Abstract
ObjectivesHigh-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.MethodsTwo health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).ResultsIncremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.DiscussionImplementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.
Highlights
In evidence-informed health policy, meta-analysis of randomised controlled trials is considered to be at the top of the hierarchy of good evidence, whereas evidence from specialists and clinical practice is considered to be at the bottom [1]
The results suggest that, on average, the cost of antenatal care (ANC) per woman ranges between $53 and $69
The costs increase by 42%, 64% and 79% compared to current practice in Scenarios 1–3, respectively
Summary
In evidence-informed health policy, meta-analysis of randomised controlled trials is considered to be at the top of the hierarchy of good evidence, whereas evidence from specialists and clinical practice is considered to be at the bottom [1]. The major new features of the 2016 WHO recommendations are eight ANC contacts during pregnancy and one obstetric ultrasound examination before gestational week 24 for all pregnant women. The ultrasound recommendation is based on a Cochrane systematic review from 2015 that includes 11 randomised controlled trials on populations from six countries (Australia, Norway, South Africa, Sweden, the United Kingdom and the United States of America) [4, 6]; no low- or lower- to middle-income countries were included in this review
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