PMID- 26413788 OWN - NLM STAT- MEDLINE DCOM- 20160530 LR - 20220331 IS - 1932-6203 (Electronic) IS - 1932-6203 (Linking) VI - 10 IP - 9 DP - 2015 TI - Improving Maternal Care through a State-Wide Health Insurance Program: A Cost and Cost-Effectiveness Study in Rural Nigeria. PG - e0139048 LID - 10.1371/journal.pone.0139048 [doi] LID - e0139048 AB - BACKGROUND: While the Nigerian government has made progress towards the Millennium Development Goals, further investments are needed to achieve the targets of post-2015 Sustainable Development Goals, including Universal Health Coverage. Economic evaluations of innovative interventions can help inform investment decisions in resource-constrained settings. We aim to assess the cost and cost-effectiveness of maternal care provided within the new Kwara State Health Insurance program (KSHI) in rural Nigeria. METHODS AND FINDINGS: We used a decision analytic model to simulate a cohort of pregnant women. The primary outcome is the incremental cost effectiveness ratio (ICER) of the KSHI scenario compared to the current standard of care. Intervention cost from a healthcare provider perspective included service delivery costs and above-service level costs; these were evaluated in a participating hospital and using financial records from the managing organisations, respectively. Standard of care costs from a provider perspective were derived from the literature using an ingredient approach. We generated 95% credibility intervals around the primary outcome through probabilistic sensitivity analysis (PSA) based on a Monte Carlo simulation. We conducted one-way sensitivity analyses across key model parameters and assessed the sensitivity of our results to the performance of the base case separately through a scenario analysis. Finally, we assessed the sustainability and feasibility of this program's scale up within the State's healthcare financing structure through a budget impact analysis. The KSHI scenario results in a health benefit to patients at a higher cost compared to the base case. The mean ICER (US$46.4/disability-adjusted life year averted) is considered very cost-effective compared to a willingness-to-pay threshold of one gross domestic product per capita (Nigeria, US$ 2012, 2,730). Our conclusion was robust to uncertainty in parameters estimates (PSA: median US$49.1, 95% credible interval 21.9-152.3), during one-way sensitivity analyses, and when cost, quality, cost and utilization parameters of the base case scenario were changed. The sustainability of this program's scale up by the State is dependent on further investments in healthcare. CONCLUSIONS: This study provides evidence that the investment made by the KSHI program in rural Nigeria is likely to have been cost-effective; however, further healthcare investments are needed for this program to be successfully expanded within Kwara State. Policy makers should consider supporting financial initiatives to reduce maternal mortality tackling both supply and demand issues in the access to care. FAU - Gomez, Gabriela B AU - Gomez GB AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom. FAU - Foster, Nicola AU - Foster N AD - Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa. FAU - Brals, Daniella AU - Brals D AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - Nelissen, Heleen E AU - Nelissen HE AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - Bolarinwa, Oladimeji A AU - Bolarinwa OA AD - Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria. FAU - Hendriks, Marleen E AU - Hendriks ME AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - Boers, Alexander C AU - Boers AC AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - van Eck, Diederik AU - van Eck D AD - Pharmaccess Foundation, Amsterdam, The Netherlands. FAU - Rosendaal, Nicole AU - Rosendaal N AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - Adenusi, Peju AU - Adenusi P AD - Hygeia Nigeria Ltd, Lagos, Nigeria. FAU - Agbede, Kayode AU - Agbede K AD - Ogo Oluwa Hospital, Bacita, Kwara State, Nigeria. FAU - Akande, Tanimola M AU - Akande TM AD - Department of Epidemiology and Community Health, University of Ilorin Teaching Hospital, Ilorin, Nigeria. FAU - Boele van Hensbroek, Michael AU - Boele van Hensbroek M AD - Global Child Health Group, Emma Children's Hospital AMC, Amsterdam, The Netherlands. FAU - Wit, Ferdinand W AU - Wit FW AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. FAU - Hankins, Catherine A AU - Hankins CA AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom. FAU - Schultsz, Constance AU - Schultsz C AD - Department of Global Health/Amsterdam Institute for Global Health and Development, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. LA - eng PT - Journal Article PT - Research Support, Non-U.S. Gov't DEP - 20150928 PL - United States TA - PLoS One JT - PloS one JID - 101285081 SB - IM MH - Budgets MH - Cohort Studies MH - *Cost-Benefit Analysis MH - Female MH - Health Services/economics/statistics & numerical data MH - Hospitals MH - Humans MH - Insurance, Health/*economics MH - Maternal Health/*economics MH - Nigeria MH - Pregnancy MH - *Rural Population PMC - PMC4587550 COIS- Competing Interests: The authors have the following interests. This study was funded by the Health Insurance Fund. Dr. Peju Adenusi (PA) is the CEO of Hygeia Community Health Care (HCHC), part of Hygeia Nigeria Ltd, a healthcare provider in Nigeria. HCHC is a beneficiary of the Health Insurance Fund and the implementing partner through which the subsidised health insurance scheme is marketed and offered locally. Diederik van Eck (DVE) is an actuarial analyst at PharmAccess Foundation. PharmAccess Foundation is a not-for-profit foundation, a beneficiary of the Health Insurance Fund, and the provider of technical assistance including program development and management oversight for the insurance activities in Nigeria. All other authors have declared that they have no competing interests. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors. EDAT- 2015/09/29 06:00 MHDA- 2016/05/31 06:00 PMCR- 2015/09/28 CRDT- 2015/09/29 06:00 PHST- 2015/03/12 00:00 [received] PHST- 2015/09/07 00:00 [accepted] PHST- 2015/09/29 06:00 [entrez] PHST- 2015/09/29 06:00 [pubmed] PHST- 2016/05/31 06:00 [medline] PHST- 2015/09/28 00:00 [pmc-release] AID - PONE-D-15-10767 [pii] AID - 10.1371/journal.pone.0139048 [doi] PST - epublish SO - PLoS One. 2015 Sep 28;10(9):e0139048. doi: 10.1371/journal.pone.0139048. eCollection 2015.