Price tag

1
A Price Tag for Newborn and Child Survival
Dr. Joy Lawn BM BS MRCP (Paeds) MPH Saving
Newborn Lives/Save the Children-USA and MRC,
Cape Town South Africa and Institute of Child
Health London
2
The Team
Newborn series costing Neff Walker Joy Lawn Simon
Cousins Zulfiqar Bhutta Luc de Bernis Gary
Darmstadt
Child series costing Neff Walker Jennifer
Bryce Joy Lawn Zulfiqar Bhutta Saul Morris Bob
Black
Combining the newborn and child costings All the
above plus Saul Morris and Gareth Jones
3
Outline

• Countdown context
• Combining The Lancet Price Tags for newborn
  child survival
• Costs for lives saved the bottom line
• Comparison with other costings
• Consequences

4
Countdown context

• The majority of newborn, child and maternal
  deaths are preventable with existing
  interventions
• Some countries or some single interventions have
  been successful in rapid scaling up, but overall
  we need to accelerate progress
• Accelerated progress will require investment
  how much will the essential interventions cost?
• Donor investment in child health has increased
  but seems to be most focussed on vertical
  programmes
• What is the financial gap? Where will the money
  come from for MNCH health systems and how will it
  get to where it is needed most in countries? How
  can the poor be protected?

5
The Lancet Child Survival series Key findings
Full coverage (99) with 23 proven interventions
could reduce under-five mortality by 66,
saving 6 million child deaths/year
LIVES
6
The Lancet Neonatal Survival series Key findings
Coverage (90) with 16 proven interventions
delivered through packages could reduce neonatal
mortality by up to 67 equivalent to 2.7 million
deaths/year
LIVES
7
Combining newborn and child survival costing
Methods assumptions
Bellagio series Neonatal series Countdown combined
Countries 42 75 60
Interventions 23 8 neonatal 16 7 of the 8 neonatal in Bellagio series 32
Current coverage 2000 2000 Updated with Countdown data
Target coverage 99 90 99
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Combined costing
Objective

• To estimate the running costs at 99 coverage
  for selected essential interventions for newborn
  and child health in the 60 priority countries
• Current running costs based on current coverage
  (updated from Countdown report)
• Additional cost to provide these interventions to
  those currently unreached

9
Combined costing
Methods assumptions

• Intervention-specific cost
• Cost of commodities (ORS, antibiotics, vaccines)
• Cost of service delivery (community health worker
  time, staff time and clinic's running costs,
  theatre time)
• Programme cost associated
• Staff and support inputs
  (training,
  supervision, monitoring and evaluation etc)
• Amortised costs for buildings, equipment and
  transport
• Incorporates the increasing costs required to
  reach the unreached at higher levels of coverage
  based on assumptions from the WHO CHOICE model

Current running costs
Does NOT include costs to expand infrastructure
(new hospitals) produce new human resources
(pre-service training of new midwives)
10
Integrated service delivery timetable for
preventive child survival interventions included
(adaptation needed for countries)
Birth
Approximate child age in months
Before
Weeks
birth
1
-
2
2
4
9
21
27
33
39
45
51
57
6
15
Antimalarial
intermittent
preventive treatment
Contact with trained health care worker Birth
Tetanus Toxoid
Nevirapine

replacement feeding
Neonatal interventions
Breastfeeding
antenatal steroids
Preventive interventions
Insecticide-treated
materials
Hib vaccine
Zinc
Water sanitation
Complementary
feeding
Vitamin A
Measles vaccine
Includes clean delivery with skilled attendant,
temperature management, antibiotics for premature
rupture of membranes and neonatal sepsis, steroids
11
Lancet Neonatal Survival series
For health systems with higher coverage and
capacity
12
Combined costing results
Lives saved in the 60 countries
Proportion of deaths averted at 99 coverage Number of lives that could be saved in the 60 countries
All under 5 child deaths 67 6.6 million
Two thirds of newborn and child deaths are
preventable with existing interventions 6.6
million lives a year
13
Combined costing results Cost in 60 countries

• US 7 billion annually in new resources or US
  1.62 per capita in the 60 countries
• US 4.3 billion is already being spent
• US 25 per child under 5 per year for the total
  cost all the essential interventions

14
Combined costing results Cost in 60 countries

• Sensitivity analysis was performed by varying
  the following inputs
• Coverage estimates
• Drug costs
• Community worker costs
• Results in a range of
• US 4.6 to 10.7 billion

15
Combined costing results
Costs by service delivery approach
16
Combined costing results Costs saved in
treatment by preventive care
Estimated annual running costs of delivering
treatment interventions at current (2004)
coverage levels, with and without savings from
expanded prevention, in millions of 2004 US
Savings US 700 million
17
Combined costing results Costs saved by
integrated delivery
Estimated annual cost per child life saved
comparing integrated and parallel delivery of
preventive interventions in millions of 2004 US
18
Economical policy choices

• Cost-effective packages within the continuum of
  care
• Delivery at all levels through outreach,
  family-community care, and facility-based
  clinical care synergistic effect
• Initial focus on outreach and health education to
  families and communities which is feasible even
  in weak health systems and gives economic
  benefits through prevention in reducing treatment
  costs

19
Comparison with other relevant costings

• World Health Report 2005 reaching MDGs 4 5
• Inputs
• 75 countries with similar interventions
• Results
• 52 billion over 10 years
• 7.8 billion per year once at coverage of 95
• Per capita cost of 1.50
• Commission for Macroeconomics and Health
• Inputs
• Includes the cost of new infrastructure and human
  resources and running costs related to malaria,
  maternal and child health components of the total
  CMH costing
• Results
• 21.8 billion (14 to 25.5) out of total of 46
  billion
• Specific MNCH per capita costs of 4.5

20
Less than 10 of what was spent on tobacco
products in the US in 2003
Is US 7 billion/year to save 6.6 million
children and newborns affordable?
Only a little more than the US4 billion lost to
poor countries in migrating skilled professionals
About half of the US12 to US20 billion
committed annually to the fight against HIV/AIDs
Less than 10 global Overseas Development Aid
estimated total of US78 billion
21
Commitments. few poor countries deliver
Low income countries must spend more and
prioritise reaching the poor as per Abuja target
of 15 of government spending on health
22
Commitments. few donor countries deliver
Donor countries must meet their commitment of
0.7 of GDP
23
Not just more money spending better and
reaching the poor
Some low income countries halved their neonatal
mortality rates in the 1990s (Sri Lanka,
Nicaragua, Honduras, Peru, Indonesia)
Success is possible in low-income countries with
leadership and systematic investment to provide
essential interventions to the poor women and
children
Source Martines J et al Lancet 2005
24
Costing the future

• Move to MNCH incorporate costs for further
  maternal interventions
• Approaches to identify the financing gap at
  country level and simplification of current tools
• More long term efforts to improve the input data
• Disability outcomes (eg by preventing birth
  asphyxia) not included
• Coverage data for specific interventions not
  routinely available
• Almost no data on societal and opportunity costs

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Conclusion Commitment and leadership

• US 7 billion or 1.64 per capita per year would
  save 6.6 million babies and children and also
  reduce maternal deaths
• Current spending is not enough - limited
  information on resource flows suggests donor
  inputs for most MNCH essential interventions is a
  very low proportion
• More investment is required alongside strategic,
  phased planning - rapid gains can be made and
  many lives saved especially by starting at
  community level
• The leaders of both rich and poor countries have
  a responsibility to the mothers and children of
  the world

26
Thank you!
WHO, Rivers of life
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Comparison with WHO cost estimates
Model element/ Approach Lancet Child/ Neonatal Survival Combined Lancet Child/ Neonatal Survival Combined WHO World Health Report Relative to Bryce et al, WHO estimate is likely to be
What is costed? What is costed? Running costs Scale-up running costs
Countries Countries 60 75
Interventions Interventions 32 16 sets
Target coverage Target coverage 99 95
Delivery strategy Delivery strategy Integrated delivery timetable Some vertical some combined.