COST EFFECTIVENESS AND SCALABILITY OF AN mHEALTH INTERVENTION TO IMPROVE PREGNANCY SURVEILLANCE AND CARE SEEKING IN RURAL BANGLADESH
Embargo until
2021-05-01
Date
2017-04-06
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Johns Hopkins University
Abstract
Background: Proven health interventions, when implemented with high fidelity and adequate coverage, could save millions of maternal and newborn lives. In many low and middle-income countries, however, coverage levels of these interventions are still low. The mCARE program, implemented from 2011 to 2015 in Gaibandha district in Bangladesh, was implemented with the aim of developing and testing a mobile phone-based system to improve healthcare-seeking behaviors of pregnant women during and after their pregnancy through health worker-delivered automated and personally scheduled Short Message Service (SMS) and home visit reminders. Despite the growing recognition of the potential benefits of mobile health (mHealth) in improving knowledge, care seeking, and treatment adherence, little evidence exists on the value of mHealth for money or affordability in developing countries.
Methods: Following established guidelines (e.g. CHEERS, ISPOR), we present analyses of the costs, consequences and affordability of the study drawn from a wide spectrum of datasets from the mCARE project including system-generated data on utilization, financial records from implementation and technical organizations, interviews with local experts and stakeholders, observations of service provision and exit interviews with 100 pregnant women in rural Bangladesh. Secondary data were also drawn from the literature and published national surveys. We used an ingredients-based approach to measure program costs by activity, and developed an Excel-based spreadsheet model to forecast program, provider and user costs and consequences for various alternatives and service delivery scenarios. The Lives Saved Tool (LiST) was used to model the number of lives saved and disability adjusted life years (DALYs) averted stemming from increases in coverage over time. We tested the robustness of the results though deterministic and probabilistic sensitivity analyses using Monte Carlo simulations. Finally, based on cost-effectiveness findings, we assessed the affordability of implementing the mCARE program using a budget impact analysis and cost-effectiveness affordability curves from the perspective of a budget holder.
Results: At a cost of $12 per newborn death averted and $0.41 per DALY averted, the comprehensive mCARE program, which includes pregnancy surveillance and personally scheduled SMS and home visit reminders, is highly cost-effective from a program perspective, compared to a basic mCARE program, which does not include scheduled SMS and home visit reminders (Chapter 5). When delivered at scale over a 10-year analytic time horizon (2016 to 2025) and compared against a paper-based alternative, the comprehensive mCARE model costs $580,185 in the first year (2016) to start up and incrementally increases from $1,730,599 to $6,917,807 in the subsequent years (2017 to 2025) with incremental geographical expansion to another district each year. An estimated 19,682 total lives (including maternal, neonatal, and stillbirth) would be saved as a result, over a 10-year period. This corresponds to an incremental cost per DALY averted of $47 (Chapter 6). Assuming a willingness to fund $1,080 per DALY averted, based on the Bangladesh gross national income (GNI) per capita, the program has a 97% probability of being highly cost-effective. Key activities driving costs and estimates of cost-effectiveness, include census enumeration, pregnancy surveillance, and supervision and training. The annual program budget impact of implementing the comprehensive mCARE program versus the existing paper-based system in Gaibandha district is an additional $258,508 in the first year (2015) and $102,658 in subsequent years (2016 to 2020) – without adjusting for inflation and excluding overhead costs (Chapter 7). Above a budget threshold of $2.5 million, the program has a 93% probability of being cost-effective. Nationwide implementation of the comprehensive mCARE program would cost an estimated $47 million over the 2015-2020 period, comprising 0.9% of total annual health expenditure ($5.4 billion) and 2.5% of public health expenditure ($1.9 billion).
Conclusion: The results suggest that implementing the comprehensive mCARE program in Bangladesh may be cost-effective and affordable. Study findings are based on the primary data of 690 pregnant women; additional data are needed to verify forecasted costs and consequences of implementation at scale. Assumptions of the translation of changes in coverage for key maternal and newborn health services, including antenatal care, facility delivery and postnatal care, are dependent on supply side factors – relying on adequate human resources, supplies and commodities, and other inputs associated with quality of care, the measurement of which was beyond our scope. Even given these limitations, the study findings provide information that can help project the resources necessary to fund the program, and the consequences of potential variations of cost inputs at different levels of scale, which can be used to guide efforts of the government of Bangladesh to adopt, implement and sustain the mCARE program.
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Keywords
Cost-effectiveness, Scalability, Affordability, Economic Evaluation, mHealth, mCARE, Pregnancy Surveillance, Care-seeking, Mobile phone, Community Health Worker, Bangladesh