4. Cost–Effective Strategies for the Excess Burden of Disease in Developing Countries

An intense effort by the government of Indonesia to increase the number of births attended by skilled health providers began in 1993 with the introduction of three-year nursing training followed by a year of training in midwifery. From 1996, this was supplemented by a further package of training interventions, including an in-service course; a supervisory system with peer review and continuing education; a maternal and perinatal audit system; and an information, education, and communication strategy aimed at the community.

Data were collected in three districts of South Kalimantan from 1996, before and after the additional package of training, which permitted measurement of its added value. Before the additional training, 90 percent of births took place at home and only 37 percent were attended by a skilled attendant. By 1998-99, 510 midwives were posted in the districts and skilled attendants at delivery had increased to 59 percent. The training package allowed the midwives to gain confidence and skills in the management of obstetric complications, but despite this, the proportion of women admitted to a hospital for a cesarean section declined from 1.7 percent to 1.4 percent. The proportion admitted to hospital with a complication requiring a life-saving intervention also declined from 1.1 percent to 0.7 percent (Ronsmans and others 2001). Significantly more of the midwives who had participated in the training programs were competent in five key skills than those who had not participated.

Walker and others (2002) undertook an economic analysis of the training programs, distinguishing between those programs run for facilities-based midwives and those run for village-based midwives, which included residential internship at district hospitals. They assessed the incremental cost-effectiveness of these programs from the standpoint of the health care provider. Walker and others estimated that the first scheme could be expanded to increase the number of competent midwives based in facilities and villages in South Kalimantan by 1 percent at incremental costs of US$765 and US$1,176, respectively. Replication in other regions would cost between 50 and 60 percent extra.

Source: Authors.