A structured review of the recent literature on the economic consequences of preterm birth

S Petrou, O Eddema, L Mangham

Archives of Diseases in Children: Fetal and Neonatal Edition 2011, 96:3:F223-232 | DOI: 10.1093/heapol/czp066

DOI: 10.1136/adc.2009.161117

Abstract

Although survival rates for preterm infants have greatly improved over the last three to four decades, these infants remain at risk of developing a broad range of short-term and long-term complications. Despite the large body of work on the clinical sequelae of preterm birth, relatively little is known about its economic consequences. This paper represents a structured review of the recent scientific literature on the economic consequences of preterm birth for the health services, for other sectors of the economy, for families and carers and, more broadly, for society. A total of 2497 studies were identified by a pretested literature search strategy, 52 of which were included in the final review. Of these 52 studies, 19 reported the costs associated with the initial period of hospitalisation, 35 reported costs incurred following the initial hospital discharge (without providing costs for the entire remaining period of childhood), four of which also reported costs associated with the initial period of hospitalisation, while two reported costs incurred throughout childhood. The paper highlights the variable methodological quality of this body of literature. The results of the studies included in the review are summarised and critically appraised. The paper also highlights gaps in our current knowledge of the topic and identifies requirements for further research in this area.

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Interventions to improve providers’ ability to diagnose and treat uncomplicated malaria: a literature review

L Mangham

REACT Working Paper, London School of Hygiene and Tropical Medicine, 2010, London.

Executive Summary

Prompt access to effective malaria treatment is important, and many individuals rely on providers to diagnose malaria and dispense the recommended treatment. Whether the emphasis is on presumptive or parasitological diagnosis, ensuring that providers are able to supply treatment in line with national guidelines is critical for patient care. There are, however, longstanding problems with the care available at many public health facilities and private sector outlets. Given these problems and the recent interest in the use of RDTs, there is a need for interventions that improve the ability and practice of providers to treat patients that present at a health facility with a fever. This literature review examines the evidence available on interventions to improve providers’ ability to diagnose or treat uncomplicated malaria.

A comprehensive search of the published literature was undertaken using bibliographic databases. Relevant publications in the grey literature were identified from review articles, reference lists of relevant publications and from websites of development agencies. Publications since 1990 were eligible if they met all of the following inclusion criteria:

  • The intervention was intended to improve providers’ ability to diagnose or treat uncomplicated malaria.
  • The population exposed to the intervention are providers.
  • The study design included a comparison group.
  • The effect was reported on a malaria-related outcome.
  • The study setting was an area of endemic malaria transmission in sub-Saharan Africa or Asia.

Evidence on effectiveness was synthesized using three types of outcome: i) presumptive treatment of uncomplicated malaria; ii) appropriate treatment of uncomplicated malaria (following a diagnostic test); and iii) the accuracy of prescribing antimalarial treatment regimens.

Twenty-nine publications were eligible for the review, which report on 27 studies and 32 different interventions. The majority of the studies were from Africa, with 8 from Kenya, 5 from Tanzania, 4 from Uganda and 3 from Nigeria. The majority of the interventions were designed to focus on malaria, though several included malaria within the Integrated Management of Childhood Illnesses (IMCI). Provider training was dominant, and the principal activity in 21 of 32 interventions. The training interventions included studies focusing on presumptive treatment of malaria, and studies on diagnostic testing.

Most interventions had a significant positive effect on the presumptive treatment of uncomplicated malaria, and the accuracy of the doses and advice given. The provision of RDTs and training on diagnostic tests improved the appropriate treatment of malaria, though the proportion of test negative patients receiving antimalarials often remained relatively high. No studies compared an intervention in both public and private sector providers and only two programmes reported on the cost-effectiveness of the intervention.

Further work on interventions to improve the appropriate treatment of febrile patients would be valuable. The studies show that provider training and the provision of RDTs can be beneficial, though suggest that conventional approaches may have only a limited effect.

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Scaling up in international health: what are the key issues?

LJ Mangham, K Hanson

Health Policy and Planning, 2010, 25(2):85-96 | DOI: 10.1093/heapol/czp066

Published: 13 January 2010

Abstract

The term ‘scaling up’ is now widely used in the international health literature, though it lacks an agreed definition. We review what is meant by scaling up in the context of changes in international health and development over the last decade. We argue that the notion of scaling up is primarily used to describe the ambition or process of expanding the coverage of health interventions, though the term has also referred to increasing the financial, human and capital resources required to expand coverage.

We discuss four pertinent issues in scaling up the coverage of health interventions: the costs of scaling up coverage; constraints to scaling up; equity and quality concerns; and key service delivery issues when scaling up.

We then review recent progress in scaling up the coverage of health interventions. This includes a considerable increase in the volume of aid, accompanied by numerous new health initiatives and financing mechanisms. There have also been improvements in health outcomes and some examples of successful large-scale programmes. Finally, we reflect on the importance of obtaining a better understanding of how to deliver priority health interventions at scale, the current emphasis on health system strengthening and the challenges of sustaining scaling up in the prevailing global economic environment.

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The cost of preterm birth throughout childhood in England and Wales

LJ Mangham, S Petrou, LW Doyle, ES Draper, N Marlow

Pediatrics 2009, 123(2): e312-e327 | DOI: 10.1542/peds.2008-1827

Abstract

Background: Infants born preterm are at increased risk of adverse health and developmental outcomes. Mortality and morbidity after preterm birth impose a burden on finite public sector resources. This study considers the economic consequences of preterm birth from birth to adult life and compares the costs accruing to those born preterm with those born at term.

Methods: A decision-analytic model was constructed to estimate the costs to the public sector over the first 18 years after birth, stratified by week of gestational age at birth. Costs were discounted and reported in UK pounds at 2006 prices. Probabilistic sensitivity analysis was used to examine uncertainty in the model parameters and generate confidence intervals surrounding the cost estimates.

Results: The model estimates the costs associated with a hypothetical cohort of 669601 children and is based on live birth and preterm birth data from England and Wales in 2006. The total cost of preterm birth to the public sector was estimated to be £2.946 billion (US $4.567 billion), and an inverse relationship was identified between gestational age at birth and the average public sector cost per surviving child. The incremental cost per preterm child surviving to 18 years compared with a term survivor was estimated at £22885 (US $35471). The corresponding estimates for a very and extremely preterm child were substantially higher at £61781 (US $95760) and £94740 (US $146847), respectively.

Conclusions: Despite concerns about ongoing costs after discharge from perinatal services, the largest contribution to the economic implications of preterm birth are hospital inpatient costs after birth, which are responsible for 92.0% of the incremental costs per preterm survivor.

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Designing a Discrete Choice Experiment for Application in a Low-Income Country

LJ Mangham, K Hanson, B McPake

Health Policy and Planning 2009, 24: 151-158 | DOI: 10.1093/heapol/czn047

Abstract

Understanding the preferences of patients and health professionals is useful for health policy and planning. Discrete choice experiments (DCEs) are a quantitative technique for eliciting preferences that can be used in the absence of revealed preference data. The method involves asking individuals to state their preference over hypothetical alternative scenarios, goods or services. Each alternative is described by several attributes and the responses are used to determine whether preferences are significantly influenced by the attributes and also their relative importance. DCEs are widely used in high-income contexts and are increasingly being applied in low- and middle-income countries to consider a range of policy concerns. This paper aims to provide an introduction to DCEs for policy-makers and researchers with little knowledge of the technique. We outline the stages involved in undertaking a DCE, with an emphasis on the design considerations applicable in a low-income setting.

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Employment preferences of public sector nurses in Malawi: Results from a discrete choice experiment

LJ Mangham, K Hanson

Tropical Medicine and International Health 2008, 13(12):1-9 | DOI: 10.1111/j.1365-3156.2008.02167.x

Abstract

Objectives: To understand the employment preferences of Malawian public sector registered nurses, and to ascertain whether salary increases significantly affect how nurses regard their employment.

Methods: A discrete choice experiment was used to assess the significance of six job attributes on nurses’ preferences over pairs of job descriptions: net monthly pay, provision of government housing, opportunities to upgrade their qualifications, typical workload, availability of resources and place of work. A multivariate model was used to estimate the extent to which nurses were willing to trade between their monetary benefits, non-monetary benefits, and working conditions, and to determine the relative importance of the job attributes.

Results: Most nurses were willing to trade among attributes, and very few appeared to have preferences that were dominated by a single job attribute. All attributes had a statistically significant influence on nurses’ preferences, and further analysis showed the rate at which they were willing to forego pay increases for other improvements in their employment conditions. Opportunities to upgrade professional qualifications, government housing and the increases in net monthly pay had the greatest impact on nurses’ employment choices.

Conclusions: Salary enhancement can improve the motivation and retention of nurses, as well as improvements of employment conditions, which support existing efforts to address the health worker shortage.

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Who benefits from public spending on health care in Malawi? An application of benefit incidence analysis to the health sector in Malawi

LJ Mangham

Malawi Medical Journal 2006, 18(2):60-65 | DOI: 10.4314/mmj.v18i2.10911

Abstract

A principal objective of the Malawi government is to provide public health services that reach poor men and women. This paper assesses to what extent the Government has been successful in achieving this. Malawi was also found to be more successful than other countries in Africa at providing health services that reach the poor. The analysis of benefit incidence finds that the distribution of benefits across socio-economic groups is largely explained by differences in the utilization of health services and the lower reported incidence of illness among the poor, rather than the distribution of the health subsidy.

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