How much does safe motherhood cost?

10 World Health • SlstYeor, No. l, Jonuory-Februory 1998 How much does safe motherhood cost? Craig Lissner & Eva Weissman A spreadsheet designed to support the planning and management of safe motherhood interventions shows how their costs can be realistically estimated. Planners and decision-makers have a wide variety of choices when trying to tackle the causes of maternal and newborn mortality and morbidity. For instance, they have to decide: • whether to focus more on the quality of essential obstetric care at the referral level or at the peripheral level; • whether to work more on improv- ing health care provider skills or on improving the system within which the providers work; • whether to strengthen links be- tween the community and the health centre, or between the peripheral facility and the referral centre. In deciding what a new safe mother- hood programme should consist of, or what changes should be made to an existing programme, a careful assessment of the cost of each option must be made. The costs associated with each of the approaches outlined above, for example, will be very different. Cost assessment is needed for the following processes: • selecting essential interventions that are appropriate to the local setting and respond to local needs; • planning feasible and sustainable ways of carrying out these inter- ventions; • comparing the cost of maternal health interventions with that of meeting other locally defined health needs ; • planning the financing of the interventions proposed; • making a rational distribution of the staff, equipment and other inputs required to implement the programme. Mother-baby Package Costing Spreadsheet To help programme planners and managers assess costs, WHO, work- ing with staff of the World Bank, developed the Mother-Baby Package Costing Spreadsheet. The spread- sheet is based on the Mother-Baby Package, a set of interventions designed to reduce maternal and neonatal mortality in developing countries. The model is inclusive but can easily be modified to fit the maternal health programme plan- ner's own needs and priorities. It can be used to estimate either the cost of a whole programme for the district under study, or just the cost of upgrading the existing one. It provides estimates of total cost, cost per capita and cost per birth for the district. These estimates are broken down by input (such as drugs, sup- plies, salaries and infrastructure), intervention (such as those required for haemorrhage, eclampsia and sepsis), and by service location (hospital, health centre, health post). The spreadsheet includes all of the interventions defined in the Mother- Baby Package, as summarized in the table below. The spreadsheet is made up of a series of linked worksheets on the following aspects of the programme: • direct costs, showing the costs directly incurred in carrying out each intervention, such as the cost of drugs and vaccines, laboratory diagnoses, blood supplies, hospi- tal beds per day, and medical personnel for all interventions; • clinical staff salaries, including benefits and in-service training, for the various categories of staff required for the provision of maternal and newborn health services; • overhead costs, to show the cost of maintenance, utilities, support Mother-Baby Package interventions included in the spreadsheet Antenatal care Basic antenatal care Management of syphilis, gonorrhoea, and chlamydia Management of severe anaemia Malaria treatment (where applicable) Normal delivery care Clean and safe delivery and postpartum care Essential obstetric care Management of eclampsia, sepsis, haemorrhage, caesarean delivery, abortion complications Family planning services Postpartum family planning information and services World Health • SlstYeor, No. 1, Jonuory-februory 1998 Gonorrhoea & S hl Chlamydia Yf ~ is l % Severe Eclampsia l % Anaemia Abortion Complications 4 % l % Caesarean Section 5% Haemorrhage 9% family Planning 14% . Blood Transport IEC & Social Supplies (Petrol) Marketing 2% 1 % Laboratory 3% Supplies Support Salaries 3% l % Supervision 3% Bed/ Hotel Costs 4% Maintenance & Utilities 6% Supplies 10% r----~~ Capitol Cost 16% 11 Fig. 1. Cost of Mother-Baby Package, by intervention (lowincome scenario) Fig. 2. Cost of Mother-Baby Package, by input (low-income scenario) staff, supervision, and informa- tion, education and communica- tion activities related to delivering the services in the package; • annual capital costs, to give information on the costs and depreciation related to buildings and large items of equipment; • referrals, to show client contacts with the health system, based on care-seeking behaviour, referral patterns, and number of contacts for each intervention; • demography, to give information on the population and birth rate in the district, estimates of the incidence of pregnancy-related complications, and information about the existing health system infrastructure. The series of worksheets ends with one which summarizes all of the others in order to show the total cost of the programme, as well as break- downs by intervention, input and level. Sample applications of the costing spreadsheet District-level use of the spreadsheet involves carefully assessing each input and modifying it to fit the setting in which it is to be used. However, for illustrative purposes, two scenarios have been worked out, one to represent a low-income devel- oping country, and the other to represent a middle-income develop- ing country. For this exercise, the basic spreadsheet assumptions were not modified, and were based on the Mother-Baby Package and other clinical guidelines developed by . WHO. The calculations showed that the total cost of implementing the full set of interventions in the Mother- Baby Package was $2.60 per capita in the low-income scenario, and $5.60 in the middle-income sce- nario. Figure 1 shows the break- down of this total cost by intervention in the low-income setting. Almost half of the cost was associated with providing antenatal care (25%) and delivery care (20%) for normal birth. The other major interventions in terms of cost were family planning (14%), management of newborn complications (13 %) and management of haemorrhage (9%). It is noteworthy that the cost of integrating care for sexually transmitted diseases into maternal care was found to be relatively low, accounting for less than 2% of the total. Figure 2 shows the same total cost figure broken down by input. In this view, the largest share of the cost is attributable to salaries, with 39% for clinical salaries, and an additional 3% for support salaries. In the middle-income scenario, where labour costs were much higher, salaries accounted for almost 70% of total cost. The next largest item was the annual cost of capital, which was followed by the cost of drugs (12%) and consumable sup- plies (10%) . Conclusion Two conclusions can be drawn from this approach to costing safe mother- hood interventions. The first is that it is not excessively difficult to estimate all of the costs involved. The second, of equal importance, is that the safe motherhood interven- tions needed are affordable, even in low-income developing countries. Their cost compares favourably with that of other interventions, such as measles immunization or the control of acute respiratory infections in children. • Craig Lissner is with the Maternal and Newborn Health/Safe Motherhood unit, Division of Reproductive Health (Technical Support), World Health Organization, 121 1 Geneva 27, Switzerland. Eva Weissman is an international public health consultant based in New York.