Cost-effectiveness of Zinc Supplementation for Prevention of Childhood Diarrhoea in Tanzania.

OBJECTIVE: To assess the cost-effectiveness of prophylactic zinc supplementation for preventing diarrhoea in young children in Tanzania. DESIGN: Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3% discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions. SETTING: Tanzania. PARTICIPANTS: A hypothetical cohort of 10,000 children ages 6 weeks to 18 months. RESULTS: The intervention costs of zinc supplementation were estimated as $109,800 (95% uncertainty interval: 61,716-171,507). Zinc supplementation was estimated to avert 2,200 (776-3,737) diarrhoeal episodes, 14,080 (4,692-25,839) sick days, 1,584 (522-2,927) outpatient visits, 561 (160-1,189) inpatient bed-days, 0.51 (0.15-1.03) deaths, and 19.3 (6.1-37.5) DALYs (discounted at 3% per year). Zinc supplementation reduced diarrhoea care costs by $12, 887 (4,089-25,058). The incremental cost per DALY averted was $4,950 (1,678-17,933). Incremental cost-effectiveness ratios (ICERs) estimated from a health system perspective were similar to the results from the societal perspective. ICERs were substantially lower (more favourable) when future outcomes were not discounted, but all ICERs were above contemporary thresholds for cost-effectiveness in this setting. CONCLUSION: Prophylactic zinc reduced diarrhoea incidence and associated healthcare utilization; however it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.

Traditional and Complementary Medicine in Tanzania: Regulation Awareness, Adherence and Challenges.

BACKGROUND: The demand for and use of Traditional and Complementary Medicine (T&CM) has recently increased worldwide drawing a public health attention including malpractice, which puts the health of its clients at risk. Despite efforts made by Tanzania to integrate T&CM in the health system to protect the clients, regulating the subsector has remained a challenge due to lack of information and operational factors facing the regulatory frameworks in Tanzania. The aim of this study was to determine the extent of imperfect information, regulation adherence and challenges among T&CM practitioners and regulators in Tanzania. METHODS: In-depth interviews were carried out with T&CM practitioners in Dar es Salaam Region in Tanzania, and officials from the Ministry of Health and the study municipals. Purposive and snowballing approaches were used to select study participants. Thematic data analysis was done with the help of NVIVO. RESULTS: Awareness of regulations and tools used for regulating the T&CM operations among practitioners was generally very low. There was fragmentation of knowledge on what they were practicing as well as on awareness of the regulations, and what is regulated. Practitioners argued that they cannot be controlled by conventional medical trained personnel. Regulators at municipal level reported to have had no knowledge, interest, and time to work on T&CM. Lack of adequately trained and qualified manpower, lack of financial resources, poor transport and other infrastructure at the municipal regulatory units aggravated non-adherence to regulations, and therefore rendered ineffectiveness to the regulatory framework. CONCLUSION: Existence of imperfect information on T&CM among regulators and practitioners affect effectiveness of T&CM regulatory process. Awareness of regulations among practitioners, presence of knowledgeable regulators, as well as capacity would facilitate adherence to regulations.

Cost-effectiveness of an electronic clinical decision support system for improving quality of antenatal and childbirth care in rural Tanzania: an intervention study.

BACKGROUND: QUALMAT project aimed at improving quality of maternal and newborn care in selected health care facilities in three African countries. An electronic clinical decision support system was implemented to support providers comply with established standards in antenatal and childbirth care. Given that health care resources are limited and interventions differ in their potential impact on health and costs (efficiency), this study aimed at assessing cost-effectiveness of the system in Tanzania. METHODS: This was a quantitative pre- and post- intervention study involving 6 health centres in rural Tanzania. Cost information was collected from health provider's perspective. Outcome information was collected through observation of the process of maternal care. Incremental cost-effectiveness ratios for antenatal and childbirth care were calculated with testing of four models where the system was compared to the conventional paper-based approach to care. One-way sensitivity analysis was conducted to determine whether changes in process quality score and cost would impact on cost-effectiveness ratios. RESULTS: Economic cost of implementation was 167,318 USD, equivalent to 27,886 USD per health center and 43 USD per contact. The system improved antenatal process quality by 4.5% and childbirth care process quality by 23.3% however these improvements were not statistically significant. Base-case incremental cost-effectiveness ratios of the system were 2469 USD and 338 USD per 1% change in process quality for antenatal and childbirth care respectively. Cost-effectiveness of the system was sensitive to assumptions made on costs and outcomes. CONCLUSIONS: Although the system managed to marginally improve individual process quality variables, it did not have significant improvement effect on the overall process quality of care in the short-term. A longer duration of usage of the electronic clinical decision support system and retention of staff are critical to the efficiency of the system and can reduce the invested resources. Realization of gains from the system requires effective implementation and an enabling healthcare system. TRIAL REGISTRATION: Registered clinical trial at www.clinicaltrials.gov ( NCT01409824 ). Registered May 2009.

Cost-effectiveness of clinical decision support system in improving maternal health care in Ghana.

OBJECTIVE: This paper investigated the cost-effectiveness of a computer-assisted Clinical Decision Support System (CDSS) in the identification of maternal complications in Ghana. METHODS: A cost-effectiveness analysis was performed in a before- and after-intervention study. Analysis was conducted from the provider's perspective. The intervention area was the Kassena- Nankana district where computer-assisted CDSS was used by midwives in maternal care in six selected health centres. Six selected health centers in the Builsa district served as the non-intervention group, where the normal Ghana Health Service activities were being carried out. RESULTS: Computer-assisted CDSS increased the detection of pregnancy complications during antenatal care (ANC) in the intervention health centres (before-intervention = 9 /1,000 ANC attendance; after-intervention = 12/1,000 ANC attendance; P-value = 0.010). In the intervention health centres, there was a decrease in the number of complications during labour by 1.1%, though the difference was not statistically significant (before-intervention =107/1,000 labour clients; after-intervention = 96/1,000 labour clients; P-value = 0.305). Also, at the intervention health centres, the average cost per pregnancy complication detected during ANC (cost -effectiveness ratio) decreased from US$17,017.58 (before-intervention) to US$15,207.5 (after-intervention). Incremental cost -effectiveness ratio (ICER) was estimated at US$1,142. Considering only additional costs (cost of computer-assisted CDSS), cost per pregnancy complication detected was US$285. CONCLUSIONS: Computer -assisted CDSS has the potential to identify complications during pregnancy and marginal reduction in labour complications. Implementing computer-assisted CDSS is more costly but more effective in the detection of pregnancy complications compared to routine maternal care, hence making the decision to implement CDSS very complex. Policy makers should however be guided by whether the additional benefit is worth the additional cost.

Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres.

BACKGROUND: Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a "know-do gap" where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers. METHODS: This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations. RESULTS: Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations. CONCLUSIONS: Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context.

Cost to households in treating maternal complications in northern Ghana: a cross sectional study.

BACKGROUND: The cost of treating maternal complications has serious economic consequences to households and can hinder the utilization of maternal health care services at the health facilities. This study estimated the cost of maternal complications to women and their households in the Kassena-Nankana district of northern Ghana. METHODS: We carried out a cross-sectional study between February and April 2014 in the Kassena-Nankana district. Out of a total of 296 women who were referred to the hospital for maternal complications from the health centre level, sixty of them were involved in the study. Socio-demographic data of respondents as well as direct and indirect costs involved in the management of the complications at the hospital were collected from the patient's perspective. Analysis was performed using STATA 11. RESULTS: Out of the 60 respondents, 60% (36) of them suffered complications due to prolonged labour, 17% (10) due to severe abdominal pain, 10% (6) due to anaemia/malaria and 7% (4) due to pre-eclampsia. Most of the women who had complications were primiparous and were between 21-25 years old. Transportation cost accounted for the largest cost, representing 32% of total cost of treatment. The median direct medical cost was US$8.68 per treatment, representing 44% of the total cost of treatment. Indirect costs accounted for the largest proportion of total cost (79%). Overall, the median expenditure by households on both direct and indirect costs per complication was US$32.03. Disaggregating costs by type of complication, costs ranged from a median of US$58.33 for pre-eclampsia to US$6.84 for haemorrrhage. The median number of days spent in the hospital was 2 days - five days for pre-eclampsia. About 33% (6) of households spent more than 5% of annual household expenditure and therefore faced catastrophic payments. CONCLUSION: Although maternal health services are free in Ghana, women still incur substantial costs when complications occur and face the risk of incurring catastrophic health expenditure.

Costs associated with implementation of computer-assisted clinical decision support system for antenatal and delivery care: case study of Kassena-Nankana district of northern Ghana.

OBJECTIVE: This study analyzed cost of implementing computer-assisted Clinical Decision Support System (CDSS) in selected health care centres in Ghana. METHODS: A descriptive cross sectional study was conducted in the Kassena-Nankana district (KND). CDSS was deployed in selected health centres in KND as an intervention to manage patients attending antenatal clinics and the labour ward. The CDSS users were mainly nurses who were trained. Activities and associated costs involved in the implementation of CDSS (pre-intervention and intervention) were collected for the period between 2009-2013 from the provider perspective. The ingredients approach was used for the cost analysis. Costs were grouped into personnel, trainings, overheads (recurrent costs) and equipment costs (capital cost). We calculated cost without annualizing capital cost to represent financial cost and cost with annualizing capital costs to represent economic cost. RESULTS: Twenty-two trained CDSS users (at least 2 users per health centre) participated in the study. Between April 2012 and March 2013, users managed 5,595 antenatal clients and 872 labour clients using the CDSS. We observed a decrease in the proportion of complications during delivery (pre-intervention 10.74% versus post-intervention 9.64%) and a reduction in the number of maternal deaths (pre-intervention 4 deaths versus post-intervention 1 death). The overall financial cost of CDSS implementation was US$23,316, approximately US$1,060 per CDSS user trained. Of the total cost of implementation, 48% (US$11,272) was pre-intervention cost and intervention cost was 52% (US$12,044). Equipment costs accounted for the largest proportion of financial cost: 34% (US$7,917). When economic cost was considered, total cost of implementation was US$17,128-lower than the financial cost by 26.5%. CONCLUSIONS: The study provides useful information in the implementation of CDSS at health facilities to enhance health workers' adherence to practice guidelines and taking accurate decisions to improve maternal health care.

Factors Associated with HIV Testing and Receiving Results during Antenatal Care in Tanzania

Mother to child transmission of HIV (MTCT) control goal is achievable when all pregnant mothers test for HIV and collect the results enabling timely eligibility and access to anti-retroviral therapy (ART). This study aimed to determine factors associated with uptake of HIV testing during antenatal care in Tanzania. Using 2011-2012 Tanzania HIV and Malaria Indicator Survey data; 3555 women who attended antenatal clinic and delivered in the last two years were analyzed. One was considered HIV tested if she took HIV test and collected results. Bivariate and multivariate analysis was done using STATA version 12. High proportion (76) tested for HIV during antenatal care; factors significantly associated (p0.05) with testing included receiving information on HIV testing during antenatal care; age; education and wealth. Proportion taking HIV test was high; prevention of MTCT (PMTCT) strategies should focus on increasing information on testing during antenatal care (ANC); targeting the young; less educated and poor