title: Cost-effectiveness analysis of a voucher scheme combined with obstetrical quality improvements: quasi experimental results from Uganda.
abstract: 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.
authors.affiliation: 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 yalfonso@jhsph.edu.
authors.forename: Y Natalia
authors.initials: YN
authors.lastname: Alfonso
authors.affiliation: 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.
authors.forename: David
authors.initials: D
authors.lastname: Bishai
authors.affiliation: 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.
authors.forename: John
authors.initials: J
authors.lastname: Bua
authors.affiliation: 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.
authors.forename: Aloysius
authors.initials: A
authors.lastname: Mutebi
authors.affiliation: 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.
authors.forename: Crispus
authors.initials: C
authors.lastname: Mayora
authors.affiliation: 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.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Ekirapa-Kiracho
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D061889:Healthcare Financing; D006801:Humans; D008428:Maternal Mortality; D009774:Obstetrics / Q000191:economics* / Q000458:organization & administration / Q000592:standards; D011247:Pregnancy; D058996:Quality Improvement / Q000191:economics / Q000458:organization & administration*; D012051:Reimbursement Mechanisms / Q000191:economics / Q000458:organization & administration; D014454:Uganda
keywords: Africa; Maternal mortality; Uganda; cost-effectiveness; demand-side financing; economic evaluation; financial incentives; health financing; health system strengthening; institutional deliveries; maternity services; obstetric care; quasi-experimental trial; supply-side financing; vouchers