Affordable Access

Publisher Website

Participatory learning and action cycles with women's groups to prevent neonatal death in low-resource settings: A multi-country comparison of cost-effectiveness and affordability.

  • Pulkki-Brännström, Anni-Maria1, 2
  • Haghparast-Bidgoli, Hassan2
  • Batura, Neha2
  • Colbourn, Tim2
  • Azad, Kishwar3
  • Banda, Florida4
  • Banda, Lumbani5
  • Borghi, Josephine6
  • Fottrell, Edward2
  • Kim, Sungwook7
  • Makwenda, Charles5
  • Ojha, Amit Kumar8
  • Prost, Audrey2
  • Rosato, Mikey9
  • Shaha, Sanjit Kumer3
  • Sinha, Rajesh8
  • Costello, Anthony2
  • Skordis, Jolene2
  • 1 Department of Epidemiology and Global Health, Umeå University, Umeå S-901 87, Sweden. , (Sweden)
  • 2 UCL Institute for Global Health, UCL (University College London), 30 Guilford Street, London, WC1N 1EH, UK.
  • 3 Perinatal Care Project, Diabetic Association of Bangladesh, 122 Kazi Nazrul Islam Avenue, Dhaka 1000, Bangladesh. , (Bangladesh)
  • 4 MaiMwana Project, Mchinji, Malawi. , (Malawi)
  • 5 Parent and Child Health Initiative (PACHI), Area 14 Plot 171, Lilongwe, Malawi. , (Malawi)
  • 6 Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
  • 7 Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.
  • 8 Ekjut, Plot no. - 556B, Potka Chakradharpur, West Singhbhum, Pin - 833102, Jharkhand, India. , (India)
  • 9 Women and Children First (UK), United House, North Road, London, N7 9DP, UK.
Published Article
Health Policy and Planning
Oxford University Press
Publication Date
Feb 16, 2021
DOI: 10.1093/heapol/czaa081
PMID: 33085753


WHO recommends participatory learning and action cycles with women's groups as a cost-effective strategy to reduce neonatal deaths. Coverage is a determinant of intervention effectiveness, but little is known about why cost-effectiveness estimates vary significantly. This article reanalyses primary cost data from six trials in India, Nepal, Bangladesh and Malawi to describe resource use, explore reasons for differences in costs and cost-effectiveness ratios, and model the cost of scale-up. Primary cost data were collated, and costing methods harmonized. Effectiveness was extracted from a meta-analysis and converted to neonatal life-years saved. Cost-effectiveness ratios were calculated from the provider perspective compared with current practice. Associations between unit costs and cost-effectiveness ratios with coverage, scale and intensity were explored. Scale-up costs and outcomes were modelled using local unit costs and the meta-analysis effect estimate for neonatal mortality. Results were expressed in 2016 international dollars. The average cost was $203 (range: $61-$537) per live birth. Start-up costs were large, and spending on staff was the main cost component. The cost per neonatal life-year saved ranged from $135 to $1627. The intervention was highly cost-effective when using income-based thresholds. Variation in cost-effectiveness across trials was strongly correlated with costs. Removing discounting of costs and life-years substantially reduced all cost-effectiveness ratios. The cost of rolling out the intervention to rural populations ranges from 1.2% to 6.3% of government health expenditure in the four countries. Our analyses demonstrate the challenges faced by economic evaluations of community-based interventions evaluated using a cluster randomized controlled trial design. Our results confirm that women's groups are a cost-effective and potentially affordable strategy for improving birth outcomes among rural populations. © The Author(s) 2020. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

Report this publication


Seen <100 times