The cost-effectiveness of SCI in increasing skilled care at delivery
Between 2002 and 2005, the proportion of institutional births increased by 20.8% in Diapaga, a mean annual rate of increase of 6.5% (Hounton et al. 2008). In the first 2 years, between 2002 and 2004, there was a very similar annual rate of increase in Ouargaye (6.6% in SCI supported facilities, 6.3% in the others). However, between 2004 and 2005, there was a sharp increase in the proportion of institutional births (31.1% in SCI supported facilities, 32.6% in the others) which corresponds with the introduction of community mobilisation and behavioural change communication activities across Ouargaye district.
The health system in Burkina Faso is standardised, irrespective of donors (Direction des Infrastructures des Equipements et de la Maintenance (DIEM) 2004; Direction de la Santé de la Famille (DSF) and Ministère de la Santé, Burkina Faso 2004a,b,c). Comparing Ouargaye and Diapaga districts, the only distinctive intervention appeared to be SCI demand side activities. Hence, it is likely that the observed sharp increase between 2004 and 2005 in the proportion of institutional births in Ouargaye was the result of CMBCC activities. It is unlikely to have been by chance and there are no obvious confounding factors. While these trends refer to institutional births, approximately 95% of such births are at Health Centres, and we assume that the same rates of change occur at all health facilities.
We assume that, in the absence of SCI, the proportion of institutional births in Ouargaye would have increased by 6.6% between 2004 and 2005. There were 6900 deliveries at Health Centres in Ouargaye in 2005 but, had the previous trend rate applied, there would have been 5581 deliveries, 1319 fewer.
If these additional institutional deliveries are attributed solely to the stimulus of demand for skilled care by the CMBCC activities, which cost 37.5 million CFA2, our narrow measure of incremental cost per delivery was 28 431 CFA or $164 international dollars.3 This is our favoured estimate. It compares with the average cost per delivery in Health Centres across the two districts which we estimate below to be $214 international dollars.
If, however, SCI programme management costs (260.9 million CFA) are also included, the incremental cost per delivery increases markedly to 226 232 CFA or $1306 international dollars.
Costs and cost structures
Table 1 shows the maternal health costs and cost structures of Health Centres in Ouargaye and in Diapaga and the two District Hospitals. Patient costs, such as items paid for by user fees or purchased outside health facilities, are not included although we recognise that such costs may affect utilisation. For reference, the mean catchment population of Health Centres in the two districts is just under 12 000. These estimates represent one of the first attempts to cost standard maternal health care provision, as opposed to emergency obstetric care, in a developing country (Jowett 2000).
Table 1. Summary of District Hospital and Health Centre costs and cost structures in Ouargaye and Diapaga Districts, Burkina Faso
|Mean Ouargaye Health Centres||11 012 675||14.3||11.1||2.1||6.8||63.3||2.4|
|Mean Diapaga Health Centres||11 181 940||15.8||4.6||3.3||10.4||60.3||5.7|
|Ouargaye District Hospital||43 794 077||15.0||4.1||4.0||13.0||58.9||5.0|
|Diapaga District Hospital||50 177 268||12.0||6.3||5.3||16.4||53.1||6.9|
Comparing the two districts, mean total maternal health costs are very similar: 11.0 million CFA ($63 518 international dollars) in Ouargaye compared with 11.2 million CFA ($64 673 international dollars) in Diapaga. In terms of the mean distribution of costs, the pattern is fairly similar in the two districts, apart from other personnel costs. These are significantly higher in Ouargaye because this is the category to which we allocated the costs of SCI CMBCC activities.
By far, the most important single item is buildings, infrastructure and equipment, accounting for over 60% of total annualised costs. Health worker costs are the next largest category. The other categories – other personnel, drugs and medicines, other recurrent costs, and vehicles – each account for relatively small proportions, 2–11%, of total costs. Mean capital costs (including vehicles alongside buildings, infrastructure and equipment) across all Health Centres account for 66% of total maternal health care costs and recurrent costs the remaining 34%.
Table 1 also shows the maternal health care costs, and cost patterns, for the two District Hospitals. Total maternal health care costs are broadly comparable in magnitude at the two District Hospitals, 43.8 million CFA ($252 916 international dollars) at Ouargaye and 50.2 million CFA ($289 862 international dollars) at Diapaga. The pattern of costs is also roughly similar. The greater differences are between the District Hospitals and the Health Centres, in the magnitude of maternal health care costs, fairly obviously, and, less obviously, in the pattern of costs. Total maternal health care costs at the Ouargaye District Hospital are 4.0 times as great as the mean for the Health Centres in that district. The ratio in Diapaga, between District Hospital and the mean for the Health Centres, is similar (4.5). The proportions of costs attributable to drugs and medicines and to other recurrent costs (which includes minor equipment) are distinctly higher in the District Hospitals than in the Health Centres but the proportion of costs attributable to buildings, infrastructure and (major) equipment is lower. In summary, therefore, the difference in the magnitude and pattern of costs at the District Hospitals by comparison with the Health Centres reflects the greater scale, complexity and diversity of health care at the District Hospitals.
Table 2 shows total costs, the number of deliveries and the average costs per delivery, both mean values and the range from highest to lowest values. Total costs are highest at Kantchari Health Centre in Diapaga district (22.4 million CFA, $129 341 international dollars) and lowest at Dahangou Health Centre in Ouargaye district (7.8 million CFA, $45 040 international dollars). The ratio of highest to lowest total maternal health care costs is just under 3.
Table 2. Decomposition of average cost per delivery, Ouargaye and Diapaga Districts, Burkina Faso
|Total costs (CFA)||11 095 339||7 820 900 (Dahangou) to 22 443 033 (Kantchari)||11 012 675||11 181 940|
|Deliveries||300||65 (Tapoa Djerma) to 1375 (Mahadaga)||314||285|
|Average costs (CFA)||37 042||11 357 (Mahadaga) to 132 097 (Tapoa Djerma)||35 113||39 268|
|Average costs factor||3.17||1.00 (Mahadaga) to 11.63 (Tapoa Djerma)||3.01||3.37|
|Total costs factor||0.69||0.50 (Dahangou) to 1.44 (Kantchari)||0.69||0.70|
|Deliveries factor||0.22||0.05 (Tapoa Djerma) to 1.00 (Mahadaga)||0.23||0.21|
There is much greater variation in the number of deliveries. The highest number of deliveries, 1375, was at Mahadaga Health Centre, a missionary health centre in Diapaga district. The lowest number, 65, was at Tapoa Djerma Health Centre, also in Diapaga district. The ratio of highest to lowest number of deliveries is over 21. Mahadaga has the lowest average cost per delivery figure, 11 357 CFA ($65.58 international dollars) per delivery, and Tapoa Djerma, the highest figure, 132 097 CFA ($762.75 international dollars) per delivery. The ratio of highest to lowest average cost per delivery is nearly 12. The average cost per delivery across the two districts is 37 042 CFA or $214 international dollars.
Average cost per delivery is one possible measure of relative performance. However, adjustment for a number of other factors provides better measures of efficiency and points to different rankings of Health Centres. Table 3 adjusts for the different populations covered by the Health Centres to derive the utilisation factor, again showing both mean values and the range from highest to lowest values. The two extreme examples illustrate the effect of adjustment for population. Logobou Health Centre in Diapaga district has 32% of the number of deliveries of Mahadaga but since it covers 1.7 times the population of Mahadaga, Logobou’s utilisation factor is only 19% of Mahadaga’s. Nabangou Health Centre in Ouargaye district has just 6% of the number of deliveries of Mahadaga but since it covers only about 20% of the population of Mahadaga, Nabangou’s utilisation factor is 28% of Mahadaga’s.
Table 3. Decomposition of deliveries factor, Ouargaye and Diapaga Districts, Burkina Faso
|Deliveries factor||0.22||0.05 (Tapoa Djerma) to 1.00 (Mahadaga)||0.23||0.21|
|Population||11 984||3403 (Nabangou) to 28 755 (Logobou)||10 455||13 585|
|Population factor||0.71||0.20 (Nabangou) to 1.70 (Logobou)||0.62||0.80|
|Utilisation factor||0.31||0.10 (Botou) to 1.00 (Mahadaga)||0.37||0.26|
The utilisation factor is a different and in some ways superior measure of performance of a Health Centre to total cost per delivery given that the latter is determined to a considerable extent by just two factors: the fixed cost of buildings and the population of the area that the Health Centre serves. Mahadaga remains the top ranked Health Centre by utilisation but, otherwise, the rankings of Health Centres change considerably between the average cost per delivery and the utilisation factor, as Table 4 shows. The correlation coefficient between the two rankings is only 0.546. SCI Health Centres rank higher by the utilisation factor than by cost per delivery while the opposite is true of Health Centres in Diapaga.
Table 4. Rankings for 43 Health Centres in Ouargaye and Diapaga Districts, Burkina Faso, by utilisation and by average cost per delivery
|Ouargaye mean ranking|| ||15.6||18.4|
|Diapaga mean ranking|| ||28.7||25.6|
However, the analysis does not – or should not – stop there. Just as comparison of cost per delivery figures prompts a search for the underlying explanations for observed variations, so the reasons for differences in utilisation should be pursued. There are several different possibilities. Contrary to our assumption that the number of births is proportionate to population, there may be some variation between Health Centre areas although any variation is unlikely to be substantial. The proportion of pregnant women seeking to deliver at a Health Centre will vary according to local cultural factors, the ease and cost of travel, and the reputation of the nearest Health Centre(s). The extent of travel to Health Centres outside the catchment area – although some such Health Centres may actually be closer in terms of time or distance – may be a significant determinant of observed differences in utilisation. Certainly, there is anecdotal evidence that people travel to Mahadaga from all over Diapaga because of the quality of care provided there.