Costing of community maternal and child health interventions : a review of the literature with applications for conducting cost-effectiveness studies and for advocacy

An introduction discusses the importance of community-level costing, showing that community interventions are a cost-effective means of reaching otherwise unreachable groups. Next, the report reviews costing methodologies that have been used for MCH in general, identifying three major categories of studies: those using predictive costing; those using actual costing; and cost-effective analyses, which can be used for either of the first two types. The report then briefly presents the community component of the Integrated Management of Childhood Illnesses (IMCI), including a description of the research in progress on the costing of the community component. The review shows clearly that community-based interventions can be cost-effective in delivering essential MCH services and can reach groups that are typically beyond the reach of formal health care systems. Such interventions also raise the demand for and use of facility-based services, benefits that are not easily measurable in the context of cost-effectiveness studies. In sub-Saharan Africa, community interventions are complementary to, and not in competition with, fixed health care systems, adding value and results to facility-based health care. Very few rigorous cost-effectiveness studies of community interventions have been done to date in sub-Saharan Africa. Additional studies are an important research priority. In general, such studies should be kept simple and easily interpretable. It is important to count all pertinent costs, including capital costs and indirect costs such as management, supervision, and administration. Once these indirect costs are known, it is important to find an appropriate method to allocate them to the services ultimately provided. A simplified version of activity-based costing (ABC), based on interviews or observation of staff time, is likely to be the most practical alternative. It is also important to ensure that the relevant benefits of these interventions are included, such as demand creation and improvements in preventive health practices. For both planning and advocacy purposes, the results of community- level costing studies should be presented in a straightforward and easily understandable manner. Start-up costs and capital costs, to be funded by donors, should be separated from recurrent costs, which are often assumed by ministries of health or by the communities themselves.