Alfonso Y Natalia, Bishai David, Bua John, Mutebi Aloysius, Mayora Crispus, Ekirapa-Kiracho Elizabeth
Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda
Department of Population, Family and Reproductive Health, Johns Hopkins University Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA Department of Health Policy, Planning and Management, School of Public Health, College of Health Sciences, Makerere University, PO Box 7072, Kampala, Uganda.
Health Policy Plan. 2015 Feb;30(1):88-99. doi: 10.1093/heapol/czt100. Epub 2013 Dec 25.
The maternal mortality ratio (MMR) in Uganda has declined significantly during the last 20 years, but Uganda is not on track to reach the millennium development goal of reducing MMR by 75% by 2015. More evidence on the cost-effectiveness of supply- and demand-side financing programs to reduce maternal mortality could inform future strategies. This study analyses the cost-effectiveness of a voucher scheme (VS) combined with health system strengthening in rural Uganda against the status quo. The VS, implemented in 2010, provided vouchers for delivery services at public and private health facilities (HF), as well as round-trip transportation provided by private sector workers (bicycles or motorcycles generally). The VS was part of a quasi-experimental non-randomized control trial. Improvements in institutional delivery coverage (IDC) rates can be estimated using a difference-in-difference impact evaluation method and the number of maternal lives saved is modelled using the evidence-based Lives Saved Tool. Costs were estimated from primary and secondary data. Results show that the demand for births at HFs enrolled in the VS increased by 52.3 percentage points. Out of this value, conservative estimates indicate that at least 9.4 percentage points are new HF users. This 9.4% bump in IDC implies 20 deaths averted, which is equivalent to 1356 disability-adjusted-life years (DALYs) averted. Cost-effectiveness analysis comparing the status quo and VS's most conservative effectiveness estimates shows that the VS had an incremental cost-effectiveness ratio per DALY averted of US$302 and per death averted of US$20 756. Although there are limitations in the data measures, a favourable cost-effectiveness ratio persists even under extreme assumptions. Demand-side vouchers combined with supply-side financing programs can increase attended deliveries and reduce maternal mortality at a cost that is acceptable.
在过去20年里，乌干达的孕产妇死亡率（MMR）显著下降，但乌干达并未走上在2015年将MMR降低75%这一千年发展目标的正轨。关于供应方和需求方融资项目降低孕产妇死亡率的成本效益的更多证据可为未来战略提供参考。本研究分析了乌干达农村地区一项代金券计划（VS）与卫生系统强化相结合相对于现状的成本效益。2010年实施的VS为在公立和私立医疗机构（HF）的分娩服务提供代金券，以及由私营部门工作人员提供的往返交通（通常是自行车或摩托车）。VS是一项准实验性非随机对照试验的一部分。机构分娩覆盖率（IDC）的提高可以使用差分影响评估方法进行估计，挽救的孕产妇生命数量使用基于证据的挽救生命工具进行建模。成本从一级和二级数据中估算得出。结果显示，参与VS的医疗机构的分娩需求增加了52.3个百分点。在这个数值中，保守估计表明至少9.4个百分点是新的HF用户。IDC提高的这9.4%意味着避免了20例死亡，相当于避免了1356个伤残调整生命年（DALY）。将现状与VS最保守的效果估计进行比较的成本效益分析表明，VS每避免一个DALY的增量成本效益比为302美元，每避免一例死亡的增量成本效益比为20756美元。尽管数据测量存在局限性，但即使在极端假设下，有利的成本效益比依然存在。需求方代金券与供应方融资项目相结合可以以可接受的成本增加分娩接生并降低孕产妇死亡率。
