title: Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria.
abstract: BACKGROUND
  While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria.
  
  
  RESULTS
  We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program's scale up within the State's healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9-152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program's scale up by the State is dependent on further investments in healthcare.
  
  
  CONCLUSIONS
  This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care.
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Gabriela B
authors.initials: GB
authors.lastname: Gomez
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Nicola
authors.initials: N
authors.lastname: Foster
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Daniella
authors.initials: D
authors.lastname: Brals
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Heleen E
authors.initials: HE
authors.lastname: Nelissen
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Oladimeji A
authors.initials: OA
authors.lastname: Bolarinwa
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Marleen E
authors.initials: ME
authors.lastname: Hendriks
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Alexander C
authors.initials: AC
authors.lastname: Boers
authors.affiliation: Pharmaccess Foundation, Amsterdam, The Netherlands.
authors.forename: Diederik
authors.initials: D
authors.lastname: van Eck
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Nicole
authors.initials: N
authors.lastname: Rosendaal
authors.affiliation: Hygeia Nigeria Ltd, Lagos, Nigeria.
authors.forename: Peju
authors.initials: P
authors.lastname: Adenusi
authors.affiliation: Ogo Oluwa Hospital, Bacita, Kwara State, Nigeria.
authors.forename: Kayode
authors.initials: K
authors.lastname: Agbede
authors.affiliation: Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria.
authors.forename: Tanimola M
authors.initials: TM
authors.lastname: Akande
authors.affiliation: Global Child Health Group, Emma Children's Hospital AMC, Amsterdam, The Netherlands.
authors.forename: Michael
authors.initials: M
authors.lastname: Boele van Hensbroek
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Ferdinand W
authors.initials: FW
authors.lastname: Wit
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Catherine A
authors.initials: CA
authors.lastname: Hankins
authors.affiliation: Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
authors.forename: Constance
authors.initials: C
authors.lastname: Schultsz
mesh_terms: D002017:Budgets; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D006296:Health Services / Q000191:economics / Q000706:statistics & numerical data; D006761:Hospitals; D006801:Humans; D007348:Insurance, Health / Q000191:economics*; D000068097:Maternal Health / Q000191:economics*; D009549:Nigeria; D011247:Pregnancy; D012424:Rural Population