Academic journal article Bulletin of the World Health Organization

Economic Evaluation of Neonatal Care Packages in a Cluster-Randomized Controlled Trial in Sylhet, Bangladesh/Evaluation Economique Des Programmes De Soins Neonataux Dans Un Essai Controle Randomise Par Grappes a Sylhet, Bangladesh/Evaluacion Economica De Los Paquetes De Atencion Neonatal En Un Ensayo Controlado Aleatorio Por Grupos En Sylhet, Bangladesh

Academic journal article Bulletin of the World Health Organization

Economic Evaluation of Neonatal Care Packages in a Cluster-Randomized Controlled Trial in Sylhet, Bangladesh/Evaluation Economique Des Programmes De Soins Neonataux Dans Un Essai Controle Randomise Par Grappes a Sylhet, Bangladesh/Evaluacion Economica De Los Paquetes De Atencion Neonatal En Un Ensayo Controlado Aleatorio Por Grupos En Sylhet, Bangladesh

Article excerpt

Introduction

Globally, an estimated 7.6 million children aged younger than 5 years--including 3.1 million infants less than 28 days old--died in 2010. (1) Of the deaths that occur each year among children less than 5 years old, 99% occur in low--and middle-income countries, 28% occur in south-east Asia and 4% occur in Bangladesh alone. (2) In Bangladesh, neonatal deaths comprise 74% of infant deaths and 60% of the deaths that occur in children less than 5 years of age. (3) Although neonatal mortality has declined in Bangladesh over the last decade, an estimated 83 070 neonatal deaths still occur in the country each year. Cost-effective strategies to improve access to neonatal health services will have to be developed and implemented in Bangladesh if Millennium Development Goal 4 is to be attained. (4)

The Project for Advancing the Health of Newborns and Mothers was established in Bangladesh in 2002 by researchers, programme managers and policy-makers who wanted to reduce neonatal mortality in rural areas of the country. (5) The Project tested the effectiveness of two strategies for the delivery of maternal and neonatal health services--known as the "home-care" and "community-care" models--in a cluster-randomized controlled trial in Sylhet division. (5) The results of the trial indicated that implementation of the home-care strategy led to a 28% reduction in neonatal mortality during the final year of the intervention. (5) In contrast, no significant reduction in neonatal mortality was observed in the community-care arm.

Although data on the cost-effectiveness of some community-based strategies for reducing neonatal mortality in low--and middle-income countries are emerging, (6) the cost-effectiveness of either of the strategies explored in Bangladesh's Sylhet division (5) has not been investigated. The aim of the present study was to fill this gap.

Methods

Study site and population

The activities of the Project for Advancing the Health of Newborns and Mothers were implemented, among a population of about 500 000, in the Beanibazar, Zakiganj and Kanaighat subdistricts of Sylhet division. (5) Sylhet was selected as a study area because it had been found to have a higher level of neonatal mortality--63 neonatal deaths per 1000 live births--and a higher fertility rate--4.2 births per woman--than any of the other five of Bangladesh's divisions. (4) When the Project was launched, those living in Sylhet had relatively poor access to health services and showed low levels of utilization of skilled birth attendants. (7) At the same time, however, none of the nongovernmental organizations (NGOs) present in the division were considered capable of ensuring the Project's sustainability and promoting the large-scale delivery of any test intervention. (5) The study was registered as International Standard Randomised Controlled Trial number NCT00198705.

Interventions

The Project had three study arms: home care, community care and a control arm in which the pre-existing level of care was left largely unsupplemented (Table 1). (5) All three arms included attempts to strengthen the health systems in subdistrict health complexes and health and family welfare centres. The three subdistrict health complexes in the Project area provided a basic package of inpatient, outpatient and emergency services for mothers with neonates but no emergency obstetric care. Women who required emergency obstetric care were usually referred to Sylhet Medical College, which lies about 8.5 km from the study area. (8) The 24 health and family welfare centres in the Project area focused on the provision of outpatient services, including outpatient maternal, reproductive and child health services. During the study, the supply of antibiotics to all levels of the local health system was strengthened but remained sporadic. There was considerable between-facility variation in the working hours of medical personnel. …

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