Bolivia programme evaluation of a package to reach an underserved population: Community-based maternal and newborn care economic analysis

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Study Justification:
The study aimed to address the inequitable access to health services for indigenous communities in the Bolivian highlands. It focused on evaluating a package of maternal and newborn interventions using locally recruited, volunteer Community Health Workers (vCHWs). The study aimed to assess the economic impact of the intervention and provide insights into alternative models to improve access to care.
Highlights:
– The study identified and tested a package of maternal and newborn interventions using vCHWs in two municipalities in Bolivia.
– It estimated the additional economic and financial costs of the intervention from the perspective of the Bolivian Ministry of Health.
– The study analyzed the cost of intervention-stimulated increases in facility attendance using national surveillance data.
– Three scale-up scenarios were modeled to explore potential efficiency gains and improve access to care.
– The evaluation raised important questions about the effectiveness of the model in reducing neonatal mortality and inequalities.
Recommendations:
– Increase coverage of vCHWs to reach a higher percentage of expectant mothers in the catchment area.
– Improve intervention design to reduce costs and increase efficiency.
– Strengthen management and support by the local implementing partner to enhance the effectiveness of the intervention.
– Explore innovative alternative models to address stagnant inequitable access to care.
Key Role Players:
– Bolivian Ministry of Health
– Save the Children-Saving Newborn Lives
– Local implementing partner
– Community Health Workers (vCHWs)
Cost Items for Planning Recommendations:
– Intervention design costs
– Set-up costs
– Implementation costs
– Additional paid staff costs (management and support)
– vCHW supervision costs
– Annual financial cost per vCHW
Please note that the cost items provided are for budget planning purposes and not the actual costs.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides detailed information on the Bolivian program evaluation, including the methodology, costs, and outcomes. However, the abstract does not mention specific data sources or statistical analysis methods used, which could be improved. To strengthen the evidence, the authors could include more information on the sample size, data collection methods, and statistical significance of the findings. Additionally, providing references to previous research or similar programs could further support the study’s conclusions.

To address inequitable access to health services of indigenous communities in the Bolivian highlands, the Bolivian Ministry of Health, with the support of Save the Children-Saving Newborn Lives, conducted operational research to identify, implement and test a package of maternal and newborn interventions using locally recruited, volunteer Community Health Workers (vCHW) between 2008 and 2010. The additional annual economic and financial costs of the intervention were estimated from the perspective of the Bolivian Ministry of Health in two municipalities. The cost of interventionstimulated increases in facility attendance was estimated with national surveillance data using a pre-post comparison, adjusted for secular trends in facility attendance. Three scale-up scenarios were modelled by varying the levels of coverage and the number (per mother and child pair) and frequency of home visits. Average cost per mother and average cost per home visit are presented in constant 2015US$. Eighteen per cent of expectant mothers in the catchment area were visited at least once. The annualized additional financial cost of the community-based intervention across both municipalities was $43 449 of which 3% ($1324) was intervention design, 20% ($8474) set-up and 77% ($33 651) implementation. Drivers of additional costs were additional paid staff (68%), 81% of which was for management and support by local implementing partner and 19% of which was for vCHWsupervision. The annual financial cost per vCHW was $595. Modelled scale-up scenarios highlight potential efficiency gains. Recognizing local imperatives to reduce inequalities by targeting underserved populations, the observed low coverage by vCHWs resulted in a high cost per mother and child pair ($296). This evaluation raises important questions about this model’s ability to achieve its ultimate goals of reducing neonatal mortality and inequalities through behaviour change and increased care seeking and has served to inform innovative alternative models, better equipped to tackle stagnant inequitable access to care.

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Based on the evaluation of the Bolivia program, here are some innovations that can be considered to improve access to maternal health in underserved populations:

1. Targeted Approach: Develop interventions that specifically address the unique needs and barriers faced by the underserved population. This could involve tailoring services to address geographical remoteness, cultural beliefs, language barriers, and financial constraints.

2. Community Engagement: Engage the local community in the design and implementation of interventions. This ensures that the solutions are culturally appropriate, acceptable, and sustainable. Community leaders, traditional birth attendants, and local healthcare providers can be involved to build trust and increase utilization of services.

3. Technology and Telemedicine: Explore the use of technology and telemedicine to overcome geographical barriers. This could include mobile health applications, teleconsultations, and remote monitoring of maternal health indicators. Technology can bridge the gap between the community and healthcare facilities, enabling timely access to care and reducing costs.

4. Task Shifting and Training: Empower local healthcare providers, such as midwives and nurses, to provide comprehensive maternal health services. This can address the shortage of skilled healthcare professionals in underserved areas and improve access to quality care.

5. Financial Sustainability: Develop sustainable financing models to ensure the availability and affordability of maternal health services. This could involve public-private partnerships, health insurance schemes, or innovative financing mechanisms to support service provision.

6. Monitoring and Evaluation: Implement robust monitoring and evaluation systems to assess the impact and effectiveness of interventions. Regular data collection and analysis will help identify areas for improvement and guide future interventions.

By implementing these innovations, it is possible to develop more efficient and effective approaches to improve access to maternal health in underserved populations.
AI Innovations Description
Based on the description provided, the recommendation to improve access to maternal health in underserved populations is to develop innovative alternative models that are better equipped to tackle stagnant inequitable access to care. The evaluation of the Bolivia program highlighted the challenges and limitations of the community-based intervention using volunteer Community Health Workers (vCHWs). The low coverage by vCHWs resulted in a high cost per mother and child pair, indicating the need for more efficient and effective approaches.

To develop an innovation, it is important to consider the following:

1. Targeted Approach: Identify the specific needs and barriers faced by the underserved population in accessing maternal health services. This could include factors such as geographical remoteness, cultural beliefs, language barriers, and financial constraints.

2. Community Engagement: Involve the local community in the design and implementation of the intervention. This ensures that the solution is culturally appropriate, acceptable, and sustainable. Engaging community leaders, traditional birth attendants, and local healthcare providers can help build trust and increase utilization of services.

3. Technology and Telemedicine: Explore the use of technology and telemedicine to overcome geographical barriers. This could include mobile health applications, teleconsultations, and remote monitoring of maternal health indicators. Technology can help bridge the gap between the community and healthcare facilities, enabling timely access to care and reducing costs.

4. Task Shifting and Training: Consider task shifting by training and empowering local healthcare providers, such as midwives and nurses, to provide comprehensive maternal health services. This can help address the shortage of skilled healthcare professionals in underserved areas and improve access to quality care.

5. Financial Sustainability: Develop a sustainable financing model that ensures the availability and affordability of maternal health services. This could involve exploring public-private partnerships, health insurance schemes, or innovative financing mechanisms to support the provision of services.

6. Monitoring and Evaluation: Implement a robust monitoring and evaluation system to assess the impact and effectiveness of the innovation. Regular data collection and analysis will help identify areas for improvement and guide future interventions.

By implementing these recommendations, it is possible to develop innovative models that can effectively improve access to maternal health services in underserved populations.
AI Innovations Methodology
To simulate the impact of the main recommendations mentioned in the abstract on improving access to maternal health, a methodology could be developed as follows:

1. Define the target population: Identify the specific underserved population that the intervention aims to reach. This could include indigenous communities in the Bolivian highlands.

2. Data collection: Gather data on the current access to maternal health services in the target population. This could include information on facility attendance, utilization rates, barriers to access, and health outcomes.

3. Develop a simulation model: Create a simulation model that incorporates the main recommendations mentioned in the abstract. This model should consider factors such as targeted approaches, community engagement, technology and telemedicine, task shifting and training, financial sustainability, and monitoring and evaluation.

4. Input data and assumptions: Input the collected data and make assumptions about the potential impact of each recommendation on improving access to maternal health. This could include assumptions about the percentage increase in facility attendance, the reduction in geographical barriers through technology, the increase in skilled healthcare providers through task shifting, and the financial implications of implementing the recommendations.

5. Run the simulation: Use the simulation model to run different scenarios based on varying levels of coverage, frequency of home visits, and other relevant parameters. This will help assess the potential impact of the recommendations on access to maternal health services.

6. Analyze the results: Analyze the simulation results to determine the potential improvements in access to maternal health services. This could include evaluating changes in facility attendance, cost per mother and child pair, and other relevant indicators.

7. Sensitivity analysis: Conduct sensitivity analysis to test the robustness of the simulation results. This involves varying the input parameters and assumptions to assess the impact on the outcomes.

8. Interpretation and recommendations: Interpret the simulation results and provide recommendations based on the findings. This could include identifying the most effective recommendations and potential areas for further improvement.

By following this methodology, it is possible to simulate the impact of the main recommendations mentioned in the abstract on improving access to maternal health in the target population. This can help inform decision-making and guide the development of innovative models that are better equipped to address inequitable access to care.

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