Economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) in Sindh, Pakistan

Background: Hypertensive disorders of pregnancy, particularly pre-eclampsia and eclampsia (PE/E), can lead to life-threatening complications or even the death of a mother or a newborn. Because there are few clinical trials of community-based interventions for PE/E, there is little evidence about the cost-effectiveness of these interventions. The aim of this dissertation is to conduct an economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) combined with routine pregnancy care, compared to routine pregnancy care alone, in Sindh, Pakistan. Methods: A mixed-methods (i.e., qualitative and quantitative) approach to economic evaluation was undertaken alongside the CLIP Trial. A literature review of published epidemiological and economic studies was carried out to document evidence on PE/E interventions and guide the design of the economic model. Data were collected through focus groups, a structured questionnaire embedded into CLIP Trial surveillance, a cross-sectional survey of health facilities, and program budgetary reviews. The cost-effectiveness analysis was performed using a societal perspective. Probabilistic analysis was applied to estimate incremental cost-effectiveness ratios (ICERs), and sensitivity analysis was done to characterize uncertainties. Results: The literature review found economic studies mainly in developed countries and focused only on costs to the health system. Focus groups revealed a large burden of out-of-pocket spending and productivity losses to pregnant women and families. Health care providers and decision makers identified upfront technology costs as a key challenge for the health system. Maternal and newborn care costs varied significantly between and within public and private sectors. In the probabilistic analysis of the base case, the incremental cost of the intervention as compared to control was $20,438, while the years of life lost was -37 (i.e., negative health gains), indicating a wide range of statistical uncertainty around ICERs. Overall, the probability that ICERs fell below the country-specific threshold was less than 30%. Conclusion: This dissertation highlights knowledge gaps for costs and cost-effectiveness of PE/E interventions in low- and-middle-income countries (LMICs). The economic analysis indicates that CLIP is not a cost-effective strategy, compared to routine pregnancy care. More research is needed to conduct the process evaluation to inform policy decisions on resource allocation in Sindh, Pakistan.Medicine, Faculty ofObstetrics and Gynaecology, Department ofGraduat