A Price Tag for Newborn and Child Survival

Dr. Joy Lawn BM BS MRCP (Paeds) MPHSaving Newborn Lives/Save the Children-USA

and MRC, Cape Town South Africa

and Institute of Child Health London

The Team

Child series costingNeff Walker

Jennifer BryceJoy Lawn

Zulfiqar BhuttaSaul MorrisBob Black

Newborn series costingNeff Walker

Joy LawnSimon CousinsZulfiqar BhuttaLuc de Bernis

Gary Darmstadt

Combining the newborn and child costingsAll the above plus Saul Morris and Gareth Jones

THE LANCET

Can the world afford to save

6 million

children?

Outline

1. Countdown context

2. Combining The Lancet Price Tags for newborn & child survival

3. Costs for lives saved – the bottom line

4. Comparison with other costings

5. Consequences

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?

Full coverage (99%) with 23 proven interventions could reduce under-five mortality by 66%,

saving 6 million child deaths/year

The Lancet Child Survival series: Key findingsL

IVE

S

Additional cost of providing these interventions is US$ 5.1 billion annually

or $1.23 per capitaCO

ST

Coverage (90%) with 16 proven interventions deliveredthrough packages could reduce neonatal mortality by up

to 67% equivalent to 2.7 million deaths/year

The Lancet Neonatal Survival series: Key findingsL

IVE

S

Additional cost of providing these interventions isUS$ 4.1 billion annually

or $0.96 per capita

70% of the costs also benefit mothers and older children

CO

ST

Methods & assumptionsCombining newborn and child survival costing

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%

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

Combined costing

Objective

Does NOT include costs toexpand infrastructure (new hospitals)

produce new human resources (pre-service training of new midwives)

Combined costing

Methods & assumptions

Current running costs

• 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

Approximate child age in months

Measles vaccine

Vitamin A

Complementary

Zinc

Hib vaccine

Insecticide-treated

Breastfeeding

Neonatal interventions*

replacement feeding

Tetanus Toxoid

preventive treatment

Pre

ven

tive

inte

rven

tio

ns

Beforebirth 2 4 9 21 27 33 39 45 51 576 15

Nevirapine &

Antimalarial intermittent

Birth

antenatal steroids

* Includes clean delivery with skilled attendant, temperature management, antibiotics for premature rupture of membranes and neonatal sepsis, steroids

Weeks1 - 2

Water & sanitation

feeding

materials

Contact with trained health care worker

Birth

Integrated service delivery timetable for preventive child survival interventions included (adaptation needed for countries)

Outreach/outpatient services

Tetanus toxoid immunizationIntermittent presumptive therapy for malaria

Family-community

Breastfeeding promotion,

Case management for pneumoniaClinical

care

Antibiotics for preterm rupture of membranes#

Corticosteroids for preterm labour#

Neonatal sepsis treatment

Clean delivery and neonatal resuscitation

Lancet Neonatal Survival seriesSkilled obstetric and immediate newborn care (hygiene, warmth, breastfeeding) & resuscitation

Emergency obstetric care to manage complications eg obstruction, hemorrhage

Emergency newborn care for illness, especially sepsis management and care of very low birth weight babies including Kangaroo Mother Care

Counseling and preparation for newborn care and breastfeeding, emergency preparedness

Healthy home care including breastfeeding promotion, hygienic cord/skin care, thermal care, promoting demand for quality care

Extra care of low birth weight babies

Case management for pneumonia

Clean delivery by traditional birth attendant (if no skilled attendant is available)

Simple early newborn care

InfancyNeonatal periodPre- pregnancy PregnancyBirth

# For health systems with higher coverage and capacity

Folic acid #

Focused 4-visit antenatal package• tetanus immunisation,• management of syphilis/STIspre-eclampsia, etc

Malaria intermittent presumptive therapy*

Detection and treatment of bacteriuria#

Postnatal care to support healthy practices

Early detection and referral of complications

Lives saved in the 60 countriesCombined costing results

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

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

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

Combined costing results

Costs by service delivery approach

0

1

2

3

4

Water & sanitation Family & community Outreach/outpatients Clinical care

Co

sts

(U

S$

bill

ion

s)

pe

r y

ea

r

Costs for current coverageCosts for expanded coverage

Combined costing results

Costs saved in treatment by preventive care

0

1

2

3

4

5

6

Without prevention effects With prevention effects

Bil

lion

s of

200

4 U

S$

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

Combined costing results

Costs saved by integrated delivery

1,406

656

1,051

414

0

500

1,000

1,500

Hib Vaccine Exclusive Breastfeeding

Mil

lion

s of

200

4 U

S$

Integrated

Parallel

Estimated annual cost per child life saved comparing integrated and parallel delivery of preventive interventions in millions of 2004 US$

1. Cost-effective packages within the continuum of care

2. Delivery at all levels through outreach, family-community care, and facility-based clinical care – synergistic effect

3. 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

Economical policy choices

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

Is US$ 7 billion/year to save 6.6 million

children and newborns “affordable”?

About half of the US$12 to US$20 billion committed

annually to the fight against HIV/AIDs

Less than 10% of what was spent on tobacco products in

the US in 2003

Less than 10% global Overseas Development Aid

estimated total of US$78 billion

Less than the annual subsidisation of

the Japanese cow

Only a little more than the US$4 billion lost to poor countries in migrating skilled professionals

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

Tanzania Zambia Ethiopia

Commitments…. few donor countries deliver

Donor countries must meet their commitment of 0.7% of GDP

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

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

Costing – the future

ConclusionCommitment 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

WH

O,

Riv

ers

of

life

Thank you!

Comparison with WHO cost estimates

Model element/

Approach

Lancet Child/ Neonatal

Survival Combined

WHO World Health Report

Relative to Bryce et al,

WHO estimate is likely to be:

What is costed? Running costs Scale-up & running costs

Countries 60 75

Interventions 32 16 “sets”

Target coverage 99% 95%

Delivery strategy Integrated delivery timetable

Some vertical; some

combined.