Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural Ghana

Abstract

SummaryBackgroundEvery year, 2·9 million newborn babies die worldwide. A meta-analysis of four cluster-randomised controlled trials estimated that home visits by trained community members in programme settings in Ghana and south Asia reduced neonatal mortality by 12% (95% CI 5–18). We aimed to estimate the costs and cost-effectiveness of newborn home visits in a programme setting.MethodsWe prospectively collected detailed cost data alongside the Newhints trial, which tested the effect of a home-visits intervention in seven districts in rural Ghana and showed a reduction of 8% (95% CI −12 to 25%) in neonatal mortality. The intervention consisted of a package of home visits to pregnant women and their babies in the first week of life by community-based surveillance volunteers. We calculated incremental cost-effectiveness ratios (ICERs) with Monte Carlo simulation and one-way sensitivity analyses and characterised uncertainty with cost-effectiveness planes and cost-effectiveness acceptability curves. We then modelled the potential cost-effectiveness for baseline neonatal mortality rates of 20–60 deaths per 1000 livebirths with use of a meta-analysis of effectiveness estimates.FindingsIn the 49 zones randomly allocated to receive the Newhints intervention, a mean of 407 (SD 18) community-based surveillance volunteers undertook home visits for 7848 pregnant women who gave birth to 7786 live babies in 2009. Annual economic cost of implementation was US$203 998, or $0·53 per person. In the base-case analysis, the Newhints intervention cost a mean of $10 343 (95% CI 2963 to −7674) per newborn life saved, or $352 (95% CI 104 to −268) per discounted life-year saved, and had a 72% chance of being highly cost effective with respect to Ghana's 2009 gross domestic product per person. Key determinants of cost-effectiveness were the discount rate, protective effectiveness, baseline neonatal mortality rate, and implementation costs. In the scenarios modelled with the meta-analysis results, the ICER increased from $127 per life-year saved at a neonatal mortality rate of 60 deaths per 1000 livebirths, to $379 per life-year saved at a rate of 20 deaths per 1000 livebirths. The strategy had at least a 99% probability of being highly cost effective for lower-middle-income countries in all neonatal mortality rate scenarios modelled, and at least a 95% probability of being highly cost effective for low-income countries at neonatal mortality rates of 30 or more deaths per 1000 livebirths.InterpretationOur findings show that the seemingly modest mortality reductions achieved by a newborn home-visit strategy might in fact be cost effective. In Ghana, such strategies are also likely to be affordable. Our findings support recommendations from WHO and UNICEF that low-income and middle-income countries implement newborn home visits.FundingThe Bill & Melinda Gates Foundation, UK Department for International Development, WHO.

How to Save 1 Million Lives in a Year in Low- and Middle-Income Countries

“…New WHO guidelines on antibiotic therapy for neonatal infections have been developed [23]. Home-visiting programs have been shown to reduce neonatal mortality in low-resource settings and to be quite cost-effective [24]. …”

The role of the home visit in the comprehensive health care of children and adolescents

“…No entanto, o estudo apresenta as limitações de não ser randomizado e ter tido diferença no número de VDs fornecidas às gestantes, com mais VDs realizadas no grupo de ACS que nos demais grupos. 24 Com base populacional os africanos avaliaram programa que forneceu VD para gestantes e seus recém-nascidos (RN) na primeira semana de vida (10). O estudo envolveu cerca de 7.800 gestantes e as VDs eram realizadas por pessoas da comunidade, treinadas para orientar práticas de cuidados ao RN e a busca de assistência em caso de doença.…”

“…Essa redução representou milhares de vidas salvas por ano e o programa foi considerado altamente custo-efetivo. 10 A visita domiciliar como prática de ação integral à saúde da criança e do adolescente lúcias do quarto (p=0,05). Como nos estudos citados anteriormente, não houve mudanças para tabagismo ou animais de estimação no domicílio.…”

“…Apenas três estudos trouxeram avaliação de custos, mas em todos eles os resultados evidenciaram que as intervenções foram custoefetivas. 6,10,11 No contexto pediátrico, algumas pesquisas sinalizam para a obtenção de melhores resultados de saúde com o uso da VD, enquanto outras não encontraram diferenças significativas nos desfechos avaliados.…”

“…4 Atualmente é realizada com diversas finalidades no âmbito da criança e do adolescente, como educação de pais 5 , promoção do desenvolvimento infantil 5 , melhora do controle da asma 6 e identificação de vulnerabilidades familiares. 7,8 Alguns estudos que utilizaram a VD encontraram resultados positivos com potencial de melhora para saúde da população 6,[9][10][11] , enquanto outros mostraram resultados mistos. [12][13][14][15] Trabalho de revisão informa que a efetividade da VD na Pediatria ainda carece de esclarecimentos.…”