Abstract
Main ObjectiveFew studies have examined the long-term, impact of large-scale interventions to strengthen primary care services for women and children in rural, low-income settings. We evaluated the impact of the Ethiopian Millennium Rural Initiative (EMRI), an 18-month systems-based intervention to improve the performance of 30 primary health care units in rural areas of Ethiopia.MethodsWe assessed the impact of EMRI on maternal and child survival using The Lives Saved Tool (LiST), Demography (DemProj) and AIDS Impact Model (AIM) tools in Spectrum software, inputting monthly data on 6 indicators 1) antenatal coverage (ANC), 2) skilled birth attendance coverage (SBA), 3) post-natal coverage (PNC), 4) HIV testing during ANC, 5) measles vaccination coverage, and 6) pentavalent 3 vaccination coverages. We calculated a cost-benefit ratio of the EMRI program including lives saved during implementation and lives saved during implementation and 5 year follow-up.ResultsA total of 134 lives (all children) were estimated to have been saved due to the EMRI interventions during the 18-month intervention in 30 health centers and their catchment areas, with an estimated additional 852 lives (820 children and 2 adults) saved during the 5-year post-EMRI period. For the 18-month intervention period, EMRI cost $37,313 per life saved ($42,366 per life if evaluation costs are included). Calculated over the 18-month intervention plus 5 years post-intervention, EMRI cost $5,875 per life saved ($6,671 per life if evaluation costs are included). The cost effectiveness of EMRI improves substantially if the performance achieved during the 18 months of the EMRI intervention is sustained for 5 years. Scaling up EMRI to operate for 5 years across the 4 major regions of Ethiopia could save as many as 34,908 lives.SignificanceA systems-based approach to improving primary care in low-income settings can have transformational impact on lives saved and be cost-effective.
Highlights
Developing high quality and accessible primary care is a global priority [1,2]
Month systems-based intervention to improve the performance of 30 primary health care units (PHCUs) in rural areas of Ethiopia
In addition to these improvements in infrastructure and human resources, several service-related performance indicators showed marked improvements during the 18 months of the Ethiopian Millennium Rural Initiative (EMRI) intervention followed by a modest attenuation in performance in the 12 months following the implementation (Table 2)
Summary
Developing high quality and accessible primary care is a global priority [1,2]. With the global push to meet MDGs 4 and 5 related to maternal and child health, many efforts have been directed at strengthening rural primary care services focused primarily on women and children in low-income settings [3,4,5,6]. Other studies have demonstrated mixed results, with little effect on prevention of mother-to-child transmission of HIV [11], and other key outcomes associated with reproductive health [12], maternal and child health [13,14], and HIV [15] Despite this literature, few studies have examined the potential long- term impact of interventions on the mortality of women and children in rural, low-income settings, or the sustainability of such interventions. The Millennium Villages study, a multisector, multi-country intervention measured current impact of the program and its associated costs, it did not report overall cost-effectiveness of the intervention [6] This effort did not focus solely on primary health care; few, if any, studies have examined impact of a large-scale, system-based intervention to improve primary health care in rural settings
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