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Synthesis results
ASSESSING THE COST-EFFECTIVENESS OF SKIN BARRIER ENHANCING EMOLLIENTS
The second study looked at the cost-effectiveness of skin barrier enhancing
emollients in Bangladesh (Le Fevre et al., 2010) (++)/(+). Unlike the previous study,
this is an economic evaluation conducted retrospectively alongside a randomised
controlled trial that is also included in our systematic review (Darmstadt et al.,
2008) (++)/(++). It is a well-designed study, also scoring well on the two economic
evaluation checklists.
The clinical trial compared the use of sunflower seed oil (SSO) or a synthetic skin
emollient called Aquaphor against no treatment in order to assess impact on the risk
of sepsis and mortality for low birthweight babies at a tertiary hospital in Dhaka.
The study highlighted the very good cost-effectiveness of both interventions,
compared to other published estimates of cost effective interventions; moreover it
also looked at budgetary impact, assuming that it might be difficult for the health
care system to fund these interventions.
A detailed breakdown of the costs of providing the intervention, including separate
identification of start-up and implementation costs was provided. In total for a 20bed
facility at the hospital start-up and implementation costs came to $1,833.32.
Costs per infant treated at the hospital by either of the two interventions or
receiving standard care were also provided: on average, costs for SSO were $99.47
compared with $125.35 for Aquaphor and $93.39 for controls receiving usual care.
The economic analysis then reported the incremental cost per Year of Life Lost (YLL)
averted between the different intervention groups.
The study found that both sunflower seed oil and Aquaphor were highly cost
effective in reducing mortality. But Aquaphor was relatively much more expensive –
the cost per Year of Life Lost (YLL) averted for Aquaphor was $5.74 compared to do
nothing; cost per YLL averted for SSO versus do nothing was $2.15; incremental cost
per YLL using Aquaphor compared with SSO was $20.74. A similar study was
conducted by the same author in Egypt (Darmstadt et al., 2004) (+)/(+) which paved
the way for the implementation of this larger scale cost-effectiveness study.
All of these estimates of cost-effectiveness make good comparison with other
potential cost effective interventions highlighted in the World Bank’s Disease Control
Priorities Project (Musgrove and Fox-Rushby, 2006). Investment in these skin-barrier
enhancing emollients appears more cost effective than all of the interventions in a
South Asian context. They also make good comparison with the work of the WHO
Choosing Interventions that are Cost Effective (WHO-CHOICE) Programme, where
cost-effective interventions in South Asia range from $6 per DALY averted for
support for breast feeding to reach 50 percent coverage to $16,930 per DALY averted
for a comprehensive package of maternal and infant care at 95 percent coverage
(World Health Organization, 2011a). It should, however, be noted that this latter
analysis does not take distributional issues into account, so a direct comparison of
cost-effectiveness for interventions targeted at the urban poor is not possible. Nor
does it look at the impact on costs beyond the health sector.
Cost effective interventions can sometimes be expensive; importantly, this study
also looks at the costs of obtaining the two interventions. Given the low likelihood of
public funding in the short term in Bangladesh, the use of sunflower seed oil (albeit
not as effective as Aquaphor) is likely to be more sustainable as treatments costs are
at a level that is much more affordable to people in Bangladesh paying out of pocket
for medicine – $1.55 per month compared with $29 per month for Aquaphor (the
average monthly salary is $39). There is a strong case, however, for public funding of
Aquaphor, given the highly favourable cost-effectiveness ratio.
What are the effects of different models of delivery for improving maternal and infant health
outcomes for poor people in urban areas in low income and lower middle income countries? 43