A comparison of total cost estimates between exclusive breast-feeding and breast milk substitute usage in humanitarian contexts.

OBJECTIVE: Using a model-based analysis, we calculated the total costs associated with the exclusive breast-feeding (EBF) and breast milk substitute (BMS) usage for one infant for six months within select humanitarian contexts to (a) determine if there is a notable difference in costs and (b) use these results to inform future creation of data-informed humanitarian response standard operating procedures. DESIGN: The inputs and costing data were drawn from a mixture of local e-commerce vendors, peer-reviewed literature and personal communications with field-based humanitarian responders. To account for cost fluctuations, each input's costs along with low and high parameters are presented. All costs are presented in 2021 United States Dollars. SETTING: Humanitarian responses within Indonesia and Jordan. PARTICIPANTS: Not applicable. RESULTS: There was a notable difference in the total cost of care in both selected locations across the study arms (Indonesia: $542; Jordan: $892). CONCLUSIONS: Given the reality of limited funding for comprehensive humanitarian response around the world and the necessity of prioritising certain interventions, humanitarian response organisations should consider the notable cost difference between EBF and BMS usage (along with the proven health benefits of EBF). This difference should play a role in informing the future creation of standard operating procedures while also ensuring that all infants within a humanitarian crisis receive appropriate feeding.

Cost-effectiveness of a direct to beneficiary mobile communication programme in improving reproductive and child health outcomes in India.

INTRODUCTION: Kilkari is the largest maternal messaging programme of its kind globally. Between its initiation in 2012 in Bihar and its transition to the government in 2019, Kilkari was scaled to 13 states across India and reached over 10 million new and expectant mothers and their families. This study aims to determine the cost-effectiveness of exposure to Kilkari as compared with no exposure across 13 states in India. METHODS: The study was conducted from a programme perspective using an analytic time horizon aligned with national scale-up efforts from December 2014 to April 2019. Economic costs were derived from the financial records of implementing partners. Data on incremental changes in the practice of reproductive maternal newborn and child health (RMNCH) outcomes were drawn from an individually randomised controlled trial in Madhya Pradesh and inputted into the Lives Saved Tool to yield estimates of maternal and child lives saved. One-way and probabilistic sensitivity analyses were carried out to assess uncertainty. RESULTS: Inflation adjusted programme costs were US$8.4 million for the period of December 2014-April 2019, corresponding to an average cost of US$264 298 per year of implementation in each state. An estimated 13 842 lives were saved across 13 states, 96% among children and 4% among mothers. The cost per life saved ranged by year of implementation and with the addition of new states from US$392 ($385-$393) to US$953 ($889-$1092). Key drivers included call costs and incremental changes in coverage for key RMNCH practices. CONCLUSION: Kilkari is highly cost-effective using a threshold of India's national gross domestic product of US$1998. Study findings provide important evidence on the cost-effectiveness of a national maternal messaging programme in India. TRIAL REGISTRATION: NCT03576157.

Avoiding the Road to Nowhere: Policy Insights on Scaling up and Sustaining Digital Health.

Digital health solutions offer tremendous potential to enhance the reach and quality of health services and population-level outcomes in low- and middle-income countries (LMICs). While the number of programs reaching scale increases yearly, the long-term sustainability for most remains uncertain. In this article, as researchers and implementors, we draw on experiences of designing, implementing and evaluating digital health solutions at scale in Africa and Asia, and provide examples from India and South Africa to illustrate ten considerations to support scale and sustainability of digital health solutions in LMICs. Given the investments being made in digital health solutions and the urgent concurrent needs to strengthen health systems to ensure their responsiveness to marginalized populations in LMICs, we cannot afford to go down roads that 'lead to nowhere'. These ten considerations focus on drivers of equity and innovation, the foundations for a digital health ecosystem, and the elements for systems integration. We urge technology enthusiasts to consider these issues before and during the roll-out of large-scale digital health initiatives to navigate the complexities of achieving scale and enabling sustainability.

Examining the reach and exposure of a mobile phone-based training programme for frontline health workers (ASHAs) in 13 states across India.

Mobile phones are increasingly used to facilitate in-service training for frontline health workers (FLHWs). Mobile learning (mLearning) programmes have the potential to provide FLHWs with high quality, inexpensive, standardised learning at scale, and at the time and location of their choosing. However, further research is needed into FLHW engagement with mLearning content at scale, a factor which could influence knowledge and service delivery. Mobile Academy is an interactive voice response training course for FLHWs in India, which aims to improve interpersonal communication skills and refresh knowledge of preventative reproductive, maternal, neonatal and child health. FLHWs dial in to an audio course consisting of 11 chapters, each with a 4-question true/false quiz, resulting in a cumulative pass/fail score. In this paper, we analyse call data records from the national version of Mobile Academy to explore coverage, user engagement and completion. Over 158 596 Accredited Social Health Activists (ASHAs) initiated the national version, while 111 994 initiated the course on state-based platforms. Together, this represents 41% of the estimated total number of ASHAs registered in the government database across 13 states. Of those who initiated the national version, 81% completed it; and of those, over 99% passed. The initiation and completion rates varied by state, with Rajasthan having the highest initiation rate. Many ASHAs made multiple calls in the afternoons and evenings but called in for longer durations earlier in the day. Findings from this analysis provide important insights into the differential reach and uptake of the programme across states.

A tale of 'politics and stars aligning': analysing the sustainability of scaled up digital tools for front-line health workers in India.

INTRODUCTION: India has become a lighthouse for large-scale digital innovation in the health sector, particularly for front-line health workers (FLHWs). However, among scaled digital health solutions, ensuring sustainability remains elusive. This study explores the factors underpinning scale-up of digital health solutions for FLHWs in India, and the potential implications of these factors for sustainability. METHODS: We assessed five FLHW digital tools scaled at the national and/or state level in India. We conducted in-depth interviews with implementers, technology and technical partners (n=11); senior government stakeholders (n=5); funders (n=1) and evaluators/academics (n=3). Emergent themes were grouped according to a broader framework that considered the (1) digital solution; (2) actors; (3) processes and (4) context. RESULTS: The scale-up of digital solutions was facilitated by their perceived value, bounded adaptability, support from government champions, cultivation of networks, sustained leadership and formative research to support fit with the context and population. However, once scaled, embedding digital health solutions into the fabric of the health system was hampered by challenges related to transitioning management and ownership to government partners; overcoming government procurement hurdles; and establishing committed funding streams in government budgets. Strong data governance, continued engagement with FLHWs and building a robust evidence base, while identified in the literature as critical for sustainability, did not feature strongly among respondents. Sustainability may be less elusive once there is more consensus around the roles played between national and state government actors, implementing and technical partners and donors. CONCLUSION: The use of digital tools by FLHWs offers much promise for improving service delivery and health outcomes in India. However, the pathway to sustainability is bespoke to each programme and should be planned from the outset by investing in people, relationships and service delivery adjustments to navigate the challenges involved given the dynamic nature of digital tools in complex health systems.

Can health information through mobile phones close the divide in health behaviours among the marginalised? An equity analysis of Kilkari in Madhya Pradesh, India.

Kilkari is one of the largest maternal mobile messaging programmes in the world. It makes weekly prerecorded calls to new and expectant mothers and their families from the fourth month of pregnancy until 1-year post partum. The programme delivers reproductive, maternal, neonatal and child health information directly to subscribers' phones. However, little is known about the reach of Kilkari among different subgroups in the population, or the differentiated benefits of the programme among these subgroups. In this analysis, we assess differentials in eligibility, enrolment, reach, exposure and impact across well-known proxies of socioeconomic position-that is, education, caste and wealth. Data are drawn from a randomised controlled trial (RCT) in Madhya Pradesh, India, including call data records from Kilkari subscribers in the RCT intervention arm, and the National Family Health Survey-4, 2015. The analysis identifies that disparities in household phone ownership and women's access to phones create inequities in the population eligible to receive Kilkari, and that among enrolled Kilkari subscribers, marginalised caste groups and those without education are under-represented. An analysis of who is left behind by such interventions and how to reach those groups through alternative communication channels and platforms should be undertaken at the intervention design phase to set reasonable expectations of impact. Results suggest that exposure to Kilkari has improved levels of some health behaviours across marginalised groups but has not completely closed pre-existing gaps in indicators such as wealth and education.

mCARE, a digital health intervention package on pregnancy surveillance and care-seeking reminders from 2018 to 2027 in Bangladesh: a model-based cost-effectiveness analysis.

OBJECTIVE: We estimated the cost-effectiveness of a digital health intervention package (mCARE) for community health workers, on pregnancy surveillance and care-seeking reminders compared with the existing paper-based status quo, from 2018 to 2027, in Bangladesh. INTERVENTIONS: The mCARE programme involved digitally enhanced pregnancy surveillance, individually targeted text messages and in-person home-visit to pregnant women for care-seeking reminders for antenatal care, child delivery and postnatal care. STUDY DESIGN: We developed a model to project population and service coverage increases with annual geographical expansion (from 1 million to 10 million population over 10 years) of the mCARE programme and the status quo. MAJOR OUTCOMES: For this modelling study, we used Lives Saved Tool to estimate the number of deaths and disability-adjusted life years (DALYs) that would be averted by 2027, if the coverage of health interventions was increased in mCARE programme and the status quo, respectively. Economic costs were captured from a societal perspective using an ingredients approach and expressed in 2018 US dollars. Probabilistic sensitivity analysis was undertaken to account for parameter uncertainties. RESULTS: We estimated the mCARE programme to avert 3076 deaths by 2027 at an incremental cost of $43 million relative to the status quo, which is translated to $462 per DALY averted. The societal costs were estimated to be $115 million for mCARE programme (48% of which are programme costs, 35% user costs and 17% provider costs). With the continued implementation and geographical scaling-up, the mCARE programme improved its cost-effectiveness from $1152 to $462 per DALY averted from 5 to 10 years. CONCLUSION: Mobile phone-based pregnancy surveillance systems with individually scheduled text messages and home-visit reminder strategies can be highly cost-effective in Bangladesh. The cost-effectiveness may improve as it promotes facility-based child delivery and achieves greater programme cost efficiency with programme scale and sustainability.

Does having a mobile phone matter? Linking phone access among women to health in India: An exploratory analysis of the National Family Health Survey.

BACKGROUND: The disruptive potential of mobile phones in catalyzing development is increasingly being recognized. However, numerous gaps remain in access to phones and their influence on health care utilization. In this cross-sectional study from India, we assess the gaps in women's access to phones, their influencing factors, and their influence on health care utilization. METHODS: Data drawn from the 2015 National Family Health Survey (NFHS) in India included a national sample of 45,231 women with data on phone access. Survey design weighted estimates of household phone ownership and women's access among different population sub-groups are presented. Multilevel logistic models explored the association of phone access with a wide range of maternal and child health indicators. Blinder-Oaxaca (BO) decomposition is used to decompose the gaps between women with and without phone access in health care utilization into components explained by background characteristics influencing phone access (endowments) and unexplained components (coefficients), potentially attributable to phone access itself. FINDINGS: Phone ownership at the household level was 92·8% (95% CI: 92·6-93·0%), with rural ownership at 91·1% (90·8-91·4%) and urban at 97.1% (96·7-97·3%). Women's access to phones was 47·8% (46·7-48·8%); 41·6% in rural areas (40·5-42·6%) and 62·7% (60·4-64·8%) in urban. Phone access in urban areas was positively associated with skilled birth attendance, postnatal care and use of modern contraceptives and negatively associated with early antenatal care. Phone access was not associated with improvements in utilization indicators in rural settings. Phone access (coefficient components) explained large gaps in the use of modern contraceptives, moderate gaps in postnatal care and early antenatal care, and smaller differences in the use of skilled birth attendance and immunization. For full antenatal car, phone access was associated with reducing gaps in utilization. INTERPRETATION: Women of reproductive age have significantly lower phone access use than the households they belong to and marginalized women have the least phone access. Existing phone access for rural women did not improve their health care utilization but was associated with greater utilization for urban women. Without addressing these biases, digital health programs may be at risk of worsening existing health inequities.

Does women's mobile phone ownership matter for health? Evidence from 15 countries.

Mobile phones have the potential to increase access to health information, improve patient-provider communication, and influence the content and quality of health services received. Evidence on the gender gap in ownership of mobile phones is limited, and efforts to link phone ownership among women to care-seeking and practices for reproductive maternal newborn and child health (RMNCH) have yet to be made. This analysis aims to assess household and women's access to phones and its effects on RMNCH health outcomes in 15 countries for which Demographic and Health Surveys data on phone ownership are available. Multilevel logistic regression models were used to explore factors associated with women's phone ownership, along with the association of phone ownership to a wide range of RMNCH indicators. Study findings suggest that (1) gender gaps in mobile phone ownership vary, but they can be substantial, with less than half of women owning mobile phones in several countries; (2) the gender gap in phone ownership is larger for rural and poorer women; (3) women's phone ownership is generally associated with better RMNCH indicators; (4) among women phone owners, utilisation of RMNCH care-seeking and practices differs based on their income status; and (5) more could be done to unleash the potential of mobile phones on women's health if data gaps and varied metrics are addressed. Findings reinforce the notion that without addressing the gender gap in phone ownership, digital health programmes may be at risk of worsening existing health inequities.

Antenatal care in rural Bangladesh: current state of costs, content and recommendations for effective service delivery.

BACKGROUND: Measurement of antenatal care (ANC) service coverage is often limited to the number of contacts or type of providers, reflecting a gap in the assessment of quality as well as cost estimations and health impact. The study aims to determine service subcomponents and provider and patient costs of ANC services and compares them between community (i.e. satellite clinics) and facility care (i.e. primary and secondary health centers) settings in rural Bangladesh. METHODS: Service contents and cost data were collected by one researcher and four interviewers in various community and facility health care settings in Gaibandha district between September and December 2016. We conducted structured interviews with organization managers, observational studies of ANC service provision (n = 70) for service contents and provider costs (service and drug costs) and exit interviews with pregnant women (n = 70) for patient costs (direct and indirect costs) in health clinics at community and facility levels. Fisher's exact tests were used to determine any different patient characteristics between community and facility settings. ANC service contents were assessed by 63 subitems categorized into 11 groups and compared within and across community and facility settings. Provider and patient costs were collected in Bangladesh taka and analyzed as 2016 US Dollars (0.013 exchange rate). RESULTS: We found generally similar provider and patient characteristics between the community and facility settings except in clients' gestational age. High compliance (> 50%) of service subcomponents were observed in blood pressure monitoring, weight measurement, iron and folate supplementation given, and tetanus vaccine, while lower compliance of service subcomponents (< 50%) were observed in some physical examinations such as edema and ultrasonogram and routine tests such as blood test and urine test. Average unit costs of ANC service provision were about double at the facility level ($2.75) compared with community-based care ($1.62). ANC patient costs at facilities ($2.66) were about three times higher than in the community ($0.78). CONCLUSION: The study reveals a delay in pregnant women's initial ANC care seeking, gaps in compliance of ANC subcomponents and difference of provider and patient costs between facility and community settings.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh.

OBJECTIVE: We examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group. METHODS: Both programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women's care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation. RESULTS: The addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19-81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh's GDP per capita. CONCLUSION: mHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

Lenses and levels: the why, what and how of measuring health system drivers of women's, children's and adolescents' health with a governance focus.

Health systems are critical for health outcomes as they underpin intervention coverage and quality, promote users' rights and intervene on the social determinants of health. Governance is essential for health system endeavours as it mobilises and coordinates a multiplicity of actors and interests to realise common goals. The inherently social, political and contextualised nature of governance, and health systems more broadly, has implications for measurement, including how the health of women, children and adolescents health is viewed and assessed, and for whom. Three common lenses, each with their own views of power dynamics in policy and programme implementation, include a service delivery lens aimed at scaling effective interventions, a societal lens oriented to empowering people with rights to effect change and a systems lens concerned with creating enabling environments for adaptive learning. We illustrate the implications of each lens for the why, what and how of measuring health system drivers across micro, meso and macro health systems levels, through three examples (digital health, maternal and perinatal death surveillance and review, and multisectoral action for adolescent health). Appreciating these underpinnings of measuring health systems and governance drivers of the health of women, children and adolescents is essential for a holistic learning and action agenda that engages a wider range of stakeholders, which includes, but also goes beyond, indicator-based measurement. Without a broadening of approaches to measurement and the types of research partnerships involved, continued investments in the health of women, children and adolescents will fall short.

Are stage-based health information messages effective and good value for money in improving maternal newborn and child health outcomes in India? Protocol for an individually randomized controlled trial.

BACKGROUND: Evidence is limited on the effectiveness of mobile health programs which provide stage-based health information messages to pregnant and postpartum women. Kilkari is an outbound service that delivers weekly, stage-based audio messages about pregnancy, childbirth, and childcare directly to families in 13 states across India on their mobile phones. In this protocol we outline methods for measuring the effectiveness and cost-effectiveness of Kilkari. METHODS: The study is an individually randomized controlled trial (iRCT) with a parallel, partially concurrent, and unblinded design. Five thousand pregnant women will be enrolled from four districts of Madhya Pradesh and randomized to an intervention or control arm. The women in the intervention arm will receive Kilkari messages while the control group will not receive any Kilkari messages as part of the study. Women in both arms will be followed from enrollment in the second and early third trimesters of pregnancy until one year after delivery. Differences in primary outcomes across study arms including early and exclusive breastfeeding and the adoption of modern contraception at 1 year postpartum will be assessed using intention to treat methodology. Surveys will be administered at baseline and endline containing modules on phone ownership, geographical and demographic characteristics, knowledge, practices, respectful maternity care, and coverage for antenatal care, delivery, and postnatal care. In-depth interviews and focus group discussions will be carried out to understand user perceptions of Kilkari, and more broadly, experiences providing phone numbers and personal health information to health care providers. Costs and consequences will be estimated from a societal perspective for the 2018-2019 analytic time horizon. DISCUSSION: Kilkari is the largest maternal messaging program, in terms of absolute numbers, currently being implemented globally. Evaluations of similar initiatives elsewhere have been small in scale and focused on summative outcomes, presenting limited evidence on individual exposure to content. Drawing upon system-generated data, we explore linkages between successful receipt of calls, user engagement with calls, and reported outcomes. This is the first study of its kind in India and is anticipated to provide the most robust and comprehensive evidence to date on maternal messaging programs globally. TRIAL REGISTRATION: Clinicaltrials.gov, 90075552, NCT03576157 . Registered on 22 June 2018.

Use of Big Data and Machine Learning Methods in the Monitoring and Evaluation of Digital Health Programs in India: An Exploratory Protocol.

BACKGROUND: Digital health programs, which encompass the subsectors of health information technology, mobile health, electronic health, telehealth, and telemedicine, have the potential to generate "big data." OBJECTIVE: Our aim is to evaluate two digital health programs in India-the maternal mobile messaging service (Kilkari) and the mobile training resource for frontline health workers (Mobile Academy). We illustrate possible applications of machine learning for public health practitioners that can be applied to generate evidence on program effectiveness and improve implementation. Kilkari is an outbound service that delivers weekly gestational age-appropriate audio messages about pregnancy, childbirth, and childcare directly to families on their mobile phones, starting from the second trimester of pregnancy until the child is one year old. Mobile Academy is an Interactive Voice Response audio training course for accredited social health activists (ASHAs) in India. METHODS: Study participants include pregnant and postpartum women (Kilkari) as well as frontline health workers (Mobile Academy) across 13 states in India. Data elements are drawn from system-generated databases used in the routine implementation of programs to provide users with health information. We explain the structure and elements of the extracted data and the proposed process for their linkage. We then outline the various steps to be undertaken to evaluate and select final algorithms for identifying gaps in data quality, poor user performance, predictors for call receipt, user listening levels, and linkages between early listening and continued engagement. RESULTS: The project has obtained the necessary approvals for the use of data in accordance with global standards for handling personal data. The results are expected to be published in August/September 2019. CONCLUSIONS: Rigorous evaluations of digital health programs are limited, and few have included applications of machine learning. By describing the steps to be undertaken in the application of machine learning approaches to the analysis of routine system-generated data, we aim to demystify the use of machine learning not only in evaluating digital health education programs but in improving their performance. Where articles on analysis offer an explanation of the final model selected, here we aim to emphasize the process, thereby illustrating to program implementors and evaluators with limited exposure to machine learning its relevance and potential use within the context of broader program implementation and evaluation. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11456.

Cost analysis and provider preferences of low-dose, high-frequency approach to in-service training programs in Uganda.

BACKGROUND: Many countries in sub-Saharan Africa still face significant challenges in maternal and child health where low numbers, uneven distribution, and training deficits of the health workforce impede quality care. Low-dose, high-frequency training (LDHF), an innovative approach to in-service training, focuses on competency, team-based repetitive learning and practice in the clinical setting. In Uganda, we conducted cost analyses of local organization LDHF training programs for Post-abortion care (PAC) and Pediatric HIV to assess cost drivers and cost efficiency and compare costs to traditional workshop based training. METHODS: We collected costs with bottom up, activity based costing in LDHF and workshop training programs. All costs reported from a programmatic perspective in US$2015 across a two year analytic time horizon. A survey of trained providers was conducted to understand costs and incentives of participation as well as experience and training preferences. FINDINGS: PAC training with the LDHF approach cost US$29 957 corresponding to US$936 per provider; the traditional training of the same content was delivered at a total US$10 551 corresponding to US$527 per provider. Pediatric HIV training with LDHF approach cost US$41 677 or US$631 per provider; traditional training of Pediatric HIV cost US$18 656 or US$888 per provider trained. In traditional training programs, costs to providers were nearly equal to incentives given. In LDHF training programs, financial incentives and costs to participate were not equal and varied by roles and programs; all district trainers' incentives outweighed their costs of participation, trainee incentives were higher than costs of participation in the PAC training, but in the Pediatric HIV program, trainee incentives were lower than the costs of participation. CONCLUSIONS: Local training programs differ widely in applying LDHF principles to design and implementation thus leading to variation in costs and cost-efficiency. LDHF can be more cost-efficient than workshop based trainings if programs take advantage of the wider scope of trainees available for the facility-based trainings. Incentive differences between district trainers and trainees may influence participation and perception of training. The perspectives of providers participating in LDHF or traditional workshop training should be integrated when developing future programs for maximum uptake and participation for in-service training.

Mobile Technology for Community Health in Ghana: Is Maternal Messaging and Provider Use of Technology Cost-Effective in Improving Maternal and Child Health Outcomes at Scale?

BACKGROUND: Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. OBJECTIVE: This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. METHODS: MOTECH's "Client Data Application" allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH's other main component, the "Mobile Midwife," sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. RESULTS: MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana's districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. CONCLUSIONS: This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health.

Can community action improve equity for maternal health and how does it do so? Research findings from Gujarat, India.

BACKGROUND: Efforts to work with civil society to strengthen community participation and action for health are particularly important in Gujarat, India, given that the state has resources and capacity, but faces challenges in ensuring that services reach those most in need. To contribute to the knowledge base on accountability and maternal health, this study examines the equity effects of community action for maternal health led by Non-Government Organizations (NGOs) on facility deliveries. It then examines the underlying implementation processes with implications for strengthening accountability of maternity care across three districts of Gujarat, India. Community action for maternal health entailed NGOs a) working with community collectives to raise awareness about maternal health entitlements, b) supporting community monitoring of outreach government services, and c) facilitating dialogue with government providers and authorities with report cards based on community monitoring of maternal health. METHODS: The study combined qualitative data (project documents and 56 stakeholder interviews thematically analyzed) with quantitative data (2395 women's self-reported receipt of information on entitlements and use of services over 3 years of implementation monitored prospectively through household visits). Multivariable logistic regression examined delivery care seeking and equity. RESULTS: In the marginalised districts, women reported substantial increases in receipt of information of entitlements and utilization of antenatal and delivery care. In the marginalized and wealthier districts, a switch from private facilities to public ones was observed for the most vulnerable. Supportive implementation factors included a) alignment among NGO organizational missions, b) participatory development of project tools, c) repeated capacity building and d) government interest in improving utilization and recognition of NGO contributions. Initial challenges included a) confidence and turnover of volunteers, b) complexity of the monitoring tool and c) scepticism from both communities and providers. CONCLUSION: With capacity and trust building, NGOs supporting community based collectives to monitor health services and engage with health providers and local authorities, over time overcame implementation challenges to strengthen public sector services. These accountability efforts resulted in improvements in utilisation of public sector services and a shift away from private care seeking, particularly for the marginalised.

Simulation-based low-dose, high-frequency plus mobile mentoring versus traditional group-based training approaches on day of birth care among maternal and newborn healthcare providers in Ebonyi and Kogi States, Nigeria; a randomized controlled trial.

BACKGROUND: There is limited information from low and middle-income countries on learning outcomes, provider satisfaction and cost-effectiveness on the day of birth care among maternal and newborn health workers trained using onsite simulation-based low-dose high frequency (LDHF) plus mentoring approach compared to the commonly employed offsite traditional group-based training (TRAD). The LDHF approach uses in-service learning updates to deliver information based on local needs during short, structured, onsite, interactive learning activities that involve the entire team and are spaced over time to optimize learning. The aim of this study will be to compare the effectiveness and cost of LDHF versus TRAD approaches in improving knowledge and skill in maternal and newborn care and to determine trainees' satisfaction with the approaches in Ebonyi and Kogi states, Nigeria. METHODS: This will be a prospective cluster randomized control trial. Sixty health facilities will be randomly assigned for day of birth care health providers training through either LDHF plus mobile mentoring (intervention arm) or TRAD (control arm). There will be 150 trainees in each arm. Multiple choices questionnaires (MCQs), objective structured clinical examinations (OSCEs), cost and satisfaction surveys will be administered before and after the trainings. Quantitative data collection will be done at months 0 (baseline), 3 and 12. Qualitative data will also be collected at 12-month from the LDHF arm only. Descriptive and inferential statistics will be used as appropriate. Composite scores will be computed for selected variables to determine areas where service providers have good skills as against areas where their skills are poor and to compare skills and knowledge outcomes between the two groups at 0.05 level of statistical significance. DISCUSSION: There is some evidence that LDHF, simulation and practice-based training approach plus mobile mentoring results in improved skills and health outcomes and is cost-effective. By comparing intervention and control arms the authors hope to replicate similar results, evaluate the approach in Nigeria and provide evidence to Ministry of Health on how and which training approach, frequency and setting will result in the greatest return on investment. TRIAL REGISTRATION: The trial was retrospectively registered on 24th August, 2017 at ClinicalTrials.Gov: NCT03269240 .

Program assessment of efforts to improve the quality of postpartum counselling in health centers in Morogoro region, Tanzania.

BACKGROUND: The postpartum period represents a critical window where many maternal and child deaths occur. We assess the quality of postpartum care (PPC) as well as efforts to improve service delivery through additional training and supervision in Health Centers (HCs) in Morogoro Region, Tanzania. METHODS: Program implementers purposively selected nine program HCs for assessment with another nine HCs in the region remaining as comparison sites in a non-randomized program evaluation. PPC quality was assessed by examining structural inputs; provider and client profiles; processes (PNC counselling) and outcomes (patient knowledge) through direct observations of equipment, supplies and infrastructure (n = 18) and PPC counselling (n = 45); client exit interviews (n = 41); a provider survey (n = 62); and in-depth provider interviews (n = 10). RESULTS: While physical infrastructure, equipment and supplies were comparable across study sites (with water and electricity limitations), program areas had better availability of drugs and commodities. Overall, provider availability was also similar across study sites, with 63% of HCs following staffing norms, 17% of Reproductive and Child Health (RCH) providers absent and 14% of those providing PPC being unqualified to do so. In the program area, a median of 4 of 10 RCH providers received training. Despite training and supervisory inputs to program area HCs, provider and client knowledge of PPC was low and the content of PPC counseling provided limited to 3 of 80 PPC messages in over half the consultations observed. Among women attending PPC, 29 (71%) had delivered in a health facility and sought care a median of 13 days after delivery. Barriers to PPC care seeking included perceptions that PPC was of limited benefit to women and was primarily about child health, geographic distance, gaps in the continuity of care, and harsh facility treatment. CONCLUSIONS: Program training and supervision activities had a modest effect on the quality of PPC. To achieve broader transformation in PPC quality, client perceptions about the value of PPC need to be changed; the content of recommended PPC messages reviewed along with the location for PPC services; gaps in the availability of human resources addressed; and increased provider-client contact encouraged.

Forecasting the Value for Money of Mobile Maternal Health Information Messages on Improving Utilization of Maternal and Child Health Services in Gauteng, South Africa: Cost-Effectiveness Analysis.

BACKGROUND: Limited evidence exists on the value for money of mHealth information programs in low resource settings. OBJECTIVE: This study sought to model the incremental cost-effectiveness of gradually scaling up text messaging services to pregnant women throughout Gauteng province, South Africa from 2012 to 2017. METHODS: Data collection occurred as part of a retrospective study in 6 health centers in Gauteng province. Stage-based short message service (SMS) text messages on maternal health were sent to pregnant women twice per week during pregnancy and continued until the infant's first birthday. Program costs, incremental costs to users, and the health system costs for these women were measured along with changes in the utilization of antenatal care visits and childhood immunizations and compared with those from a control group of pregnant women who received no SMS text messages. Incremental changes in utilization were entered into the Lives Saved Tool and used to forecast lives saved and disability adjusted life years (DALYs) averted by scaling up program activities over 5 years to reach 60% of pregnant women across Gauteng province. Uncertainty was characterized using one-way and probabilistic uncertainty analyses. RESULTS: Five-year program costs were estimated to be US $1.2 million, 17% of which were incurred by costs on program development and 31% on SMS text message delivery costs. Costs to users were US $1.66 to attend clinic-based services, nearly 90% of which was attributed to wages lost. Costs to the health system included provider time costs to register users (US $0.08) and to provide antenatal care (US $4.36) and postnatal care (US $3.08) services. Incremental costs per DALY averted from a societal perspective ranged from US $1985 in the first year of implementation to US $200 in the 5th year. At a willingness-to-pay threshold of US $2000, the project had a 40% probability of being cost-effective in year 1 versus 100% in all years thereafter. CONCLUSIONS: Study findings suggest that delivering SMS text messages on maternal health information to pregnant and postpartum women may be a cost-effective strategy for bolstering antenatal care and childhood immunizations, even at very small margins of coverage increases. Primary data obtained prospectively as part of more rigorous study designs are needed to validate modeled results.