Figures & Tables
Figures
- FIGURE 1
Results of Sensitivity Analysis for Uganda and Zambia
Tables
Activity or Intervention Implemented in Uganda, Zambia, or Botha Activities targeting delay 1b Train community groups (VHTs and SMAGs) to promote facility delivery and birth preparedness Uganda and Zambia Procure bicycles, equipment, and supplies for community groups Uganda and Zambia Provide financial support to community activities (e.g., funding to attend monthly meetings, supervision costs, community assessment mappings) Uganda and Zambia Produce a documentary about safe motherhood using traditional leaders Zambia Run mass media campaigns on safe motherhood (including development of materials, air time costs, and translation costs), engage community drama groups Uganda and Zambia Identify and engage community change champions in safe motherhood Zambia Provision of revolving Fund for Village Saving Schemes Uganda MNH outreach (project or community staff visits to communities) Uganda and Zambia Activities targeting delay 2b Distribution of subsidized vouchers for transport to delivery in EmONC facilities, public and private(transport to antenatal and postnatal care were added in Phase 2) Uganda Procurement of ambulances, motorcycles, and motorbikes for transportation and referrals Uganda and Zambia District-level transport committees to improve referral Uganda Renovate MWHs near hospitals for high-risk women Uganda and Zambia, primarily Zambia Train MWH staff to operate maternity homes; costs and revenue from income-generating activities; provision of food for those in maternity homes (as applicable) Zambia Activities targeting delay 3b Provide antenatal care Uganda and Zambia Provide basic delivery care Uganda and Zambia Provision of comprehensive emergency care (blood transfusion/cesarean delivery) Uganda and Zambia Upgrade care in neonatal special care units, including purchase of equipment, training, and provision of essential medicines Uganda and Zambia Increase facility EmONC capacity, including purchase of EmONC equipment and provision of essential medicines Uganda and Zambia Establish/expand/refurbish maternity blocks, neonatal special care units, laboratories, pharmacies, and operating theaters Uganda and Zambia Hire new doctors, nurses, and midwives Uganda and Zambia, primarily Uganda Train health workers in essential newborn care and neonatal resuscitation Uganda and Zambia Train doctors in surgical obstetric care and nurses in anesthesia, train/mentor nurses in basic EmONC Uganda and Zambia Other training and mentoring (e.g., rapid syphilis screening, PMTCT, essential newborn care, UBT, maternal and perinatal death reviews) Uganda and Zambia; UBT in Zambia Supervision of frontline workers to maintain/improve skills in obstetrics/newborn care Uganda and Zambia Provide essential medicines Uganda and Zambia Provide training and oversight for maternal death reviews Uganda and Zambia Conduct health facility assessments Uganda and Zambia Health systems strengthening and program managementc Strengthen supply chain through training on procurement and stock management Uganda and Zambia Build capacity of facility staff to supervise community health workers (first delay) Zambia Provide computer-based medical records (SmartCare) Zambia Strengthen pharmacy, laboratory, and blood supply Uganda and Zambia Train health workers in data collection and health information systems (DHIS2) Uganda and Zambia Strengthen program management (staff, vehicles, meetings, workshops, etc., including management of SMGL program, monitoring and evaluation, etc.) (above facility costs) Uganda and Zambia Build provincial and district health team capacity with SMGL-supported staff (above facility costs) Uganda and Zambia ↵Abbreviations: DHIS2, district health information system 2; EmONC, emergency obstetric and neonatal care; MNH, maternal and newborn health; MWH, maternity waiting home; PMTCT, prevention of mother-to-child transmission; SMAG, Safe Motherhood Action Group; SMGL, Saving Mothers, Giving Life; UBT, uterine balloon tamponade; VHT, Village Health Team.
a In countries shown in boldface, the activities were conducted in both SMGL and comparison districts, although frequently at lower intensity/scale in comparison districts than in SMGL districts. Source: Interviews with implementing partners and district and provincial health office staff.
↵b Primary delay addressed refers to which of the 3 delays the activities is assumed to mainly address (since some of the inputs/activities may address more than one).
↵c Categorized as primarily addressing the third delay unless otherwise noted.
- TABLE 2.
Parameters Used to Calculate District Costs of MNH Care, Life-Years Lost Due to Maternal Death, and Incremental Cost-Effectiveness of Deaths Averted
Number Parameter Value Data Source Notes Costs (all) 1 Discount rate 3% WHO-CHOICE recommendation34 Locally published discount rates used in sensitivity analysis (15% in Uganda and 9.7% in Zambia)35,36 Costs 2012 2 Costs associated with the first delay Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, and implementing partners in comparison districts Interviews covered the period 2012 through 2016; start-up activities and capital costs were tracked. Costs for existing maternity waiting homes are included. 3 Costs associated with the second delay Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, implementing partners, and review of ambulance log books in comparison districts Interviews covered the period 2012 through 2016; start-up activities and capital costs were tracked. 4 Unit cost of ANC Varies by type of facility (see Table 3) Data collection at health facilities in comparison districts, interviews with implementing partners Inclusive of facility overhead costs 5 Number of ANC visits Ratio of ANC visits to number of facility births Data from health facility registers/district health offices in comparison districts Number of facility births based on SMGL districts data from 2012 6 Unit cost of vaginal delivery Varies by type of facility (see Table 3) Data collection at health facilities in comparison districts, interviews with implementing partners Inclusive of facility overhead costs and admissions (for mother and newborn) 7 Number of vaginal deliveries Varies by district Data from health facility registers/district health offices in comparison districts, Serbanescu and colleagues30 Number for SMGL districts in 2012 8 Unit cost of cesarean delivery Varies by type of facility (see Table 3) Data collection at health facilities in comparison districts, interviews with implementing partners Inclusive of facility overhead costs and admissions (for mother and newborn) 9 Number of cesarean deliveries Varies by district Data from health facility registers/district health offices in comparison districts, Serbanescu and colleagues30 Number for SMGL districts in 2012 10 Above community/facility costs Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, and implementing partners in comparison districts Interviews covered the period 2012 through 2016; start-up activities and capital costs were tracked. 11 Total costs of MNH care in 2012 Calculation Based on parameters 2–10 Costs 2016 12 Costs associated with the first delay Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, and implementing partners in SMGL districts Interviews covered the period 2012 through 2016; start-up activities and capital costs tracked. Costs for maternity waiting homes are included. 13 Costs associated with the second delay Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, implementing partners, and review of ambulance log books in SMGL districts Interviews covered the period 2012 through 2016; start-up activities and capital costs were tracked. 14 Unit cost of ANC Varies by type of facility (see Table 3) Data collection at health facilities in SMGL districts, interviews with implementing partners Inclusive of facility overhead costs 15 Number of ANC visits Ratio of ANC visits to number of facility births Data from health facility registers/district health offices in SMGL districts Number of facility births based on SMGL districts data from 2016 16 Unit cost of vaginal delivery Varies by type of facility (see Table 3) Data collection at health facilities in SMGL districts, interviews with implementing partners. Inclusive of facility overhead costs and admissions (for mother and newborn) 17 Number of vaginal deliveries Varies by district Serbanescu and colleagues30 Number for SMGL districts in 2016 18 Unit cost of cesarean delivery Varies by type of facility (see Table 3) Data collection at health facilities in SMGL districts, interviews with implementing partners Inclusive of facility overhead costs and admissions (for mother and newborn) 19 Number of cesarean deliveries Varies by district Data from health facility registers/district health offices in SMGL districts, Serbanescu and colleagues30 Number for SMGL districts in 2016 20 Above community/ facility costs Varies by district (see Table 4) Interviews with health facility staff, district health office staff, provincial health office staff, and implementing partners in comparison districts Interviews covered the period 2012 through 2016; start-up activities and capital costs were tracked. 21 Total costs of MNH care in 2016 Calculation Based on parameters 12–20 In Uganda, included cost of patients referred to Fort Portal referral hospital Deaths in 2012 22 Number of facility-based deliveries Varies by district POMS and unpublished district data,31 district offices in SMGL districts Number of deliveries for SMGL districts in 2016 multiplied by the institutional delivery rate in 2012 23 Maternal death ratio 534 deaths (Uganda) and 370 deaths (Zambia) per 100,000 live births Serbanescu and colleagues30 24 Perinatal death rate 39.3 (Uganda) and 37.9 deaths (Zambia) per 1,000 births Serbanescu and colleagues30 25 Number of maternal deaths Calculation Parameter 22 × proportion of deliveries with live births/100,000 × Parameter 23 26 Number of perinatal deaths Calculation Parameter 22/1,000 × Parameter 24 27 Total number of deaths Calculation Parameter 25 + Parameter 26 28 Life-years lost due to death Years of life left estimated as 62.5 and 45.6 for perinatal and maternal death in Uganda and 62.3 and 45.7 for perinatal and maternal death in Zambia WHO life tables40,41 Assume average age at death for maternal death is 27.5, for perinatal in first 2 days of life Deaths in 2016 29 Number of facility-based deliveries Varies by district POMS and unpublished district data,31 district offices in SMGL districts Number for SMGL districts in 2016; varied in sensitivity analysis based on results for all SMGL districts24 30 Maternal death ratio 300 deaths (Uganda) and 231 deaths (Zambia) per 100,000 live births Serbanescu and colleagues30 Decreased the percentage reduction in deaths results by 10 percentage points in sensitivity analysis 31 Perinatal death rate 34.4 (Uganda) and 28.2 deaths (Zambia) per 1,000 births Serbanescu and colleagues30 32 Number of maternal deaths Calculation Parameter 29 × proportion of deliveries with live births/100,000 × Parameter 30 33 Number of perinatal deaths Calculation Parameter 29/1,000 × Parameter 31 34 Total number of deaths Calculation Parameter 32 + Parameter 33 35 Life-years lost due to death Years of life left estimated as 62.5 and 45.6 for perinatal and maternal death in Uganda and 62.3 and 45.7 for perinatal and maternal death in Zambia WHO life tables40,41 Assume average age at death for maternal death is 27.5, for perinatal in first 2 days of life. Years of life left estimated as 62.5 and 45.6 for perinatal and maternal death in Uganda and 62.3 and 45.7 for perinatal and maternal death in Zambia. Incremental cost-effectiveness 36 Incremental costs Calculation Parameter 21 − Parameter 11 In sensitivity analysis, reassess with all donor costs treated as incremental costs. 37 Incremental deaths averted Calculation Parameter 34 − Parameter 27 38 Incremental life-years gained Calculation Parameter 35 − Parameter 28 39 Incremental cost per death averted Calculation Parameter 36/Parameter 37 40 Incremental cost per life-year gained Calculation Parameter 36/Parameter 38 Abbreviations: ANC, antenatal care; MNH, maternal and newborn health; POMS, Pregnancy Outcome Monitoring Survey; SMGL, Saving Mothers, Giving Life; WHO CHOICE, World Health Organization's Choosing Interventions that are Cost-Effective.
Uganda Zambia SMGL-Supported Districts Comparison District SMGL-Supported Districts Comparison Districts Vaginal delivery Health center III $41 $42 Health center IV $45 $57 Health center $42 $18 District/general hospital $26 $25 $12 $28 Referral hospital $24 Not available $125 $112 Cesarean delivery Health center IV $202 $337 District/general hospital $163 $140 $33 $616 Referral hospital $79 Not available $495 $458 Antenatal care visit Health center III $3.66 $5.49 Health center IV $3.59 $5.07 Health center $4.50 $3.96 District/general hospital $5.03 $4.60 $6.96 $10.75 Referral hospital $4.92 Not available $38.90 Not available Abbreviations: SGML, Saving Mothers, Giving Life.
Notes: The table includes only costs incurred at the facility level; it does not include training of facility staff. Results are presented in US 2016 dollars inclusive of capital and facility overhead costs. Data were not collected from the referral hospital receiving cases from Masindi.
Estimated Total Costsa per SMGL District Sources of Financinga SMGL-Supported Districts Comparison Districts 2016 2012 Government Donor Private Government Donor Private Uganda Costs associated with: The first delay $300,422 $0 0% 100% 0% 100% 0% 0% The second delay $58,165 $40,123 2% 98% 0% 100% 0% 0% The third delay $983,364 $613,329 48% 27% 24% 94% 3% 3% Above community/facility costsb $156,931 $0 0% 100% 0% 100% 0% 0% Total cost $1,498,881 $653,452 35% 49% 16% 96% 2% 2% Average number of facility deliveries 14,419 9,947 Total cost per facility delivery $103.95 $65.70 Zambia Costs associated with: The first delay $116,590 $7,608 10% 90% N/A 52% 48% N/A The second delay $107,149 $10,239 40% 60% N/A 100% 0% N/A The third delay $799,081 $405,234 74% 26% N/A 97% 3% N/A Above community/facility costsb $161,593 $1,663 0% 100% N/A 100% 0% N/A Total cost $1,184,413 $424,744 55% 45% N/A 97% 3% N/A Average number of facility deliveries 6,044 4,194 Total cost per facility delivery $195.98 $101.27 Abbreviations: N/A, not applicable; SMGL, Saving Mothers, Giving Life.
↵a Results are presented in US 2016 dollars, with capital and start-up costs converted to annual equivalent costs.
↵b Includes costs for offices located in districts, general and office support staff, program vehicles, and other general management and planning activities.
Number of Facility Deliveries in 2016a Number of Maternal Deathsb Number of Perinatal Deathsb Incremental Deaths Averted (Maternal and Perinatal) Incremental Life-Years Gained Total Costc Incremental Costc Incremental Cost per Death Avertedc Incremental Cost per Life-Year Gainedc Uganda Without SMGL 19,893 128 1,114 $1,306,904 With SMGL 28,838 86 992 164 9,549 $2,997,763 $1,690,859 $10,311 $177 Zambia Without SMGL 8,839 40 450 $849,489 With SMGL 12,087 28 341 121 7,362 $2,368,826 $1,519,338 $12,514 $206 Abbreviation: SGML, Saving Mothers, Giving Life.
↵a The number of district deliveries in 2016 multiplied by the institutional delivery rate for 2012 (for “without SMGL”) and for 2016 (for “with SMGL”) reported in Serbanescu et al.30
↵b Estimated using the 2016 facility deliveries with SMGL (for both “with SMGL” and “without SMGL”) and the total maternal/perinatal death rates for all SMGL-supported districts in 2016 (for with SMGL) and 201230 with adjustments for national-level secular trends (see Supplement 1) to estimate deaths if SMGL had never occurred (for without SMGL).
↵c Results are presented in US 2016 dollars, and represent the totals for the 2 SMGL-supported districts included in the analyses.
Supplemental material
Files in this Data Supplement:
- Data Sources and Adjustments for Secular Trends - Text s01, PDF
In this issue
The Costs and Cost-Effectiveness of a District-Strengthening Strategy to Mitigate the 3 Delays to Quality Maternal Health Care: Results From Uganda and Zambia
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