Cost-Effectiveness Analysis of Emergency Obstetric Services in a Crisis Environment Thesis submitted in accordance with the requirements of The University of Liverpool For the degree of Doctor in Philosophy by Danielle J.E. Deboutte April 2011 TABLE OF CONTENTS Abstract i Acknowledgments iii Acronyms ...............................................................................................................................iv List of Figures and Tables......................................................................................................vi List of Annexes....................................................................................................................viii Preface...................................................................................................................................ix Chapter 1: Background 1.1. History 2 1.2. Humanitarian assistance and healthcare 5 1.3. The health system in the DRC 7 1.4. Health Services in Bunia, Ituri 9 1.5. Standards and evaluation of humanitarian practice 12 1.6. Evaluation of Emergency Obstetric Care 18 Chapter 2: Methodology 2.1. Research environment 22 2.2. Research Question 24 2.3. Analysis 35 2.4. Reporting 37 2.5. Constraints 37 Chapter 3: Results 3.1. Case- control questionnaires 42 3.2. Effectiveness 76 3.3. Cost of caesarean section 94 3.4. Focus groups 105 Chapter 4: Discussion 4.1. Design and purpose 115 4.2. Caesarean section as an indicator of EMOC 118 4.3. Impact of EMOC as part of humanitarian assistance 131 4.4. Economic analysis 134 4.5. Humanitarian assistance and demand for healthcare 140 4.6. Funding EMOCs during transition and recovery 143 Chapter 5: Conclusions 150 References 155 Annexes 186 Cost –Effectiveness Analysis of Emergency Obstetric Services in a Crisis Environment by Danielle J.E. Deboutte ABSTRACT The study investigated the cost-effectiveness of caesarean section (CS) as the major component of Emergency Obstetric Care (EMOC) in a humanitarian context. Research was conducted from December 2007 until June 2008 in Bunia, in the north- east of the Democratic Republic of Congo. Methods A case-control study explored the factors determining whether a woman had a CS or a vaginal delivery. Cases (n=178) were randomly selected from women who had delivered by CS. Controls (n=180) were women who had delivered vaginally within two weeks of a case and were matched by place of residency. Face-to face interviews in the local language used a structured questionnaire about obstetric and socio- economic factors. Obstetric care was assessed during repeat visits to health structures using checklists. Provider cost of CS was calculated for four hospitals, of which one provided free emergency healthcare. Information about cost allocation to CS was collected from hospital managers, maternity staff, and administrators. Costs were verified with local entrepreneurs, international organisations and UN agencies. The social cost of maternal death was discussed in focus groups, which also obtained user cost information additional to the data from the case-control study. Results CS constituted 9.7% of expected deliveries in the Bunia Health Zone. During the study period, the humanitarian hospital performed 75% of all CS. There were no elective CSs in the study sample. The study found no evidence of obstetric surgery for non-medical reasons. Previous CS and prolonged labour during this delivery were the strongest predictive factors for CS. The risk increased with age of the mother and decreased with the number of children alive. i Fifteen obstetric deaths were reported to the research team, three among them were women who had a CS. After adjusting the observed number for missed pregnancy- related and late post-partum deaths, the estimated number of maternal deaths avoided by humanitarian EMOC, compared to expected mortality without additional services, ranged from 20 to 228. Compared to recent estimates for the DRC, perinatal deaths avoided ranged from 237 to 453. Cost-effectiveness was expressed as cost per year of healthy life expectancy (HALE) gained. The estimated cost of adding one year of HALE by providing CSs in a humanitarian context ranged from 3.77 USD to 9.17 USD. Comparison of the cost of EMOC and the social cost of maternal death was complicated by the existence of local customs such as “sororate”. The user capacity to pay for health insurance was found to be low. Conclusion Caesarean sections as part of humanitarian assistance were cost-effective. To keep EMOC accessible during and following the transition from emergency relief to development, a change in the national financing policy for health services is advisable. ii Acknowledgements This study would not have been possible without the people in Bunia. Special thanks to Doctors Nancy and Philip Wood for their kind and practical collaboration, including the team selection. I owe much gratitude to the members of the research team, who carried out the bulk of the investigations: Sarah Kive-Dhelo, Jeanne Espérance Losi, Mamy Awa Chango, Eugénie Drabusi and Rebecca Undehoso. I also thank the following people I met in Bunia for their personal assistance: Professor Ahuka Longombe and the management team at CME; The MSF hospital team; The staff at Rwankole hospital; The director and staff at the General Referral Hospital; Dr Dana and Ted Witmer and the staff and students of USB; The staff and students of ISPASC; The organisers and participants of the focus groups, including local religious leaders; The FARDC liaison officer with MONUC; The MONUC staff of the political affairs department; Costas Koskias, the manager of MONUC House; Brian Lewis and the demining team; Charlotte Sung Yu Yan. With regard to the design and analysis of the study, I would like to thank Dr Gillian Mann, Dr Antonieta Medina Lara, Dr Jo Borghi, Professor Charles Normand and Professor Stavros Petrou for their advice on health economics, and Dr Nynke Van den Broek for suggestions regarding research on maternal healthcare. Special thanks to Dr Tim O’Dempsey and Dr Brian Faragher, my supervisors, for guiding me through the process. Finally, the encouragement of my children Simcha and Shani, the friendly assistance of Mark Winstanley and the generous support from Lady Jane Willoughby are gratefully acknowledged. In memory of my mother iii LIST OF ACRONYMS ALNAP Active Learning Network for Accountability and Performance in Humanitarian Action ANC Antenatal Care BM Bon Marché (hospital) CEA Cost-effectiveness analysis CME Evangelical Medical Centre (Centre Médical Evangélique) CONADER National Commission for disarmament, demobilisation and reintegration CS Caesarean section CSs Caesarean sections DAC Development Assistance Committee DRC Democratic Republic of the Congo DDR Disarmament, demobilization, and reintegration DDRRR Disarmament, Demobilisation, Repatriation, Rehabilitation & Reintegration DFID Department for International Development (UK bilateral assistance) EC European Commission ECHO European Commission Humanitarian Office EDF European Development Fund EMOC Emergency Obstetric Care EMOCS Emergency Obstetric Care Services ERD Evaluative Reports Database FARDC Forces Armées de la République Démocrtatique du Congo (Congolese national army) FED European Development Fund (French acronym) FNI Front for National Integration FRPI Patriotic Front of Resistance in Ituri GDP Gross Domestic Product GHD Good Humanitarian Donorship HeRAMS Health Resources Availability Mapping System HGR General Referral Hospital (Hôpital Général de Référnce) HIV Human Immuno-deficiency Virus HNTS Health and Nutrition Tracking System IASC Inter-Agency Standing Committee ICD Inter-Congolese Dialogue IDP Internally Displaced Person IEC Information Education Communication INS National Institute for Statistics (Institut National de Statistiques) IPC Ituri Pacification Commission IRIN Integrated Regional Information Network ISPASC Institut Supérieur Pan-Africain de Santé Communautaire MISP Minimum Initial Service Package MLC Movement for the Liberation of Congo MONUC French acronym for the United Nations Mission in Congo MONUSCO United Nations Stabilisation Mission in Congo MRC Congolese Revolutionary Movement NGO non-Governmental Organization OCHA Office of the Coordinator for Humanitarian Affairs iv ODI Overseas Development Institute OECD Organization for Economic Cooperation and Development OFDA Office of US Foreign Disaster Assistance (USAID) PHC Primary Healthcare RCD Rally for Congolese Democracy (Rassemblement Congolais pour la Démocratie) RCD-ML Rassemblement Congolais pour la Démocratie- Mouvement de Libération RCD-N Rassemblement Congolais pour la Démocratie- Nationale RPF Rwanda Patriotic Front RTE Real-time Evaluation RW Rwankole hospital SMART Standardized Monitoring and Assessment of Relief and Transitions TEC Tsunami Evaluation Coalition UN United Nations UNDP United Nations Development Programme UNEG United Nations Evaluation Group UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children’s Fund UPDF Uganda People’s Defence Force USAID United Stated Agency for International Development USB Shalom University Bunia (Université Shalom de Bunia) WHO World Health Organization v LIST OF FIGURES Fig 1.1 Administrative map of the DR Congo Fig 1.2 Administrative map of Ituri Fig 1.3 Needs Assessment Framework (NAF) Fig 2.1 Map of Bunia Town Fig 4.1 Study design and resulting information Fig 4.2 Partograph Fig 4.3 Range of bridewealth amount paid by ethnic group Fig 5.1 UN phases of security LIST OF TABLES