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Benefits and Costs of Reducing Maternal
and Neonatal Mortality and Increasing
Child Immunization in Bangladesh
ANALYZING BENEFIT-COST RATIO OF HEALTH
INTERVENTIONS FOR IMPROVING MATERNAL
AND CHILD MORTALITY AND CHILD IMMUNIZATION IN BANGLADESH:
JAHANGIR A. M. KHAN, LIVERPOOL SCHOOL OF TROPICAL MEDICINE, U.K AND KAROLINSKA INSTITUTET, STOCKHOLM, SWEDEN
SAYEM AHMED, INTERNATIONAL CENTRE FORDIARRHOEALDISEASE RESEARCH, BANGLADESH (ICDDR) DHAKA AND KAROLINSKA INSTITUTET, STOCKHOLM, SWEDEN
Estimating Return on Investment in Health
Maternal and Neonatal Mortality Reduction
and Child Immunization in Bangladesh
Bangladesh Priorities
Jahangir A. M. Khan
Liverpool School of Tropical Medicine, U.K and Karolinska Institutet, Stockholm, Sweden
Sayem Ahmed
International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR, Dhaka and Karolinska
Institutet, Stockholm, Sweden
© 2016 Copenhagen Consensus Center
info@copenhagenconsensus.com
www.copenhagenconsensus.com
This work has been produced as a part of the Bangladesh Priorities project, a collaboration between
Copenhagen Consensus Center and BRAC Research and Evaluation Department.
The Bangladesh Priorities project was made possible by a generous grant from the C&A Foundation.
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LIST OF ABBREVIATIONS .................................................................................................................................. 2
EXECUTIVE SUMMARY ..................................................................................................................................... 2
INTRODUCTION ............................................................................................................................................... 5
BACKGROUND ................................................................................................................................................. 6
OBJECTIVES ...................................................................................................................................................... 9
METHODS ........................................................................................................................................................ 9
INTERVENTIONS ............................................................................................................................................... 9
MATERNAL AND NEONATAL HEALTH ............................................................................................................................ 9
CHILD IMMUNIZATION ............................................................................................................................................ 10
ESTIMATING COSTS ................................................................................................................................................ 11
ESTIMATING BENEFITS ............................................................................................................................................ 12
RETURN ON INVESTMENT ........................................................................................................................................ 13
RESULTS ......................................................................................................................................................... 13
FACILITY DELIVERY WITH SKILLED BIRTH ATTENDANTS .................................................................................. 13
Costs of interventions ................................................................................................................................... 13
Benefits of interventions .............................................................................................................................. 13
Maternal deaths reduction and benefits ..................................................................................................... 14
Neonatal deaths reduction and benefits ...................................................................................................... 14
All deaths averted and total benefits ........................................................................................................... 14
Return on investment ................................................................................................................................... 15
TRAINED BIRTH ATTENDANTS ........................................................................................................................ 16
Costs of intervention .................................................................................................................................... 16
Benefits of intervention ................................................................................................................................ 16
Maternal deaths reduction and benefits ................................................................................................................... 16
Neonatal deaths reduction and benefits ................................................................................................................... 16
All deaths averted and total benefits ........................................................................................................................ 17
Return on investment ................................................................................................................................... 17
NEONATAL HOMECARE.................................................................................................................................. 18
Costs of intervention .................................................................................................................................... 18
Benefits of intervention ................................................................................................................................ 18
Return on investment ................................................................................................................................... 18
CHILD IMMUNIZATION .................................................................................................................................. 19
Rural Slums .................................................................................................................................................. 19
Costs of intervention ................................................................................................................................................. 19
Benefits of intervention ............................................................................................................................................ 19
Return on investment ............................................................................................................................................... 20
Rural hard-to-reach areas ............................................................................................................................ 20
Costs of intervention ................................................................................................................................................. 20
Benefits of intervention ............................................................................................................................................ 21
Return on investment ............................................................................................................................................... 21
DISCUSSION ................................................................................................................................................... 21
REFERENCES ................................................................................................................................................... 24
APPENDIX 1: DESCRIPTION OF STUDIES EMPLOYED IN THE ANALYSES .......................................................... 27
List of abbreviations
DALY Disability Adjusted Life Years
DGHS Directorate General of Health Services
EPI Expanded Immunization Programme
GoB Government of Bangladesh
H&FWC Health and Family Welfare Centre
H2R Hard-to-reach
MDG Millennium Development Goals
MMR Maternal Mortality Ratio
MNCH Maternal, Newborn and Child Health
MMEIG Maternal Mortality Estimation Inter-agency Group
NGO Non-Governmental Organization
SBA Skilled Birth Attendant
SDG Sustainable Development Goals
TBA Trained Birth Attendant
YLL Years of Life Lost
YLD Years Lost Due to Disability
USD United States Dolla
2
EXECUTIVE SUMMARY
The first World Development Report in 1993 was devoted to the importance of investing in health.
Cost containment was strongly advocated in the report and cost-effectiveness was recommended as
a tool for prioritizing health interventions. During the era of Millennium Development Goals (2000-
2015), Bangladesh demonstrated remarkable success in health indicators in relation to the goals on
maternal and child mortality, among others. The current report thus intends to analyze the return on
investment for reducing maternal and neonatal mortality as well as child immunization, based on
evidence from Bangladesh and other relevant low- and middle-income countries.
The future priority of the Bangladesh government in maternal and child health is to improve coverage
of effective newborn health interventions, increase skilled birth attendance and facility deliveries.
Furthermore, the future priorities for healthcare in general address “increased access to quality health
services by strengthening the health workforce and provision of health services”; and “support the
equitable delivery of health interventions and services, particularly for underserved populations and
marginalized groups”. In addition, widespread application of large-scale community-based
approaches, especially investment in community health workers using a doorstep delivery approach,
has been recommended by a Lancet series on Bangladesh. Challenges and priorities in health sector
by the Government of Bangladesh and evidence from research initiatives mainly in Bangladesh and in
some other low- and middle-income countries were used as the basis for analyzing the returns on
investment in maternal and neonatal health and child immunization.
Our analysis assumes a service target scenario that 80% of the currently unattended births (1.5 million)
would be covered by facility delivery with presence of skilled birth attendants and 20% (374.2
thousand) would be attended by trained birth attendants at the community level. Forty percent of
neonates (748.5 thousand) would also get homecare by trained attendants at the community level.
Children in urban slums and rural hard-to-reach areas were identified as under-served population of
EPI in Bangladesh. Our estimation took an approach to expand the coverage of children in urban slums
and rural hard-to-reach areas. An estimated 665 thousands under-five children live in urban slums, of
which 57% or 372.4 thousands are currently unvaccinated. Of the estimated 1.2 million under-five
children in the rural hard-to-reach areas, 49.3% or 592.5 thousands were unvaccinated. We posit that
the coverage in urban slums would be expanded to the national full immunization coverage level at
84.7% and in rural hard-to-reach areas to 83.5% as found in a research initiative.
3
The costs of the interventions were calculated by using cost data extracted from previous studies
carried out in Bangladesh. Since the health system of Bangladesh is considered to be well structured
for providing health maternal and neonatal services to populations in rural, suburb and urban areas
through Family Health and Welfare Centres, Upazila (sub-district) Health Complexes, district hospitals
as well as regional and tertiary level hospitals, additional costs for infrastructure development was not
considered in the analysis. Direct medical costs (medicine, diagnostic tests, surgical procedure) and
out-of-pocket spending of the patients (mainly for medicine, travels, food) and if applicable training
costs (like, for health workers) were considered in the costs of intervention.
For estimating the economic benefits of interventions Disability-Adjusted Life Years (DALYs) averted
were calculated by multiplying the number of deaths with the difference in years between life
expectancy of target population and average age of death. It needs to emphasis here that DALYs
includes years of life lost (YLL) due to premature death and years lost due to disability (YLD). In this
current analysis, we included only YLL because of lack of data on disability in connection with
morbidity in all except homecare for neonates. Finally, for estimating the economic benefits of
averting the DALYs due to reduction in deaths, we adopted the method of estimating statistical years
of life, i.e. multiplying the total DALYs averted with GDP per capita (1,235 USD) of Bangladesh.
The estimates showed that providing facility-based delivery with skilled birth attendance (SBA) to
pregnant women would cost $115 million USD in total and $77.0 USD per woman served. Such
intervention was estimated to save 3,260 maternal and 37,727 neonatal mortality cases which would
avert 2.56 million DALYs, resulting in $1.33 billion USD in total economic benefits. One USD investment
on this intervention would get a return on investment of 11.5 USD. Child deliveries to 374.2 thousand
pregnant women with trained birth attendance (TBA) would cost $7 million USD, which would avert
344 maternal and 5,988 neonatal deaths and consequently 455,635 DALYs. The estimated total
benefits would be $227.4 million USD. A return of $32.5 USD was estimated from each USD invested
in this intervention. Homecare package for 748,492 neonates would cost 8.1 million USD in total, with
a unit cost of $10.9 USD per neonate served. A total of 8,907 deaths and 636,169 DALYs would be
averted, which would result in total benefits of $326.9 million USD. One USD investment in homecare
would save $40.2 USD.
Child immunization in rural slums would cost 18.0 USD for full immunization of each child, which
would cost $2.67 million USD for immunizing 148,367 children through the intervention under study.
A total 1,710 death cases and 117,985 DALYs could be averted by the intervention, which would result
in total estimated economic benefits of $61.2 million USD. Our estimates show that each USD invested
4
in the intervention would give a return of $23.0 USD. In the rural hard-to-reach areas, the intervention
under study cost $24.5 USD for vaccinating one child and the total costs for vaccinating additional
263,782 children would cost $6.46 million USD. An estimated 2,430 deaths would be prevented, which
would avert 167,639 DALYs. The total estimated benefits would be $87.0 million USD. Each USD
investment thus resulted in a return of $13.5 USD.
The economic estimates show incentives for investing in the health interventions with higher expected
return than required investment. Bangladesh has long-time experience in health service deliveries
through public, NGO, private organizations and public-private partnership (PPP). However, how these
interventions should be organized for reaching the target populations is out of scope of this report.
The level of intervention costs through public and NGO providers are generally comparable. To keep
the costs of service deliveries low, even for for-profit/private providers, market competition should
be created while making any public-private partnership.
In sum, investments in reducing maternal and neonatal deaths and child immunization were estimated
to have large returns. Inclusion of disability due to morbidity would be useful for getting a more
complete picture. Data from several countries have been employed, though efforts were made to
utilize Bangladesh specific data. Usage of more Bangladesh specific data could make the estimation
more robust. However, despite certain limitations, evidence-based findings of this report should be
useful in the health sector of Bangladesh, especially on best ways to allocate limited resources.
5
INTRODUCTION
During the era of the Millennium Development Goals (2000-2015), Bangladesh demonstrated
remarkable success in health indicators. However, economic analyses of interventions that were
conducted in Bangladesh were not enough as evidence for policy-makers so that government could
be able to make investment plans for improving the healthcare delivery system using limited
resources. A systematic review of the studies on economic evaluations of health interventions in
Bangladesh, covering the period between 1971 and 2008, found only 12 full economic evaluations,
though with variable quality of the studies (Hoque et. al. 2011). Further, cost-benefit analysis that
compares the costs of an intervention with its economic benefits was rarely found. Insufficient
economic studies of health interventions thus evoke a strong motivation for creating new evidence of
return on investment in health in Bangladesh.
Success in health outcomes in Bangladesh has been observed in a number of areas, especially in
maternal, newborn and child health as well as in immunization during MDG era 1990-2015 (GoB,
2015a). The new Sustainable Development Goals, which replaced MDGs, put emphasis on financial
sustainability of development programmes. A future vision for continuation of health improvement in
the country thus requires evidence on economic benefits in addition to health benefits, which would
be necessary for the investment plan of the government.
The findings from this report, which compared economic benefits of specific health interventions with
their costs, would be useful for priority-settings and resource allocation in healthcare sector. While
the report estimated the return on investment in particular health interventions, the deliveries of such
interventions could be implemented by the public sector in collaboration with non-governmental
organizations and the private sector for successful outcomes.
The ‘Background’ section of the report describes the health improvement (MNCH and immunization)
in Bangladesh during the MDGs era and the policy direction of the Government of Bangladesh for
future work. The ‘Method’ section explains how information on health interventions and benefits
were collected and used for estimating the return on investment. The outcomes are presented in the
‘Results’ section, followed by a ‘Discussion’ and a ‘Concluding Remarks’ section.
6
BACKGROUND
Bangladesh made tremendous improvements in health during Millennium Development Goals
(MDGs) era (2000-2015). The improvement in Bangladesh has been praised by international
development organizations, including the World Bank, the World Health Organization, the United
Nations and governments in many other countries, both regionally and globally. It is generally believed
that an integrated approach involving the government, NGOs and private sector actors contributed to
this success (GoB, 2015b).
The public infrastructure for health service delivery is spread all over the country for providing services
to people from ward level to higher levels, including union, sub-district (upazila), district, division and
national (GoB, 2015c). Health services are provided to the population through community clinics,
Union Health and Family Welfare centres, Upazila Health Complexes, district level hospitals, tertiary
level medical college hospitals and specialized hospitals. Maternal, new-born and child health services
are provided at all levels, and the Expanded Immunization Programme (EPI) has been undertaken
successfully by using the health infrastructure of the country. Along with the public health service
system, private and non-governmental organizations played strong complementary roles in providing
health services to the people.
The progress report of Bangladesh on Millennium Development Goals stated that in the area of ‘child
mortality’ (MDG 4), three indicators were used for observing progress, namely, under-five mortality
rate, infant mortality rate and immunization against measles (GoB, 2015c). The under-five mortality
rate was 151 per 1,000 live births in 1990, which was reduced to 41 per 1,000 live births in 2013. The
infant mortality rate dropped from 94 to 32 per 1,000 live births between 1990 and 2013. The
successful programs for immunization, control of diarrheal diseases and Vitamin-A supplementation
have been considered to be the most significant contributors to the decline in child and infant
mortality. Along with health programs, steady economic and social development has also been
regarded as contributors to such success. While significant improvement in child health was observed,
drowning is increasing as a reason of deaths in children at age 1-4 years in Bangladesh. Further, the
successful maternal, newborn and child health outcomes are inequitably distributed across
socioeconomic groups (Bredenkamp et al. 2012; World Bank, 2015).
Success in maternal mortality reduction in Bangladesh has also been well recognized (GoB, 2015a).
Bangladesh experienced a Maternal Mortality Ratio (MMR) of 574 per 100,000 live births in 1990/91,
which was among the highest in the world. Between 2001 and 2010, Bangladesh observed a significant
7
reduction in MMR, from 322 to 194 per 100,000 live births. The Maternal Mortality Estimation Inter-
agency Group (MMEIG), however, observed that the MMR in Bangladesh was lower, at 170 per
100,000 live births in 2013. A reduction from 574 to 170 per 100,000 live births corresponds to a 70%
fall in MMR from 1990/91 to 2013, a remarkable progress. It has been argued that an increase in the
proportion of births attended by skilled health personnel and increased coverage of antenatal care
might have contributed to such improvement. During the period of 1991-2014, the proportion of
births attended by skilled health personnel increased from 5.0% to 42.1% and antenatal care coverage
increased from 27.5% in 1993-94 to 78.6% in 2014 (GoB, 2015c).
The EPI in Bangladesh was launched on April 7, 1979 (World Health Day). During the period of 1985-
1990, EPI was intensified throughout 476 Upazila (sub-districts), 92 major Municipalities and 6 City
Corporations. EPI was made available to all target groups (infants and pregnant mothers) by 1990.
During the last few years, based on the disease burden data, new vaccines for selected emerging
diseases such as Hepatitis- B (2003) and Hib Disease (2009) have been introduced into the EPI
schedule. Hepatitis B vaccine was incorporated into the program with GAVI phase 1 support bundled
with injection safety supply, later followed by the introduction of Hib antigen. Vitamin A
supplementation was added to the program in 1990. From 1995 to 2010, 18 National immunization
days were conducted with very high (around 90%) coverage in Bangladesh in view of eradicating polio.
A measles catch-up program was conducted in 2005 (GoB, 2011). It needs to be noted here that until
1985 the vaccination coverage in general was 2%. The proportion of fully vaccinated children
increased after the involvement of the government of Bangladesh to 84.3% in 2012, which
demonstrates a greater success than many other low- and middle-income countries, including
neighboring India and Pakistan.
Bangladesh has shown remarkable coverage of immunization against preventable diseases through
its Expanded Programme for Immunization (EPI). The Government of Bangladesh is the main driver of
the programme where NGOs and the private sector play complementary roles in vaccinating people.
The weaknesses in the EPI are reflected in low coverage in rural hard-to-reach areas and urban slums
in the country. While the full immunization reached 84.7 percent at the national level, the rural hard-
to-reach (H2R) areas observed coverage between 29 percent (in low-lying areas) and 67 percent (hills)
(Uddin et al. 2012; Uddin et al. 2010). Coverage in urban slums reached 43 percent only. Research
initiatives were undertaken for creating evidence of interventions in order to increase the level of
coverage in rural H2R areas and urban slums (Uddin et al. 2009; Uddin et al. 2012). Interventions in
both rural H2R areas and urban slums used both supply and demand-side interventions to expand the
8
coverage of full immunization in these areas. However, much emphasis was placed in improving the
supply-side by, for instance, training field staff and their supervisors on invalid doses, appropriate
management of side-effects, the supply of vaccines through maintaining cold-chain, modified EPI
session schedule with extended time for vaccination and immunization screening tool in health
centres other than EPI sessions. The demand-side interventions include community support groups to
create awareness for vaccination, support health staff for night stay in vaccination sites, identify
children whose vaccination were incomplete and encourage mothers to fully vaccinate their children,
and organize meetings with service providers to review and monitor EPI activities.
Despite this progress, it was acknowledged that one single problem, is the inability to address the
problem of under coverage in specific geographic locations in Bangladesh (Uddin et al. 2012; Uddin et
al. 2010). Multiple-intervention packages were applied for increasing the coverage in those areas.
The infant mortality rate of people in the richest and poorest quintiles were 36.4 and 68.5 per 1,000
live birth and under-five mortality were 44.5 and 89.8 per 1,000 live birth, respectively (World Bank,
2015). However, inequality in immunization was remarkably low at 88.4% and 79.6% for the richest
and poorest quintiles, respectively. Similarly, the utilization of treatment of diarrhea also showed low
inequality, referring to 85.9% utilization by the richest and 75.6% by the poorest sections. However,
high inequality was observed in antenatal care and skilled birth attendance. While the richest people
accessed antenatal care and skilled birth attendance by 46.7% and 50.7% in 2003, the poorest did so
by only 6.7% and 4.9%.
Despite inequalities of different degrees across socioeconomic groups, success has been made in
several health indicators of child and maternal health. In addition to the successes in the health sector
of Bangladesh in the last few decades, new recommendations have been made for further
improvements addressing mainly universal health coverage. The new Sustainable Development Goals
(SDGs) put high emphasis on sustainability of development programs, including its financial
sustainability and affordability. SDGs (3.1 and 3.2) aim at reducing maternal mortality ratio to less than
70 per 100,000 live births, neonatal and under-five mortality to at least as low as 12 and 25 per 1,000
live births (United Nations, 2015). For reaching the relevant sustainable development goals with
economic sustainability and affordability, creation of evidence of value for money of development
programs is important.
The interventions that have been employed in this report for estimating their return on investment
were selected on the basis of government’s future challenges and priorities, and recommendation for
9
achieving universal health coverage as well as other research outcomes of the interventions from
previous studies.
OBJECTIVES
The main objective of this study is to estimate the return on investment in maternal and neonatal
mortality reduction and child immunization.
METHODS
Incremental costs and benefits of health interventions were calculated from the most recently
available (2014) coverage of maternal and neonatal health services and child immunization by health
sector of Bangladesh.
INTERVENTIONS
In this report, we estimated the costs of interventions (and mix of interventions) for providing
maternal and neonatal care and child immunization to those who were not covered by the health
system of Bangladesh. It means that we captured the data of service coverage gap and estimated the
costs for filling the gaps with evidence-based efficient interventions. According to Bangladesh
Demographic and Health Survey (BDHS), 42% of child deliveries are currently assisted by medically
trained birth attendants. It implies that of the total 3.2 million child births in a year, 1,8 million remain
unattended by any types of skilled or trained attendants. Further, while 84.7% children (12-23 months)
were fully immunized in Bangladesh, only 43% and 50.8% of children in urban slums and rural/remote
areas were found respectively fully immunized. In this report, for estimating the return on investment,
incremental costs and benefits of health interventions were calculated on top of currently (year 2014)
available coverage of maternal and neonatal health services and child immunization by health sector
of Bangladesh.
Maternal and neonatal health
A number of maternal and neonatal health interventions which demonstrated significant effect on
health improvement (mortality reduction) and were in line with health sector priorities of Bangladesh
(table 1). The costs of interventions for bringing a share of currently unattended number of pregnant
women and neonates were calculated. Further, the economic benefits of interventions were
10
estimated by quantifying the monetary value of averted maternal and neonatal deaths as a result of
interventions (detail in ‘Estimating benefits’ section below). Total benefits and costs were compared
by a benefit-cost ratio for calculating the rate of return on investment in health interventions. Table 1
below describes the current population under service coverage, intervention programs,
characteristics and size of target populations. For detail of the studies which were employed in the
analysis, the readers are referred to appendix 1.
Table 1. Description of intervention, target population
Current coverage1
Proposed
Intervention
Description of intervention
Possible target population
Size
Characteristics
Covered: 1.36 million
births covered by
trained/skilled/facility
services
Uncovered: 1.87 million
births
Facility
delivery with
skilled birth
attendants
Skilled attendants and doctors
providing Basic Emergency
Obstetric care; Doctors
providing
Comprehensive
Emergency Obstetric
Care1
80% of
uncovered
births: 1.5
million
Urban, suburb
and rural areas
proximate to
H&FWC,
Upazila (sub-
district) health
complex;
district
hospitals
Trained
(traditional)
birth
attendants
Involving trained traditional
birth attendants and perinatal,
neonatal and maternal
mortality2
20% of
unattended
births:
374,246
Rural hard-to-
reach and
remote rural
areas
Neonate
homecare
Neonatal care package: Sub-
district Health Complexes and
Health and Family Welfare
Centres secure Training,
essential drugs and supplies for
neonates, tracking neonatal
care utilization, Community
mobilizers, Community Health
Workers
40% of all
neonates:
748,492
Two lowest
socioeconomic
quintiles
1 BDHS, 2011. Value adjusted for year 2014 with 1.2% population growth
2 Brouwere VD, Lerberghe WV (ed.). 2001.
3 Jokhio et al. 2005
4 LeFevre et al. 2013
Child immunization
Children in urban slums and rural hard-to-reach areas were identified as under-covered population by
EPI in Bangladesh. Our estimates took an approach to expand the coverage of children in urban slums
and rural hard-to-reach areas. An estimated 665,000 under-five children live in urban slums, of which
57% or 372,000 are currently unvaccinated. Of the estimated 1.2 million under-five children in the
rural hard-to-reach areas, 49.25% or 592,500 are unvaccinated. We assumed in the analysis that these
11
unvaccinated under-five children would be brought under immunization using a highly effective
intervention as described in Uddin et al. (2010) and presented below in Table 2. The costs for
vaccinating additional children and the associated benefits due to deaths averted were estimated.
Table 2. Description of intervention, target population and health and economic outcomes
Immunization
coverage*
Estimated
number of fully
immunized**
Estimated
number of
Unimmunized
Intervention
Targeted
additional
children for
immunization
Urban slums: 43%
285,966
379,071
Extended EPI service schedules;
Training for service providers; Use of a
screening tool in non-EPI centers; EPI
support group1.
277,321
(if achieves
national level
of coverage,
84.7%)
Rural hard-to-
reach: 50.8%
610,596
592,549
Group A: Training of field staff and their
supervisors on valid doses; Policy
change to eliminate barriers relating to
geographical boundaries; Modified EPI
session schedules; Community support
groups
Group B: Training of field staff and their
supervisors on valid doses; Policy
change to eliminate barriers relating to
geographical boundaries; Use of a
screening tool in health centers other
than EPI session2.
394,030
(if achieves
the coverage
like research
trail, 83.5%2)
* Fully immunized at national level: 84.7%; ** Among children under 5; 1) Uddin et al. 2010; 2 Uddin et al. 2012
Estimating costs
The costs of the interventions were calculated by using cost data extracted from previous studies
carried out in Bangladesh. Since the health system of Bangladesh is considered to be well structured
for providing health in maternal and neonatal services to populations in rural, suburb and urban areas
through Family Health and Welfare Centres, Upazila (sub-district) Health Complexes, district hospitals
as well as regional and tertiary level hospitals, additional costs for infrastructure development were
not considered in the analysis. Direct medical costs (medicine, diagnostic tests, surgical procedure)
and out-of-pocket spending of the patients (mainly for medicine, travels, food) and if applicable
training costs (for healthcare workers, for instance) were considered in the costs of intervention. Costs
were adjusted for inflation at the 2014 price level and a discounting rate of 3% was used for estimating
the present value of the future costs in the base-case analysis. For a sensitivity analysis, 5% and 10%
discounting rates were applied.
12
The health system in Bangladesh has successfully developed a strong network for providing maternal,
neonatal and child health services across the country. However, the additional costs required for
interventions were reflected, such as on salary for staffs, training costs, transport, supplies and
communications etc.
Estimating benefits
Reduction in maternal and/or neonatal deaths due to health interventions were used for estimating
the number of deaths that would be averted in the target population, i.e., those who are unattended
by any trained or skilled birth attendants. We made assumptions on what the intervention mix would
be for all currently unattended pregnant women and neonates. We assumed that 80% of currently
unattended pregnant women and neonates will be covered by facility delivery with SBA and the
remaining 20% will be covered by services from trained traditional birth attendants. It is argued that
this 20% target population either live in remote rural places (distant from Family Health and Welfare
Centres) or in hard-to-reach areas (low-lying land or hills). Additionally, homecare for neonates will
cover 40% of the currently unattended population who belong to lower socioeconomic groups. The
effects of facility deliveries with SBA, deliveries by trained TBA and Homecare of neonates on
reduction of maternal and neonatal deaths were found from previous studies (Appendix 1). The
mortality rate reduction of these three different interventions was applied on the target populations
(pregnant women and neonates) in order to estimate the actual number of deaths that would be
averted.
Total averted Disability-Adjusted Life Years (DALYs) were calculated then. DALYs include years of life
lost (YLL) due to premature death and years lost due to disability (YLD). In this current analysis, we
include only YLL because of the lack of data on disability in connection with morbidity. DALYs averted
were thus calculated by multiplying the number of deaths with the difference in years between life
expectancy of target population and average age of death. Finally, for estimating the economic
benefits of averting the DALYs due to reduction in deaths, we adopted the method of estimating
statistical years of life, i.e. multiplying the total DALYs averted with GDP per capita (1,235 USD
1
) of
Bangladesh (Nugent, 2015). Using a discounting rate of 3%, the present value of the benefits was
calculated in the base case. In a sensitivity analysis, 5% and 10% discounting rates were applied.
1
Assumed by Copenhagen Consensus.
13
Return on investment
In order to measure the return on investment in health intervention (MNH services and child
immunization) through the proposed interventions, benefit-cost ratios were calculated by dividing the
total benefits with the total intervention costs. This ratio or return on investment presents how much
economic benefits would be realized for each dollar invested.
RESULTS
Facility delivery with skilled birth attendants
Safe motherhood has multiple immediate consequences. It saves the lives of pregnant women and
their neonates. Facility delivery with involvement of skilled birth attendants has demonstrated effects
on maternal and neonatal mortality reduction (Brouwere and Lerberghe, 2001; Tura et al. 2013). Using
evidence from sources in Bangladesh and other developing countries, the costs of interventions and
their economic benefits in terms of health outcomes (deaths and DALYs averted) show that such
interventions have high returns on investment.
Costs of interventions
A study on costs of pregnancy and puerperium related care in a public facility in Bangladesh found
that a treatment episode with C-section and normal delivery would cost $89.98 USD and $43.63 USD
respectively at price level of 2007 (Sarowar et al. 2010). In this cost estimation, direct medical costs
(doctors’ time, diagnostic tests, medicine, and surgical intervention) were considered. For estimating
the costs per service in a facility, we used weighted average of C-section (22.9% of all deliveries) and
normal delivery (76.1% of all deliveries) costs, which was estimated to be $77.0 USD at the price level
of 2014. The total intervention costs would thus be $115,200,178 USD for providing services to 1.5
million targeted pregnant women.
Benefits of interventions
Facility deliveries with SBA have shown reductions in both maternal and neonatal deaths (Brouwere
et al., 2001; Tura et al., 2013). In this analysis, we assumed that 80% of all unattended deliveries would
be targeted by facility delivery service with SBA.
14
Maternal deaths reduction and benefits
An estimation of safe motherhood using facility delivery with SBA found that 97% of obstructed
labour, 48% of Eclampsia, 49% of Puerperal sepsis and 48% of Haemorrhage, which together cause
60.5% of maternal deaths could be averted with secondary prevention where SBA undertake the
delivery in facilities (Appendix 1, Brouwere et al., 2001). We considered the maternal mortality ratio
of 360 per 100,000 live births on the 80% estimated unattended births, which means that a total of
3,260 deaths would take place without the intervention. This rate was observed in a control
population while studied impact of an intervention on pregnant women in Pakistan (Appendix 1:
Jokhio et al. 2005). It might be justifiable in Bangladesh context since the MMR in Bangladesh was
close to this figure (322 per 100,000 live births in year 2001).
Bringing the target population under facility delivery with skilled birth attendants we can avert
maternal deaths by 60.5%, which means that 1,757 deaths in total could be averted. Considering the
average age of maternal death at 32 years and average life expectancy of women at 72.6 years, the
DALYs averted per death is 40.6 years. It means that by reducing 3,260 deaths, a total of 132,373
DALYs would be averted. Total economic benefits from the averted DALYs were estimated at $93.4
million USD, by multiplying the total averted DALYs with GDP per capita (1,235 USD) of Bangladesh
(presented together with benefits from neonatal deaths reduction in table 3).
Neonatal deaths reduction and benefits
A literature review of the effect of health facility delivery on neonatal mortality found that 32.9
neonates per 1,000 live births die when delivered at home and only 9.9 neonates per 1,000 live births
die in facility delivery (Appendix 1: Tura et al. 2013). It means that neonatal deaths could be reduced
by 70% if deliveries took place in the facilities in comparison with home delivery. Applying the rate of
neonatal deaths reduction in the target population, we found that 34,467 deaths could be averted.
Considering the average age of death of a neonate is 4 weeks and the average life expectancy is 70.4
years, the total DALYs averted were estimated to $2,4 million USD. The total benefits due to DALYs
averted are estimated to be $1,2 billion USD.
All deaths averted and total benefits
Bringing the target population of approximately 1.5 million pregnant women into facility delivery
services with SBA would require a total investment of $115.2 million USD. From such an investment,
$2.6 million DALYs from pregnant women and their neonates could be averted. Neonatal deaths
reduction constituted 97.2% of all DALYs averted. As a consequence of total reduction in deaths and
15
DALYs of pregnant women and neonates averted, $1.33 billion USD could be saved from the economy
of Bangladesh.
Table 3. Costs and benefits of facility delivery with skilled birth attendants
Costs per
service
(USD)
Number of
target
population
Total
intervention
costs (USD)
Maternal deaths
Neonatal deaths
Total benefits
(USD)
Benefit-
Cost Ratio
Cases
averted
DALYs
averted
Cases
averted
DALYs
averted
77.0
1,496,984
115,200,178
3,260
132,373
37,727
2,556,203
1,326,395,101
11.5
(7.7; 4.0)*
* Values within parenthesis present benefit-cost ration at 5% and 10% discounting rates respectively.
We need new tables for discounted costs and benefits at 5% and 10% (not just their BCRs).
Return on investment
Applying 3% discounting rate on total benefits and costs, the benefit-cost ratio was 11.1, which means
that 1 USD investment on facility delivery with skilled birth attendants would result in a return of 11.1
USD from saving life and DALYs of mothers and neonates. The return on investment decreases to 7.41
USD and 3.84 USD if 5% and 10% discounting rates are applied, respectively.
16
Trained birth attendants
We assumed that unattended deliveries in remote rural areas and rural hard-to-reach areas are
targeted with the service from trained (traditional) birth attendants (TBA) in the community and 20%
of total unattended deliveries (374,246 pregnancies) belong to these areas. Due to lack of data on
Bangladesh, we employed findings from studies in Pakistan, which showed that services of trained
birth attendants reduced both maternal and neonatal mortality (Appendix 1: Jokhio et al. 2005).
However, the costs of similar interventions were found in cost analyses of Maternal, Neonatal and
Child Health (MANOSHI) intervention, undertaken in Dhaka, Bangladesh (Islam et al. 2010; Sarker et
al. 2010), which was used for estimating the total costs of covering the target population. We assumed
that trained traditional birth attendants were corresponding to trained community health workers
and are addressed as trained birth attendants (TBA) throughout the report.
Costs of intervention
The cost of intervention of MANOSHI programme included costs of training community health workers
(CHW) and costs of providing the services (Appendix 1: Islam et al. 2010; Sarker et al. 2010). The costs
included normal delivery costs in a birthing hut located in a community and the time allocated by CHW
for providing the services. The cost per service was estimated to $18.7 USD at the price level of 2014.
This means that a total of $6,992,923 USD would be required for providing the services to 374,246
pregnant women per year.
Benefits of intervention
Maternal deaths reduction and benefits
The study found that maternal deaths were reduced from 360 to 268 per 100,000 live births, which
means that 25.6% of deaths could be averted due to TBA intervention on MNH services. While
applying the MMR of control group in the Bangladesh context (as we did in estimation of SBA, table
3), the total maternal deaths in target population would be 1,347 in total and a reduction in deaths by
25.6% would avert 344 death cases. By reducing these deaths, 13,979 DALYs could be averted. The
economic benefits of such health outcomes were estimated at $9.9 million USD (presented together
with the benefits from neonatal deaths reduction in table 4).
Neonatal deaths reduction and benefits
The same study observed that 53 and 37 neonatal deaths per 1,000 live births could be averted due
to TBA intervention, meaning that neonatal mortality could be reduced by 30.2%. Considering the
current neonatal death rate of 53 per 1,000 live births in Bangladesh context (applying neonatal
17
mortality rate of control group, Jokhio et al. 2005), we found that 19,835 neonates would die without
any additional intervention in the target population. However, intervention with TBA would save 8,988
death cases, which translate into 441,656 DALYs averted and economic benefit of $85.9 million USD.
All deaths averted and total benefits
TBA intervention would reduce a total number of 6,332 death cases and consequently 455,635 DALYs.
By reducing these maternal and neonatal deaths and associated DALYs, would yield social benefits of
$227.4 million USD.
Table 4. Estimated benefits and costs of MNH intervention by trained birth attendants
Costs per
service
(USD)
Number of
target
population
Total
intervention
costs (USD)
Maternal deaths
Neonatal deaths
Total benefits
(USD)
Benefit-Cost
Ratio
Case
averted
DALYs
averted
Case
averted
DALYs
averted
18.7
374,246
6,992,923
344
13,979
5,988
441,656
227,424,422
32.5
(21.7; 11.2)*
* Values within parenthesis present benefit-cost ratios at 5% and 10% discounting rates respectively.
Return on investment
Applying 3% discounting rate on total benefits, we found a benefit-cost ratio of 32.5, which means
that 1 USD investment on trained TBA would result in a return of 32.5 USD. When 5% and 10%
discounting rates are applied, benefit-cost ratios reduce to 21.7 and 11.2, respectively.
18
Neonatal homecare
Costs of intervention
The cost of homecare per neonate was estimated to $10.9 USD at the price level of 2014. The costs
included costs of service providers (medical and non-medical personnel), actual and refresher
trainings and household expenditure (consultation, medicine, transport) (Appendix 1: Lefevre et al.
2013). The total costs of intervention were estimated at $8,123,927 USD for providing homecare to
748,492 targeted neonates.
Benefits of intervention
A study in Bangladesh found that neonatal deaths were 31.2 per 1,000 live births among neonates
who received homecare intervention. But for those without homecare intervention (control group),
such deaths were 43.1 per live births (Appendix 1: LeFevre et al. 2013), which means that neonatal
deaths were 28% less in intervention group. Considering this reduction rate, 8,907 neonatal deaths
could be averted if homecare intervention were carried out in the target population (40% of neonates
not born in a hospital facility). These reduced number of death cases would contribute to a total
636,169 DALYs averted. The estimated economic benefits would be $326,876,700 USD per year.
Table 5. Estimated benefits and costs of neonatal homecare intervention in the community
Costs per
service
(USD)
Number of
target
population
Total
deaths
averted
Total
DALYs
averted
Total
intervention
costs (USD)
Total
benefits
(USD)
Benefit-Cost
Ratio
10.9
748,492
8,907
636,169
8,123,927
326,876,700
40.2
(26.7; 13.8)*
* Values within parenthesis present benefit-cost ratios at 5% and 10% discounting rates respectively.
Return on investment
The total benefit-cost ratio (40.24) demonstrates that an investment of 1 USD on homecare would
make 40.24 USD as a return on investment considering a 3% discounting rate. The benefit-cost ratios
are reduced to 26.7 and 13.8 when 5% and 10% discounting rates are applied.
19
Child immunization
Rural Slums
Costs of intervention
An incremental cost estimation of a highly effective intervention for improving immunization coverage
among slum populations in Dhaka, Bangladesh, found that the average costs for vaccinating a child is
20.95 USD (Appendix 1: Hayford et. al. 2014). The costs included supervision (personnel and travel),
clinical costs (personnel, facility cost), training costs, coordinating costs and supplies, communications
and photocopying costs etc. Of the total costs per child, 73% was incurred for supervision, where
research project staff with higher salaries than those in the public sector was involved. We, therefore,
reduced the supervision costs by 50%, which reduced total costs per child to 18.0 USD at price level
of 2014. For vaccinating additional 148,367 children (up to age 2) in urban slums in Bangladesh, a total
of $2.67 million USD would be needed.
Benefits of intervention
The research initiative of highly effective immunization coverage in slum populations in Dhaka,
Bangladesh showed that 43% of slum populations were covered by immunization in the baseline,
which increased to 99% in the end line (Uddin et al. 2010). We have assumed a conservative estimation
using the national immunization coverage rate of 84.7%, instead of 99% of the study finding (Uddin et
al. 2010). An estimated 665,038 under-five children lived in slum areas in Bangladesh, of which
285,966 were fully immunized (43%) at the current coverage level. Implementation of the effective
intervention would bring 277,321 additional children under immunization. Globally, 17% of deaths
were related to vaccine preventable diseases
2
. Applying the death rate of vaccine preventable
diseases along with 90% efficacy of the vaccine, we found that 1,710 deaths could be averted among
under-five children in slums due to this highly effective intervention. Note that to reach these
immunization levels (and resultant benefits) does not require total immunization of the under 5
population every year. Rather only one age cohort of children requires vaccination every year, since
once immunized, coverage continues for many years. In this study we conservatively assume for
costing purposes, three age cohorts are vaccinated every year – namely all children before they turn
three years old. This leads to an additional 148,367 children vaccinated per year at a cost of 2.6m USD.
2
http://apps.who.int/immunization_monitoring/diseases/en/ (accessed on 22/03/2016).
20
Table 6. Benefits and costs of child immunization in urban slum populations
Costs per
child
vaccinated
(USD)
Number of
additional
children
vaccinated
per year
Total
intervention
costs (USD)
Total
deaths
averted
Total
DALYs
averted
Total benefits
(USD)
Benefit-Cost
Ratio
18.0
148,367
2,665,454
1,710
117,985
61,235,132
23.0
(15.3; 12.9)*
* Values within parenthesis present benefit-cost ratio at 5% and 10% discounting rates respectively.
Return on investment
The base estimation (3% discounting) of benefit-cost ratio of the intervention showed that 1 USD
investment in intervention on child immunization would bring $23.0 USD in return by reducing deaths
and DALYs of under-five children in slums of Bangladesh. Application of 5% and 10% discounting rates
would result in returns on investment of 15.3 USD and 12.9 USD, respectively.
Rural hard-to-reach areas
Costs of intervention
In the absence of costs of intervention data in rural hard-to-reach areas in Bangladesh, we estimated
the intervention costs from data in urban slums and a ratio of incremental costs comparing core and
satellite setting (Appendix 1: Hayford et al. 2014; Bishai et al. 2010). We found that a highly effective
intervention in urban setting (urban slums) cost $24.5 USD per child vaccinated while adjusted for
supervision costs (from research project staff to public sector staff) and from core vaccination setting
to satellite setting at price level of 2014. The total cost for intervention on target population (263,782),
children up to age of 2 years, was thus estimated to $6.5 million USD.
Table 7. Benefit and cost of child immunization in rural hard-to-reach areas
Costs per
child
vaccinated
(USD)
Number of
additional
children
vaccinated
per year
Total
intervention
costs (USD)
Total
deaths
averted
Total
DALYs
averted
Total
benefits
(USD)
Benefit-Cost
Ratio
24.5
263,782
6,458,747
2,430
167,639
87,005,650
13.5
(7.7; 3.4)*
* Values within parenthesis present benefit-cost ratios at 5% and 10% discounting rates respectively.
21
Benefits of intervention
The intervention in rural hard-to-reach areas (low-lying land and hills) increased average vaccination
coverage from 50.8% in baseline to 83.5% in the end line, which means an increase of 32.8%.
Additionally, 263,782 children per year would be vaccinated in the entire country through the tested
effective intervention. Applying the proportion of preventable deaths in rural hard-to-reach
populations, we found that increasing immunization coverage to 83.5% with 90% efficacy of vaccine
would avert 2,430 deaths among the under-five. These averted under-five deaths meant that 167,639
DALYs could be saved. Estimated total economic benefits would amount to $87.0 million USD.
Return on investment
Investment in child immunization in rural hard-to-reach areas shows that a return of 13.5 USD would
be expected from each dollar invested at 3% discounting rate. Return on investment would be to 7.7
USD and 3.4 USD when 5% and 10% discounting rates are applied, respectively.
DISCUSSION
Challenges and priorities in healthcare sector by the Government of Bangladesh and evidence from
research initiatives mainly in Bangladesh and in some other low- and middle-income countries were
used as the basis for analyzing the returns on investment in maternal and neonatal health and child
immunization. Our estimation showed that for securing relevant health services to the target
populations, the investment would provide economic benefits to the country of between 11.5 USD
and 40.2 USD for each USD invested. The largest return (40.2 USD) was found from investment in
homecare package for neonates and the lowest (11.5 USD) from facility-based delivery with SBA to
pregnant women. Since the interventions targeted different population groups, the findings should
be used more as complementary rather than competitive for priority setting.
Facility delivery with SBA was estimated to reduce deaths of pregnant women and neonates by 3,260
and 37,727 cases, respectively. Using TBA, we found that 344 of maternal deaths and 5,988 neonatal
deaths could be averted. To the number of DALYs averted and also to return on investment,
contribution of reduction in neonatal deaths were remarkably high due to higher rate of death cases
averted among them in comparison with mothers and the larger number of years of lost life (YLL)
saved. Providing homecare package through community on 40% of total neonates (currently
unattended by any medically trained workers) would require 8.1 million USD, which were estimated
to give total benefits of 326.9 million USD by saving the lives of 8,907 neonates. Intervention on
22
children for immunization in urban slums and in rural hard-to-reach cost 18.0 USD per child and 24.5
USD per child, respectively, and higher return was expected from the interventions in urban slums
(23.0 USD) than rural hard-to-reach areas (13.5 USD). Total costs of 2.67 million USD in urban slums
and 6.46 million USD in rural hard-to-reach areas would be required. The benefits would be manifolds
in both settings, estimated at 61.2 million USD and 87.0 million USD, respectively.
A framework for estimating benefits of investing in maternal, newborn, and child health using data
from South Asia and Africa found benefit-cost ratios for ‘basic’, ‘expanded’ and ‘comprehensive’
service package to be 24.0, 24.2 and 14.3 respectively (Foster and Bryant, 2013). Our estimated return
on investment or benefit-cost ratio ranged between 11.5 and 32.5 depending on types of
interventions, i.e., services provided by SBA or TBA respectively. A study of return on investment from
childhood immunization in low- and middle- income countries found that 43.8 USD (uncertainty range,
26.7-66.7) would benefit from each USD invested when broader economic benefits (due to averted
mortality and morbidity) were considered in the analysis (Ozawa et al. 2015). Among the ninety-four
countries, countries in South and South-East Asia and Sub-Sahara Africa showed high return due to a
large number of preventable cases in those areas. Similar to our study, Ozawa and colleagues found
that the investment was worthy though the size of return was much larger in their study. Difference
in return on investment could be explained by that our estimation covering a single country
(Bangladesh) with country-specific data and the return on investment was mostly calculated on the
basis of mortality cases averted, except for homecare for neonates.
The estimation had several challenges. For instance, data on target population, intervention effects
and intervention costs were collected from different sources, though efforts had been made to keep
them comparable. Costs of intervention data were used from public sources (SBA in facility), NGOs
(TBA) and research initiatives (child immunization). However, for making the costs comparable, we
adjusted for the supervision costs of research project staff since the salary of research staff members
in some organizations are often higher than the salary of public and NGO staff members. In estimating
the benefits, we considered the foregone economic loss in relation to premature deaths of pregnant
women, neonates and children under 5 for immunization. However, we could not capture the
economic loss in connection with years lost due to disability (YLD) because of the lack of relevant data.
The return on investment was thus a conservative estimate.
The economic estimation showed incentives for investing in the health interventions with higher
expected return than required investment. Bangladesh possesses extensive experience in health
service deliveries through public, NGO, for-profit organizations and public-private partnership (PPP).
23
However, how these interventions, i.e., service deliveries should be organized for reaching the target
populations is out of scope of this report. Level of intervention costs through public and NGO providers
are generally comparable. For keeping the costs of service deliveries low even with for-profit private
providers, market competition should be created while encouraging public-private partnership.
24
REFERENCES
BDHS. 2015. National Institute of Population Research and Training (NIPORT), Mitra and Associates,
and ICF International. Bangladesh Demographic and Health Survey 2014: Key Indicators. Dhaka,
Bangladesh, and Rockville, Maryland, USA: NIPORT, Mitra and Associates, and ICF International.
Bishai D, Johns B, Lefevre A, Nair D. 2010. Cost effectiveness of measles eradication, Johns Hopkins
Bloomberg School of Public Health, USA.
Brouwere VD, Lerberghe WV (ed.). 2001. Safe Motherhood Strategies: a Review of the Evidence,
Studies in Health Services Organization & Policy, 17.
Bredenkamp, C, Wagstaff, A, Buisman, L, Prencipe L. 2012. World Bank. 2014. Health Equity and
financial protection datasets – South Asia, The World Bank. Washington D.C.
El Arifeen S, Christou A, Reichenbach L, Osman FA, Azad K, Islam KS, Ahmed F, Perry HB, Peters DH.
2013. Community-based approaches and partnerships: innovations in health-service delivery in
Bangladesh, Lancet Series - Bangladesh: Innovation for Universal Health Coverage,
http://dx.doi.org/10.1016/ S0140-6736(13)62149-2.
Foster S, Bryant M. 2013. A Framework for Estimating Benefits of Investing in Maternal, Newborn, and
Child Health, Department of International Health Boston University School of Public Health, Boston,
USA.
GoB, 2011. Comprehensive Multi-Year Plan of the National Immunization Program of Bangladesh,
2011 – 2016.
GoB. 2015a. Ministry of Health and Family Welfare, Bangladesh, Partnership for Maternal, Newborn
& Child Health, WHO, World Bank and Alliance for Health Policy and Systems Research. Success Factors
for Women’s and Children’s Health: Bangladesh.
GoB. 2015b. Health Bulletin 2015. Ministry of Health and Family Welfare, Government of Bangladesh.
Dhaka.
GoB. 2015c. Millennium Development Goals – Bangladesh Progress Report 2015. General Economics
Division (GED), Bangladesh Planning Commission, Government of the People's Republic of Bangladesh.
25
Hayforda K, Uddin MJ, Koehlmoos TP, Bishai DM. 2014. Cost and sustainability of a successful package
of interventions to improve vaccination coverage for children in urban slums of Bangladesh, Vaccine
32: 2294–2299.
Hoque ME, Khan JAM, Hossain SSA, Gazi R, Rashid HA, Koehlmoos TP, Walker DG. A systematic review
of economic evaluations of health and health-related interventions in Bangladesh, Cost Effectiveness
and Resource Allocation, 9:12.
Jokhio AH, Winter HR, Cheng KK. 2005. An intervention involving traditional birth attendants and
perinatal and maternal mortality in Pakistan. N Engl J Med, 352: 2091-9.
LeFevre AE, Shillcutt SD, Waters HR, Haider S, El Arifeen S, Mannan I, Seraji HR, Shah R, Darmstadt GL,
Wall SN, Williams EK, Black RE, Santosham M, Baqui AH. 2013. Economic evaluation of neonatal care
packages in a cluster-randomized controlled trial in Sylhet, Bangladesh, Bull World Health Organ
91:736–745.
Nugent R. 2015. Benefits and costs of non-communicable disease targets for the post-2015
development agenda, Perspective Paper, Copenhagen Consensus Centre.
Sarowar MG, Medin E, Gazi R, Koehlmoos TP, Rehnberg C, Saifi R, Bhuiya A, Khan J. 2010. Calculation
of Costs of Pregnancy- and Puerperiumrelated Care: Experience from a Hospital in a Low-income
Country. J Health Popul Nutr 28(3):264-272.
Tura G, Fantahun M, Worku A. 2013. The effect of health facility delivery on neonatal mortality:
systematic review and meta-analysis. BMC Pregnancy and Childbirth 13:18.
Uddin MJ, Larson CP, Oliveras E, Khan AI, Quaiyum MA, Saha NC. 2010. Child immunization coverage
in urban slums of Bangladesh: impact of an intervention package. Health Policy and Planning 25:50–
60.
Uddin MJ, Saha NC, Islam Z, Khan IA, Shamsuzzaman, Quaiyum MA, Koehlmoos TP. 2012. Improving
low coverage of child immunization in rural hard-to-reach areas of Bangladesh: Findings from a project
using multiple interventions, Vaccine 30:168– 179.
United Nations. 2015. Transforming Our World: The 2030 Agenda for Sustainable Development,
A/RES/70/1, The United Nations.
26
World Bank. 1993. World Development Report 1993: Investing in Health. New York: Oxford University
Press. World Bank.
World Bank. 2015. Health Equity and Financial Protection Datasheets (72014), South Asia. The World
Bank, Washington D.C.
27
Appendix 1: Description of studies employed in the analyses
Author & Journal/source; Study title ; Study setting and country; Type pf study; Objective; Methods;
Data & sample size; Result
Bishai D, Johns B, Lefevre A, Nair D. 2010. Johns Hopkins Bloomberg School of Public Health, USA.;
Cost effectiveness of measles eradication; Several developing countries were included in the analysis,
i.e. Bangladesh, Brazil. Colombia, Ethiopia, Tajikistan and Uganda. ; Cost-effectiveness analysis; To
estimate the cost-effectiveness of measles eradication programs ; "A dynamic age-tiered measles
transmission model for 6 countries and a linear model that could be applied to every country in the
world."; Data from 6 developing countries were used; In Bangladesh, scale up cost per child
vaccination for core areas was 27.83 USD and for satellite areas was 37.93 USD.
Brouwere VD, Lerberghe WV (ed.). Studies in Health Services Organization & Policy, 2001(17). ; Safe
Motherhood Strategies: a Review of the Evidence; Developing country context; Secondary source
review; Secondary source review for estimating impact of skilled birth attendance (with facility) on
safe motherhood.; Secondary source and data review; Data from several studies; 99.6%, 48.8%, 49.7%
and 49.0% deaths were averted in connection to obstructed labor, eclampsia, puerperal and
haemorrhage respectively due to primary and secondary prevention through skilled birth attendant
with facility option.
Hayforda K, Uddin MJ, Koehlmoos TP, Bishai DM. Vaccine 2014: 32: 2294–2299.; Cost and
sustainability of a successful package of interventions toimprove vaccination coverage for children in
urban slums of Bangladesh; Urban slum, Bangladesh; Cost-analysis; To estimate the incremental
economic costs and explore satisfaction with a highly effectiveintervention for improving
immunization coverage among slum populations in Dhaka, Bangladesh; Combination of activity-based
costing (ABC) and an‘ingredients’ approach were used. The analysis measured economic costs,which
includes financial costs attributable to the intervention andopportunity costs.; Data from programme
; The average cost of per valid fully immunized children was estimated to 20.95 USD. The costs
comprised of external manage-ment and supervision (73%), training (11%), coordination costs (1%),
uncompensated staff time and cliniccosts (2%), and communications, supplies and other costs (13%).
Costs were associated with an estimated number of 874 children.
Islam Z, Khan JAM, Alam K, Sohni T, Sarker HS. 2010. Manoshi working paper; icddr,b and BRAC, Dhaka,
Bangladesh.; Costs of MANOSHI Delivery Centres: Normal Delivery, ANC and PNC; Urban slum, Dhaka,
Bangladesh; Cost analysis; "1. Estimate total cost of operating Manoshi delivery centres in Dhaka city
slums 2. Estimate average cost of providing normal delivery care, antenatal care and postnatal care at
Manoshi delivery centres."; A combination of bottom-up and top-down costing approach, provider
perspective cost captured; Seven delivery centres of Kamrangirchar slum in Dhaka city; "The average
cost per normal delivery conducted at the selected delivery centres was Tk. 1296 (USD 19) in 2008
and Tk. 1068 (USD 16) in 2009. The average cost of full ANC coverage was Tk. 141.23 (USD 2.07) and
that of PNC coverage was Tk. 145.02 (USD 2.13). "
28
Jokhio AH, Winter HR, Cheng KK. N Engl J Med, 2005; 352: 2091-9. ; An intervention involving
traditional birth attendants and perinatal and maternal mortality in Pakistan; Rural district in Pakistan;
Intervention impact assessment from clinical trials; Impact of training traditional birth attendant on
maternal mortality; Cluster-randomized control trial with intervention and control group;
Intervention: 10,114; control: 9,443; Maternal death per 100,000 pregnancies: Intervention= 268,
control=360; neonatal deaths per 1000 live births: intervention=340, control=439
LeFevre AE, Shillcutt SD, Waters HR, Haider S, El Arifeen S, Mannan I, Seraji HR, Shah R, Darmstadt GL,
Wall SN, Williams EK, Black RE, Santosham M, Baqui AH. 2013. Bull World Health Organ 2013; 91:736–
745. ; Economic evaluation of neonatal care packages in a cluster-randomized controlled trial in Sylhet,
Bangladesh; Sylhet, Bangladesh; Economic evaluation using cluster randomized control trial; To
evaluate and compare the cost-effectiveness of two strategies for neonatal care in Sylhet division,
Bangladesh; The incremental cost-effectiveness analysis of each strategy was estimated. The levels of
uncertainty in estimates were quantified through probabilistic sensitivity analysis.; The activities of
the Project for Advancing the Health of Newborns and Mothers were implemented, among a
population of about 500 000, in the Beanibazar, Zakiganj and Kanaighat subdistricts of Sylhet division.
Live-births: 4 979, Neonatal deaths: 155, YLL: 881, YLD: 194, DALYs: 1 075; Programme, provider and
user cost: 39 418 per 1,000 neonates.; 11.9 neonatal death averted (per 1,000 neonates) by homecare
intervention with program cost 34958 USD (per 1,000 neonates)
Sarker BK, Ahmed S, Islam N, Khan JAM; Cost Eff Resour Alloc. 2013;11(1):28; Cost of behavior change
communication channels of Manoshi -a maternal, neonatal and child health (MNCH) program in urban
slums of Dhaka, Bangladesh; Urban slum, Dhaka, Bangladesh; Cost analysis; To estimate cost of BCC
interventions for specific components of the Man oshi program in Bangladesh to a cost-per-exposure
level; Micro-costing, provider prespective; Data on inputs and prices were collected from both primary
and secondary sources. Primary data were obtained by interviewing BRAC staffs who were involved in
implementing BCC tools an observation of BCC session. These sessions were undertaken in all five
broad intervention areas of Manoshi, namely the Dhanmondi, Gulshan, Uttara, Mohammadpur and
Jatrabari regions in Dhaka city.; Per exposure, the cost of face-to-face counseling was found to be 3.08
BDT during pregnancy detection, 3.11 BDT during pregnancy confirmation, 12.42 BDT during antenatal
care, 18.96 BDT during delivery care and 22.65 BDT during post-natal care.
Sarowar MG, Medin E, Gazi R, Koehlmoos TP, Rehnberg C, Saifi R, Bhuiya A, Khan J. 2010. J Health
Popul Nutr 28(3):264-272.; Calculation of Costs of Pregnancy- and Puerperiumrelated Care:
Experience from a Hospital in a Low-income Country.; The inpatient obstetric and labour ward of
Seconday level General Hospital run by public financing in Dhaka, the capital city of Bangladesh; Cost-
analysis; The aim of this case study was to calculate the cost of pregnancy- and puerperium-related
cases admitted to a secondary care hospital and to identify the practical challenges of carrying out this
type of cost-calculation study in Bangladesh.; The study used a mixed method of ‘micro-costing’ and
‘step-down cost allocation’ for collecting information on different cost items.; 162 mothers were
included, of which 146 mothers completed the care. ; Mean cost for c-section delivery: 89.98 USD and
normal delivery: 43.63 USD
Tura G, Fantahun M, Worku A. BMC Pregnancy and Childbirth 2013: 13:18.; The effect of health facility
delivery on neonatal mortality: systematic review and meta-analysis. ; The middle and low-income
29
countries; Meta analysis; Review was conducted with the aim of determining the pooled effect of
health facility delivery on neonatal mortality; Meta analysis: Pooled effect size was determined in the
form of relative risk in the random-effects model; 37 studies under systematic review; Neonatal death
in health facility is 14,821 out of 150,4450 live births and susch mortality was 3,365 out of 102,355 live
births
Uddin MJ, Larson CP, Oliveras E, Khan AI, Quaiyum MA, Saha NC. 2010. Health Policy and Planning
25:50–60.; Child immunization coverage in urban slums of Bangladesh: impact of an intervention
package; Urban slum, Bangladesh; Impact assessment ; To assess the impact of an EPI (Expanded
Programme on Immunization) intervention package, implemented within the existing servicedelivery
system, to improve the child immunization coverage in urban slums of Dhaka, Bangladesh; ‘before
and after’ assessment of selected immunization-coverage indicators; Baeline: 529; endline: 526; the
proportion of fully immunized children of was 43% in baseline which was incresed to 99% in endline
Uddin MJ, Saha NC, Islam Z, Khan IA, Shamsuzzaman, Quaiyum MA, Koehlmoos TP. Vaccine, 2012:
30:168– 179; Improving low coverage of child immunization in rural hard-to-reach areas of
Bangladesh: Findings from a project using multiple interventions; Rural low-lying land (haor) and hills
in Bangladesh; Impact assessment ; "to assess the impact of combined interventions to improve the
child immunization coverage in rural hard-to-reach areas of Bangladesh."; Baseline and endline
comparison; Haor: 720 in baseline, 721 in endline (group A; 720 in baseline and 720 in endline (group
B) AND Hills: 720 in baseline, 722 in endline (group A), 720 in baseline, 721 in endline (group B) ; On
average in haor and hills: Coverage in baseline=48% and endline 86% in group A and coverage in
baseline 53.5% and endline 81% in group B. Final increase in all areas=32.75%
© Copenhagen Consensus Center 2016
Bangladesh, like most nations, faces a large number of challenges. What should be the top priorities for
policy makers, international donors, NGOs and businesses? With limited resources and time, it is crucial
that focus is informed by what will do the most good for each taka spent. The Bangladesh Priorities
project, a collaboration between Copenhagen Consensus and BRAC, works with stakeholders across
Bangladesh to find, analyze, rank and disseminate the best solutions for the country. We engage
Bangladeshis from all parts of society, through readers of newspapers, along with NGOs, decision makers,
sector experts and businesses to propose the best solutions. We have commissioned some of the best
economists from Bangladesh and the world to calculate the social, environmental and economic costs
and benefits of these proposals. This research will help set priorities for the country through a nationwide
conversation about what the smart - and not-so-smart - solutions are for Bangladesh's future.
For m o r e in forma t io n v isit w w w .Bangladesh -Priorit i e s . c o m
C O P E N H A G E N C O N S E N S U S C E N T E R
Copenhagen Consensus Center is a think tank that investigates and publishes the best policies and
investment opportunities based on social good (measured in dollars, but also incorporating e.g. welfare,
health and environmental protection) for every dollar spent. The Copenhagen Consensus was conceived
to address a fundamental, but overlooked topic in international development: In a world with limited
budgets and attention spans, we need to find effective ways to do the most good for the most people. The
Copenhagen Consensus works with 300+ of the world's top economists including 7 Nobel Laureates to
prioritize solutions to the world's biggest problems, on the basis of data and cost-benefit analysis.
