Objectives In this study, we explored strategies for upscaling coverage of Community case management (CCM) of childhood pneumonia across the eleven regions of Ethiopia. Our first objective was to estimate the sub-national cost-effectiveness of upscaling coverage of CCM. Our second objective was explore the costs, health effects, and geographical inequality impacts associated with three scale-up scenarios promoting different policy-aims: maximizing health, reducing geographical inequalities, and achieving 90% universal coverage.
Methods We collected data through literature review and used Markov modelling to estimate sub-national cost-effectiveness. Health effects were modeled as life years gained and under-five deaths averted. Inequality impacts were measured by the GINI index applied to health. In scenario analysis we explored three different scale-up strategies: 1) maximizing health by prioritizing the regions where the intervention was the most cost-effective, 2) reducing geographical inequalities by prioritizing the regions with high baseline under-five mortality rate (U5MR), and 3) universal upscaling to 90% coverage in all the regions.
Results The regional incremental-cost effectiveness ratio (ICER) of scaling up the intervention coverage varied from 26 USD per life year gained in Addis to 199 USD per life year gained in the Southern Nations, Nationalities, and Peoples’ region. Universal upscaling of CCM in all regions would cost about 1.3 billion USD and prevent about 90,000 under-five deaths. This is less than 15,000 USD per life saved and translates to an increase in life expectancy at birth of 1.6 years across Ethiopia. In scenario analysis, we found that prioritizing regions with high U5MR is effective in reducing geographical inequalities, although at the cost of fewer lives saved as compared to the health maximizing strategy.
Conclusions Our model results illustrate a trade-off between maximizing health and reducing health inequalities, two common policy-aims in low-income settings.
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