title: Cost and cost-effectiveness of newborn home visits: findings from the Newhints cluster-randomised controlled trial in rural Ghana.
abstract: BACKGROUND
  Every year, 2·9 million newborn babies die worldwide. A meta-analysis of four cluster-randomised controlled trials estimated that home visits by trained community members in programme settings in Ghana and south Asia reduced neonatal mortality by 12% (95% CI 5-18). We aimed to estimate the costs and cost-effectiveness of newborn home visits in a programme setting.
  
  
  METHODS
  We prospectively collected detailed cost data alongside the Newhints trial, which tested the effect of a home-visits intervention in seven districts in rural Ghana and showed a reduction of 8% (95% CI -12 to 25%) in neonatal mortality. The intervention consisted of a package of home visits to pregnant women and their babies in the first week of life by community-based surveillance volunteers. We calculated incremental cost-effectiveness ratios (ICERs) with Monte Carlo simulation and one-way sensitivity analyses and characterised uncertainty with cost-effectiveness planes and cost-effectiveness acceptability curves. We then modelled the potential cost-effectiveness for baseline neonatal mortality rates of 20-60 deaths per 1000 livebirths with use of a meta-analysis of effectiveness estimates.
  
  
  RESULTS
  In the 49 zones randomly allocated to receive the Newhints intervention, a mean of 407 (SD 18) community-based surveillance volunteers undertook home visits for 7848 pregnant women who gave birth to 7786 live babies in 2009. Annual economic cost of implementation was US$203 998, or $0·53 per person. In the base-case analysis, the Newhints intervention cost a mean of $10 343 (95% CI 2963 to -7674) per newborn life saved, or $352 (95% CI 104 to -268) per discounted life-year saved, and had a 72% chance of being highly cost effective with respect to Ghana's 2009 gross domestic product per person. Key determinants of cost-effectiveness were the discount rate, protective effectiveness, baseline neonatal mortality rate, and implementation costs. In the scenarios modelled with the meta-analysis results, the ICER increased from $127 per life-year saved at a neonatal mortality rate of 60 deaths per 1000 livebirths, to $379 per life-year saved at a rate of 20 deaths per 1000 livebirths. The strategy had at least a 99% probability of being highly cost effective for lower-middle-income countries in all neonatal mortality rate scenarios modelled, and at least a 95% probability of being highly cost effective for low-income countries at neonatal mortality rates of 30 or more deaths per 1000 livebirths.
  
  
  CONCLUSIONS
  Our findings show that the seemingly modest mortality reductions achieved by a newborn home-visit strategy might in fact be cost effective. In Ghana, such strategies are also likely to be affordable. Our findings support recommendations from WHO and UNICEF that low-income and middle-income countries implement newborn home visits.
  
  
  BACKGROUND
  The Bill & Melinda Gates Foundation, UK Department for International Development, WHO.
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK. Electronic address: catherine.pitt@lshtm.ac.uk.
authors.forename: Catherine
authors.initials: C
authors.lastname: Pitt
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana.
authors.forename: Theresa
authors.initials: T
authors.lastname: Tawiah
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Seyi
authors.initials: S
authors.lastname: Soremekun
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK; Department of Global Health, Academic Medical Center, University of Amsterdam and Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands.
authors.forename: Augustinus H A
authors.initials: AH
authors.lastname: ten Asbroek
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana; Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
authors.forename: Alexander
authors.initials: A
authors.lastname: Manu
authors.affiliation: Kintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana.
authors.forename: Charlotte
authors.initials: C
authors.lastname: Tawiah-Agyemang
authors.affiliation: Institute for Global Health, University College London, London, UK.
authors.forename: Zelee
authors.initials: Z
authors.lastname: Hill
authors.affiliation: Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK; Kintampo Health Research Centre, Ghana Health Service, Kintampo, Brong Ahafo Region, Ghana.
authors.forename: Seth
authors.initials: S
authors.lastname: Owusu-Agyei
authors.affiliation: Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Betty R
authors.initials: BR
authors.lastname: Kirkwood
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
mesh_terms: D000328:Adult; D003150:Community Health Workers / Q000193:education*; D003362:Cost-Benefit Analysis; D003906:Developing Countries; D005260:Female; D005869:Ghana / Q000453:epidemiology; D006792:House Calls / Q000191:economics*; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D011181:Postnatal Care / Q000191:economics*; D011247:Pregnancy; D011295:Prenatal Care / Q000191:economics; D016032:Randomized Controlled Trials as Topic; D019035:Rural Health Services / Q000191:economics; D012424:Rural Population