Dataset Information

Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India.

ABSTRACT:

Background

A variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention-ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DALY) averted as a result of ReMiND intervention as compared to routine maternal and child health programs without ReMiND.

Methods

A decision tree was parameterized on MS-Excel spreadsheet to estimate the change in DALYs and cost as a result of implementing ReMiND intervention compared with routine care, from both health system and societal perspective. A time horizon of 10 years starting from base year of 2011 was considered appropriate to cover all costs and effects comprehensively. All costs, including those during start-up and implementation phase, besides other costs on the health system or households were estimated. Consequences were measured as part of an impact assessment study which used a quasi-experimental design. Proximal outputs in terms of changes in service coverage were modelled to estimate maternal and infant illnesses and deaths averted, and DALYs averted in Uttar Pradesh state of India. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

Results

Cumulatively, from year 2011 to 2020, implementation of ReMiND intervention in UP would result in a reduction of 312 maternal and 149,468 neonatal deaths. This implies that ReMiND program led to a reduction of 0.2% maternal and 5.3% neonatal deaths. Overall, ReMiND is a cost saving intervention from societal perspective. From health system perspective, ReMiND incurs an incremental cost of INR 12,993 (USD 205) per DALY averted and INR 371,577 (USD 5865) per death averted.

Conclusions

Overall, findings of our study suggest strongly that the mHealth intervention as part of ReMiND program is cost saving from a societal perspective and should be considered for replication elsewhere in other states.

SUBMITTER: Prinja S

PROVIDER: S-EPMC6020234 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Publications

Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India.

Prinja Shankar S Bahuguna Pankaj P Gupta Aditi A Nimesh Ruby R Gupta Madhu M Thakur Jarnail Singh JS

Cost effectiveness and resource allocation : C/E 20180625

<h4>Background</h4>A variety of mobile-based health technologies (mHealth) have been developed for use by community health workers to augment their performance. One such mHealth intervention-ReMiND program, was implemented in a poor performing district of India. Despite some research on the extent of its effectiveness, there is significant dearth of evidence on cost-effectiveness of such mHealth interventions. In this paper we evaluated the incremental cost per disability adjusted life year (DAL ...[more]

PMID: 29983645

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Project description:BackgroundThe main intervention under ReMiND program consisted of a mobile health application which was used by community health volunteers, called ASHAs, for counselling pregnant women and nursing mothers. This program was implemented in two rural blocks in Uttar Pradesh state of India with an overall aim to increase quality of health care, thereby increasing utilization of maternal & child health services. The aim of the study was to assess annual & unit cost of ReMiND program and its scale up in UP state.Method and materialsEconomic costing was done from the health system and patient's perspectives. All resources used during designing & planning phase i.e., development of application; and implementation of the intervention, were quantified and valued. Capital costs were annualised, after assessing their average number of years for which a product could be used and accounting for its depreciation. Shared or joint costs were apportioned for the time value a resource was utilized under intervention. Annual cost of implementing ReMiND in two blocks of UP along and unit cost per pregnant woman were estimated. Scale-up cost for implementing the intervention in entire state was calculated under two scenarios - first, if no extra human resource were employed; and second, if the state government adopted the same pattern of human resource as employed under this program.ResultsThe annual cost for rolling out ReMiND in two blocks of district Kaushambi was INR 12.1 million (US $ 191,894). The annualised start-up cost constituted 9% of overall cost while rest of cost was attributed to implementation of the intervention. The health system program costs in ReMiND were estimated to be INR 31.4 (US $ 0.49) per capita per year and INR 1294 (US $ 20.5) per registered women. The per capita incremental cost of scale up of intervention in UP state was estimated to be INR 4.39 (US $ 0.07) when no additional supervisory staffs were added.ConclusionThe cost of scale up of ReMiND in Uttar Pradesh is 6% of annual budget for 'reproductive and child health' line item under state budget, and hence appears to be financially sustainable.

Project description:BackgroundAn m-health application has been developed and implemented with community health workers to improve their counseling in a rural area of India. The ultimate aim was to generate demand and improve utilization of key maternal, neonatal, and child health services. The present study aims to assess the impact and cost-effectiveness of this project.Methods/designA pre-post quasi-experimental design with a control group will be used to undertake difference in differences analysis for assessing the impact of intervention. The Annual Health Survey (2011) will provide pre-intervention data, and a household survey will be carried out to provide post-intervention data.Two community development blocks where the intervention was introduced will be treated as intervention blocks while two controls blocks are selected after matching with intervention blocks on three indicators: average number of antenatal care checkups, percentage of women receiving three or more antenatal checkups, and percentage of institutional deliveries. Two categories of beneficiaries will be interviewed in both areas: women with a child between 29 days and 6 months and women with a child between 12 and 23 months. Propensity score matched samples from intervention and control areas in pre-post periods will be analyzed using the difference in differences method to estimate the impact of intervention in utilization of key services.Bottom-up costing methods will be used to assess the cost of implementing intervention. A decision model will estimate long-term effects of improved health services utilization on mortality, morbidity, and disability. Cost-effectiveness will be assessed in terms of incremental cost per disability-adjusted life year averted and cost per unit increase in composite service coverage in intervention versus control groups.ConclusionsThe study will generate significant evidence on impact of the m-health intervention for maternal, neonatal, and child services and on the cost of scaling up m-health technology for accredited social health activists in India.

Project description:BackgroundDespite substantial reductions in perinatal deaths (stillbirths and early neonatal deaths), India's perinatal mortality rates remain high, both nationally and in individual states. Rates are highest among disadvantaged socio-economic groups. To address this, India's National Health Mission has trained community health workers called Accredited Social Health Activists (ASHAs) to counsel and support women by visiting them at home before and after childbirth. We conducted a qualitative study to explore the roles of ASHAs' home visits in improving equity in perinatal health between socio-economic position groups in rural Uttar Pradesh (UP), India.MethodsWe conducted social mapping in four villages of two districts in UP, followed by three focus group discussions in each village (12 in total) with ASHAs and women who had recently given birth belonging to 'higher' and 'lower' socio-economic position groups (n = 134 participants). We analysed the data in NVivo and Dedoose using a thematic framework approach.ResultsHome visits enabled ASHAs to build trusting relationships with women, offer information about health services, schemes and preventive care, and provide practical support for accessing maternity care. This helped many women and families prepare for birth and motivated them to deliver in health facilities. In particular, ASHAs encouraged women who were poorer, less educated or from lower caste groups to give birth in public Community Health Centres (CHCs). However, women who gave birth at CHCs often experienced insufficient emergency obstetric care, mistreatment from staff, indirect costs, lack of medicines, and referrals to higher-level facilities when complications occurred. Referrals often led to delays and higher fees that placed the greatest burden on families who were considered of lower socio-economic position or living in remote areas, and increased their risk of experiencing perinatal loss.ConclusionsThe study found that ASHAs built relationships, counselled and supported many pregnant women of lower socio-economic positions. Ongoing inequities in health facility births and perinatal mortality were perpetuated by overlapping contextual issues beyond the ASHAs' purview. Supporting ASHAs' integration with community organisations and health system strategies more broadly is needed to address these issues and optimise pathways between equity in intervention coverage, processes and perinatal health outcomes.

Project description:BackgroundEffective, scalable strategies to improve maternal, fetal, and newborn health and reduce preventable morbidity and mortality are urgently needed in low- and middle-income countries. Building on the successes of previous checklist-based programs, the World Health Organization (WHO) and partners led the development of the Safe Childbirth Checklist (SCC), a 28-item list of evidence-based practices linked with improved maternal and newborn outcomes. Pilot-testing of the Checklist in Southern India demonstrated dramatic improvements in adherence by health workers to essential childbirth-related practices (EBPs). The BetterBirth Trial seeks to measure the effectiveness of SCC impact on EBPs, deaths, and complications at a larger scale.Methods/designThis matched-pair, cluster-randomized controlled, adaptive trial will be conducted in 120 facilities across 24 districts in Uttar Pradesh, India. Study sites, identified according to predefined eligibility criteria, were matched by measured covariates before randomization. The intervention, the SCC embedded in a quality improvement program, consists of leadership engagement, a 2-day educational launch of the SCC, and support through placement of a trained peer "coach" to provide supportive supervision and real-time data feedback over an 8-month period with decreasing intensity. A facility-based childbirth quality coordinator is trained and supported to drive sustained behavior change after the BetterBirth team leaves the facility. Study participants are birth attendants and women and their newborns who present to the study facilities for childbirth at 60 intervention and 60 control sites. The primary outcome is a composite measure including maternal death, maternal severe morbidity, stillbirth, and newborn death, occurring within 7 days after birth. The sample size (n = 171,964) was calculated to detect a 15% reduction in the primary outcome. Adherence by health workers to EBPs will be measured in a subset of births (n = 6000). The trial will be conducted in close collaboration with key partners including the Governments of India and Uttar Pradesh, the World Health Organization, an expert Scientific Advisory Committee, an experienced local implementing organization (Population Services International, PSI), and frontline facility leaders and workers.DiscussionIf effective, the WHO Safe Childbirth Checklist program could be a powerful health facility-strengthening intervention to improve quality of care and reduce preventable harm to women and newborns, with millions of potential beneficiaries.Trial registrationBetterBirth Study Protocol dated: 13 February 2014; ClinicalTrials.gov: NCT02148952 ; Universal Trial Number: U1111-1131-5647.

Project description:BackgroundUttar Pradesh (UP), India continues to have a high burden of mortality among young children despite recent improvement. Therefore, it is vital to understand the risk factors associated with under-five (U5) deaths and episodes of severe illness in order to deliver programs targeted at decreasing mortality among U5 children in UP. However, in rural UP, almost every child has one or more commonly described risk factors, such as low socioeconomic status or undernutrition. Determining how risk factors for childhood illness and death are understood by community members, community health workers and facility staff in rural UP is important so that programs can identify the most vulnerable children.MethodsThis qualitative study was completed in three districts of UP that were part of a larger child health program. Twelve semi-structured interviews and 21 focus group discussions with 182 participants were conducted with community members (mothers and heads of households with U5 children), community health workers (CHWs; Accredited Social Health Activists and Auxiliary Nurse Midwives) and facility staff (medical officers and staff nurses). All interactions were recorded, transcribed and translated into English, coded and clustered by theme for analysis. The data presented are thematic areas that emerged around perceived risk factors for childhood illness and death.ResultsThere were key differences among the three groups regarding the explanatory perspectives for identified risk factors. Some perspectives were completely divergent, such as why the location of the housing was a risk factor, whereas others were convergent, including the impact of seasonality and certain occupational factors. The classic explanatory risk factors for childhood illness and death identified in household surveys were often perceived as key risk factors by facility staff but not community members. However, overlapping views were frequently expressed by two of the groups with the CHWs bridging the perspectives of the community members and facility staff.ConclusionThe bridging views of the CHWs can be leveraged to identify and focus their activities on the most vulnerable children in the communities they serve, link them to facilities when they become ill and drive innovations in program delivery throughout the community-facility continuum.

Project description:The National Health Policy (2017) of India advocates Universal Health Coverage through inclusive growth, decentralization, and rebuilding a cohesive community through a participatory process. To achieve this goal, understanding social organization, and community relationships - defined as social capital - is critical. This study aimed to explore the influence of individual and community-level social capital on a critical health system performance indicator, three-doses of diphtheria-pertussis-tetanus (DPT3) immunization among 12-59 month children, in rural Uttar Pradesh (UP), India. The analysis is based on a cross-sectional survey from two districts of UP, which included 2239 children 12-59 months of age (level 1) from 1749 households (level 2) nested within 346 communities (level 3). We used multilevel confirmatory factor analysis to generate standardized factor scores of social capital constructs (Organizational Participation, Social Support, Trust and Social Cohesion) of the household heads and mothers both at individual and community level, which were then used in the multilevel logistic regressions to explore the independent and contextual effect of social capital on a child's DPT3 immunization status. The result showed only community-level Social Cohesion of the mothers was associated with a child's DPT3 immunization status (Adjusted odds ratio = 1.25, 95% confidence interval = 1.12-1.54; p = 0.04). Beyond its independent effect on utilization of immunization service, the collective Social Cohesion of the mothers significantly modified the relationship of child age, mother's knowledge of immunization, community wealth, and communities' contact with frontline workers with immunization status of the child. With a strong theoretical underpinning, the result substantially contributes to understanding the individual and contextual predictors of immunization service utilization and further advancing the literature of social capital in India. This study can serve as a starting point to catalyze social capital within the health interventions for achieving wellbeing and the collective development of society.

Dataset Information

Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India.

Background

Methods

Results

Conclusions

Publications

Cost effectiveness of mHealth intervention by community health workers for reducing maternal and newborn mortality in rural Uttar Pradesh, India.

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