Health Policy and Planning
Volume 30 Issue 1 February 2015
http://heapol.oxfordjournals.org/content/current

Bypassing birth centres for childbirth: an analysis of data from a community-based prospective cohort study in Nepal
Rajendra Karkee1, Andy H Lee2,* and Colin W Binns2
Author Affiliations
1School of Public Health and Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal and 2School of Public Health, Curtin University, Perth, WA 6845, Australia
Abstract
Background In Nepal, women residing in rural areas tend to bypass local birth centres and deliver at urban hospitals, despite the availability of obstetric care in these centres. This study investigated the incidence of bypassing, characteristics of bypassers and their reasons for bypassing the birth centres.
Methods A prospective cohort study was undertaken in the Kaski district of central Nepal. The 353 pregnant women of 5 months or more gestation recruited from the community had access to local birth centres. They were interviewed at baseline using a structured questionnaire, and were followed up within 45 days post-partum. Comparisons were made between women who delivered at birth centres and those who gave birth at hospital. Logistic regression analysis was performed to determine the factors affecting the risk of bypassing.
Results Of the final sample of 258 participants who delivered in a health facility, 181 women (70.2%) bypassed their nearest birth centres to deliver at hospitals. Bypassers tended to be wealthy and have intrapartum complications, but the likelihood of bypassing apparently decreased by higher parity and frequent (four or more) antenatal care visits. Availability of operating facility, adequacy of medical supplies and equipment and competent health staff at the facility were the main reasons for their bypassing decision.
Conclusions The risk of bypassing for childbirth was high in central Nepal. Provision of quality and reliable emergency obstetric services together with well trained and competent staff at birth centres are recommended to reduce bypassing and pressure on the public hospital system.

.
The administrative costs of community-based health insurance: a case study of the community health fund in Tanzania
Josephine Borghi1,2,*, Suzan Makawia2 and August Kuwawenaruwa2
Author Affiliations
1London School of Hygiene and Tropical Medicine, 15–17 Tavistock Place, London WC1H 9SH, UK and 2Ifakara Health Institute, Kiko Avenue, Plot 463, Kiko Avenue Mikocheni, P.O. Box 78, 373 Dar es Salaam, Tanzania
Accepted October 29, 2013.
Abstract
Community-based health insurance expansion has been proposed as a financing solution for the sizable informal sector in low-income settings. However, there is limited evidence of the administrative costs of such schemes. We assessed annual facility and district-level costs of running the Community Health Fund (CHF), a voluntary health insurance scheme for the informal sector in a rural and an urban district from the same region in Tanzania. Information on resource use, CHF membership and revenue was obtained from district managers and health workers from two facilities in each district. The administrative cost per CHF member household and the cost to revenue ratio were estimated. Revenue collection was the most costly activity at facility level (78% of total costs), followed by stewardship and management (13%) and pooling of funds (10%). Stewardship and management was the main activity at district level. The administration cost per CHF member household ranged from USD 3.33 to USD 12.12 per year. The cost to revenue ratio ranged from 50% to 364%. The cost of administering the CHF was high relative to revenue generated. Similar studies from other settings should be encouraged.

.
Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda
Y Natalia Alfonso1,*, David Bishai1, John Bua2, Aloysius Mutebi2, Crispus Mayora2 and
Elizabeth Ekirapa-Kiracho2
Author Affiliations
1Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA 2Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
Abstract
The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS’s most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable.

.
Buy now, saved later? The critical impact of time-to-pandemic uncertainty on pandemic cost-effectiveness analyses
Tom Drake1,2,3,*, Zaid Chalabi1 and Richard Coker1,4
Author Affiliations
1London School of Hygiene and Tropical Medicine, Kepple Street, London, WC1E 7HT, UK, 2Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Oxford, OX3 7BN, UK, 3Mahidol University Rajvithi Road, Bangkok 10400, Thailand and 4National University of Singapore, Lower Kent Ridge Road, Singapore 119077
Accepted November 21, 2013.
Abstract
Background Investment in pandemic preparedness is a long-term gamble, with the return on investment coming at an unknown point in the future. Many countries have chosen to stockpile key resources, and the number of pandemic economic evaluations has risen sharply since 2009. We assess the importance of uncertainty in time-to-pandemic (and associated discounting) in pandemic economic evaluation, a factor frequently neglected in the literature to-date.
Methods We use a probability tree model and Monte Carlo parameter sampling to consider the cost effectiveness of antiviral stockpiling in Cambodia under parameter uncertainty. Mean elasticity and mutual information (MI) are used to assess the importance of time-to-pandemic compared with other parameters. We also consider the sensitivity to choice of sampling distribution used to model time-to-pandemic uncertainty.
Results Time-to-pandemic and discount rate are the primary drivers of sensitivity and uncertainty in pandemic cost effectiveness models. Base case cost effectiveness of antiviral stockpiling ranged between is US$112 and US$3599 per DALY averted using historical pandemic intervals for time-to-pandemic. The mean elasticities for time-to-pandemic and discount rate were greater than all other parameters. Similarly, the MI scores for time to pandemic and discount rate were greater than other parameters. Time-to-pandemic and discount rate were key drivers of uncertainty in cost-effectiveness results regardless of time-to-pandemic sampling distribution choice.
Conclusions Time-to-pandemic assumptions can “substantially” affect cost-effectiveness results and, in our model, is a greater contributor to uncertainty in cost-effectiveness results than any other parameter. We strongly recommend that cost-effectiveness models include probabilistic analysis of time-to-pandemic uncertainty.