Discusión de limitantes de incertidumbres y alcances del estudio

Provider cost was calculated for four hospitals, three of which offered comprehensive EMOC. Because of security concerns, the theatre at RW was closed outside daytime hours. Both the total (6,241.87 USD) and the average cost (111.46 USD) of CS at RW were lower than at the other hospitals.

The average cost per CS at the evaluated level of service provision for the three round-the- clock providers was 171.58 USD for HGR, 200.00USD for CME and 144.17 USD for BM. CS cost estimates using a comparable method found similar provider costs in other developing countries. (161)

The annual cost of providing EMOCS, as measured by the total cost of performing CSs was 14,069.97 USD for HGR, 11,600.17 USD for CME and 103,514.22 USD for BM. The cost calculations excluded international travel and housing cost for foreign employees. The actual expenditure of the NGO managing BM, and of the Christian church groups supporting CME, can therefore not be imputed from the calculations in this study. It is notable that the total annual cost of performing CSs at BM in 2008 was more than seven times (7.3) the amount estimated for HGR and almost nine times (8.9) the estimated EMOC expenditure for CME during the same year.

Sensitivity analysis looked at the effect of a proportional change in workload on cost. With maternity bed-occupancy by EMOC patients only available for BM, the first analysis used the available figure of 60% for BM, and assumed three in-patient days for non-surgical and six days for surgical deliveries in the other hospitals.

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The sensitivity analysis assumed two in-patient days for non-surgical and six in-patient days for surgical patients in all four hospitals (Table 3.3.6). For BM, the second analysis resulted in a cost reduction by 11.9%. For HGR there was a slight increase in cost by 1.2%. For CME, the cost increased by 5.8%. The difference was largest for RW, with the cost of CS increasing by 14%. It can therefore be concluded that the first calculations for BM did not under-estimate the cost of EMOC in comparison to the other hospitals in the study. An estimated 718 women received EMOC at BM in 2008. Assuming that all CSs were performed to avoid maternal or foetal death, the cost per expected healthy life year (HALE) gained ranged between 3.77 USD and 9.17 USD. The highest cost estimate was based on the lowest estimated number of maternal and perinatal deaths avoided.

Studies expressing the cost-effectiveness ratio (CER) in HALE are less common than those using disability adjusted life years (DALY). HALE was used as a composite measure without further discounting. Although DALY and HALE are not directly comparable, a study in Ghana found that DALY was usually valued higher in childhood than HALE, and that the difference between the two indices was relatively small for communicable, maternal and perinatal conditions. (162)

As the denominator in this CEA included both maternal and neonatal lives, a change in estimated HALE of either group would influence the CER. The HALE estimate at birth was taken from the WHO Statistical Information System (WHOSIS).(163) The life tables used for these estimates started from a systematic review of all available evidence on levels and trends in child and adult mortality. (164) To make information comparable between UN member states, population and mortality data were informed by assessments from WHO, UNICEF, and the UN Population Division. The tables took account of trends in child mortality and of the magnitude of the effect of HIV in countries with a substantial epidemic.

WHOSIS mentions the lack of reliable data on morbidity and mortality, especially from low- income countries, (such as the DR Congo) as a limiting factor. Since the literature provided no HALE estimate for 24-year old women, this figure was derived by interpolation between HALE at birth and HALE at age 60. While the validity of this procedure is open for debate, maternal survival accounts for a small fraction of HALE in the equation.

The estimated perinatal death rate in Bunia at the time of the study was based on recorded stillbirths and early neonatal deaths in all health structures providing some EMOC.

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Some perinatal deaths were reported by other health facilities. To include these in the numerator, the denominator would have to include all deliveries in health centres. This would have resulted in a lower estimated perinatal death rate.

Since the cause of perinatal death was often difficult to determine, the assumption that the difference between the observed and the expected rate was due to CSs performed in the context of humanitarian assistance cannot be confirmed. However, since there was no evidence of provider-or-user preference, the indication for CS would have been maternal, foetal, or possibly both. Global estimates of intrapartum stillbirths and intrapartum-related neonatal deaths suggest that these account for 23% of neonatal deaths, and are responsible for 10% of deaths in children under five years of age. (165) The probability of dying under five in the DR Congo was 205/1000 in 2006.xxxvii In the CER, the estimated number of perinatal deaths avoided was 237. As mentioned before, 25% of CSs in the study sample were performed because of foetal distress, or included foetal distress as an indication. Out of an expected total of 958 CSs in 2008, the number of CSs for foetal distress would have been 239.

With the closing down of BM in the transition from relief to development, the workload at other hospitals was bound to increase. To provide care for the additional number of patients at the Government Hospital, HGR, and at the Mission Hospital, CME, resources would need to be scaled up. The incremental cost for these hospitals was modelled to reflect an increase to four CSs per week at HGR and three per week at CME. The required additional investment for one year was estimated at 11,371.33 USD at HGR and 14,359.12 USD at CME. The average cost of performing one CS would drop to 122.31 USD at HGR and to 166.41 USD at CME. At this rate, the two hospitals combined would cover one third of the expected additional number of patients needing EMOC.

The incremental cost calculations relied on unconfirmed assumptions with regard to additional staff needs. Following the recommendation of a former head nurse in a Belgian hospital, a maximum of seven surgical patients was assumed for one nurse during one shift. In 1997, MSF estimated that, in refugee camp situations, one nurse would be able to take care of 20 patients during an eight-hour shift. (166) However, health facilities set up in refugee camps usually rely on the nearest referral hospital for major surgery and EMOC.

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Fourteen nurses (13 general nurses and one midwife) worked in the BM maternity at the time of the study. Assuming 60% of their time was allocated to EMOC (14x0.6) = 8.4 nurses were needed to take full-time care of 14 surgical beds. If one nurse works on average two days out of three, this would mean 5.6 nurses on duty for eight hours each, or 1.9 nurses for each shift. The staff employment in BM was close to the estimate of one nurse for seven patients.

The additional staff needs in the calculations were relatively small (one full-time nurse for CME, two for HGR), with 55.7% of one monthly salary of 161USD added for CME and 15% of two salaries of 120 USD for HGR. The study was unable to establish whether nursing staff already employed at CME and HGR had spare time while on duty.

In cost-effectiveness analysis, interventions costing less than 100 USD/year gained are sometimes described as highly cost-effective. (167) Some health economists argue that setting a threshold is not possible, because of the interaction between cost-effectiveness, burden of disease and available funds.(168) The Commission on Macroeconomics and Health recommended the use of Gross Domestic Product (GDP) as an indicator. Interventions costing less than the GDP per capita were qualified as highly cost-effective.xxxviii In either case, the results of the study suggest that EMOCS were a cost-effective part of humanitarian assistance in Bunia. The observed effectiveness of CS was similar to international standards and the average cost per CS at BM was in the same range as estimates for the other hospitals in the area.

Cost estimates did not cover expenses specific to employment of expatriate staff such as international travel and housing. The investment required from national and developmental sources to completely take over EMOCS provision at the 2008 level would therefore approximate the annual cost of EMOC at BM. At the time of the study, CME relied on user fees and international charity, while HGR received developmental assistance from the EC in addition to user fees. It seems unlikely that either hospital would be able to rapidly scale up its budget for EMOC to the 2008 level of BM.

In countries recovering from violent conflict, there are many difficulties with continued funding of healthcare. In areas such as maternal and childcare, the withdrawal of emergency relief organizations will leave unfulfilled needs unless other providers take over service provision.

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Examples of delays in transitional funding abound. In 2005, two years after the end of the second Liberia war, USAID and OFDA co-hosted a workshop aiming to harmonise the US Government’s health programmes in Liberia in order to promote the best possible transition from emergency assistance to health development. Maternal and child health (MCH) was identified as one of five priority areas. Priority interventions for MCH were the “establishment and re-invigoration” of referral centres, together with training of health workers. (169) In June 2010, MSF, an emergency–oriented international NGO, handed over its last two hospitals in Liberia to the Ministry of Health. (170)

Next best use of resources

Strengthening PHC

The emergency-only policy implied that BM did not perform first line PHC activities, including ante- and postnatal care, or uncomplicated deliveries. In spite of this, 1214 vaginal deliveries took place at BM during the study period of six months. The majority were women who arrived at the hospital in an advanced stage of labour. Reasons for choosing BM as the place to deliver were free services and good quality of care.

At the time of the study, changes in the national health policy were being implemented, defining the functions to be performed at different levels of care. Activities at health centres concentrated on preventive and first line curative action, as well as normal deliveries, with referral of complications to the hospital. The NGO managing BM was also active in training local health workers.

Using the same life-expectancy estimates, according to the WHO standard package, implementing the full mother-baby package including EMOC would cost (525,650/9556) = 55USD per expected healthy year of life gained. Investing in improving ANC and perinatal interventions at health centres and in the community would have been a less cost-effective short-term strategy.xxxix

The additional cost of providing more comprehensive maternal and neonatal healthcare, as described in the WHO “Mother-Baby Package” could not be estimated during the study period. Improving the capacity of health centres, in addition to the provision of EMOC, is a long-term challenge. (171)

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PHC services at health centres would need to be strengthened further to increase the coverage of antenatal care, including the cost-effective screening tests proposed by WHO (CHOICE). Laboratory tests and subsequent treatment if needed would have to be available and affordable. Increased use of family planning would require long-term changes in the attitude of providers and users. Strategies to influence those changes exceed the usual activities of humanitarian action.

Strengthening existing referral services

The violent conflict in Ituri is historically rooted in ethnic differences. Politico-military allegiances and economic power reflect this ethnic division. The NGO managing BM abandoned an initial attempt at strengthening the existing public hospital, partly because of problems with equity of access. (172) Faith-based organisations working in healthcare had been co-opted into the public health system. They followed the national health policy regulations, though organisations applied their own rules on fee exemption for destitute patients. Especially in the context of ethnic violence, judgements concerning beneficiaries may be biased.(173) None of the faith-based service providers had the capacity to expand services quickly, in order to accommodate the increasing number of patients during the peak of the conflict in 2003.

Setting up an emergency hospital in parallel to existing services made it possible to provide free healthcare without modifying the health system, which was based on cost-sharing and cost recovery. It also allowed equitable access in a context of severe ethnic tension.

During and after the conflict, international donors supported government health structures with structural maintenance, equipment and supplies, as well as with staff incentives. In 2007, WHO obtained financing from the Central Emergency Relief Fund (CERF) to refurbish the theatre at HGR and to conduct staff training in sterilisation techniques. Meanwhile, plans were made for the closure of BM, with a handover of services to other health structures. The options for increasing coverage of EMOC beyond the urban area are twofold: establishing EMOCS in rural hospitals, or increasing access to existing services in the town area. The first option was being put into practice, with limited success, due to a shortage of skilled health workers willing to live in the rural areas.

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The possibility of creating waiting mothers’ shelters in the town had not been considered. A World Bank publication claims that an increase in institutional deliveries with reduction of maternal mortality has been found in several countries, for example in Cuba, where the maternal mortality ratio reportedly fell from 118 to 31/100,000 as a result of maternity waiting homes. (174)

According to Congolese criminal law, induced abortion was illegal at the time of the study. (175) The UN listed the DRC among countries where abortion is permitted to save the life of the woman, specifying that “the abortion laws in these countries do not expressly allow abortions to be performed to save the life of the woman, but general principles of criminal legislation allow abortions to be performed for this reason on the ground of necessity.” (176) The same UN source estimated the use of modern contraceptive methods at 4%.xl

Mortality related to unsafe abortion is highest in Africa, with an estimated ratio of 110 deaths per 100,000 live births. (177) While advocating human rights is an important part of humanitarian action, the legal framework would have to be clarified before advocating safe induced abortion at HGR. In the faith-based health facilities CME and RW, induced abortion was prohibited on religious grounds.