Hounton S 1,2 , Belemsaga D 3 , Newlands D 2 , Meda N 3 , De Brouwere V 4

Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009

COST EFFECTIVENESS ANALYSIS OF ALTERNATIVE TRAINING STRATEGIES

FOR IMPROVING ACCESS TO EMERGENCY OBSTETRIC CARE IN

BURKINA FASO

Hounton S1,2, Belemsaga D3, Newlands D2 , Meda N3, De Brouwere V4

1WHO-MDSC, Burkina Faso, 2University of Aberdeen, UK 3Centre MURAZ, Burkina Faso, 4ITM, Antwerp, Belgium


1. Maternal and newborn mortality very high. How to ensure skilled ?

2. Skilled health human resources (number,

coverage, availability, access)

3. Effectiveness and cost- effectiveness of strategies to address shortage ?

BACKGROUND


3

OBJECTIVES1. Effectiveness of surgical teams led by specialists, medical doctors, and clinical officers in providing life saving interventions

2. Value for money

3. Policy recommendation for effective coverage of emergency obstetric care in rural areas

Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009Inaugural Conference of the African Health Economics and Policy Association (AfHEA)Accra - Ghana, 10th - 12th March 2009

METHODS (1) Study design: Cost-effectiveness analysis (surgeries:

c-sections)- Strategy 1: Team led by a specialist (OBGY, surgeon)- Strategy 2: Team led by a general practitioner- Strategy 3: Team led by a clinical officerComparability of case-mix and supporting environment

Place and participants- Burkina Faso (6 / 13 regions)- All district hospitals

Study period: Oct – Dec 2007 Perspective: health system Time horizon: 15 years

NANORO

TO

SECTEUR 15

SINDOU

BANFORA

ORODARA

SECTEUR 22

GAOUA

BATIE

DIEBOUGOU

HOUNDE

DANO LEO

BOROMO

DEDOUGOU

DANDE

SOLENZO

NOUNA

KOUDOUGOUREO

TOMA

TOUGAN

YAKO

OUAHIGOUYA

ZORGHO

ZABRE

MANGA

PO

TENKODOGO

SAPONE

KOMBISSIRI

OUARGAYEPAMA

FADA N'GOURMAKOUPELA

DIAPAGA

KAYA

BOUSSEZINIARE

OUAGADOUGOU

SEGUENEGA

TITAO

KONGOUSSI

DJIBO

SEBBA

BOULSA

BOGANDE

GOROM-GOROM

BARSALOGHO

DORI

KM

100500

Health Districts


METHODS (2) Effectiveness measures

- Maternal and newborn case fatality rates- Post caesarean complications

(haemorrhage, infections, loosening of sutures)

Costing methodology aims- Average annual cost of training and deployment of providers- Average annual costs of putting in place a surgical team

Incremental Cost Effectiveness Ratio (ICER)


METHODS (3) Data sources, data collection

- Retrospective case extraction of registries (Jan - Dec 2006)- Reports (MOH, University), interviews of stakeholders on barriers and facilitators of the substitutes strategies

Data analysis- Descriptive statistics, multivariate analysis (case-mix)- Macro costing, annual costs estimates (useful lifespan of items,

3% discount rate, allocation of total costs to caesarean section

by appropriate proxies of the volume and time)- Sensitivity analysis on major costs categories


RESULTS (1): CASES PROFILEType of providers

Characteristics

Obstetricians N = 1020

Trained doctors N = 552

Clinical officers N = 733

Mothers’ reported conditions (%)

- Obstructive labour - Ruptured Uterus - Eclampsia - Haemorrhage - Other

Referral status (%) - Referred from other facilities - Referred by provider to higher level facility

Duration of caesarean-section (minutes) - Mean (SD)

Duration of post operative hospital stay (days) - Mean (SD)

Post operative complications (/000) - Haemorrhage - Wound infection - Wound dehiscence

39 11 7 5 38 85 15 46 (20) 6 (5) 15 11 4

51 7 1 6 35 77 23 57 (27) 9 (5) 18 4 0

53 11 2 6 28 71 29 53 (23) 9 (6) 20 14 1


RESULTS (2) : OUTCOMES Case fatality rates of caesarean deliveries by provider,

district hospitals, 2004-2005, Burkina Faso

Newborns(/1000 c-sections)

Mothers(/1000 c-sections)

0

50

100

150

200

250

Obstetricians General practitioners Clinical officers

0

10

20

30

40

50

60

70

80

Obstetricians General practitioners Clinical officers


RESULTS (3) : COSTINGICER of caesarean deliveries by providers’ teams, district hospitals, 2006

Providers (Surgical teams led by…)

Total costs of surgical team

Cost per c-section

Newborns CFR (/ 1000 c-sections)

Obstetricians (O) 8 577 736 92 858 99

Trained doctors (D) 3 466 938 37 531 125 Clinical officers (CO) 3 222 433 34 884 198 ICER from Trained Doctors to Obstetricians

2 127 962

ICER from Clinical Officers to Obstetricians 585 596 ICER from Clinical Officers to Trained Doctors

36 260

All costs are in XOF, currency in French speaking countries, West Africa: 1USD = 500 XOF ICER: Incremental cost of saving one extra newborn life per 1000 caesarean-sections


RESULTS (4): “ENHANCED STRATEGIES”

ICER of caesarean deliveries by providers’ teams, district hospitals, 2006

Providers (Surgical teams led by…)

Total costs of surgical team

Cost per c-section

Newborns CFR (/ 1000 c-sections)

Obstetricians (O) 8 577 736 92 858 99 Trained doctors (D)* 4 205 141 45 523 112 Clinical officers (CO)** 3 796 782 41 102 161.5 ICER from Trained Doctors to Obstetricians

3 641 154

ICER from Clinical Officers to Obstetricians

828 096

ICER from Clinical Officers to Trained Doctors

89 313

* Enhanced “essential surgery” = two years degree-seeking training, salary incidence, incentives (management at district level, allowances for living conditions in remote areas ** Enhanced clinical officer = current clinical officers subjected every two years to a refresher course coupled with an effective supervision programme All costs are in XOF, currency in French speaking countries, West Africa: 1USD = 500 XOF


Comparable skills & practices of c-section (thus life saving interventions) between obstetricians and trained doctors

Results comparable to those in Mozambique, Malawi, Zambia, however higher CFR with clinical officers in our settings

Delegation of surgical tasks from specialists to substitutes: necessary, effective and cost-effective in rural areas

HRH : incentives are primarily about career path, supportive environment, degree (prestige), and monetary incentives

Limitations: comparability of settings, providers, cases

DISCUSSIONS


All current options for providing emergency surgeries are viable

Trained doctors: most cost effective option

Potential for improved cost-effectiveness of trained doctors if career paths and incentives provided

In Burkina Faso, given shortage will remain for foreseeable future, delegation of surgical tasks from specialists to middle level health substitutes has proven to be effective, is cost effective in the short and mid runs

CONCLUSION


ACKNOWLEDGEMENTS West Africa Health Organization (WAHO)

Grant WAHO, N°13 Centre MURAZ, 2005

Ministry of health, Centre MURAZ (Burkina Faso)

Collaborators: Sombie I, Cecile Tamini, Mamadou Barro, Fadima Bocoum, Abdoulaye Traore, Moctar Ouédraogo, Peter Byass

Documents

Hounton S 1,2 , Belemsaga D 3 , Newlands D 2 , Meda N 3 , De Brouwere V 4