Article Text

Cost-effectiveness of community health systems strengthening: quality improvement interventions at community level to realise maternal and child health gains in Kenya
  1. Meghan Bruce Kumar1,2,3,
  2. Jason J Madan4,
  3. Peter Auguste4,
  4. Miriam Taegtmeyer1,5,
  5. Lilian Otiso6,
  6. Christian B Ochieng7,
  7. Nelly Muturi7,
  8. Elizabeth Mgamb8,
  9. Edwine Barasa3,9
  1. 1 Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
  2. 2 MARCH Centre, London School of Hygiene & Tropical Medicine, London, UK
  3. 3 Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme Nairobi, Nairobi, Kenya
  4. 4 University of Warwick, Warwick Medical School, Coventry, UK
  5. 5 Tropical Infectious Diseases Unit, Liverpool University Hospitals Foundation Trust, Liverpool, UK
  6. 6 LVCT Health, Nairobi, Kenya
  7. 7 Research and Strategic Information, LVCT Health, Nairobi, Kenya
  8. 8 Department of Health, Migori County Government, Migori, Kenya
  9. 9 Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
  1. Correspondence to Dr Miriam Taegtmeyer; Miriam.Taegtmeyer{at}


Introduction Improvements in maternal and infant health outcomes are policy priorities in Kenya. Achieving these outcomes depends on early identification of pregnancy and quality of primary healthcare. Quality improvement interventions have been shown to contribute to increases in identification, referral and follow-up of pregnant women by community health workers. In this study, we evaluate the cost-effectiveness of using quality improvement at community level to reduce maternal and infant mortality in Kenya.

Methods We estimated the cost-effectiveness of quality improvement compared with standard of care treatment for antenatal and delivering mothers using a decision tree model and taking a health system perspective. We used both process (antenatal initiation in first trimester and skilled delivery) and health outcomes (maternal and infant deaths averted, as well as disability-adjusted life years (DALYs)) as our effectiveness measures and actual implementation costs, discounting costs only. We conducted deterministic and probabilistic sensitivity analyses.

Results We found that the community quality improvement intervention was more cost-effective compared with standard community healthcare, with incremental cost per DALY averted of $249 under the deterministic analysis and 76% likelihood of cost-effectiveness under the probabilistic sensitivity analysis using a standard threshold. The deterministic estimate of incremental cost per additional skilled delivery was US$10, per additional early antenatal care presentation US$155, per maternal death averted US$5654 and per infant death averted US$37 536 (2017 dollars).

Conclusions This analysis shows that the community quality improvement intervention was cost-effective compared with the standard community healthcare in Kenya due to improvements in antenatal care uptake and skilled delivery. It is likely that quality improvement interventions are a good investment and may also yield benefits in other health areas.

  • health economics
  • maternal health
  • child health
  • health systems evaluation

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Supplementary materials


  • Handling editor Lei Si

  • Twitter @kumeghan, @MiriamTaegtmeye, @edwinebarasa

  • Contributors MBK, JJM, MT, EB conceived of the study. MT, LO obtained funding for the study. MBK, LO, NM, EM collected primary data on effectiveness measures. CBO analysed the effectiveness data. MBK, JJM, EB developed the model structure. MT, LO, CBO, EM commented on the model structure. MBK, JJM, PA analysed the model. MBK drafted the first version of the article. All coauthors input comments on the draft article before submission.

  • Funding The study presented in this paper is part of the REACHOUT programme. This programme has received funding from the European Union Seventh Framework Programme (FP7/2007-2013 FP7/2007-2011) under grant agreement number 306090. This publication reflects only the authors’ views, and the European Union is not liable for any use that may be made of the information contained herein. The USAID SQALE CHS Program is made possible by the generous support of the American people through the US Agency for International Development (USAID) and is implemented under cooperative agreement number AID-OAA-A-16-00018. This study was also funded by the Public Health Intervention Development Scheme through the UKRI Medical Research Council award ref MR/T003324/1.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

  • Data availability statement Data are available in a public, open access repository. All data relevant to the study are included in the article or uploaded as supplementary information, except probabilistic sensitivity analysis sampling data. These are currently in an Excel sheet so will be made available via a publicly available repository.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.