COST EFFECTIVENESS AND SCALABILITY OF AN mHEALTH INTERVENTION TO IMPROVE PREGNANCY SURVEILLANCE AND CARE SEEKING IN RURAL BANGLADESH

Background: Proven health interventions, when implemented with high fidelity and adequate coverage, could save millions of maternal and newborn lives. In many low and middle-income countries, however, coverage levels of these interventions are still low. The mCARE program, implemented from 2011 to 2015 in Gaibandha district in Bangladesh, was implemented with the aim of developing and testing a mobile phone-based system to improve healthcare-seeking behaviors of pregnant women during and after their pregnancy through health worker-delivered automated and personally scheduled Short Message Service (SMS) and home visit reminders. Despite the growing recognition of the potential benefits of mobile health (mHealth) in improving knowledge, care seeking, and treatment adherence, little evidence exists on the value of mHealth for money or affordability in developing countries. Methods: Following established guidelines (e.g. CHEERS, ISPOR), we present analyses of the costs, consequences and affordability of the study drawn from a wide spectrum of datasets from the mCARE project including system-generated data on utilization, financial records from implementation and technical organizations, interviews with local experts and stakeholders, observations of service provision and exit interviews with 100 pregnant women in rural Bangladesh. Secondary data were also drawn from the literature and published national surveys. We used an ingredients-based approach to measure program costs by activity, and developed an Excel-based spreadsheet model to forecast program, provider and user costs and consequences for various alternatives and service delivery scenarios. The Lives Saved Tool (LiST) was used to model the number of lives saved and disability adjusted life years (DALYs) averted stemming from increases in coverage over time. We tested the robustness of the results though deterministic and probabilistic sensitivity analyses using Monte Carlo simulations. Finally, based on cost-effectiveness findings, we assessed the affordability of implementing the mCARE program using a budget impact analysis and cost-effectiveness affordability curves from the perspective of a budget holder. Results: At a cost of $12 per newborn death averted and$0.41 per DALY averted, the comprehensive mCARE program, which includes pregnancy surveillance and personally scheduled SMS and home visit reminders, is highly cost-effective from a program perspective, compared to a basic mCARE program, which does not include scheduled SMS and home visit reminders (Chapter 5). When delivered at scale over a 10-year analytic time horizon (2016 to 2025) and compared against a paper-based alternative, the comprehensive mCARE model costs $580,185 in the first year (2016) to start up and incrementally increases from$1,730,599 to $6,917,807 in the subsequent years (2017 to 2025) with incremental geographical expansion to another district each year. An estimated 19,682 total lives (including maternal, neonatal, and stillbirth) would be saved as a result, over a 10-year period. This corresponds to an incremental cost per DALY averted of$47 (Chapter 6). Assuming a willingness to fund $1,080 per DALY averted, based on the Bangladesh gross national income (GNI) per capita, the program has a 97$258,508 in the first year (2015) and $102,658 in subsequent years (2016 to 2020) – without adjusting for inflation and excluding overhead costs (Chapter 7). Above a budget threshold of$2.5 million, the program has a 93% probability of being cost-effective. Nationwide implementation of the comprehensive mCARE program would cost an estimated $47 million over the 2015-2020 period, comprising 0.9$5.4 billion) and 2.5% of public health expenditure ($1.9 billion). Conclusion: The results suggest that implementing the comprehensive mCARE program in Bangladesh may be cost-effective and affordable. Study findings are based on the primary data of 690 pregnant women; additional data are needed to verify forecasted costs and consequences of implementation at scale. Assumptions of the translation of changes in coverage for key maternal and newborn health services, including antenatal care, facility delivery and postnatal care, are dependent on supply side factors – relying on adequate human resources, supplies and commodities, and other inputs associated with quality of care, the measurement of which was beyond our scope. Even given these limitations, the study findings provide information that can help project the resources necessary to fund the program, and the consequences of potential variations of cost inputs at different levels of scale, which can be used to guide efforts of the government of Bangladesh to adopt, implement and sustain the mCARE program

Korea's Universal Health Coverage: challenges and overcoming strategies

행사명 : Workshop on Innovative Development Case Studie

Sibling Relationships of Adolescents with Congenital Heart Disease

Adolescents with congenital heart disease (CHD) continuously need family support because of their repeated follow ups, treatments, and complications. However, sibling relationships have not been well studied among adolescents with CHD. The purpose of the present study was to explore the relationships between adolescents with CHD and their siblings, and to examine these relationships according to birth order and age. Adolescents aged from 13 to 21 years who had been diagnosed with CHD and had siblings were included as participants. The Sibling Relationship Questionnaire (SRQ) was used. The SRQ consists of four factors: warmth/closeness, conflict, relative power/status, and rivalry. A univariate general linear model was conducted to identify the sibling relationship factors according to birth order and sibling ages. The score for relative power/status of participants who were the eldest sibling was higher than that of younger siblings. The score for rivalry increased as sibling age increased. Therefore, healthcare providers need to investigate sibling relationships and to explain the importance of self-identity and power balance between adolescents with CHD and their siblings to parents

Using the lives saved tool (LiST) to model mHealth impact on neonatal survival in resource-limited settings.

While the importance of mHealth scale-up has been broadly emphasized in the mHealth community, it is necessary to guide scale up efforts and investment in ways to help achieve the mortality reduction targets set by global calls to action such as the Millennium Development Goals, not merely to expand programs. We used the Lives Saved Tool (LiST)--an evidence-based modeling software--to identify priority areas for maternal and neonatal health services, by formulating six individual and combined interventions scenarios for two countries, Bangladesh and Uganda. Our findings show that skilled birth attendance and increased facility delivery as targets for mHealth strategies are likely to provide the biggest mortality impact relative to other intervention scenarios. Although further validation of this model is desirable, tools such as LiST can help us leverage the benefit of mHealth by articulating the most appropriate delivery points in the continuum of care to save lives

Standardized framework for evaluating costs of active case-finding programs: An analysis of two programs in Cambodia and Tajikistan.

INTRODUCTION:Over the years, technological and process innovations enabled active case finding (ACF) programs to expand their capacities and scope to have evolved to close gaps in missing TB patients globally. However, with increased ACF program's operational complexity and a need for significant resource commitments, a comprehensive, transparent, and standardized approach in evaluating costs of ACF programs is needed to properly determine costs and value of ACF programs. METHODS:Based on reviews of program activity and financial reports, multiple interviews with program managers of two TB REACH funded ACF programs deployed in Cambodia and Tajikistan, we first identified common program components, which formed the basis of the cost data collection, analysis, reporting framework. Within each program component and sub-activity group, cost data were collected and organized by relevant resource types (human resource, capital, recurrent, and overhead costs). Total shared, indirect and overhead costs were apportioned into each activity category based on direct human resource contribution (e.g. a number of staff and their relative level of effort dedicated to each program component). Capital assets were assessed specific to program components and were annualized based on their expected useful life and a 3% discount rate. All costs were assessed based on the service provider perspective and expressed in 2015 USD. RESULTS:Over the two program years (April 2013 to December 2015), the Cambodia and Tajikistan ACF programs cumulated a total cost of $336,951 and$771,429 to screen 68,846 and 1,980,516 target population, bacteriologically test 4,589 and 19,764 presumptive TB, diagnose 731 and 2,246 TB patients in the respective programs. Recurrent costs were the largest cost components (54% and 34%) of the total costs for the respective programs and Xpert MTB/RIF (Xpert) testing incurred largest program component/activity cost for both programs. Cost per screening was $0.63 and$0.10 and cost per Xpert test was $25 and$18; Cost per TB case detected (Xpert) was $373 and$343 in Cambodia and Tajikistan. CONCLUSIONS:Results from two contextually and programmatically different multi-component ACF programs demonstrate that our tool is fully capable of comprehensively and transparently evaluating and comparing costs of various ACF programs

Model-based cost-effectiveness analysis of oral antivirals against SARS-CoV-2 in Korea

OBJECTIVES Many countries have authorized the emergency use of oral antiviral agents for patients with mild-to-moderate cases of coronavirus disease 2019 (COVID-19). We assessed the cost-effectiveness of these agents for reducing the number of severe COVID-19 cases and the burden on Korea’s medical system. METHODS Using an existing model, we estimated the number of people who would require hospital/intensive care unit (ICU) admission in Korea in 2022. The treatment scenarios included (1) all adult patients, (2) elderly patients only, and (3) adult patients with underlying diseases only, compared to standard care. Based on the current health system capacity, we calculated the incremental costs per severe case averted and hospital admission for each scenario. RESULTS We estimated that 236,510 COVID-19 patients would require hospital/ICU admission in 2022 with standard care only. Nirmatrelvir/ritonavir (87% efficacy) was predicted to reduce this number by 80%, 24%, and 17% when targeting all adults, adults with underlying diseases, and elderly patients (25, 8, and 4%, respectively, for molnupiravir, with 30% efficacy). Nirmatrelvir/ritonavir use is likely to be cost-effective, with predicted costs of US$8,878, US$8,964, and US$1,454, per severe patient averted for the target groups listed above, respectively, while molnupiravir is likely to be less cost-effective, with costs of US$28,492, US$29,575, and US$7,915, respectively. CONCLUSIONS In Korea, oral treatment using nirmatrelvir/ritonavir for symptomatic COVID-19 patients targeting elderly patients would be highly cost-effective and would substantially reduce the demand for hospital admission to below the capacity of the health system if targeted to all adult patients instead of standard care

mCARE, a digital health intervention package on pregnancy surveillance and care-seeking reminders from 2018 to 2027 in Bangladesh: a model-based cost-effectiveness analysis

Objective We estimated the cost-effectiveness of a digital health intervention package (mCARE) for community health workers, on pregnancy surveillance and care-seeking reminders compared with the existing paper-based status quo, from 2018 to 2027, in Bangladesh.Interventions The mCARE programme involved digitally enhanced pregnancy surveillance, individually targeted text messages and in-person home-visit to pregnant women for care-seeking reminders for antenatal care, child delivery and postnatal care.Study design We developed a model to project population and service coverage increases with annual geographical expansion (from 1 million to 10 million population over 10 years) of the mCARE programme and the status quo.Major outcomes For this modelling study, we used Lives Saved Tool to estimate the number of deaths and disability-adjusted life years (DALYs) that would be averted by 2027, if the coverage of health interventions was increased in mCARE programme and the status quo, respectively. Economic costs were captured from a societal perspective using an ingredients approach and expressed in 2018 US dollars. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.Results We estimated the mCARE programme to avert 3076 deaths by 2027 at an incremental cost of $43 million relative to the status quo, which is translated to$462 per DALY averted. The societal costs were estimated to be $115 million for mCARE programme (48$1152 to $462 per DALY averted from 5 to 10 years.Conclusion Mobile phone-based pregnancy surveillance systems with individually scheduled text messages and home-visit reminder strategies can be highly cost-effective in Bangladesh. The cost-effectiveness may improve as it promotes facility-based child delivery and achieves greater programme cost efficiency with programme scale and sustainability

Lung‐ and liver‐dominant phenotypes of Korean eight constitution medicine have different profiles of genotype associated with each organ function

Abstract Eight Constitution Medicine (ECM), a ramification of traditional Korean medicine, has categorized people into eight constitutions. The main criteria of classification are inherited differences or predominance in the functions of organs, such as the liver or lung, diagnosed through ECM‐specific pulse patterns. This study investigated the association between single nucleotide polymorphism (SNP) genotypes and ECM phenotypes and explored candidate genetic makeups responsible for each constitution using a genome‐wide association study (GWAS). Sixty‐three healthy volunteers, who were either categorized as the Hepatonia (HEP, n = 32) or Pulmotonia (PUL, n = 31) constitution, were enrolled. HEP and PUL are two contrasting ECM types representing the dominant liver and lung phenotypes, respectively. SNPs were analyzed from the oral mucosa DNA using a commercially available microarray chip that can identify 820,000 SNPs. We conducted GWAS using logistic regression analysis and additive mode genotypes and constructed phylogenetic trees using the SNPhylo program with 8 SNPs specific for the liver phenotype and 15 SNPs for the lung phenotype. Although genome‐wide significant SNPs were not found, the phylogenetic tree showed a clear difference between the two constitutions. This is the first observation suggesting genetic involvement in the ECM and can be extended to all ECM constitutions