Saving lives, saving costs Investment Case for

Benefits for the health sector

Mother and Child Health

Community Health Workers (CHWs) have provided health care to South African communities for decades, assuming a variety of roles and performing a number of tasks focused on health promotion and disease prevention. CHWs are particularly important in rural and remote populations with limited access to healthcare. They can play a crucial role in throughout pregnancy, the postnatal period and early childhood, saving the lives and improving the health of young children and their families.
Mortality of children under the age of five years is one of the most important public health challenges in South Africa. Every year, an estimated 40,000 children die before their fifth birthday. The under-five mortality rate (U5MR) has declined in the last decade but it remains unacceptably high at 42 deaths per 1,000 live births, according to the 2016 South Africa Demographic & Health Survey. As progress has been made reducing deaths from HIV/AIDS and other infectious causes, half of all child deaths now take place in the neonatal period, or the first month of life. The leading causes of death for children under-five include pneumonia (17%), complications of prematurity (12%), injuries (9%), diarrhoea (9%), and HIV/AIDS (9%).
Table 1.Estimated proportionate causes of death in South Africa for neonates, infants and children, 2015

Cause of death	0-27 days	1-59 months	0-4 years
HIV/AIDS	0.8	11.5	8.7
Diarrhoeal diseases	0	11.8	8.7
Pertussis	0	0.6	0.4
Tetanus	0	0	0
Measles	0	1.7	1.2
Meningitis/encephalitis	0.1	1.7	1.3
Malaria	0	0.1	0.1
Acute lower respiratory infections	6	20.9	16.9
Prematurity	35	3.9	12.2
Birth asphyxia and birth trauma	21.4	1.9	7.1
Sepsis and other infectious conditions of the newborn	14.5	0	3.8
Other communicable, perinatal and nutritional conditions	11	14.7	13.8
Congenital anomalies	9.2	8.3	8.6
Other non-communicable diseases	0.4	11.1	8.3
Injuries	1.5	11.6	9

(source: WHO for the year 2015, cause of death input to the LiST model)

The potential impact of interventions supported by Community Health Workers

In South Africa, several studies have shown the importance of community health workers to child health. To show the impact that CHW interventions can have on reducing child mortality, a model based analysis was conducted using the Lives Saved Tool (LiST). LiST was used to estimate the health impact of scaling up interventions that could potentially be delivered directly by CHWs at community level, or promoted by CHWs in homes and communities and delivered at the health centre or hospital. Interventions throughout pregnancy, the postnatal period, and early childhood that have been shown to reduce mortality were used in the model (Box 1).

Box 1. Interventions scaled up in LiST by 10 percentage points*^ ANC 4+ (including syphilis, hypertension, diabetes, pre-eclampsia detection and case management) Micronutrient supplementation in pregnancy Exclusive breastfeeding (0-6 months) Extended breastfeeding (6-23 months) Complementary feeding Clean postnatal practices Improved sanitation Handwashing with soap Vaccines: pentavalent, pneumococcal, rotavirus, measles ORS for diarrhoea (used data on ORS for this input, not RHF) Zinc for diarrhoea Antibiotics for pneumonia (used data on care-seeking as a proxy) *Coverage of skilled birth attendance and health facility delivery were already over 95% according to SADHS 2016 so these interventions and their components were left unchanged, but presumably good CHW support could help families advocate for better care during delivery and coverage of quality newborn care could increase. ^ Interventions were scaled up by 10 percentage points from 2017 values in the first year of the CHW program (i.e. 2018), and extrapolated at that coverage level through 2027. Additional inputs to the CHW platform that may facilitate a further increase in coverage would result in more deaths averted.

The modelled LiST results showed that with an increase in coverage of key interventions by only 10 percentage points, an average of 3,500 under-five deaths would be prevented each year. Cumulatively between 2017 and 2027, over 34,800 lives would be saved.

Improvements to feeding practices including early, exclusive and extended breastfeeding as well as complementary feeding would have the biggest impact (Table 2). The case detection and referral that CHWs could provide for pneumonia and diarrhoea would save more than 900 lives and account for 28% of the deaths prevented. Preventive care, mainly support for improved hygiene and sanitation practices accounts for 14% of lives saved. Promotion of vaccines accounts for 11% of the lives saved and promotion of quality antenatal care accounts for an additional 9%.
Table 2.Additional deaths prevented in with a 10 percentage point increase from 2016 coverage levels

Intervention	Number of deaths prevented in the first year of CHW scale up	% deaths prevented
Pregnancy
Micronutrient supplementation, syphilis detection and treatment	294	9%
Breastfeeding
Early, exclusive and extended breastfeeding, complementary feeding)	1270	38%
Preventive
Improved hygiene (Clean postnatal practices, handwashing with soap, improved sanitation)	453	14%
Vaccines
Pentavalent, pneumococcal, rotavirus, measles	357	11%
Curative
Case management of pneumonia	537	16%
ORS and zinc for diarrhoea	407	12%
Total	3,314	100%

With a life expectancy of 64 years and a discount rate of 3%, each death averted would translate into 28.6 DALYs averted. For the annual 3,314 deaths averted, the number of DALYs averted would stand at 94,741. Cumulatively over 10 years just under 1 million DALYs would be averted.

Cost per DALY averted

If the CHWs spend 40% of their time on mother and child health, the cost of the MCH CHW platform would amount to R2.2 billion. The cost per DALY averted would stand at R23,761. The WHO’s thresholds for cost-effectiveness categorise as cost-effective an intervention whose cost per DALY averted is equal or inferior to three times the GDP per capita and as highly effective when the cost per DALY averted is equal or inferior to the GDP per capita. For a GDP cost per capita of R78,254 for this intervention the cost per DALY averted is 30% of the GDP per capita and is classified as highly cost-effective.


Share of CHW time 40%

Deaths averted: 34,800 over 10 years

DALYs averted: 1 million

Cost/DALY averted: R23,761