The Benefits of a Universal Home-Based Neonatal Care Package in Rural India: An Extended Cost-Effectiveness Analysis

Excerpt

Each year, 27 percent of the world’s newborn deaths— about 748,000—occur in India according to 2013 estimates (UN IGME 2014). India’s newborn mortality rate (NMR) has declined by nearly 43 percent since 1990. However, this decline has been much slower than the decline in the mortality rate for children under age five years, which has dropped by 58 percent during the same period. Consequently, the share of newborn deaths among all under-five deaths in India has risen from 41 percent in 1990 to 56 percent in 2013, highlighting the relative lack of progress made in newborn survival. Conditions associated with neonates—such as preterm birth complications and sepsis—rank among the top 10 causes of all premature mortality in India (CDC 2015). A study in 2005 found that prematurity and low birth weight, infections, birth asphyxia, and birth trauma caused nearly 80 percent of newborn deaths (Bassani and others 2010).

India’s NMR of 29 per 1,000 live births continues to be among the highest in the world, underscoring the need for a policy response (UN IGME 2014) (figure 18.1). Although antenatal care and other preventive interventions such as encouraging institutional delivery and improving maternal health care access have been implemented, their impact on newborn survival has been minimal (Hollowell and others 2009; Lim and others 2010; Singh and others 2013). Good quality postnatal care may prevent about 67 percent of all newborn deaths (WHO 2012) in India. However, availability of and access to postnatal care remain low. Data from the District Level Household Survey conducted between 2007 and suggest that only 45 percent of newborns in India underwent a health examination within the first 24 hours (IIPS 2010).

In addition to low levels of access to newborn care in general, large regional and socioeconomic differences in access lead to significant variations in outcomes. The mortality among newborns in India’s rural areas is twice that in urban areas—34 and 17 per 1,000 live births, respectively— with mortality rates substantially exceeding the national average in the poorer and larger states of Madhya Pradesh, Uttar Pradesh, Odisha, Rajasthan, Jammu and Kashmir, and Chhattisgarh (Chand and others 2013).

In this chapter, we examine the health and economic benefits and the cost to the government associated with scaling up a publicly financed home-based neonatal care (HBNC) package in rural India. We consider two intervention scenarios against a baseline of no HBNC:

1. In the first scenario, we examine the scaling up of access to HBNC through the current network of accredited social health activists (ASHA)—a group of community health workers (CHWs) that covers 60.1 percent of India’s villages (or roughly 54 percent of the rural population)—to those not presently receiving care. Of rural newborns, 39.8 percent receive some form of home- or facility-based newborn care during the first 10 days of life (IIPS 2010). By extending HBNC within the current network of ASHA workers, 72 percent of the rural newborn population would have access to care either through the HBNC package or their existing home-or facility-based care.

2. In the second scenario, we analyze a near-universal setting in which access to HBNC—through expansion of the network of CHWs—is extended to 83.4 percent of those not presently receiving care. With this extension, 90 percent of the rural neonate population would have access to the HBNC package or their existing home- or facility-based care.

Box 18.1 provides information on the types of CHWs and the primary health systems in which they operate.