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Original research
The cost-effectiveness of using results-based financing to reduce maternal and perinatal mortality in Malawi
  1. Jobiba Chinkhumba1,2,
  2. Manuela De Allegri3,
  3. Stephan Brenner3,
  4. Adamson Muula4,
  5. Bjarne Robberstad2
  1. 1Department of Health Systems and Policy, Health Economics and Policy Unit, University of Malawi College of Medicine, Blantyre, Malawi
  2. 2Department of Global Public Health and Primary Care, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
  3. 3Institute of Public Health, Medical Faculty, University of Heidelberg, Heidelberg, Germany
  4. 4School of Public Health and Family Medicine, University of Malawi College of Medicine, Blantyre, Malawi
  1. Correspondence to Dr Jobiba Chinkhumba; jchinkhumba{at}mac.medcol.mw

Abstract

Introduction Results-based financing (RBF) is being promoted to increase coverage and quality of maternal and perinatal healthcare in sub-Saharan Africa (SSA) countries. Evidence on the cost-effectiveness of RBF is limited. We assessed the cost-effectiveness within the context of an RBF intervention, including performance-based financing and conditional cash transfers, in rural Malawi.

Methods We used a decision tree model to estimate expected costs and effects of RBF compared with status quo care during single pregnancy episodes. RBF effects on maternal case fatality rates were modelled based on data from a maternal and perinatal programme evaluation in Zambia and Uganda. We obtained complementary epidemiological information from the published literature. Service utilisation rates for normal and complicated deliveries and associated costs of care were based on the RBF intervention in Malawi. Costs were estimated from a societal perspective. We estimated incremental cost-effectiveness ratios per disability adjusted life year (DALY) averted, death averted and life-year gained (LYG) and conducted sensitivity analyses to how robust results were to variations in key model parameters.

Results Relative to status quo, RBF implied incremental costs of US$1122, US$26 220 and US$987 per additional DALY averted, death averted and LYG, respectively. The share of non-RBF facilities that provide quality care, life expectancy of mothers at time of delivery and the share of births in non-RBF facilities strongly influenced cost-effectiveness values. At a willingness to pay of US$1485 (3 times Malawi gross domestic product per capita) per DALY averted, RBF has a 77% probability of being cost-effective.

Conclusions At high thresholds of wiliness-to-pay, RBF is a cost-effective intervention to improve quality of maternal and perinatal healthcare and outcomes, compared with the non-RBF based approach. More RBF cost-effectiveness analyses are needed in the SSA region to complement the few published studies and narrow the uncertainties surrounding cost-effectiveness estimates.

  • maternal health
  • child health
  • health economics
  • public health
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2019-002260

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    Footnotes

    • Handling editor Lei Si

    • Contributors JC and BR made substantial contributions to the development and design of the model. SB, MDA and AM provided substantial input to ensure model structure reflects situation on the ground. SB, AM and MDA made substantial contributions to acquisition of some of the data for the study. JC drafted the initial manuscript. All authors contributed substantially to the manuscript and interpretation of the data. All authors approved the final version of the manuscript to be published. The corresponding author attests that all listed authors meet the authorship criteria and that no one meeting the criteria has been omitted.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Ethics approval Ethical approval for the study was obtained from University of Malawi, College of Medicine Research and Ethics Committee (COMREC) protocol P.02/13/1353.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.