Udochisom Anaba, Sara Chace Dwyer, Amy Dempsey and Charlotte Warren
Complications during childbirth contribute to maternal deaths, however, timely interventions by a skilled provider can prevent many of these deaths. Hypertensive disorders of pregnancy like pre-eclampsia and eclampsia (PE/E) are a major cause of maternal deaths worldwide. An estimated 75% of maternal deaths are a result of the following causes: severe bleeding (mostly bleeding after childbirth), infections (usually after childbirth), high blood pressure during and immediately after pregnancy (PE/E), complications from delivery, and complications from abortion.
USAID’s Ending Eclampsia project implemented a package of interventions at the primary health care level to prevent and treat PE/E and has shown promising preliminary results in Nigeria, Bangladesh, and Pakistan. The package of interventions includes training primary health care to diagnose PE/E, administer antihypertensive drugs, and manage it by administering magnesium sulfate and referrals onward as needed. In addition, primary health care workers received monitoring and mentoring after training. In Nigeria, the project also included community-level interventions such as training and supporting women’s group leaders and lay health workers to provide peer support and education on PE/E in their communities. While these interventions have been promising, sustaining progress will require ownership in the form of financial contributions and commitment from country governments. Given the promising approach, the project seeks to provide implementation cost estimates for stakeholders considering replication and scale up.
Assessing resource needs to scale-up interventions
Scaling up community-level interventions involves considerable resources and assessing the quantity of necessary resources can be challenging. Required resources that are not typically included in the budget or expenditure reports but should be considered in the total cost of an intervention include: people’s time, use of public buildings, donated supplies and equipment, and contributions by the community or government in which the intervention takes place.
USAID’s Ending Eclampsia project used an “ingredients cost method” to retrospectively identify the economic cost of project interventions in Nigeria, Bangladesh, and Pakistan. The idea behind this method is that every program has ingredients (inputs) and each ingredient has a cost. This detailed method aims to determine all the ingredients and the cost required to replicate a program based on fair market rates. In Nigeria, for example, the project first identified all of the inputs that went into each activity, including the training of trainers, training for primary health care workers on the detection and management of PE/E, and ongoing monitoring support at the facility level, among others. Once the inputs for each activity were identified, a value was determined for that input. This includes the opportunity costs that program recipients incur to participate in the program. The result is a complete understanding of the resources and costs required to implement a program through a societal lens. Since the package of interventions was different in each country and based on the country’s specific context, different ingredients were used for each of the three countries.
Rather than a lump sum estimate, the ingredients approach used for this cost analysis provides governments and organizations with detailed cost information, allowing for better approximation of program/intervention replication and scale-up. It also accounts for differences in the costs to initiate and maintain a program. However, applying this costing approach retrospectively is time-intensive, and it could be difficult to estimate costs for all project inputs, especially if the implementer did not bear the cost. Therefore, collecting accurate cost data in real time saves time in conducting these analyses.
While government financial ownership of interventions is expected, Ministries of Health may not have sufficient funds to cover all the costs associated with the intervention. In this case, the government can advocate for additional funding from the Finance Ministry and identify other sources of funding, such as private investment or donor funding to help cover the cost for program scale-up. In the current funding climate, donors may choose to contribute a one-time cost (e.g. training), while the government handles recurrent costs (e.g. refresher trainings). Furthermore, communities can contribute in-kind by donating their time or use of community spaces, depending on the program personnel and infrastructure needs.
The cost ingredient approach can serve as a first step in costing program interventions to ascertain true costs. The following questions need to be considered when conducting a cost analysis for scale-up: when will scale-up occur? which costs are one-off and which are recurring? and, who bears the cost? Higher-level analyses, such as cost-effectiveness and cost-benefit analyses, can be conducted based on each country’s needs. A Willingness to Pay analysis – one that examines the maximum price a consumer is willing to pay for a good or service – can also be explored to ascertain how much a certain group (e.g. clients, organizations, or governments) would be willing to pay for certain aspects of the program.
Understanding the costs of PE/E interventions can make all the difference to ensure successful implementation of such a program. By estimating the true cost to replicate or scale a program, governments can budget and plan for additional funding.
Note: The authors work for The Ending Eclampsia project