Hounton S 1,2 , Belemsaga D 3 , Newlands D 2 , Meda N 3 , De Brouwere V 4

1. Cost effectiveness analysis of alternative training strategies for improving access to emergency obstetric care in Burkina Faso Hounton S1,2, Belemsaga D3, Newlands D2 , Meda N3, De Brouwere V4 1WHO-MDSC, Burkina Faso, 2University of Aberdeen, UK 3Centre MURAZ, Burkina Faso, 4ITM, Antwerp, Belgium

2. Background Maternal and newbornmortalityveryhigh. How to ensureskilled ? Skilledhealthhuman resources (number, coverage, availability, access) Effectiveness and cost- effectiveness of strategies to addressshortage ?

3. OBJECTIVES Effectiveness of surgical teams led by specialists, medical doctors, and clinical officers in providing life saving interventions Value for money Policy recommendation for effective coverage of emergency obstetric care in rural areas

4. Methods (1) • Study design: Cost-effectiveness analysis (surgeries: c-sections) - Strategy 1: Team led by a specialist (OBGY, surgeon) - Strategy 2: Team led by a general practitioner - Strategy 3: Team led by a clinical officer Comparability of case-mix and supporting environment • Place and participants - Burkina Faso (6 / 13 regions) - All district hospitals • Study period: Oct – Dec 2007 • Perspective: health system • Time horizon: 15 years

5. Methods (2) • Effectiveness measures - Maternal and newborn case fatality rates - Post caesarean complications (haemorrhage, infections, loosening of sutures) • Costing methodology aims - Average annual cost of training and deployment of providers - Average annual costs of putting in place a surgical team • Incremental Cost Effectiveness Ratio (ICER)

6. Methods (3) • Data sources, data collection - Retrospective case extraction of registries (Jan - Dec 2006) - Reports (MOH, University), interviews of stakeholders on barriers and facilitators of the substitutes strategies • Data analysis - Descriptive statistics, multivariate analysis (case-mix) - Macro costing, annual costs estimates (useful lifespan of items, 3% discount rate, allocation of total costs to caesarean section by appropriate proxies of the volume and time) - Sensitivity analysis on major costs categories

7. Results (1): cases profile

8. 250 200 150 100 50 0 Obstetricians General practitioners Clinical officers 80 70 60 50 40 30 20 10 0 Obstetricians General practitioners Clinical officers Results (2) : outcomes • Case fatality rates of caesarean deliveries by provider, district hospitals, 2004-2005, Burkina Faso • Newborns (/1000 c-sections) • Mothers (/1000 c-sections)

9. Results (3) : costing ICER of caesarean deliveries by providers’ teams, district hospitals, 2006

10. RESULTS (4): “Enhanced strategies” ICER of caesarean deliveries by providers’ teams, district hospitals, 2006

11. Discussions • Comparable skills & practices of c-section (thus life saving interventions) between obstetricians and trained doctors • Results comparable to those in Mozambique, Malawi, Zambia, however higher CFR with clinical officers in our settings • Delegation of surgical tasks from specialists to substitutes: necessary, effective and cost-effective in rural areas • HRH : incentives are primarily about career path, supportive environment, degree (prestige), and monetary incentives • Limitations: comparability of settings, providers, cases

12. Conclusion • All current options for providing emergency surgeries are viable • Trained doctors: most cost effective option • Potential for improved cost-effectiveness of trained doctors if career paths and incentives provided • In Burkina Faso, given shortage will remain for foreseeable future, delegation of surgical tasks from specialists to middle level health substitutes has proven to be effective, is cost effective in the short and mid runs

13. Acknowledgements • West Africa Health Organization (WAHO) Grant WAHO, N°13 Centre MURAZ, 2005 • Ministry of health, Centre MURAZ (Burkina Faso) • Collaborators: Sombie I, Cecile Tamini, Mamadou Barro, Fadima Bocoum, Abdoulaye Traore, Moctar Ouédraogo, Peter Byass