1. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 COST EFFECTIVENESS ANALYSIS OF ALTERNATIVE TRAINING STRATEGIES FOR IMPROVING ACCESS TO EMERGENCY OBSTETRIC CARE IN BURKINA FASO Hounton S 1,2, Belemsaga D 3, Newlands D 2, Meda N 3, De Brouwere V 4 1 WHO-MDSC, Burkina Faso, 2 University of Aberdeen, UK 3 Centre MURAZ, Burkina Faso, 4 ITM, Antwerp, Belgium

2. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 1. Maternal and newborn mortality very high. How to ensure skilled ? 2. Skilled health human resources (number, coverage, availability, access) 3. Effectiveness and cost- effectiveness of strategies to address shortage ? BACKGROUND

3. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 3 OBJECTIVES 1. Effectiveness of surgical teams led by specialists, medical doctors, and clinical officers in providing life saving interventions 2. Value for money 3. Policy recommendation for effective coverage of emergency obstetric care in rural areas

4. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 METHODS (1)  Study design: Cost-effectiveness analysis (surgeries: c-sections) - Strategy 1: Team led by a specialist (OBGY, surgeon) - Strategy 2: Team led by a general practitioner - Strategy 3: Team led by a clinical officer Comparability of case-mix and supporting environment  Place and participants - Burkina Faso (6 / 13 regions) - All district hospitals  Study period: Oct – Dec 2007  Perspective: health system  Time horizon: 15 years

5. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 METHODS (2)  Effectiveness measures - Maternal and newborn case fatality rates - Post caesarean complications (haemorrhage, infections, loosening of sutures)  Costing methodology aims - Average annual cost of training and deployment of providers - Average annual costs of putting in place a surgical team  Incremental Cost Effectiveness Ratio (ICER)

6. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 METHODS (3)  Data sources, data collection - Retrospective case extraction of registries (Jan - Dec 2006) - Reports (MOH, University), interviews of stakeholders on barriers and facilitators of the substitutes strategies  Data analysis - Descriptive statistics, multivariate analysis (case-mix) - Macro costing, annual costs estimates (useful lifespan of items, 3% discount rate, allocation of total costs to caesarean section by appropriate proxies of the volume and time) - Sensitivity analysis on major costs categories

7. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 RESULTS (1): CASES PROFILE

8. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 RESULTS (2) : OUTCOMES  Case fatality rates of caesarean deliveries by provider, district hospitals, 2004-2005, Burkina Faso  Newborns (/1000 c-sections)  Mothers (/1000 c-sections) 0 50 100 150 200 250 ObstetriciansGeneral practitionersClinical officers 0 10 20 30 40 50 60 70 80 ObstetriciansGeneral practitionersClinical officers

9. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 RESULTS (3) : COSTING ICER of caesarean deliveries by providers’ teams, district hospitals, 2006

10. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 RESULTS (4): “ENHANCED STRATEGIES” ICER of caesarean deliveries by providers’ teams, district hospitals, 2006

11. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009  Comparable skills & practices of c-section (thus life saving interventions) between obstetricians and trained doctors  Results comparable to those in Mozambique, Malawi, Zambia, however higher CFR with clinical officers in our settings  Delegation of surgical tasks from specialists to substitutes: necessary, effective and cost-effective in rural areas  HRH : incentives are primarily about career path, supportive environment, degree (prestige), and monetary incentives  Limitations: comparability of settings, providers, cases DISCUSSIONS

12. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009  All current options for providing emergency surgeries are viable  Trained doctors: most cost effective option  Potential for improved cost-effectiveness of trained doctors if career paths and incentives provided  In Burkina Faso, given shortage will remain for foreseeable future, delegation of surgical tasks from specialists to middle level health substitutes has proven to be effective, is cost effective in the short and mid runs CONCLUSION

13. Inaugural Conference of the African Health Economics and Policy Association (AfHEA) Accra - Ghana, 10th - 12th March 2009 ACKNOWLEDGEMENTS  West Africa Health Organization (WAHO) Grant WAHO, N°13 Centre MURAZ, 2005  Ministry of health, Centre MURAZ (Burkina Faso)  Collaborators: Sombie I, Cecile Tamini, Mamadou Barro, Fadima Bocoum, Abdoulaye Traore, Moctar Ouédraogo, Peter Byass