Cost Effectiveness of Implementing Integrated Management of Neonatal and Childhood Illnesses Program in District Faridabad, India

Saturday, 9th of January 2016

Cost Effectiveness of Implementing Integrated Management of Neonatal and Childhood Illnesses Program in District Faridabad, India

Shankar Prinja,
Pankaj Bahuguna,
Pavitra Mohan,
Sarmila Mazumder,
Sunita Taneja,
Nita Bhandari,
Henri van den Hombergh, …

Excerpt below; full text is at http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0145043

Abstract

Introduction

Despite the evidence for preventing childhood morbidity and mortality, financial resources are cited as a constraint for Governments to scale up the key health interventions in some countries. We evaluate the cost effectiveness of implementing IMNCI program in India from a health system and societal perspective.

Methods

We parameterized a decision analytic model to assess incremental cost effectiveness of IMNCI program as against routine child health services for infant population at district level in India. Using a 15-years time horizon from 2007 to 2022, we populated the model using data on costs and effects as found from a cluster-randomized trial to assess effectiveness of IMNCI program in Haryana state. Effectiveness was estimated as reduction in infant illness episodes, deaths and disability adjusted life years (DALY). Incremental cost per DALY averted was used to estimate cost effectiveness of IMNCI. Future costs and effects were discounted at a rate of 3%. Probabilistic sensitivity analysis was undertaken to estimate the probability of IMNCI to be cost effective at varying willingness to pay thresholds.

Results

Implementation of IMNCI results in a cumulative reduction of 57384 illness episodes, 2369 deaths and 76158 DALYs among infants at district level from 2007 to 2022. Overall, from a health system perspective, IMNCI program incurs an incremental cost of USD 34.5 (INR 1554) per DALY averted, USD 34.5 (INR 1554) per life year gained, USD 1110 (INR 49963) per infant death averted. There is 90% probability for ICER to be cost effective at INR 2300 willingness to pay, which is 5.5% of Indias GDP per capita. From a societal perspective, IMNCI program incurs an additional cost of USD 24.1 (INR 1082) per DALY averted, USD 773 (INR 34799) per infant death averted and USD 26.3 (INR 1183) per illness averted in during infancy.

Conclusion

IMNCI program in Indian context is very cost effective and should be scaled-up as a major child survival strategy.

Citation: Prinja S, Bahuguna P, Mohan P, Mazumder S, Taneja S, Bhandari N, et al. (2016) Cost Effectiveness of Implementing Integrated Management of Neonatal and Childhood Illnesses Program in District Faridabad, India. PLoS ONE 11(1): e0145043. doi:10.1371/journal.pone.0145043

Editor: Umberto Simeoni, Centre Hospitalier Universitaire Vaudois, FRANCE

Received: June 2, 2015; Accepted: November 29, 2015; Published: January 4, 2016

Copyright: © 2016 Prinja et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: The study was funded by the World Health Organization, Geneva (through an umbrella grant from USAID); the United Nations Childrens Fund, New Delhi; and the GLOBVAC Program of the Research Council of Norway through grant No 183722. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Neonatal and infant mortality accounts for 55% and 77% of total under-5 child mortality in India respectively [1–4]. Reducing high levels of infant and neonatal mortality is the key towards achieving the fourth Millennium Development Goal (MDG-4) goal. While various measures are being undertaken by Government of India for reducing child mortality, specific focus remains on improving neonatal and infant survival. Against this backdrop, Integrated Management of Childhood Illnesses (IMCI) was implemented in India after being adapted as Integrated Management of Neonatal and Childhood Illnesses (IMNCI) [5]. Specific focus is laid on early newborn care through home visits and improving home-based newborn care practices, besides upgrading skills of health workers and doctors for managing sick children at health facilities. It also aims at strengthening of health systems through better availability of drugs and personnel, and provision of referral services [6].

Review of evidence on the impact of Integrated Management of Childhood Illnesses (IMCI) shows that it is associated with reduction in childhood morbidity [7]. Trials from Tanzania and Brazil indicate lesser morbidities among the children who lived in areas where the IMCI program was implemented [8–10]. Similarly, studies from Uganda and Bangladesh show better performance of health workers trained in IMCI in diagnosing and managing sick children [9,11]. Studies on effect of IMNCI on childhood mortality have been less conclusive. While a 13% reduction in childhood mortality was found in Tanzania, no significant difference in mortality was observed in Brazil or Bangladesh. A recent cluster-randomized trial from district Faridabad in Haryana state of India reported a 15% (6% to 23%) reduction in infant mortality (adjusted hazard ratio of 0.85) as a result of IMNCI program [12]. Similarly, reduction in prevalence of pneumonia and diarrhoea was modelled using estimates from the IMNCI effectiveness trial [13]. The adjusted risk ratios reported for pneumonia and diarrhoea among infants with IMNCI were 0.73 (0.52, 1.04) and 0.71 (0.60, 0.83), as compared to a setting of routine care without IMNCI.

Despite evidence base on impact of IMCI, Child Survival Countdown conference in 2005 noted lack of financial resources as a constraint by Governments in scaling up the key health interventions in some countries [7]. India introduced the IMNCI program in 2002 on a pilot basis in 6 districts. Currently IMNCI is being implemented in 433 districts out of a total of 640 districts [14].

Although IMCI program has been evaluated from an economic viewpoint in Africa [8] and Bangladesh, however, no economic evaluation of the IMNCI program has been reported in India. Operational differences in the way IMNCI is implemented vis a vis IMCI make it difficult to generalize results from such economic evaluations from Africa to India. Secondly, results from previous economic evaluations of IMCI program have been limited to cost comparisons, while an overall incremental cost effectiveness analysis is lacking [15,16]. In the present paper we analyze the incremental cost effectiveness of implementing IMNCI at district level against a comparator of routine child health services. We report outcomes from both health system and societal perspective.