Cost-Effectiveness of Interventions to Improve Maternal, Newborn and Child Health Outcomes: A WHO-CHOICE Analysis for Eastern Sub-Saharan Africa and South-East Asia

Document Type : Original Article


1 Department of Health Systems Governance and Financing, World Health Organization (WHO), Geneva, Switzerland

2 School of Population and Global Health, The University of Western Australia, Crawley, WA, Australia

3 Department of Nutrition for Health and Development, World Health Organization (WHO), Geneva, Switzerland

4 Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization (WHO), Geneva, Switzerland

5 Department of Sexual and Reproductive Health and Research, World Health Organization (WHO), Geneva, Switzerland

6 Department of Immunization, Vaccines and Biologicals (IVB), World Health Organization (WHO), Geneva, Switzerland


Information on cost-effectiveness allows policy-makers to evaluate if they are using currently available resources effectively and efficiently. Our objective is to examine the cost-effectiveness of health interventions to improve maternal, newborn and child health (MNCH) outcomes, to provide global evidence relative to the context of two geographic regions.
We consider interventions across the life course from adolescence to pregnancy and for children up to 5 years old. Interventions included are those that fall within the areas of immunization, child healthcare, nutrition, reproductive health, and maternal/newborn health, and for which it is possible to model impact on MNCH mortality outcomes using the Lives Saved Tool (LiST). Generalized cost-effectiveness analysis (GCEA) was used to derive average cost-effectiveness ratios (ACERs) for individual interventions and combinations (packages). Costs were assessed from the health system perspective and reported in international dollars. Health outcomes were estimated and reported as the gain in healthy life years (HLYs) due to the specific intervention or combination. The model was run for 2 regions: Eastern sub-Saharan Africa (SSA-E) and South-East Asia (SEA).
The World Health Organization (WHO) recommended interventions to improve MNCH are generally considered cost-effective, with the majority of interventions demonstrating ACERs below I$100/HLY saved in the chosen settings (lowand middle-income countries [LMICs]). Best performing interventions are consistent across the two regions, and include family planning, neonatal resuscitation, management of pneumonia and neonatal infection, vitamin A supplementation, and measles vaccine. ACERs below I$100 can be found across all delivery platforms, from community to hospital level. The combination of interventions into packages (such as antenatal care) produces favorable ACERs.
Within each region there are interventions which represent very good value for money. There are opportunities to gear investments towards high-impact interventions and packages for MNCH outcomes. Cost-effectiveness tools can be used at national level to inform investment cases and overall priority setting processes.


  1. World Health Organization (WHO). Trends in Maternal Mortality 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: WHO; 2019.
  2. World Health Organization (WHO). MDGs: Progress Made in Health.
  3. United Nations. Transforming Our World: The 2030 Agenda for Sustainable Development. United Nations; 2015.
  4. Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-451. doi:10.1016/s0140-6736(13)60937-x
  5. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392(10159):1859-1922. doi:10.1016/s0140-6736(18)32335-3
  6. The Partnership for Maternal, Newborn & Child Health (PMNCH). A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health. PMNCH; 2011.
  7. Tracking Progress towards Universal Coverage for Reproductive, Newborn and Child Health: The 2017 Report. Washington, DC: United Nations Children’s Fund (UNICEF), World Health Organization (WHO); 2017.
  8. World Health Organization (WHO), United Nations Development Programme (UNDP). Non-Communicable Disease Prevention and Control: A Guidance Note for Investment Cases.   Accessed December 20, 2020.
  9. World Bank Group. GFF Country Implementation Guidelines.   Accessed September 20, 2019. Published 2019.
  10. Bertram MY, Lauer JA, Stenberg K, Edejer TT. Methods for the Economic evaluation of health care interventions for priority setting in the health system: an update from WHO-CHOICE. Int J Health Policy Manag. 2021; In Press. doi:10.34172/ijhpm.2020.244
  11. Bertram MY, Chisholm D, Watts R, Waqanivalu T, Varghese C, Prasad V. Cost-effectiveness of population level and individual level interventions to combat Non-Communicable Disease in Eastern sub-Saharan Africa and South East Asia: a WHO-CHOICE analysis. Int J Health Policy Manag. 2021; Forthcoming.
  12. Ralaidovy AH, Lauer JA, Pretorius C, Briët OJ, Patouillard E. Priority setting in HIV, tuberculosis, and malaria–new cost-effectiveness results from WHO-CHOICE. Int J Health Policy Manag. 2021; In Press. doi:10.34172/ijhpm.2020.251
  13. Bertram MY, Lauer JA, Stenberg K, Ralaidovy AH, Edejer TT. Progressive realisation of universal health coverage in low- and middle-income countries: beyond. Int J Health Policy Manag. 2021; Forthcoming.
  14. Adam T, Lim SS, Mehta S, et al. Cost effectiveness analysis of strategies for maternal and neonatal health in developing countries. BMJ. 2005;331(7525):1107. doi:10.1136/bmj.331.7525.1107
  15. Edejer TT, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Cost effectiveness analysis of strategies for child health in developing countries. BMJ. 2005;331(7526):1177. doi:10.1136/bmj.38652.550278.7C
  16. World Health Organization (WHO). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva: WHO; 2016.
  17. World Health Organization (WHO). WHO Guidelines on Maternal, Newborn, Child and Adolescent Health. WHO; 2020.   Accessed  February 1, 2020.
  18. Walker N, Tam Y, Friberg IK. Overview of the Lives Saved Tool (LiST). BMC Public Health. 2013;13(Suppl 3):S1. doi:10.1186/1471-2458-13-s3-s1
  19. USAID. FamPlan - A Computer Program for Projecting Family Planning Requirements.  Accessed October 22,  2019.
  20. Index Mundi: OECD members - Contraceptive prevalence website.  Accessed February 1, 2020.
  21. Stover J, McKinnon R, Winfrey B. Spectrum: a model platform for linking maternal and child survival interventions with AIDS, family planning and demographic projections. Int J Epidemiol. 2010;39(Suppl 1):i7-10. doi:10.1093/ije/dyq016
  22. Salomon JA, Vos T, Hogan DR, et al. Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2129-2143. doi:10.1016/s0140-6736(12)61680-8
  23. Avenir Health. OneHealth Tool.
  24. Bertram MY, Stenberg K, Brindley C, et al. Disease control programme support costs: an update of WHO-CHOICE methodology, price databases and quantity assumptions. Cost Eff Resour Alloc. 2017;15:21. doi:10.1186/s12962-017-0083-6
  25. Stenberg K, Lauer JA, Gkountouras G, Fitzpatrick C, Stanciole A. Econometric estimation of WHO-CHOICE country-specific costs for inpatient and outpatient health service delivery. Cost Eff Resour Alloc. 2018;16:11. doi:10.1186/s12962-018-0095-x
  26. Serje J, Bertram MY, Brindley C, Lauer JA. Global health worker salary estimates: an econometric analysis of global earnings data. Cost Eff Resour Alloc. 2018;16:10. doi:10.1186/s12962-018-0093-z
  27. Horton S, Levin C. Cost-effectiveness of interventions for reproductive, maternal, neonatal, and child health. In: Black RE, Laxminarayan R, Temmerman M, Walker N, eds. Reproductive, Maternal, Newborn, and Child Health: Disease Control Priorities, Third Edition (Volume 2). Washington, DC: The International Bank for Reconstruction and Development, The World Bank; 2016.
  28. World Health Organization (WHO). WHO Recommendation: Calcium Supplementation During Pregnancy for Prevention of Pre-Eclampsia and its Complications. WHO; 2018.
  29. World Health Organization (WHO). Essential Nutrition Actions: Mainstreaming Nutrition Through the Life-Course. WHO; 2019.
  30. Institute for Health Metrics and Evaluation (IHME). Financing Global Health 2018: Countries and Programs in Transition. Seattle, WA: IHME, 2019.
  31. Bhutta ZA, Das JK, Bahl R, et al. Can available interventions end preventable deaths in mothers, newborn babies, and stillbirths, and at what cost? Lancet. 2014;384(9940):347-370. doi:10.1016/s0140-6736(14)60792-3
  32. Clark H, Coll-Seck AM, Banerjee A, et al. A future for the world's children? a WHO-UNICEF-Lancet Commission. Lancet. 2020;395(10224):605-658. doi:10.1016/s0140-6736(19)32540-1