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Research Note

Cost per insertion and couple year of protection for post-partum intrauterine devices and implants provided during service scale-up in Kigali, Rwanda

[version 1; peer review: 1 approved with reservations, 1 not approved]
PUBLISHED 31 Aug 2018
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Abstract

Introduction: In two high-volume government hospitals, their two affiliated health facilities, and two additional health facilities, we developed and implemented post-partum intrauterine device (PPIUD) and post-partum (PP) implant promotions and service delivery procedures between May and July 2017 in Kigali, Rwanda. Between August 2017 and July 2018, 9,073 pregnant women received PPIUD/PP implant promotions who later delivered in one of our selected facilities. Of those, 2,633 had PPIUDs inserted, and 955 had PP implants inserted.
Methods: Here, we detail the expenditures during the implementation from the payer perspective (including both the implementation costs and the cost of contraceptive methods) and estimate the cost per PPIUD insertion, PP implant insertion, and couple years of protection (CYP) for PPIUD and PP implant users. Research costs for formative work were excluded.
Results: A total of $74,147 USD was spent on the implementation between August 2017 and July 2018. The largest expense (34% of total expenses) went toward personnel, including doctoral-level, administrative, data management and nurse counseling staff. Training for PPIUD and implant providers and promoters comprised 8% of total expenses. Recruitment and reimbursements comprised 6% of expenses. Costs of implants to the government comprised 12% of the expenses, much higher than the cost of IUDs (1%). Costs per insertion were $25/PPIUDs and $77/PP implant. Costs per CYP were $5/PPIUDs and $20/PP implant.
Conclusion: The PPIUD/PP implant service implementation provided services at a low cost per insertion and CYP. Understanding the cost per PPIUD/PP implant inserted and CYP can help to inform the cost of scaling up PPIUD/PP implant service implementation activities and resource allocation decision-making by the Rwandan Ministry of Health.

Keywords

Couple year of protection, post-partum, intrauterine device, contraceptive implant, Rwanda

Introduction

Voluntary family planning (FP) is one of the most cost-effective public health interventions, reducing both maternal and child mortality and improving national economies1. However, there is high unmet need for family planning in the developing world. In post-partum periods, 50–90% of women experience unmet need2, while 95% of women desire to avoid pregnancy for at least 1 year after delivery3. In Rwanda, although only 2% of post-partum women report a desire for another child within 2 years of delivery, the unmet need in the post-partum period is 51%4.

To meet women’s post-partum fertility goals and improve maternal-child health via birth spacing or limiting5, the Rwandan government has made post-partum family planning a key objective of the Rwandan Family Planning 2020 Commitment (Objective 2: ‘Scale up the post-partum family planning (PPFP) in all health facilities in Rwanda to increase method choice including access to long term methods…’) with the goal of preventing 250,000 unintended pregnancies annually6.

Long-acting reversible contraceptive (LARC) methods (the copper intrauterine device (IUD) and hormonal implant) are not only the most effective reversible methods (lasting 10 and 3–5 years, respectively, with typical use failure rates <1%/year), but are very cost-effective7. A post-partum IUD (PPIUD) can be inserted immediately after delivery of the placenta, during a cesarean delivery, up to 48 hours after childbirth, or beginning at 4 weeks after delivery8,9 (https://www.mcsprogram.org/resource/pathway-of-opportunities-for-postpartum-women-to-adopt-family-planning/). A post-partum (PP) implant can be inserted any time after delivery (https://www.mcsprogram.org/resource/pathway-of-opportunities-for-postpartum-women-to-adopt-family-planning/). However, IUDs and implants make up a relatively small share of method use in Rwanda (http://www.familyplanning2020.org/entities/81).

To address this issue, funding from a Bill and Melinda Gates Grand Challenge Award was received to improve PPIUD supply and demand in Kigali, Rwanda, with supplementary funding from Emory University to provide PP implant services. Briefly, in two large health centers (providing antenatal care (ANC), family planning, and infant vaccination services), their two adjoining referral hospitals (providing routine and complex labor and delivery), and two additional large health centers (providing ANC, family planning, routine labor and delivery, and infant vaccination services), Emory-based non-governmental organization Projet San Francisco (PSF) developed and implemented PPIUD and PP implant promotions and service delivery procedures in August 2017. By July 2018, 9,073 pregnant women received PPIUD/PP implant promotions who later delivered in one of our selected facilities. Of those, 2,633 had PPIUDs inserted, and 955 had PP implants inserted. This represented a significant increase in PPIUD and PP implant uptake versus the 6 months prior to our implementation (p<0.001)10. Here, we detail expenditures during the implementation and estimate the cost per PPIUD insertion, PP implant insertion, and couple years of protection (CYP) for PPIUD and PP implant users to inform decision-making by the Ministry of Health and to estimate the cost of scaling up activities.

Methods

Ethical considerations and consent

The Emory University Institutional Review Board (IRB) and the Rwanda National Ethics Committee (RNEC) approved the research component (focus group discussions and surveys) of the project (IRB 00001497). Written informed consent was obtained from all participants prior to enrollment. The Emory University IRB determined the programmatic service delivery component of the project (PPIUD promotions and insertions performed in government clinics) was exempt from review.

PPIUD/PP Implant program development and operations

The PPIUD/PP implant intervention (described in detail previously10) was developed with input from stakeholders, providers, community health workers (CHW), and couples/clients. Stakeholders included the Rwanda Ministry of Health, the District Mayors, the Rwandan Family Planning Technical Working Group, and clinic directors. Through formative work between May and July 2017, we evaluated knowledge, attitudes, and practices regarding PPIUD/PP implant services among community health workers and providers and clients/couples. This formative work led to the development of intervention operational procedures and a promotional flipchart to be delivered to women or couples. Promotions were conducted primarily by counselors during ANC, labor and delivery, and infant vaccination services or within the community by CHW. In August of 2017, nurses and midwives working in labor and delivery and family planning departments began training in PPIUD insertions (implant insertion training had been previously provided). Clinic staff and CHWs were trained to promote the PPIUD/PP implant services. Follow-up appointments for PPIUD clients were between 10 days and 6 weeks after PPIUD insertion.

PPIUD/PP implant program costs

We used a standard, comprehensive micro-costing approach as recommended11 to calculate the net cost of the PPIUD/PP implant intervention from the payer perspective. Using standardized data collection tools, resource use data was collected from expenditure records, study case report forms, and interviews with program implementers.

Part-time salaries and fringe were provided for three Emory researchers and the PSF Director. PSF-based personnel included a dedicated physician with part-time support from two project physicians, two study coordinators, a senior nurse counselor, a data manager, and two promotions managers. Per diems were provided for trainees during training activities. Training costs included the costs of training providers to insert PPIUDs during a 2-day didactic training and mentored practical certification process, and the costs of training PPIUD/PP implant promotional agents. Field travel included travel for Emory-based researchers and transportation for local staff. Other field expenses included wire transfer fees, transcription and translation services, and meals during trainings. Recruitment/reimbursement expenses began in February/March 2018 and included: PPIUD client transport reimbursement for follow-up visits ($2.29 United States Dollars [USD]/client), reimbursements for CHW promoters ($0.57 USD/client presenting their referral when requesting a PPIUD or PP implant), reimbursements for providers ($1.20 USD/PPIUD and $0.57 USD/PP implant insertion), and reimbursements to the selected facilities for administrative costs associated with implementing the PPIUD/PP implant program ($57 USD/facility/month). CHW and clinic provider reimbursements used the Rwandan performance-based-financing (PBF) system as a guide12. Communications expenses included internet and phone airtime for staff. Field consumables/office supplies included specula, forceps, batteries, logbooks, chargers for tablets, PPIUD kits and various office supplies.

We also included the cost of methods (estimated from the prices incurred by the United Nations Population Fund (UNFPA) in 2015 of $0.37 USD per copper T380 IUD and $8.93 USD per Jadelle levonorgestrel rod implant (http://mshpriceguide.org/en/home/), and converted to 2018 USD ($0.39 and $9.49 USD, respectively). Expenditures are reported by activity in 2018 USD.

Only implementation costs related to service provision were included (i.e., we did not include research costs for formative work conducted between May and July 2017). Thus, the expenses presented represent the frontline implementation costs required to implement the program between August 2017 and July 2018 from the payer’s perspective. No discounting of costs was performed given the short time horizon. We follow the Consolidated Health Economic Evaluation Reporting Standards11.

PPIUD/PP implant program outcomes

Outcomes of interest include the number of PPIUDs and PP implants inserted and the cumulative couple years of protection (CYP) for PPIUD and PP implant users. CYP is a commonly used estimate of the length of contraceptive protection against pregnancy provided per unit of that method and is estimated at 4.6 for the Copper T380 IUD and 3.8 CYP for Jadelle (5 year) implant13 (https://www.usaid.gov/what-we-do/global-health/family-planning/couple-years-protection-cyp). Using the cost measures and outcomes of interest, we calculated the cost per PPIUD inserted, cost per PP implant inserted, cost per CYP for PPIUD users, and cost per CYP for PP implant users. No discounting of outcomes was performed given the short time horizon of the 12-month implementation.

Results

Raw data for this study are available in Dataset 114.

PPIUD/PP implant program costs

Program costs are summarized in Table 1. A total of $74,147 USD was spent on the implementation between August 2017 and July 2018. The largest expense (34% of total expenses) went toward personnel, including doctoral-level (MD and PhD) researchers, and administrative, data management and nurse counseling staff. Trainings for PPIUD and implant promoters and PPIUD providers comprised 8% of total expenses. Recruitment and reimbursements comprised 6% of expenses. Costs of implants to the government comprised 12% of the expenses, much higher than the cost of IUDs (1%).

Table 1. Allocation of costs for the PPIUD/PP implant implementation by activity (August 2017–July 2018).

Only direct costs included; all costs in 2018 USD.

Costs incurred by implementation
team
USDPercentage
of total
Salaries and fringe: PSF and clinic staff$25,05134%
Salaries and fringe: Emory employees$14,225 19%
Trainings$6,099 8%
Field travel$5,363 7%
Other field expenses$5,820 8%
Recruitment/reimbursement$4,510 6%
Communication$1,427 2%
Field consumables/office supplies$1,129 2%
Field facilities$433 1%
Cost of methods
Cost of implants*$9,063 12%
Cost of IUDs*$1,027 1%
Total Expenses$74,147

*$0.39/IUD and $9.49/implant (2018 USD). PPIUD, post-partum intrauterine device; PP, post-partum, IUD, intrauterine device; USD, United States Dollars.

PPIUD/PP implant program outcomes

Program outcomes are summarized in Table 2. Costs per insertion were $25/PPIUDs and $77/PP implant. Costs per CYP were $5/PPIUDs and $20/PP implant.

Table 2. Outcomes of interest for the PPIUD/PP implant implementation (August 2017–July 2018).

All costs in 2018 USD.

IUD outcomesValue
PPIUDs inserted (N)2,633
Cumulative CYP for PPIUD users*12,112
Cost per PPIUD inserted$25
Cost per CYP for PPIUD users$5
Implant outcomes
PP Implants inserted (N)955
Cumulative CYP for PP implant users*3,629
Cost per PP implant inserted$77
Cost per CYP for PP implant users$20

*Assumes CYP for IUD is 4.6 and for the Jadelle implant is 3.8. PPIUD, post-partum intrauterine device; PP, post-partum; CYP, couple years of protection; USD, United States Dollars.

Discussion

The PPIUD/PP implant implementation provided services at a low cost per insertion and CYP. Understanding the cost per PPIUD/PP implant inserted can help to inform decision-making by the Ministry of Health and to estimate the cost of scaling up PPIUD/PP implant service implementation activities. Since cost per CYP is a standard and commonly used measure, our estimates of cost of CYP also help the government to determine contraception funding priorities.

For comparison, in a previous study conducted in Rwanda, 478 PPIUDs were inserted over 15 months in 12 sites at an incremental cost of $95,004 USD. After amortization of training costs over three years, investigators estimated outcomes of $110/PPIUD inserted and $24/CYP for the PPIUD15.

Several other studies have made estimates of method cost per CYP, though not specifically in post-partum periods. The World Bank estimated that the cost per CYP for reversible modern methods in Ethiopia, Uganda, Burkina Faso, and Cameroon was lowest for the IUD ($4.14-$23.35), while the costs per CYP for oral contraceptive pills (OCPs) ($17.00-$31.45) and implants and injectables ($19.84-$58.54) were much higher16. Using data from 13 USAID tier one priority reproductive health countries and service delivery costs, researchers estimated that the cost per CYP was <$2.00 for the IUD and roughly $4.00 for Sino-Implant, $7.00 for DMPA and OCPs, and $8.00 for Jadelle17. Finally, a study in Zambia estimated costs per CYP were $8.69 for the IUD and $15.15 for the implant18.

Although it is difficult to compare estimates of cost per CYP across studies because of different approaches to measuring and including costs, these studies all indicate that the IUD has the lowest cost per CYP versus other reversible methods, and that estimated costs per CYP are consistency higher for the implant versus the IUD, largely because of difference in commodity costs (http://mshpriceguide.org/en/home/).

Limitations

Similar to the other studies cited here, we included costs from the payer perspective only; however, we recognize that more detailed costing analyses including the societal perspective would be informative and would likely strengthen evidence to increase LARC services (since women are saved time traveling to clinic for OCP refills or 3-monthly injectables). It would have also been informative to estimate the cost per promotional method employed (e.g., promotions occurring during ANC, labor and delivery, infant vaccination, or delivered in the community by CHW), but as many women received multiple promotions from several places and our promotional strategies evolved over time, this was not possible in the present study. Given our short time horizon, we did not amortize our training costs as in another PPIUD/PP implant in Rwanda15, though the education provided during trainings may translate into service provision over several years in the future; amortization would have decreased our estimated costs per insertion and CYP. Finally, our results are most generalizable to sub-Saharan African countries.

Conclusions

There is consensus in the international community that greater investment in postpartum family planning, and the IUD in particular, is needed. We have developed a successful, multi-level intervention that increases PPIUD and PP implant uptake that has low costs per insertion and CYP. Future analyses will explore whether the intervention is cost-effective (or potentially cost-saving).

Data availability

Underlying data are available from Harvard Dataverse. Dataset 1: Replication Data for an interim evaluation of a multi-level intervention to improve post-partum intrauterine device (PPIUD) services in Rwanda (https://doi.org/10.7910/DVN/WLZ7PC)14.

Data are available under a Creative Commons Zero (“CC0”) Public Domain Dedication Waiver.

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Wall KM, Ingabire R, Allen S and Karita E. Cost per insertion and couple year of protection for post-partum intrauterine devices and implants provided during service scale-up in Kigali, Rwanda [version 1; peer review: 1 approved with reservations, 1 not approved]. Gates Open Res 2018, 2:39 (https://doi.org/10.12688/gatesopenres.12858.1)
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Version 4
VERSION 4 PUBLISHED 31 Aug 2018
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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