Cost analysis of a training course to improve antenatal Care in Kenya, Tanzania and Nigeria

Principal investigator: Viviana Mangiaterra, Aleksandra Torbica (CERGAS)

Team UB/Cergas: Carlo Federici, Aleksandra Torbica, Viviana Mangiaterra

Partners: Liverpool School of Tropical Medicine (LSTM) – UK

Sponsor: Global Fund (GF)

Duration: Jan 2023- Jan 2024

Abstract:
Antenatal care (ANC) and post-natal care (PNC) have long served as effective platforms for providing a range of HIV, tuberculosis (TB), and Malaria health services, which can reduce the risk of complications during pregnancy and childbirth, resulting in improved health outcomes. In the last quarter of 2022. In Kenya, Tanzania, and Nigeria a series of training sessions were delivered to health care workers (HCWs) with the aim to improve the quality of integrated HIV, TB, and malaria services in ANC/PNC. The training was conducted in the Dodoma and Zanzibar regions of the Republic of Tanzania; Garissa, Uasin Gishu and Vihiga counties in Kenya and the Oyo state in Nigeria using a blended learning (BL) approach and including 52 essential practices for reproductive, maternal, new-born and child health (RMNCH). Compared to more traditional Face-2-Face (F2F) approaches, the BL approach substitutes some of the frontal hours of training with remote learning modules. This report presents the results of analysis made to evaluate the cost of the ANC and PNC training intervention and the consequences in terms of improved delivery of care services.

A cost-consequence analysis was conducted reporting the costs of designing and implementing the training package as well as its impact on routinely collected quality indicators for ANC and PNC care. An ingredient approach was used to calculate the full economic cost of designing and implementing the intervention. Both the perspectives of the implementers of the training and the costs of the recipients of the course were considered. The cost analysis was carried out in a subsample of facilities receiving the training in Dodoma and Zanzibar (Tanzania), Vihiga (Kenya) and Oyo (Nigeria). The costs of a previously implemented F2F training in Vihiga (Kenya) and Oyo (Nigeria) was also estimated for comparison with the BL approach. All costs were converted from local currencies to 2021 USD rate. The analysis of the impact of the BL training on quality of care indicators was carried out only for Kenya. Data on ANC quality indicators were derived from the Kenya Aggregated Health Information  System (KHIS) which contained monthly data at the facility level on several ANC/PNC indicators. A synthetic control approach, using data from intervention and control facilities from the same counties, was adopted to estimate the potential impact of the training on 14 indicators related to HIV, TB, and Malaria services as well as other ANC quality indicators.

The total cost of designing the BL training package was estimated at USD 21,261, mostly determined by labour costs for the design of course contents and for coordinating meetings for the roll-out of the BL training.  The cost per participant of deploying the training varied between USD 624 in Kenya and USD 1,267 in Zanzibar (Tanzania), mostly due to the different number of participants attending the F2F component of the training and the different share of fixed costs apportioned to each participant. By December 2022, 13 Facilities had reached 80% training saturation in Kenya’s selected intervention counties and were included in the intervention group, whereas 223 facilities from the same counties were included in the control group. In total, 30 healthcare workers received the training. At 6 months after implementation, no significant impact was observed for any of the care indicators considered. Notably, only indicators for HIV and partly for Malaria and Syphilis were available from the KHIS, whereas no indicators were found for TB care during ANC or PNC.

Training is an essential component for ensuring quality of care. Its costs are not negligible and require careful planning and adequate financial allocation. A sub-group analysis limited to only 13 healthcare facilities in Kenya did not find clear evidence on the impact of a BL approach on the quality of care for HIV, TB, Malaria, and Syphilis during ANC. Further research based on more granular and fit-for-purpose data may contribute to providing additional evidence on the impact of these kinds of training on quality of care and ultimately on final health outcomes.