METHODS An expert panel consisting of researchers with expertise in pharmacoeconomics and outcomes research was convened and the clinical focus of the registry was finalized after extensive discussion. A list of key continuous, categorical and descriptive variables was developed to capture all relevant data with each variable defined in a data dictionary. A web-based data collection tool was designed to capture and store the resulting metadata. A keyword based search strategy was developed to retrieve the published sources of literature. Finally, articles were screened for relevancy and data was extracted to populate the registry. Expert opinions were taken from the panel at each stage to arrive at consensus and ensure validity of the registry. RESULTS The registry focused on economic evaluation literature of hormonal contraceptives used for contraception. The registry consisted of 65 articles comprising of 22 cost-effectiveness analyses, 9 cost-utility analyses, 7 cost-benefit analyses, 1 cost-minimization, 14 cost analyses, 10 cost of illness studies and 2 quality of life studies. The best practices followed in the development of the registry were summarized as recommendations. The completed registry, data dictionary and associated data files can be accessed in the supplementary information files. CONCLUSION This registry is a comprehensive database of economic evaluations, including costs, clinical probabilities and health-state utility estimates. The collated data captured from published information in this registry can be used to identify trends in the literature, conduct systematic reviews and meta-analysis and develop novel pharmacoeconomic models.
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Affiliation(s)
- Annesha White
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
- Department of Pharmacotherapy, UNT System College of Pharmacy, 3500 Camp Bowie Blvd, IREB 211, Fort Worth, TX 76107 USA
| | - Meenakshi Srinivasan
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
| | | | - Samuel Peasah
- Mercer University College of Pharmacy, Atlanta, GA 30341 USA
| | - Marc Fleming
- University of North Texas System College of Pharmacy, University of North Texas Health Science Center, Fort Worth, TX 76107 USA
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Joshi B, Moray KV, Sachin O, Chaurasia H, Begum S. Cost Effectiveness of Introducing Etonorgestrel Contraceptive Implant into India's Current Family Welfare Programme. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:267-277. [PMID: 32776166 DOI: 10.1007/s40258-020-00605-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The aim of this study was to provide evidence to policy makers on cost effectiveness and budget impact for the introduction of the etonorgestrel implant into the Indian public health system. METHODS An economic evaluation was conducted to ascertain the potential costs and outcomes of adding the etonorgestrel implant to the public health system of India as compared to the current scenario. A decision analytical model (Markov cohort) was conceptualized from a societal perspective, where a hypothetical population of 15-year-old females was followed until menopause. The primary outcome was incremental cost-utility ratio (ICUR). Sources for model inputs included country-level secondary data analysis, government reports, an observational primary costing study, a systematic review of etonorgestrel implant and targeted literature reviews. One-way and probabilistic sensitivity analyses (OWSA and PSA) were performed to account for uncertainty. The impact of etonorgestrel implant introduction on the annual Indian health budget was also analysed. RESULTS The base-case ICUR was 16,475 Indian rupees (INR) (USD 232) per quality-adjusted life-year gained, which showed the etonorgestrel implant to be very cost effective (ICUR below willingness-to-pay threshold of INR 137,945 [USD 1943]). OWSA showed that discount rate, percentage of people who do not use contraceptives and costs of managing side effects were the important parameters that affected ICUR. PSA showed that ICUR values of all 1000 Monte Carlo simulations were cost effective. Budget impact analysis showed that introduction of the implant would account for < 1% of the total annual health budget of India, even if acceptance of the implant varied between 0.2 and 4%. CONCLUSION Adding the etonorgestrel implant to the public health system would be cost effective for India, with a feasible budgetary allocation.
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Affiliation(s)
- Beena Joshi
- Health Technology Assessment Resource Hub, Indian Council of Medical Research, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, 400012, India.
| | - Kusum V Moray
- Health Technology Assessment Resource Hub, Indian Council of Medical Research, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, 400012, India
| | - Oshima Sachin
- Department of Health Research, Ministry of Health and Family Welfare, New Delhi, India
| | - Himanshu Chaurasia
- Health Technology Assessment Resource Hub, Indian Council of Medical Research, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, 400012, India
| | - Shahina Begum
- Biostatistics Department, Indian Council of Medical Research, National Institute for Research in Reproductive Health, Jehangir Merwanji Street, Parel, Mumbai, 400012, India
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Babigumira JB, Barnhart S, Mendelsohn JM, Murenje V, Tshimanga M, Mauhy C, Holeman I, Xaba S, Holec MM, Makunike-Chikwinya B, Feldacker C. Cost-effectiveness analysis of two-way texting for post-operative follow-up in Zimbabwe's voluntary medical male circumcision program. PLoS One 2020; 15:e0239915. [PMID: 32997710 PMCID: PMC7526887 DOI: 10.1371/journal.pone.0239915] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 09/16/2020] [Indexed: 12/21/2022] Open
Abstract
Objective Although adverse events (AEs) following voluntary medical male circumcision (VMMC) are rare, their prompt ascertainment and management is a marker of quality care. The use of two-way text messaging (2wT) for client follow-up after VMMC reduces the need for clinic visits (standard of care (SoC)) without compromising safety. We compared the cost-effectiveness of 2wT to SoC for post-VMMC follow-up in two, high-volume, public VMMC sites in Zimbabwe. Materials and methods We developed a decision-analytic (decision tree) model of post-VMMC client follow-up at two high-volume sites. We parameterized the model using data from both a randomized controlled study of 2wT vs. SoC and from the routine VMMC program. The perspective of analysis was the Zimbabwe government (payer). The time horizon covered the time from VMMC to wound healing. Costs included text messaging; both in-person and outreach follow-up; and AE management. Costs were estimated in 2018 U.S. dollars. The outcome of analysis was AE yield relative to the globally accepted safety standard of a 2% AE rate. We estimated the incremental cost per percentage increase in AE ascertainment and the incremental cost per additional AE identified. We conducted univariate and probabilistic sensitivity analyses. Results 2wT increased the costs due to text messaging by $4.42 but reduced clinic visit costs by $2.92 and outreach costs by $3.61 –a net savings of $2.10. 2wT also increased AE ascertainment by 50% (92% AE yield in 2wT compared to 42% AE yield in SoC). Therefore, 2wT dominated SoC in the incremental analysis: 2wT was less costly and more effective. Results were generally robust to univariate and probabilistic sensitivity analysis. Conclusions 2wT is cost-effective for post-VMMC follow-up in Zimbabwe. Countries in which VMMC is a high-priority HIV prevention intervention should consider this mHealth intervention to reduce overall cost per VMMC, increasing the likelihood of current and future VMMC program sustainability.
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Affiliation(s)
- Joseph B. Babigumira
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, School of Pharmacy, University of Washington, Seattle, WA, United States of America
- * E-mail:
| | - Scott Barnhart
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
- Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Joanna M. Mendelsohn
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | - Vernon Murenje
- International Training and Education Center for Health (I-TECH), Harare, Zimbabwe
| | - Mufuta Tshimanga
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
| | - Christina Mauhy
- Zimbabwe Community Health Intervention Project (ZiCHIRE), Harare, Zimbabwe
| | | | | | - Marrianne M. Holec
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
| | | | - Caryl Feldacker
- Department of Global Health, University of Washington, Seattle, WA, United States of America
- International Training and Education Center for Health (I-TECH), Seattle, WA, United States of America
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Cost-effectiveness of integrated HIV prevention and family planning services for Zambian couples. AIDS 2020; 34:1633-1642. [PMID: 32701577 DOI: 10.1097/qad.0000000000002584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To present the incremental cost from the payer's perspective and effectiveness of couples' family planning counseling (CFPC) with long-acting reversible contraception (LARC) access integrated with couples' voluntary HIV counseling and testing (CVCT) in Zambia. This integrated program is evaluated incremental to existing individual HIV counseling and testing and family planning services. DESIGN Implementation and modelling. SETTING Fifty-five government health facilities in Zambia. SUBJECTS Patients in government health facilities. INTERVENTION Community health workers and personnel promoted and delivered integrated CVCT+CFPC from March 2013 to September 2015. MAIN OUTCOME MEASURES We report financial costs of actual expenditures during integrated program implementation and outcomes of CVCT+CFPC uptake and LARC uptake. We model primary outcomes of cost-per-: adult HIV infections averted by CVCT, unintended pregnancies averted by LARC, couple-years of protection against unintended pregnancy by LARC, and perinatal HIV infections averted by LARC. Costs and outcomes were discounted at 3% per year. RESULTS Integrated program costs were $3 582 186 (2015 USD), 82 231 couples received CVCT+CFPC, and 56 409 women received LARC insertions. The program averted an estimated 7165 adult HIV infections at $384 per adult HIV infection averted over a 5-year time horizon. The program also averted 62 265 unintended pregnancies and was cost-saving for measures of cost-per-unintended pregnancy averted, cost-per-couple-year of protection against unintended pregnancy, and cost-per-perinatal HIV infection averted assuming 3 years of LARC use. CONCLUSION Our intervention was cost-savings for CFPC outcomes and CVCT was effective and affordable in Zambia. Integrated couples-focused HIV and family planning was feasible, affordable, and leveraged HIV and unintended pregnancy prevention.
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Assebe LF, Negussie EK, Jbaily A, Tolla MTT, Johansson KA. Financial burden of HIV and TB among patients in Ethiopia: a cross-sectional survey. BMJ Open 2020; 10:e036892. [PMID: 32487582 PMCID: PMC7265036 DOI: 10.1136/bmjopen-2020-036892] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES HIV and tuberculosis (TB) are major global health threats and can result in household financial hardships. Here, we aim to estimate the household economic burden and the incidence of catastrophic health expenditures (CHE) incurred by HIV and TB care across income quintiles in Ethiopia. DESIGN A cross-sectional survey. SETTING 27 health facilities in Afar and Oromia regions for TB, and nationwide household survey for HIV. PARTICIPANTS A total of 1006 and 787 individuals seeking HIV and TB care were enrolled, respectively. OUTCOME MEASURES The economic burden (ie, direct and indirect cost) of HIV and TB care was estimated. In addition, the CHE incidence and intensity were determined using direct costs exceeding 10% of the household income threshold. RESULTS The mean (SD) age of HIV and TB patient was 40 (10), and 30 (14) years, respectively. The mean (SD) patient cost of HIV was $78 ($170) per year and $115 ($118) per TB episode. Out of the total cost, the direct cost of HIV and TB constituted 69% and 46%, respectively. The mean (SD) indirect cost was $24 ($66) per year for HIV and $63 ($83) per TB episode. The incidence of CHE for HIV was 20%; ranges from 43% in the poorest to 4% in the richest income quintile (p<0.001). Similarly, for TB, the CHE incidence was 40% and ranged between 58% and 20% among the poorest and richest income quintiles, respectively (p<0.001). This figure was higher for drug-resistant TB (62%). CONCLUSIONS HIV and TB are causes of substantial economic burden and CHE, inequitably, affecting those in the poorest income quintile. Broadening the health policies to encompass interventions that reduce the high cost of HIV and TB care, particularly for the poor, is urgently needed.
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Affiliation(s)
- Lelisa Fekadu Assebe
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
- Disease Prevention and Control, Ministry of Health, Addis Ababa, Ethiopia
| | | | - Abdulrahman Jbaily
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Mieraf Taddesse Taddesse Tolla
- Department Of Global Health and Population, Harvard T.H.Chan School of Public Health,Harvard University, Boston, Massachusetts, USA
| | - Kjell Arne Johansson
- Department Of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Bergen, Norway
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Nuwasiima A, Nuwamanya E, Babigumira JU, Nalwanga R, Asiimwe FT, Babigumira JB. Acceptability and utilization of family planning benefits cards by youth in slums in Kampala, Uganda. Contracept Reprod Med 2019; 4:10. [PMID: 31396395 PMCID: PMC6681485 DOI: 10.1186/s40834-019-0092-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/29/2019] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND This study was conducted to test the acceptability and utilization of family planning benefits cards (FPBCs) as incentives to increase family planning uptake among youth living in urban slums in Uganda. METHODS We conducted a one-year pilot study with two sub-studies on acceptability and utilization of FPBCs. The acceptability study utilized a quantitative cross-sectional design and was part of a baseline household survey while the utilization study was a primary analysis of claims and clinic data. We performed descriptive analyses and analyses of the association between different variables using binary logistic regression. RESULTS The acceptability study included 280 eligible females. The majority were married (52%), Christian (87%), and aged 20 and above (84%). Acceptability of the program was high (93%). Seventy-two percent of females used the card at least once to access reproductive health services. Twenty-seven percent of female users discontinued family planning and 14% changed family planning methods during the study. Female users of short-term contraceptive methods were 11 times more likely to discontinue use of FPBCs compared to those who used long-term methods (adjusted OR = 10.9, P = 0.011). Participants in professional/managerial employment were 30 times more likely to discontinue compared to the unemployed (adjusted OR = 30.3, P = 0.015). Participants of parity equal to two were 89% less likely to discontinue use of FPBCs compared to those of parity equal to zero (adjusted OR = 0.1, P = 0.019). CONCLUSION Family planning benefits cards, deployed as incentives to increase uptake of family planning, exhibited high acceptability and utilization by youth in urban slums in Uganda. There was evidence that use of short-term contraception methods, professional employment, and lower parity were associated with discontinuation of modern family planning methods after initial enrolment. TRIAL REGISTRATION MUREC1/7 No. 10/05-17. Registered 19th, July 2017.
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Affiliation(s)
| | | | | | | | | | - Joseph B. Babigumira
- Department of Global Health, University of Washington, 1959 NE Pacific Street, Health Sciences Building F-151-B, Box 357630, Seattle, WA 98195 USA
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Zakiyah N, van Asselt ADI, Setiawan D, Cao Q, Roijmans F, Postma MJ. Cost-Effectiveness of Scaling Up Modern Family Planning Interventions in Low- and Middle-Income Countries: An Economic Modeling Analysis in Indonesia and Uganda. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:65-76. [PMID: 30178267 DOI: 10.1007/s40258-018-0430-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES The aim was to estimate the long-term cost-effectiveness of improved family planning interventions to reduce the unmet need in low- and middle-income countries, with Indonesia and Uganda as reference cases. METHODS The analysis was performed using a Markov decision analytic model, where current situation and several scenarios to reduce the unmet need were incorporated as the comparative strategies. Country-specific evidence was synthesized from the demographic and health survey and published studies. The model simulated the sexual and reproductive health experience of women in the reproductive age range over a time horizon of women's reproductive years, from the healthcare payer perspective. Modeled outcomes included clinical events, costs and incremental cost-effectiveness ratios (ICERs) expressed as cost per disability-adjusted life year (DALY) averted. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty on modeled outcomes. RESULTS In the hypothetical cohort of 100,000 women, scenarios to reduce the unmet need for family planning would result in savings within a range of US$230,600-US$895,100 and US$564,400-US$1,865,900 in Indonesia and Uganda, respectively. The interventions would avert an estimated 1859-3780 and 3705-12,230 DALYs in Indonesia and Uganda, respectively. The results of our analysis indicate that scaling up family planning dominates the current situation in all scenarios in both countries, with lower costs and fewer DALYs. These results were robust in sensitivity analyses. CONCLUSION Scaling up family planning interventions could improve women's health outcomes substantially and be cost-effective or even cost saving across a range of scenarios compared to the current situation.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
| | - A D I van Asselt
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, The Netherlands
| | - D Setiawan
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Q Cao
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - F Roijmans
- Unit Training, Consultancy and Projects, i + Solutions, 3447 GN, Woerden, The Netherlands
| | - M J Postma
- Unit of PharmacoTherapy, Epidemiology and Economics (PTE2), Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, 9700 RB, Groningen, The Netherlands
- Department of Health Sciences, University Medical Center Groningen, University of Groningen, 9713 GZ, Groningen, The Netherlands
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11
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Nuwamanya E, Nuwasiima A, Babigumira JU, Asiimwe FT, Lubinga SJ, Babigumira JB. Study protocol: using a mobile phone-based application to increase awareness and uptake of sexual and reproductive health services among the youth in Uganda. A randomized controlled trial. Reprod Health 2018; 15:216. [PMID: 30577872 PMCID: PMC6303874 DOI: 10.1186/s12978-018-0642-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several cost-effective programs are being implemented around the world that use mobile technology to improve Sexual and Reproductive Health (SRH) uptake and awareness among youth. Mobile phone applications are a viable and effective means of increasing access to SRH services and tools in low and middle-income countries. This paper presents a protocol for a pilot study of a novel program, a mobile phone-based sexual and reproductive health services awareness and delivery application with the objective of increasing the demand for SRH services amongst the youth in Uganda. METHODS The study employs rigorous evaluation methods to ascertain the impact of the mobile application. We propose a randomized control trial study to determine the causal effect of the mobile phone app in creating awareness and increasing uptake of sexual and reproductive health services in Uganda. The main outcome of the impact evaluation is the percentage change in the SRH services and tools uptake, SRH knowledge and sexual behavior. We will also conduct a model-based incremental cost-effectiveness analysis (CEA) and budget impact analysis (BIA). The main outcomes of the economic evaluation will be the average cost per app user, cost per app service and tool provided. We will also test the in-app advertising model as a way to generate revenue to sustain the program subsidies and related costs. DISCUSSION The study seeks to establish the proof of concept of using a mobile application to increase create awareness and increase uptake of SRH tools and services among youth in Uganda. The study results will lead to the development of a demand-driven, culturally-relevant, and easy-to-use mobile app to enhance the uptake of SRH services among the youth in Uganda and globally. TRIAL REGISTRATION MUREC1/7 No. 07/05-18 . Registered 29th June 2018.
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Affiliation(s)
- Elly Nuwamanya
- Global Health Economics Ltd, P.O Box 27011, Kampala, Uganda
| | - Afra Nuwasiima
- Global Health Economics Ltd, P.O Box 27011, Kampala, Uganda
| | | | | | - Solomon J. Lubinga
- Global Medicines Program, Department of Global Health, University of Washington, P.O. Box 357630, Seattle, WA 98195 USA
| | - Joseph B. Babigumira
- Global Medicines Program, Department of Global Health, University of Washington, P.O. Box 357630, Seattle, WA 98195 USA
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12
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Målqvist M, Hultstrand J, Larsson M, Kc A. High levels of unmet need for family planning in Nepal. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 17:1-6. [PMID: 30193712 DOI: 10.1016/j.srhc.2018.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/12/2018] [Accepted: 04/29/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Providing access to family planning services is a basic component and a cost-effective intervention to reduce maternal mortality worldwide. It is closely linked to women's decision-making power and female emancipation. Unmet need for family planning is thus an indicator going beyond maternal health with far reaching societal implications. This study examines the level of unmet need for family planning in Nepal and its distribution along structural determinants. METHODS Data from the Multiple Indicator Cluster Survey 2014 was utilized for analysis. Prevalence of unmet need for family planning was calculated and logistic regression models used to ascertain inequity. RESULTS A total unmet need for family planning of 40.9% among the 10,688 included women was observed. No major differences between socioeconomic groups could be detected, except for a somewhat higher rate of unmet need among the least educated. Total fertility rate among the women included was 2.59. Contraceptive use among adolescents was alarmingly low, with almost none reporting using any type of contraception. CONCLUSION The lack of major inequity implies that the high level of unmet need for contraception is a general problem in society and must be addressed broadly. A special focus on education and provision for adolescents is needed in Nepal.
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Affiliation(s)
- Mats Målqvist
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Jenny Hultstrand
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Margareta Larsson
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.
| | - Ashish Kc
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; UN Health Section, UNICEF Nepal Country Office, UN House, Pulchowk, Nepal.
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13
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Shrime MG, Alkire BC, Grimes C, Chao TE, Poenaru D, Verguet S. Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist. World J Surg 2018; 41:1401-1413. [PMID: 28105528 DOI: 10.1007/s00268-017-3875-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold. METHODS The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created. RESULTS Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed. CONCLUSION Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.
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Affiliation(s)
- Mark G Shrime
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA.
- Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA.
| | - Blake C Alkire
- Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, USA
- Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Caris Grimes
- Kings Centre for Global Health and Kings Health Partners, Kings College, London, UK
| | - Tiffany E Chao
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Dan Poenaru
- MyungSung Medical College, Addis Ababa, Ethiopia
- Montreal Children's Hospital, Montreal, Canada
- Department of Surgery, McGill University, Montreal, Canada
| | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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14
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Nuwasiima A, Nuwamanya E, Navvuga P, Babigumira JU, Asiimwe FT, Lubinga SJ, Babigumira JB. Study protocol: incentives for increased access to comprehensive family planning for urban youth using a benefits card in Uganda. A quasi-experimental study. Reprod Health 2017; 14:140. [PMID: 29078815 PMCID: PMC5659021 DOI: 10.1186/s12978-017-0400-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/17/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of contraception is one of the most cost-effective public health interventions and has the potential to prevent about 30% of maternal and 10% of child deaths in developing countries. Voucher-based initiatives for family planning are an effective and viable means of increasing contraceptive use. In this paper, we present a protocol for a pilot study of a novel incentive, a family planning benefits card (FPBC) program to increase uptake of family planning services among urban poor youth in Uganda while leveraging private sector funding. METHODS The study employs both impact and health economic evaluation methods to assess the effect of the FPBC program. We propose a quasi-experimental study design with two separate pre- and post-samples to measure program effectiveness. The main outcome of the impact evaluation is the percentage change in the prevalence of modern contraceptive use and unmet need for contraception. We will also conduct model-based incremental cost-effectiveness and budget impact analyses. The main outcomes of the economic evaluation are the cost per enrolled youth and cost per pregnancy averted, and cost per disability-adjusted life-year (DALY) averted. We will also pilot a corporate social responsibility model of sponsorship for the FPBC program in partnership with local corporations. Budget impact analysis will examine the potential affordability of scaling up the FPBC program and the fiscal implications of this scale up to the corporate social responsibility (CSR) budgets of partner corporations, the government, and the individual taxpayer. DISCUSSION In this study, we propose an impact and economic evaluation to establish the proof concept of using a FPBC program to increase uptake of family planning services among urban poor youth in Uganda. The results of this study will present stakeholders in Uganda and internationally with a potentially viable option for corporate-sponsored access to family planning in urban poor communities. TRIAL REGISTRATION MUREC1/7 No. 10/05-17. Registered 19th July 2017.
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Affiliation(s)
- Afra Nuwasiima
- Global Health Economics Ltd, P.O Box 27011, Kampala, Uganda.
| | - Elly Nuwamanya
- Global Health Economics Ltd, P.O Box 27011, Kampala, Uganda
| | | | | | | | - Solomon J Lubinga
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, P.O. Box 357630, Seattle, WA, 98195, USA.,Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, 98195, USA
| | - Joseph B Babigumira
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, P.O. Box 357630, Seattle, WA, 98195, USA.,Global Medicines Program, Department of Global Health, University of Washington, Seattle, WA, 98195, USA
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Tibaijuka L, Odongo R, Welikhe E, Mukisa W, Kugonza L, Busingye I, Nabukalu P, Ngonzi J, Asiimwe SB, Bajunirwe F. Factors influencing use of long-acting versus short-acting contraceptive methods among reproductive-age women in a resource-limited setting. BMC WOMENS HEALTH 2017; 17:25. [PMID: 28376779 PMCID: PMC5379613 DOI: 10.1186/s12905-017-0382-2] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 03/30/2017] [Indexed: 11/27/2022]
Abstract
Background Unplanned pregnancy remains a common problem in many resource-limited settings, mostly due to limited access to modern family planning (FP) services. In particular, use of the more effective long-acting reversible contraceptive (LARC) methods (i.e., intrauterine devices and hormonal implants) remains low compared to the short-acting methods (i.e., condoms, hormonal pills, injectable hormones, and spermicides). Among reproductive-age women attending FP and antenatal care clinics in Uganda, we assessed perceptions and practices regarding the use of modern contraceptive methods. We specifically aimed to evaluate factors influencing method selection. Methods We performed a mixed-methods cross-sectional study, in which we administered structured interviews to 180 clients, and conducted 4 focus group discussions (FGDs) with 36 clients and 8 in-depth personal qualitative interviews with health service providers. We summarized quantitative data and performed latent content analysis on transcripts from the FGDs and qualitative interviews. Results The prevalence of ever use for LARC methods was 23%. Method characteristics (e.g., client control) appeared to drive method selection more often than structural factors (such as method availability) or individual client characteristics (such as knowledge and perceptions). The most common reasons for choosing LARC methods were: longer protection; better child-spacing; and effectiveness. The most common reasons for not choosing LARC methods included requiring a client-controlled method and desiring to conceive in the near future. The most common reasons for choosing short-acting methods were ease of access; lower cost; privacy; perceived fewer side effects; and freedom to stop using a method without involving the health provider. The personal characteristics of clients, which appeared to be important were client knowledge and number of children. The structural factor which appeared to be important was method availability. Conclusions Our results suggest that interventions to improve uptake of LARC among reproductive age women in this setting should consider: incorporating desired method-characteristics into LARC methods; targeted promotion and supply of LARC; and increased counselling, sensitization, and education.
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Affiliation(s)
- Leevan Tibaijuka
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda.
| | - Robert Odongo
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Emma Welikhe
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Wilber Mukisa
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Lilian Kugonza
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Imelda Busingye
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Phelomena Nabukalu
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joseph Ngonzi
- Department of Obstetrics and Gynecology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Stephen B Asiimwe
- Department of Internal Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda.,Department of Epidemiology and Biostatistics, University of California San Francisco, California, USA
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16
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Zakiyah N, van Asselt ADI, Roijmans F, Postma MJ. Economic Evaluation of Family Planning Interventions in Low and Middle Income Countries; A Systematic Review. PLoS One 2016; 11:e0168447. [PMID: 27992552 PMCID: PMC5167385 DOI: 10.1371/journal.pone.0168447] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 12/01/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND A significant number of women in low and middle income countries (L-MICs) who need any family planning, experience a lack in access to modern effective methods. This study was conducted to review potential cost effectiveness of scaling up family planning interventions in these regions from the published literatures and assess their implication for policy and future research. STUDY DESIGN A systematic review was performed in several electronic databases i.e Medline (Pubmed), Embase, Popline, The National Bureau of Economic Research (NBER), EBSCOHost, and The Cochrane Library. Articles reporting full economic evaluations of strategies to improve family planning interventions in one or more L-MICs, published between 1995 until 2015 were eligible for inclusion. Data was synthesized and analyzed using a narrative approach and the reporting quality of the included studies was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement. RESULTS From 920 references screened, 9 studies were eligible for inclusion. Six references assessed cost effectiveness of improving family planning interventions in one or more L-MICs, while the rest assessed costs and consequences of integrating family planning and HIV services, concerning sub-Saharan Africa. Assembled evidence suggested that improving family planning interventions is cost effective in a variety of L-MICs as measured against accepted international cost effectiveness benchmarks. In areas with high HIV prevalence, integrating family planning and HIV services can be efficient and cost effective; however the evidence is only supported by a very limited number of studies. The major drivers of cost effectiveness were cost of increasing coverage, effectiveness of the interventions and country-specific factors. CONCLUSION Improving family planning interventions in low and middle income countries appears to be cost-effective. Additional economic evaluation studies with improved reporting quality are necessary to generate further evidence on costs, cost-effectiveness, and affordability, and to support increased funding and investments in family planning programs.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Antoinette D I van Asselt
- Unit of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frank Roijmans
- Unit Training, Consultancy and Projects, i+Solutions, Woerden, The Netherlands
| | - Maarten J Postma
- Unit of PharmacoTherapy, -Epidemiology & -Economics (PTEE), Department of Pharmacy, University of Groningen, Groningen, The Netherlands.,Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Institute of Science in Healthy Aging & healthcaRE (SHARE), University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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17
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Lubinga SJ, Atukunda EC, Wasswa-Ssalongo G, Babigumira JB. Potential Cost-Effectiveness of Prenatal Distribution of Misoprostol for Prevention of Postpartum Hemorrhage in Uganda. PLoS One 2015; 10:e0142550. [PMID: 26560140 PMCID: PMC4641649 DOI: 10.1371/journal.pone.0142550] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 10/25/2015] [Indexed: 11/23/2022] Open
Abstract
Background In settings where home birth rates are high, prenatal distribution of misoprostol has been advocated as a strategy to increase access to uterotonics during the third stage of labor to prevent postpartum hemorrhage (PPH). Our objective was to project the potential cost-effectiveness of this strategy in Uganda from both governmental (the relevant payer) and modified societal perspectives. Methods and Findings To compare prenatal misoprostol distribution to status quo (no misoprostol distribution), we developed a decision analytic model that tracked the delivery pathways of a cohort of pregnant women from the prenatal period, labor to delivery without complications or delivery with PPH, and successful treatment or death. Delivery pathway parameters were derived from the Uganda Demographic and Health Survey. Incidence of PPH, treatment efficacy, adverse event and case fatality rates, access to misoprostol, and health resource use and cost data were obtained from published literature and supplemented with expert opinion where necessary. We computed the expected incidence of PPH, mortality, disability adjusted life years (DALYs), costs and incremental cost effectiveness ratios (ICERs). We conducted univariate and probabilistic sensitivity analyses to examine robustness of our results. In the base-case analysis, misoprostol distribution lowered the expected incidence of PPH by 1.0% (95% credibility interval (CrI): 0.55%, 1.95%), mortality by 0.08% (95% CrI: 0.04%, 0.13%) and DALYs by 0.02 (95% CrI: 0.01, 0.03). Mean costs were higher with prenatal misoprostol distribution from governmental by US$3.3 (95% CrI: 2.1, 4.2) and modified societal (by US$1.3; 95% CrI: -1.6, 2.8) perspectives. ICERs were US$191 (95% CrI: 82, 443) per DALY averted from a governmental perspective, and US$73 (95% CI: -86, 256) per DALY averted from a modified societal perspective. Conclusions Prenatal distribution of misoprostol is potentially cost-effective in Uganda and should be considered for national-level scale up for prevention of PPH.
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Affiliation(s)
- Solomon J. Lubinga
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, Washington, United States of America
- * E-mail:
| | - Esther C. Atukunda
- Department of Pharmacology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - George Wasswa-Ssalongo
- Department of Obstetrics and Gynecology, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Joseph B. Babigumira
- Pharmaceutical Outcomes Research and Policy Program, Department of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Global Medicines Program, Department of Global Health, University of Washington, Seattle, Washington, United States of America
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18
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Kibira SPS, Muhumuza C, Bukenya JN, Atuyambe LM. "I Spent a Full Month Bleeding, I Thought I Was Going to Die…" A Qualitative Study of Experiences of Women Using Modern Contraception in Wakiso District, Uganda. PLoS One 2015; 10:e0141998. [PMID: 26524603 PMCID: PMC4629884 DOI: 10.1371/journal.pone.0141998] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 10/15/2015] [Indexed: 11/18/2022] Open
Abstract
Introduction There is high unmet need for family planning (FP) in Uganda as well as high contraceptive discontinuation rates. These contribute to the high fertility rates that in part are due to unplanned pregnancies. There are gaps in knowledge about experiences that couples go through while using contraceptives in their lives. This study explored women’s experiences during the course of their contraceptive use. Methods We conducted a qualitative study involving 30 women who had used modern contraception for at least one year in Wakiso district, central Uganda. We used in-depth interviews to obtain their personal accounts. Index women were approached through health officers at four health centres in the district. All ethical approvals and informed consent were obtained. We used conventional content analysis; identifying codes through open coding, on which basis categories were developed and grouped into overarching themes. Results Women’s accounts were summarised in the following themes: negative experiences with modern contraceptive use, motivation to continue using FP in spite of these negative experiences, the role of influential people, and discontinuation of use. Negative accounts dominated the experiences of most women but they expressed strong desire to continue using modern contraception even amidst all challenges. Health workers emerged as the most influential people that played a vital role in women’s decisions. Conclusion Varied negative experiences with modern contraception and misperceptions exist amidst a determination to continue use. Partner engagement, health service strengthening to improve side effects management and health worker skills, and engaging older women that have successfully used contraception as community champions, are potential strategies to support women’s contraceptive decisions.
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Affiliation(s)
- Simon P. S. Kibira
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
- Centre for International Health, Department of Global Public Health and Primary care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
- * E-mail:
| | - Christine Muhumuza
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Justine N. Bukenya
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Lynn M. Atuyambe
- Department of Community Health and Behavioural Sciences, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Diamond-Smith NG, Moreau C, Bishai DM. Reducing unintended pregnancies: a microsimulation of contraceptive switching, discontinuation, and failure patterns in france. Stud Fam Plann 2015; 45:429-41. [PMID: 25469928 DOI: 10.1111/j.1728-4465.2014.00006.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although the rate of contraceptive use in France is high, more than one-third of pregnancies are unintended. We built a dynamic microsimulation model that applies data from the French COCON study on method switching, discontinuation, and failure rates to a hypothetical population of 20,000 women, followed for five years. We use the model to estimate the adjustment factor needed to make the survey data fit the demographic profile of France by adjusting for underreporting of contraceptive nonuse and abortion. We then test three behavior-change scenarios that could reduce unintended pregnancies: decreasing method failure, increasing time using effective methods, and increasing switching from less effective to more effective methods. Our model suggests that decreasing method failure is the most effective means of reducing unintended pregnancies, but we found that all of the scenarios reduced unintended pregnancies by at least 25 percent. Dynamic microsimulations may have great potential in reproductive health research and prove useful for policymakers.
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Affiliation(s)
- Nadia G Diamond-Smith
- Postdoctoral fellow, Global Health Group, University of California, San Francisco, 50 Beale Street, 12th Floor, San Francisco, CA 94105..
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Morse JE, Rowen TS, Steinauer J, Byamugisha J, Kakaire O. A qualitative assessment of Ugandan women's perceptions and knowledge of contraception. Int J Gynaecol Obstet 2013; 124:30-3. [PMID: 24156991 DOI: 10.1016/j.ijgo.2013.07.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 07/08/2013] [Accepted: 09/18/2013] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To determine Ugandan women's perceptions and knowledge of contraception. METHODS Healthy prepartum women were recruited from a national referral and university teaching hospital to participate in 1 of 5 focus group discussions on contraception. Transcripts were translated and coded by 2 researchers using inductive and deductive methods. RESULTS Forty-six women participated in the focus group discussions. The major themes that emerged were around family planning as a method to space pregnancies and manage finances, as well as men's roles in decision making regarding contraception. Notable among the many incorrect notions about adverse effects of contraception were fears about cancer and infertility. CONCLUSION The results indicate that, among the study group of Ugandan women, decision making regarding family planning involves a complex negotiation among women, partners, and families. Furthermore, pervasive myths may hinder a woman's ability to choose safe and effective contraception. These findings are useful to healthcare providers and the greater public-health community.
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Affiliation(s)
- Jessica E Morse
- Department of Obstetrics and Gynecology, Duke University, Durham, USA.
| | - Tami S Rowen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Jody Steinauer
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, USA
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, Makerere University, Kampala, Uganda
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Lubinga SJ, Levine GA, Jenny AM, Ngonzi J, Mukasa-Kivunike P, Stergachis A, Babigumira JB. Health-related quality of life and social support among women treated for abortion complications in western Uganda. Health Qual Life Outcomes 2013; 11:118. [PMID: 23855524 PMCID: PMC3718758 DOI: 10.1186/1477-7525-11-118] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 07/10/2013] [Indexed: 12/05/2022] Open
Abstract
Background While the impact of abortion complications on clinical outcomes and healthcare costs has been reported, we found no reports of their impact on Health-Related Quality of Life (HRQoL), nor the role of social support in moderating such outcomes. In this study, we performed an assessment of the relationship between abortion complications, HRQoL and social support among women in Uganda. Methods We interviewed women who were discharged after treatment for abortion complications and, as a comparison, women visiting a regional referral hospital for routine obstetric care. We administered the EuroQol instrument and the Social Support Questionnaire Short-Form, and collected demographic and socioeconomic data. We performed descriptive analyses using t-tests, Wilcoxon rank-sum tests and chi-square tests, and multivariable linear regressions with interaction effects to examine the associations between abortion complications, EQ-5D utility scores and social support. Results Our study included 139 women (70 with abortion complications, and 69 receiving routine obstetric care). In four out of the 5 dimensions of the EQ-5D, a larger proportion of women with abortion complications reported “some or severe” problems than women receiving routine obstetric care (self-care: 42% v 24%, p=0.033; usual activities: 49% v 16%, p<0.001; pain/discomfort: 68% v 25%, p<0.001; and anxiety/depression: 60% v 22%, p<0.001). After adjusting for age, social support, wealth tertile, employment status, marital status, and HIV status, women with abortion complications had a 0.12 (95% CI: 0.07, 0.18, p < 0.001) lower mean EQ-5D utility score than those receiving routine obstetric care. An analysis of the modifying effect of social support showed that a one-unit higher average number of people providing social support was associated with larger mean difference in EQ-5D utility score when comparing the two groups, while a one unit higher average satisfaction score with social support was associated with smaller mean differences in EQ-5D utility score. Conclusions Our study suggests that abortion complications are associated with diminished HRQoL and the magnitude of the association depends on social support. However, the mediating role of social support in a setting of social and legal proscriptions to induced abortion is complex.
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Affiliation(s)
- Solomon J Lubinga
- Department of Pharmacy, Pharmaceutical Outcomes Research and Policy Program, University of Washington, Seattle, WA, USA.
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Aremu O. The influence of socioeconomic status on women's preferences for modern contraceptive providers in Nigeria: a multilevel choice modeling. Patient Prefer Adherence 2013; 7:1213-20. [PMID: 24353406 PMCID: PMC3862587 DOI: 10.2147/ppa.s51852] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Contraceptives are one of the most cost effective public health interventions. An understanding of the factors influencing users' preferences for contraceptives sources, in addition to their preferred methods of contraception, is an important factor in increasing contraceptive uptake. This study investigates the effect of women's contextual and individual socioeconomic positions on their preference for contraceptive sources among current users in Nigeria. METHODS A multilevel modeling analysis was conducted using the most recent 2008 Nigerian Demographic and Health Surveys data of women aged between 15 and 49 years old. The analysis included 1,834 ever married women from 888 communities across the 36 states of the federation, including the Federal Capital Territory of Abuja. Three outcome variables, private, public, and informal provisions of contraceptive sources, were considered in the modeling. RESULTS There was variability in women's preferences for providers across communities. The result shows that change in variance accounted for about 31% and 19% in the odds of women's preferences for both private and public providers across communities. Younger age and being from the richest households are strongly associated with preference for both private and public providers. Living in rural areas and economically deprived neighborhoods were the community level determinants of women's preferences. CONCLUSION This study documents the independent association of contextual socioeconomic characteristics and individual level socioeconomic factors with women's preferences for contraceptive commodity providers in Nigeria. Initiatives that seek to improve modern contraceptive uptake should jointly consider users' preferences for sources of these commodities in addition to their preference for contraceptive type.
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Affiliation(s)
- Olatunde Aremu
- School of Health, Sport, and Bioscience, Health Studies Field, University of East London, London, United Kingdom
- Correspondence: Olatunde Aremu, University of East London, Romford Road, Stratford, London, E15 4LZ, United Kingdom, Tel +44 77 6267 4797, Fax +44 20 8223 4965, Email ;
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