Abstract
Pakistani women suffer the highest rate of maternal mortality in South Asia. A lack of comprehensive knowledge about maternal and newborn health (MNH) services costs impedes policy decisions to maximize the benefit from existing, as well as emerging, MNH interventions in Pakistan. We compared MNH service costs at different levels of care. A cross-sectional survey was conducted during January to March 2016 as part of a large economic evaluation in Sindh, Pakistan. Health providers and facilities were selected from a sampling frame, inclusive of public and private sectors. This study utilized a broad perspective (i.e. costs to the health system and patients/families). The unit costs of MNH services were determined through a simultaneous allocation method in the public facilities; and patient billing department in the private facilities. Descriptive analysis was performed, and an analysis of variance (ANOVA) test was applied to compare overall mean costs both within and between health facilities. A total of 31 eligible health providers and facilities (n = 25 in private; n = 7 in public) were included in the final analysis. An ambulatory visit (AV) for routine antenatal care (ANC) costs $3.6 and $0.9 at secondary- and tertiary-level public facilities, respectively. In the private sector, the costs of an AV for ANC were slightly less ($2.8) at secondary-level and much higher ($6) at tertiary-level facilities compared to the public sector. Diagnostic test costs were much higher in private facilities. The average costs of inpatient admissions were $30.5 at general ward (GW), and $151 at the intensive care unit (ICU) in public facilities. In-patient admissions costs were lower such as $9.3 at GW and $36.5 at ICU in private facilities. Understanding cost is critical to guide decisions of resource allocation within the public sector; and risk mitigation for excessive OOP costs through third party payer for services in the private sector.
Highlights
Maternal and newborn mortality has declined over the past 10 years [1]
In Pakistan, a situational analysis revealed that only 65% pregnant women seek routine antenatal care (ANC), nearly 48% deliveries occur without the assistance of a skilled care provider, fewer than 50% of women seek either postpartum and/or newborn care [4]
The department-level costs were later divided by the average number of patients attending clinics and the number of beds to calculate the unit costs for ambulatory visits and inpatient admissions, respectively
Summary
Maternal and newborn mortality has declined over the past 10 years [1]. The 2015 estimates from the Global Burden of Disease indicate that most countries (122 of 195, 63%) have achieved Sustainable Development Goal 3.1, a reduction of global maternal mortality ratio to less than 70 per 100,000 live births by 2030 [2]. High burdens of both maternal and newborn mortality continue to impose a significant challenge in many low- and middle-income countries (LMICs), where resources to seek and provide timely and effective healthcare are scarce [3]. Pakistan has the world’s sixth largest population and has the highest maternal mortality ratio in South Asia (348 per 100,000 live births). This compares poorly with neighboring countries, including Bangladesh and Bhutan, and many countries in sub-Saharan Africa where maternal deaths have substantially declined since 1990 [2]. The Lady Health Workers (LHWs) under the National Program provide basic health education related to antenatal, postpartum, and newborn care; and serve as a referral point to health facilities. It is further estimated that over 80% of healthcare spending is out-of-pocket (OOP), and predominately in the private sector [7]
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