Discussion
This systematic review based on 22 studies covering 17 individual countries provides the most up-to-date and comprehensive overview of cost of maternal health service provision in LMICs from year 2000 to today. In all, we found that only 16% of all LMICs have at least one costing study published. A previous article associated the dearth of costing studies in LMICs to the lack of technical capacity to conduct such studies, and incomplete or absent records of activity-linked resource data.49 It might also be a case of lack of interest locally on the part of policy makers, providers and researchers.
Of the available studies that we were able to retrieve, diverse methods were used in collecting and analysing cost. Indeed, the impact on final cost estimates that these various methods bring are well recognised.50 For example, cost estimates will vary depending on if a bottom-up or top-down costing approach is taken.50 The real issue though is not the use of different methods, but the need for more application of best practices for costing in order to improve validity and comparability of results. Apart from established best practices including use of bottom-up or combined use of both bottom-up and top-down costing approaches in a mixed approach, the use of US$ or International Dollars in presenting findings and incorporation of indirect costs into analysis,25 49 50 our review showed that there are other methodological issues requiring consensus. These include requirement for triangulation of data sources for cost analyses, specific cost components that should be included, for example, should fringe benefits such as health insurance, scholarship for health workers, etc be included in costing? Other issues include approach to cost disaggregation, time allocation for health workers and use of median cost as a summary measure, as well as approach to amortisation of capital projects in cost analyses.
As regards cost of service provision, median cost of publicly provided ANC provision in health centres across four countries was US$8.50. Cost of ANC was slightly cheaper with NGO-led provision while it was costlier to provide in hospitals and within the private sector. We were able to draw these parallels because all studies used the microcosting approach and costing was principally based on the 2001 WHO recommendation of focused ANC.51 The latest global guidelines however, recommend an increase from four visits during pregnancy to eight contacts with skilled personnel.52 This will ultimately have implications on service cost, as time spent in consultation and human resources required for ANC contacts will have to increase. As such, cost of ANC provision with this new package may be higher than initial estimates.
For delivery with skilled birth attendance in public health facilities, there was a wide variation for both normal vaginal and caesarean delivery with the least cost reported in Uganda and the highest in Brazil. A previous study suggests that there is a relationship between cost per service increments with increasing GDP per capita.37 Yet, it is difficult to accept that the marked difference in cost is because Brazil is an UMIC and others are LMIC/LIC. Looking more closely at the break down of cost in Brazil, it becomes apparent that the major cost drivers in Brazil relates to personnel. While service in Uganda was provided by medical doctors, clinical or nursing officers,29 the Brazil study costed vaginal delivery provided by obstetricians.40 Based on this finding, there may be a financial case for cost savings as it relates to task-shifting and task-sharing of delivery services in LMICs, as has been demonstrated for several other global health priorities.53 This finding adds to the established evidence on efficiency and effectiveness of task-shifting of maternal health interventions as a policy.54
After adjustments, the range of cost for FP service provision estimated in our review was put at US$0.82 to US$2.72. This tallies with findings from an evidence brief by WHO, which estimated the average cost per modern contraceptive as US$1.01.55 In our review, FP service provision by NGOs was the least costly. This is probably because of the significant financial contributions from international donors which help subsidise the cost of FP commodities and the widely lauded efficiency of NGO-managed health services.56 We could not ascertain a pattern with cost of PNC provision because only one study in our review costed the service and provided disaggregated cost, with cost per service estimated at US$5.04.37
As complications require more resources, it was not surprising to find that PAC with management of complications was costlier than PAC alone. The more severe the complication, the higher the cost of service provision with uterine laceration and shock costing the highest. The cost also varied based on type of facility, with the service costing more if care is provided in a hospital as opposed to health centres. Keeping hospitalisation rates to the barest minimum was an approach used to reduce cost of PAC provision in South Africa.44 We noted though that while cost of the actual emergency treatment was reported in all studies, none of the studies costed for FP and community empowerment through awareness and mobilisation, both of which are key components of comprehensive PAC.57
Our review pointed to some economies of scale for service provision as reported in Burkina Faso, Ghana, Haiti and Rwanda.38 39 41 43 48 This phenomenon occurred irrespective of the provider (NGO vs public) and the facility level (health centre vs hospital). Indeed, a major share of cost of service provision are fixed costs, so an increasing output does not necessarily increase the unit healthcare provision costs proportionally.58 A coordinated approach to ensure maximal utilisation of facility-based maternal health services may result in a more efficient use of resources for service provision.
Implications for practice and research
Our review highlights some critical methodological issues that need to be addressed to develop the practice of costing maternal health services. We believe that propagating consensus around already established costing approaches such as the WHO’s Mother-Baby Package Costing tool,59 PACCM developed by the Guttmacher Institute33 and TDABC, promoted as being valuable in LMICs60 will be a good next step in improving the quality of costing studies.
Indeed, there is global recognition of the need for more transparency and monitoring of financial resources required for achieving the SDGs in LMICs.61 However, from this review, it is clear that the number of available costing studies done at high level of methodological rigour that can be used for monitoring investments made in maternal health is low in LMICs. Certainly, more costing studies of PNC need to be conducted to better understand patterns, especially given the need for LMICs to scale up the implementation of postpartum care.62
Strengths and limitations
Strengths of this review are its inclusion of costing studies published in both peer-reviewed and grey literature, inflation of cost to comparable 2019 US Dollar equivalents and disaggregation of cost components for the various services. Doing this allowed us to for the first time be able to compare and contrast costs of providing the different maternal health services across countries, facility and provider types.
However, some limitations of our review need to be acknowledged. It was not possible to make meaningful comparisons in all cases. For example, there was only one study that costed provision of PNC which also had disaggregated cost.37 In addition, we could not fully describe the specific package of care provided to women in every study, as significant detail on care packages were not typically reported in the included studies. However, by including only studies published from year 2000, we ensured that we were comparing like-for-like recommended services, as global guidance regarding care packages were updated around this period. Finally, despite our best efforts, there were some costing studies not publicly available. For example, Blaakman makes reference to costing studies published in Kenya, Malawi and Rwanda.47 However, full texts of these could not be retrieved. Anecdotal evidence also suggests that there are more costing exercises being conducted in LMICs by Ministries of Health, many of which are not published online.