Potential cost-effectiveness of universal access to modern contraceptives in Uganda

Abstract

Background: Over two thirds of women who need contraception in Uganda lack access to modern effective methods. This study was conducted to estimate the potential cost-effectiveness of achieving universal access to modern contraceptives in Uganda by implementing a hypothetical new contraceptive program (NCP) from both societal and governmental (Ministry of Health (MoH)) perspectives.

Methodology/principal findings: A Markov model was developed to compare the NCP to the status quo or current contraceptive program (CCP). The model followed a hypothetical cohort of 15-year old girls over a lifetime horizon. Data were obtained from the Uganda National Demographic and Health Survey and from published and unpublished sources. Costs, life expectancy, disability-adjusted life expectancy, pregnancies, fertility and incremental cost-effectiveness measured as cost per life-year (LY) gained, cost per disability-adjusted life-year (DALY) averted, cost per pregnancy averted and cost per unit of fertility reduction were calculated. Univariate and probabilistic sensitivity analyses were performed to examine the robustness of results. Mean discounted life expectancy and disability-adjusted life expectancy (DALE) were higher under the NCP vs. CCP (28.74 vs. 28.65 years and 27.38 vs. 27.01 respectively). Mean pregnancies and live births per woman were lower under the NCP (9.51 vs. 7.90 and 6.92 vs. 5.79 respectively). Mean lifetime societal costs per woman were lower for the NCP from the societal perspective ($1,949 vs. $1,987) and the MoH perspective ($636 vs. $685). In the incremental analysis, the NCP dominated the CCP, i.e. it was both less costly and more effective. The results were robust to univariate and probabilistic sensitivity analysis.

Conclusion/significance: Universal access to modern contraceptives in Uganda appears to be highly cost-effective. Increasing contraceptive coverage should be considered among Uganda's public health priorities.

Figure 1. Markov model.

The model illustrates the different states of contraception through which women between 15 and 49 years of age in Uganda transition. Each state is associated with a cost and a value of disability-adjusted life years lost. All states may progress to dead.

Figure 2. Tornado diagrams of univariate sensitivity analysis from the societal perspective.

The diagram shows, for a comparison between the new contraceptive program and the current contraceptive program, the impact of uncertainty surrounding different variables on incremental cost (a) and incremental disability-adjusted life years (b). The most influential variables are shown.

Figure 3. Incremental cost-effectiveness scatter plot obtained from probabilistic sensitivity analysis.

The figure shows the distribution of cost-effectiveness pairs on the cost-effectiveness plane.

Figure 4. Cost-effectiveness acceptability curves obtained from probabilistic sensitivity analysis.

The curves show, for 10,000 simulated samples, the probability that the new contraceptive program is cost-effective compared to the current contraceptive program at varying thresholds of cost-effectiveness (willingness to pay to avert an additional disability-adjusted life year).