Implementing standard antenatal care interventions: health system cost at primary health facilities in Tanzania

Background Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system are unknown, particularly in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania. Methods We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Costs were collected in Tanzanian shillings and converted to 2018 US$. Results The health system cost of providing ANC services at six facilities (2 health centres and 4 dispensaries) was US$185,282 under the focused model. We estimated that the cost would increase by about 90% at health centres and 97% at dispensaries to US$358,290 by introducing the standard model. Personnel cost accounted for more than one third of the total cost, and more than two additional nurses are required per facility for the standard model. The costs per pregnancy increased from about US$33 to US$63 at health centres and from about US$37 to US$72 at dispensaries. Conclusion Introduction of a standard ANC model at primary health facilities in Tanzania may double resources requirement compared to current practice. Resources availability has been one of the challenges to effective implementation of the current focused ANC model. More research is required, to consider whether the additional costs are reasonable compared to the additional value for maternal and child health.

Health System Cost of Post-Abortion Care (PAC): A Systematic Review

Background: Despite the increasing trend of Post Abortion Care (PAC) needs and provision, the evidence related to its health system cost is lacking. The study aims to review the health system costs of Post-Abortion Care (PAC) per patient at a national level.Methods: A systematic review of literatures related to PAC cost published in 1994 – October 2020 was performed. Electronic databases such as PubMed, Medline, The Cochrane Library, CINAHL, and PsycINFO were used to search the literature. Following the title and abstract screening, reporting quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. PAC costs were extrapolated into, US dollars ($US) and international dollars ($I), both in 2019. Content analysis was also conducted to synthesize the qualitative findings.Results: Twelve studies met the inclusion criteria. All studies reported direct medical cost per patient in accessing PAC, but only three of them included indirect medical cost. All studies reported either average or range of cost. In terms of range, The highest direct cost of PAC with MVA (Medical Vacuum Aspiration) services can be found in Colombia, between $US50.58-212.47, while the lowest is in Malawi ($US15.2-139.19). The highest direct cost of PAC with D&C (Dilatation and Curettage), services was in El Salvador ($US65.22-240.75), while the lowest is in Bangladesh ($US15.71-103.85). Among two studies providing average indirect cost data, Uganda with $US105.04 is the highest average indirect medical cost, while Rwanda with $US51.44 is the lowest on the cost of indirect medical.Conclusions: Our review shows variability in cost of PAC across countries. This study depicts a clearer picture of how costly it is for women to access PAC service, although it is still seemingly underestimated. When a study compared the use of UE method between MVA and D&C, it is confirmed that MVA treatments tend to have lower costs and potentially reduce a significant cost. Therefore, by looking at both clinical and economic perspective, improving and strengthening the quality and accessibility of PAC with MVA is a priority.

Active Lives South Australia health economic analysis: an evidence base for the potential of health promotion strategies supporting physical activity guidelines to reduce public health costs while improving wellbeing

Aim The COVID-19 pandemic has threatened individual and population wellbeing and strategies to jointly address these challenges within budget constraints are required. The aim of our research is to analyse evidence from the Active Lives South Australia study to consider the potential of physical activity (PA) health promotion strategies to be health-system cost saving while addressing wellbeing challenges. Methods The Active Lives South Australia study compares adult populations who meet and do not meet physical activity (PA) guidelines (150+ minutes of weekly physical activity) with respect to their subjective wellbeing and health care utilisation. Subject and results Adults who met PA guidelines had better wellbeing across all aspects with and without adjustment for age, sex and income covariates. Analysis showed significant associations between meeting guidelines and lower probabilities of visiting and utilisation of GPs, specialist doctors, other health professionals, hospital inpatient admissions, outpatient clinic and emergency department visits, and an overall A$1760 lower cost per person annually. Controlling for age, sex and income, health expenditure for adults who met PA guidelines was significantly lower by A$1393 per person annually. That translated to A$804 million potential annual SA health system cost saving by shifting all adults to meeting PA guidelines. Conclusion There is significant potential for effective health promotion strategies to be net cost saving while addressing wellbeing challenges of COVID-19 recovery where they can shift target populations from not meeting to meeting PA guidelines.

Health System Cost of Post-Abortion Care (PAC): A Systematic Review

Background: Despite the increasing trend of Post Abortion Care (PAC) needs and provision, the evidence related to its health system cost is lacking. The study aims to review the health system costs of Post-Abortion Care (PAC) per patient at a national level.Methods: A systematic review of literatures related to PAC cost published in 1994 – October 2020 was performed. Electronic databases such as PubMed, Medline, The Cochrane Library, CINAHL, and PsycINFO were used to search the literature. Following the title and abstract screening, reporting quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. PAC costs were extrapolated into, US dollars ($US) and international dollars ($I), both in 2019. Content analysis was also conducted to synthesize the qualitative findings.Results: Twelve studies met the inclusion criteria. All studies reported direct medical cost per patient in accessing PAC, but only three of them included indirect medical cost. All studies reported either average or range of cost. In terms of range, The highest direct cost of PAC with MVA (Medical Vacuum Aspiration) services can be found in Colombia, between $US50.58-212.47, while the lowest is in Malawi ($US15.2-139.19). The highest direct cost of PAC with D&C (Dilatation and Curettage), services was in El Salvador ($US65.22-240.75), while the lowest is in Bangladesh ($US15.71-103.85). Among two studies providing average indirect cost data, Uganda with $US105.04 is the highest average indirect medical cost, while Rwanda with $US51.44 is the lowest on the cost of indirect medical.Conclusions: Our review shows variability in cost of PAC across countries. This study depicts a clearer picture of how costly it is for women to access PAC service, although it is still seemingly underestimated. When a study compared the use of UE method between MVA and D&C, it is confirmed that MVA treatments tend to have lower costs and potentially reduce a significant cost. Therefore, by looking at both clinical and economic perspective, improving and strengthening the quality and accessibility of PAC with MVA is a priority.

Multiple effects health economic evaluation of the Ahead of The Game Study for mental health promotion in sporting club communities

Background This study evaluates the Ahead Of The Game (AOTG) mental health promotion strategy for adolescent males relative to usual practice in team based sporting club community settings, allowing for joint incremental effects across 13 dimensions and 5 domains alongside intervention implementation costs. Methods Analysis is undertaken between matched communities with difference in differences analysis of joint multiple pre-post effect changes alongside implementation costs employing radar plots in cost-disutility space. A robust bootstrapping method allowed including all observed change in effect data from 343 AOTG and 273 control arm participants across 13 effect dimensions. Results Triangulation across joint evidence shows mean incremental effects favoured AOTG in all dimensions (10/13 significantly at 5% level) and in simple aggregation to each of five pre-specified 5 domains (each significant at < 1% level) and global measures (significant at 0.001% level), while mean AOTG implementation costs were conservatively estimated as $37.47 per participant. Conclusion The AOTG strategy was found to represent an effective mental health promotion strategy across all domains and globally with associated significant potential for downstream health system cost savings to offset against modest implementation costs. Evaluation methods extend conventional cost-effectiveness analysis to enable robust joint presentation and triangulation under uncertainty of multiple effect dimensions alongside costs. Trial registration ANZCTR, ACTRN12617000709347. Registered 17th May 2017.

The health system costs of post abortion care in Tanzania

Background Unsafe abortion is common in Tanzania. Currently, postabortion care (PAC) is legally provided, but there is little information on the national cost. We estimated the health system costs of offering PAC in Tanzania in 2018, at existing levels of care and when hypothetically expanded to meet all need. Methods We employed a bottom-up costing methodology. Between October 2018 and February 2019, face-to-face interviews were conducted with facility administrators and PAC providers in a sample of 40 health facilities located across seven mainland regions and Zanzibar. We collected data on the direct and indirect cost of care, fees charged to patients, and costs incurred by patients for PAC supplies. Sensitivity analysis was used to explore the impact of uncertainty in the analysis. Results Overall, 3850 women received PAC at the study facilities in 2018. At the national level, 77,814 women received PAC, and the cost per patient was $58. The national health system cost for PAC provision at current levels totaled nearly $4.5 million. Meeting all need for PAC would increase costs to over $11 million. Public facilities bore the majority of PAC costs, and facilities recovered just 1% of costs through charges to patients. On average PAC patients incurred $7 in costs ($6.17 for fees plus $1.35 in supplies). Conclusions Resources for health care are limited. While working to scale up access to PAC services to meet women’s needs, Tanzanian policymakers should consider increasing access to contraception to prevent unintended pregnancies.

Implementing Standard Antenatal Care Interventions: Health System Cost at Primary Health Facilities in Tanzania.

Background Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system is unknown, particulary in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania. Methods We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Cost were collected in Tanzanian shillings and converted to 2018 US$. Results The health system cost of providing ANC services was US$185,282 under the focused model and the cost increased by about 90% at health centres and 97% at dispensaries to US$358,290 for the standard model. Personnel cost accounted for more than one third of the total cost for both models. With the standard model, costs per pregnancy increased from about US$33 to US$63 at health centres and from about US$37 to US$72 at dispensaries Conclusion Introduction of a standard ANC model at primary healthcare facilities in Tanzania will double resources use compared to current practice. While resources availability has been one of the challenge to effective implementation of the focused ANC model, more research is required, to consider whether these costs are reasonable compared to the additional value for maternal and child health.

Cost analysis of pediatric intensive care: a low-middle income country perspective

Background Globally, Pediatric Intensive Care Unit (PICU) admissions are amongst the most expensive. In low middle-income countries, out of pocket expenditure (OOP) constitutes a major portion of the total expenditure. This makes it important to gain insights into the cost of pediatric intensive care. We undertook this study to calculate the health system cost and out of pocket expenditure incurred per patient during PICU stay. Methods Prospective study conducted in a state of the art tertiary level PICU of a teaching and referral hospital. Bottom-up micro costing methods were used to assess the health system cost. Annual data regarding hospital resources used for PICU care was collected from January to December 2018. Data regarding OOP was collected from 299 patients admitted from July 2017 to December 2018. The latter period was divided into four intervals, each of four and a half months duration and data was collected for 1 month in each interval. Per patient and per bed day costs for treatment were estimated both from health system and patient’s perspective. Results The median (inter-quartile range, IQR) length of PICU stay was 5(3–8) days. Mean ± SD Pediatric Risk of Mortality Score (PRISM III) score of the study cohort was 22.23 ± 7.3. Of the total patients, 55.9% (167) were ventilated. Mean cost per patient treated was US$ 2078(₹ 144,566). Of this, health system cost and OOP expenditure per patient were US$ 1731 (₹ 120,425) and 352 (₹ 24,535) respectively. OOP expenditure of a ventilated child was twice that of a non- ventilated child. Conclusions The fixed cost of PICU care was 3.8 times more than variable costs. Major portion of cost was borne by the hospital. Severe illness, longer ICU stay and ventilation were associated with increased costs. This study can be used to set the reimbursement package rates under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Tertiary level intensive care in a public sector teaching hospital in India is far less expensive than developed countries.

Cost Analysis of Pediatric Intensive Care: A Low-Middle Income Country Perspective

Background: Globally, Pediatric Intensive Care Unit (PICU) admissions are amongst the most expensive. This makes it important to gain insights into the cost of pediatric intensive care units. We undertook this study to calculate the health system cost and out of pocket expenditure incurred per patient during Pediatric Intensive Care Unit (PICU) stayMethods: Prospective study conducted in a state of art tertiary level PICU of a teaching and referral hospital. Bottom-up micro costing methods were used to assess the health system cost. Annual data regarding hospital resources used for PICU care was collected from January 2018 to December 2018. Data regarding out of pocket expenditure (OOP) was collected from 299 patients who were admitted from July 2017 to December 2018. The study period was divided into four intervals, each of 4 and a half months duration and data was collected for 1 month in each interval. Per patient and per bed day costs for treatment were estimated both from health system and patient’s perspective. Results: The median (inter-quartile range, IQR) length of PICU stay was 5(3–8) days. Mean ± SD PRISM score of the study cohort was 22.23 ± 7.3. Of the total patients, 55.9% (167) were ventilated. Mean cost per patient treated was US$ 2,078(₹ 144,566). Of this, health system cost and OOP expenditure per patient were US$ 1,731 (₹ 120,425) and 352 (₹ 24,535) respectively. OOP expenditure of a ventilated child was twice that of a non‐ ventilated child. Conclusions: The fixed cost of PICU care were 3.5 times more than variable costs. Major portion of cost is borne by hospital. Severe illness, longer ICU stay and ventilation were associated with increased costs. This study can be used to set the reimbursement package rates under Ayushman Bharat – Pradhan Mantri Jan Arogya Yojana (AB-PMJAY). Tertiary care state of art intensive care in a public sector teaching hospital in India is far less expensive than developed countries.