Cost-Effectiveness of Interventions
This section summarizes the costs and health benefits of strategies to address conditions that are specific to women and conditions that affect women disproportionately. Table 10.5 presents cost-effectiveness estimates for recognized effective interventions.
[Table .]
Conditions Specific to Women
Conditions specific to women include the cluster of diseases related to women's maternal function plus chlamydia (which is predominantly but not exclusively a female disease) and female-specific cancers.
Maternal Conditions
The analysis developed in chapter 26 uses a model for maternal and perinatal conditions that generates 128 potential scenarios. According to the findings of this theoretical exercise, the cost per DALY averted of mother and baby packages could vary from US$77 to US$151 in Sub-Saharan Africa and from US$143 to US$278 in South Asia, depending on the complexity of the intervention.
Prenatal care prevents almost a quarter of maternal deaths, especially when backed by essential and emergency obstetric care to deal with conditions detected during the course of pregnancy care. Good prenatal care includes information, education, and communication activities and behavior-change communication to increase women's skills in relation to the identification of danger signs and potential complications and where to seek care in these cases (Dayaratna and others 2000). In Uganda, for example, integral prenatal care ranged from US$2.26 (public services) to US$6.43 (religious mission services) per pregnant woman per year (Levin and others 1999).
Another important service is supplementation with iron and folic acid. Iron deficiency accounts for 1.8 percent of women's deaths and 2.6 percent of female DALY losses. Iron and folic acid supplements administered to highly anemic pregnant women can save lives at a cost of US$13 per DALY averted (Berman and others 1991), demonstrating that this intervention is very cost-effective.
Good maternal health services can strengthen the entire health system. A health facility that is equipped to provide essential obstetric care can also treat accidents, trauma, and other medical emergencies. The costs of emergency obstetric care vary depending on the country. In Uganda, costs per episode vary from US$73 (public hospital) to US$86 (mission hospital) (Levin and others 1999). In Bolivia, the cost of a cesarean section ranges from US$56 to US$104 (Rosenthal and Percy 1991), and the cost of a normal delivery varies from US$11 to US$16 (Dmytraczenko and others 1998).
In developing countries, 61 percent of maternal deaths occur 23 to 48 hours after delivery because of such problems as postpartum hemorrhage and hypertensive disorders or after 48 hours because of sepsis. Complications from unsafe abortions account for 13 percent of maternal deaths, though this figure is probably an underestimate because of the scarcity of data. Little information is available on costs related to postnatal care given the different kind of interventions and the severity of cases, but the literature generally agrees that emergency obstetric care can reduce costs. As concerns postabortion care, costs per case in LMICs could vary from US$4.40 to US$17.19 (Dayaratna and others 2000).
Millions of premature deaths, illnesses, and injuries could be avoided by helping women prevent unwanted pregnancies and obtain prompt treatment for reproductive health problems. The contraception costs per couple-year of protection could vary, depending on the method used, from US$6 (intrauterine device) to US$20 (condoms or injections) (Dayaratna and others 2000). A 1999 experiment by the Planned Parenthood Association of South Africa considered total health planning costs per couple-year of protection, including travel expenses to health clinics. Comparing these costs with total health planning costs in services provided by community-based doctors, the study found that the former cost US$44 per couple-year of protection and the latter cost US$42.
Chlamydia
Although not specific to women, chlamydia is nine times more prevalent among women than among men, and its consequences and treatment are much more complicated and severe for women, affecting women's and infants' health during pregnancy and the postnatal period. Chlamydia is widespread in low-income countries. Chlamydia, as well as other sexually transmitted diseases, could be prevented by using condoms, with an average cost per DALY averted in developing countries estimated at US$3.40 in noncore target groups and US$12.60 in core target groups (Mumford and others 1998). Detecting chlamydia in pregnant women could cost $4.38 per case, with treatment, at $3.82 per case, being less expensive than detection (Shultz, Schulte and Berman 1992). Chlamydia's adverse effects are trachoma (chronic conjunctivitis, endemic in Africa and Asia), reproductive tract infections, genital ulcer disease in tropical countries, and infertility. The cost of each adverse outcome averted varies from about US$85 to US$308 (Shultz, Schulte, and Berman 1992).
Neoplasms
Cancers specific to women are responsible for high levels of female morbidity and mortality, with cervical cancer being one of the most important. Recommended strategies involve early detection and treatment. The following are the main strategies to prevent cervical cancer:
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screening and treatment performed during the same visit
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screening and treatment performed at two separate visits
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traditional three-visit intervention, in which a cytology sample is obtained during the first visit, a diagnostic colposcopy is performed for those who screened positive during the second visit, and treatment is provided at the third visit.
The data on costs associated with cervical cancer detection and treatment in developing countries are limited. In Honduras in 1991, costs per visit for cervical cancer detection varied from US$5.60 (small clinics) to US$12.90 (larger clinics) (Mumford and others 1998). Lower detection costs were found in Ecuador in 1996 (US$2.95 to US$3.51 per visit) and in Zimbabwe in 1995 (US$3.00 to US$3.90 per visit). Recent studies on cervical cancer screening in South Africa show that the two-visit method is more cost-effective than the traditional three-visit method, US$39 per DALY averted compared with US$81 (Goldie and others 2001). Studies in Vietnam found costs equivalent to US$725 per DALY averted with cytology screening (Suba and others 2001).
Regarding treatment of cervical cancer, Rose and Lappas's (2000) studies in developed countries find costs varying from US$2,384 to US$28,770 per DALY averted. Costs are lower in developing countries, ranging from US$52.51 to US$432.42 per visit in Mexico and from US$12.35 to US$95.82 per visit in Zimbabwe. Differences in treatment costs are associated with the kinds of procedures used. How the results of cost-effectiveness studies for cervical cancer prevention and screening interventions in developed countries might translate to health care delivery settings in developing countries is not clear, but prevention could clearly play an important role.
Many studies of breast cancer prevention view diet as an important condition explaining the predisposition for breast cancer. Ministries of health in many developing countries invest in promotion and prevention, issuing communications and guidelines for early detection using self-testing as a cost-effective way to provide information. Few studies of the cost-effectiveness of different breast cancer treatments are available, especially in developing countries. One on the management of breast cancer in Brazil in 1995 showed extremely high costs of US$1,678 per death averted (Arredondo, Lockett, and Icaza 1995).
Conditions That Affect Women Disproportionately
Few studies on shared diseases that affect women disproportionately include gender-related considerations, especially in developing countries. Most literature on Alzheimer's disease, unipolar depressive disorders, and osteoarthritis presented in this section is based on studies in developed countries with no specific analysis of gender differences in relation to cost-effectiveness.
Alzheimer's Disease and Other Dementias
Alzheimer's disease is linked to genetic and other risk factors, including increasing age, positive family history of dementia, and lower levels of education. Treatment is based mostly on drugs, and the practical benefits of treatment translate mainly into reduced caregiver hours.
Some studies have found that interventions aimed at reducing caregiver stress, even providing low-dose antipsychotic medication, can be effective. However, the costs of undertaking such interventions have not been quantified; thus, their cost-effectiveness cannot be calculated. Institutional care for patients with any form of dementia is extremely limited in LMICs. The costs of setting up institutions for those with Alzheimer's disease and the costs of care are prohibitive. In this context, inexpensive, home-based care appears to be the only viable option for Alzheimer's disease patients in developing countries. These countries will therefore have to face the challenges of addressing families' needs in relation to financial and social support and caregiver training. Another issue is the tradeoff between women's income-earning opportunities and their traditional primary role as family caregivers.
Unipolar Depressive Disorders
Depression is among the most disabling and costly illnesses in the world, especially for women. Despite good short-term treatment outcomes, long-term outcomes remain disappointing. Costs associated with depression affect not just the sufferers themselves, but also their families and friends (time dedicated to caregiving); employers (payment for treatment and care, as well as for reduced productivity); and society (provision of mental health care financed by taxpayers). Most of these costs are difficult to obtain, but the consensus is that the indirect costs of depression are larger than the direct costs.
The treatment setting for depression is usually primary health care, with many kinds of episodic treatments combining old and new generations of antidepressants and psychosocial procedures. Averting depressive episodes results in average gains of up to 50 disability days per treated case per year. Studies of the factors influencing women's access to screening, prevention, and treatment for depression and the cost-effectiveness of treatment options should be a priority in developing countries.
Osteoarthritis
Despite clear evidence of a reduction in symptoms and delayed progression of osteoarthritis with weight reduction, no formal studies of cost-effectiveness are available. Education and exercise programs for osteoarthritis are available in developed countries, but such programs are unknown in developing countries. Studies of the effect of diet and physical exercise in preventing osteoarthritis in women are a priority not just in developed countries, but especially in developing countries with fiscally strapped health systems and growing elderly populations.
Acetaminophen is thought to be the most cost-effective initial treatment with drugs. In addition, some cost-effectiveness measures of using several kinds of medicines (acetaminophen, naproxen, misoprostol, celecoxib, and rofecoxib) under different conditions are available. Sigal (2002) shows that by using different combinations of medicines, treatment costs can vary from US$2,001 to US$2,140 per quality-adjusted life year, but these costs are prohibitive for developing countries.
Another treatment for osteoarthritis is synovial fluid replacement, but given the costs of this intervention, it is not currently recommended for developing regions. Surgical interventions for osteoarthritis, such as joint replacement, sare most commonly performed in developed countries. Sigal and others (2004) review a number of interventions for osteoarthritis and suggest a cost per quality-adjusted life year of US$6,000 for knee replacements. In developing countries, however, the availability of surgical interventions is constrained by its costs and by the availability of surgeons qualified to perform the operation.
