Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

Abstract

IntroductionCountries aspiring to universal health coverage view close-to-community (CTC) providers as a low-cost means of increasing coverage. However, due to lack of coordination and unreliable funding, the quality of large-scale CTC healthcare provision is highly variable and routine data about service quality are not trustworthy. Quality improvement (QI) approaches are a means of addressing these issues, yet neither the costs nor the budget impact of integrating QI approaches into CTC programme costs have been assessed.MethodsThis paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios.ResultsAnnualised economic unit costs ranged from $62 in Mozambique to $254 in Ethiopia per CTC provider supervised, driven by the context, type of community health model and the intensity of the intervention. The budget impact of Ministry-led QI for community health is estimated at 0.53% or less of the general government expenditure on health in all countries (and below 0.03% in three of the five countries).ConclusionCTC provision is a key component of healthcare delivery in many settings, so QI has huge potential impact. The impact is difficult to establish conclusively, but as a first step we have provided evidence to assess affordability of QI for community health. Further research is needed to assess whether QI can achieve the level of benefits that would justify the required investment.

SEEP-CI: A Structured Economic Evaluation Process for Complex Health System Interventions

“…Given the challenges described above, we were unable to robustly estimate effects, cost-effectiveness ratios, or net monetary benefit for REACHOUT. However, we were able to conduct a detailed, country-specific exercise in costing the interventions evaluated, which has been reported elsewhere [ 11 ]. The key parameter from that costing exercise was the cost per CHW of QI.…”

“…The teams were not required to work on any specific health area or issue due to differences in context and the local nature of community health, though most dealt with broad areas of maternal and child health. Further details of the specifics of the intervention can be found elsewhere [ 10 , 11 ].…”

Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya

“…The denominator or effectiveness in each ICER was calculated using the impact of the QI intervention on a reference target population of 12 208 pregnant women annually per subcounty. (To estimate the population of pregnant women per subcounty annually, we took the average of two values: the first takes the average population of the three costing subcounties (in Nairobi, densely populated) 30 ; the second of the values was obtained from national data: the national population from 2019 census divided by the number of subcounties nationally. Each of these values was then multiplied by the percentage of the Kenyan population that is female, age distribution and fertility rate 44–46 ; detailed in online supplemental file 2 .)…”

“…While the costs of a QI programme can be calculated fairly easily, 30 estimating the benefits of QI interventions at community level is a challenge. Outcomes are likely to be improved across a wide set of health areas or conditions.…”

Harnessing the health systems strengthening potential of quality improvement using realist evaluation: an example from southern Tanzania

“…Second, available data on implementation of other relevant QI interventions were collated. We reviewed publications from the EQUIP intervention ( Tancred, 2016 ; Tancred et al , 2017 , 2018 ; Waiswa et al , 2017 ; Baker et al , 2018 ) (some of which were produced from extensive qualitative data from QI team members and mentors at the community, health facility and district levels) and other collaborative QI interventions with multi-level components in LMIC settings ( Singh et al , 2013 ; Cofie et al , 2014 ; Tesfaye et al , 2014 ; Kumar et al , 2019 ). From the EQUIP intervention, the following additional documents were reviewed: learning session minutes, mentoring and coaching records, and EQUIP project staff reports.…”