Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda†

Abstract

The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable.

In Tanzania, The Many Costs Of Pay-For-Performance Leave Open To Debate Whether The Strategy Is Cost-Effective

“…Nonetheless, the international literature suggests that the cost-effectiveness of a voucher scheme to promote maternal health through the coverage of facility-based deliveries with vouchers varies from $33 per additional institutional delivery in Uganda 34 to $91 in Bangladesh. 35 In another study, removing user fees for delivery care was estimated to cost $25 per additional delivery.…”

Vouchers for family planning and sexual and reproductive health services: A review of voucher programs involving Marie Stopes International among 11 Asian and African countries

“…However, average costs for delivery were higher than those for delivery in public facilities. Uncomplicated and complicated voucher deliveries cost US $29.40 and US $111.85, respectively, versus US $19.17 and US $71.22 for uncomplicated and complicated deliveries in public facilities [29]. In Madagascar, the number of couple-years of protection per month increased from 957 to 1100 (14.9%) after the vouchers [5,15,[17][18][19]28,29] 2008-2012 The proportion of newborns delivered at health facilities increased among individuals who used the voucher; in villages where a voucher user was present; and during the period 2010-2011 vs 2008.…”

“…Voucher users were more likely than non-voucher users to have access to improved drinking water (as per DHS definition, sources of improved drinking water are those believed to be relatively free of disease) (92.0% vs 83.5%; P = 0.006) but less likely to own livestock (53.4% vs 40.3%; P = 0.003) or have high-quality flooring (84.3% vs 76.3%; P = 0.002). Use among poor women Uganda B [5,15,[17][18][19]28,29] 2008-2012 The difference in service use between poor and non-poor populations was lower among women from villages with a voucher user vs villages with no voucher users. In all, 98% of voucher users were considered poor according to the Poverty Grading Tool used.…”

“…Satisfaction with services Uganda B [5,15,[17][18][19]28,29] 2008-2012 Higher proportions of providers from voucher facilities conducted the clinical examinations vs their counterparts from comparison facilities for prenatal (51.2% vs 35%) and postnatal care (25.8% vs 3%). 94% of voucher users reported being satisfied with the services they received vs 76% of non-voucher users.…”

The cost effectiveness of a quality improvement program to reduce maternal and fetal mortality in a regional referral hospital in Accra, Ghana

“…[3] A thorough discussion on efforts to improve demand-side financing is available from the WHO. [4] Recent successful examples include the expansive incentive-based Janani Suraksha Yojana program in India[5], a voucher-scheme in Uganda[6], and maternal insurance in Nigeria[7]. These programs report incremental cost-effectiveness ratios (ICER) of $46-$302 per disability-adjusted life-year (DALY) averted and have been deemed highly cost effective.…”