Article Text
Abstract
Objectives To examine the impact and cost-effectiveness of user fee exemption by contracting out essential health package services to Christian Health Association of Malawi (CHAM) facilities through service-level agreements (SLAs) to inform policy-making in Malawi.
Methods The analysis was conducted from the government perspective. Financial and service utilisation data were collected for January 2015 through December 2016. The impact of SLAs on utilisation of maternal and child health (MCH) services was examined using propensity score matching and random-effects models. Subsequently, the improved services were converted to quality-adjusted life years (QALYs) gained, using the Lives Saved Tool (LiST), and incremental cost-effectiveness ratios (ICERs) were generated.
Findings Over the 2 years, a total of $1.5 million was disbursed to CHAM facilities through SLAs, equivalent to $1.24 per capita. SLAs were associated with a 13.8%, 13.1%, 19.2% and 9.6% increase in coverage of antenatal visits, postnatal visits, delivery by skilled birth attendants and BCG vaccinations, respectively. This was translated into 434 lives saved (95% CI 355 to 512) or 11 161 QALYs gained (95% CI 9125 to 13 174). The ICER of SLAs was estimated at $134.7/QALYs gained (95% CI $114.1 to $164.7).
Conclusions The cost per QALY gained for SLAs was estimated at $134.7, representing 0.37 of Malawi’s per capita gross domestic product ($363). Thus, MCH services provided with Malawi’s SLAs proved cost-effective. Future refinements of SLAs could introduce pay for performance, revising the price list, streamlining the reporting system and strengthening CHAM facilities’ financial and monitoring management capacity.
- cost-effectiveness
- user fees
- maternal and child health
- health economics
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Footnotes
WZ and DS contributed equally.
Handling editor Valery Ridde
Contributors WZ conceived, designed and implemented the study. DS, TH and JEN contributed to the statistical analyses. HM contributed to data collection. PS-F, GM, SS and AD contributed to the design of the study and quality control. WZ, DS and TH drafted the manuscript. All authors contributed to critically reviewing the manuscript and the interpretation of the results.
Funding This study is funded by the USAID supported Heath Policy Plus (HP+) Project.
Disclaimer Views expressed in this article are those of the authors and do not necessarily reflect the views of the authors’ institutions or the funder of this study.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data were primarily obtained from DHIS2 owned by the Ministry of Health, Malawi