School of Public Health, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda.
Department of Epidemiology and Global Health, Umeå University, SE 901 87, Umeå, Sweden.
Health Res Policy Syst. 2019 Apr 5;17(1):36. doi: 10.1186/s12961-019-0439-9.
High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.
Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).
Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.
Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.
在资源匮乏的环境下，很少有高质量的有效性和成本效益证据可用于卫生政策决策。在这种情况下，需要采用创新方法来生成具有本地相关性的证据。本研究旨在通过估计最近（2016 年）世卫组织产前护理建议与卢旺达目前实践相比的增量成本效益，为卢旺达的产前护理建议决策提供信息。
通过对目前在卢旺达执业的妇科医生/产科医生进行专家 elicitation，构建了两种基于预期孕产妇和围产儿死亡率降低的健康结果情景（乐观情景、悲观情景）。从社会角度构建了三种成本情景，为期一年。成本分析的两个主要投入是对 373679 名妇女假设队列的 ANC 就诊分布进行蒙特卡罗模拟，以及使用最近对卢旺达现行 ANC 实践进行的一次主要成本研究的数据来估算新建议的单位成本。结果以 2015 年美元报告，并与 2015 年卢旺达人均国内生产总值（697 美元）进行比较。
在乐观情景下，估计增量健康收益为 162509 个生命年（LYS），在悲观情景下为 65366 LYS。在成本情景下，增量成本在 580 万美元至 1100 万美元之间（与目前的做法相比，分别增加了 42%和 79%）。在乐观结果情景下，每 LYS 的增量成本在 36 美元（低 ANC 就诊）至 67 美元（高 ANC 就诊）之间，而在悲观结果情景下，每 LYS 的增量成本在 90 美元（低 ANC 就诊）至 168 美元（高 ANC 就诊）之间。在所有六个情景中，增量成本效益均低于基于 GDP 的阈值。
在卢旺达实施新的世卫组织 ANC 建议可能非常具有成本效益；然而，所需的额外资源是巨大的。本研究表明，专家 elicitation 与其他数据相结合如何为资源匮乏环境中的卫生政策决策提供负担得起的本地相关证据来源。
