Implementation of the Integrated Neonatal Care Kit to Reduce Neonatal Infection in Rural Pakistan: A Cost-Utility Analysis
Background: Neonatal mortality accounts for nearly half of all deaths among children under five. With 46 neonatal deaths per 1,000 live births, Pakistan has the highest neonatal mortality rate in the world, bolstering the need for interventions that improve newborn survival. A recent cluster randomized controlled trial (cRCT) estimated the effect of an integrated neonatal care kit (iNCK) on neonatal mortality compared to standard of care in Rahimyar Khan, Pakistan. Objective: To strengthen the evidence-base towards wide-scale implementation of the iNCK, we evaluated the cost-effectiveness of iNCK distribution compared to standard care from the healthcare payer perspective. Methods: We performed a cost-utility analysis using a Markov model based on cRCT trial data and a comprehensive literature review. The base case was either standard care or distribution of the iNCK to pregnant mothers whose infant was followed over a lifetime time horizon. Outcome measures were life years, disability-adjusted life years (DALYs), costs and incremental net monetary benefit (INMB, at a cost-effectiveness threshold of USD 15.50), discounted at 3%. We conducted deterministic sensitivity analysis to assess parameter uncertainty. Results: At a cost-effectiveness threshold of USD 15.50, distribution of the iNCK resulted in lower expected DALYs (28.70 versus 29.54 years) at lower expected cost (USD 72.41 versus 86.11), translating to an INMB of USD 27 per iNCK distributed. These results were sensitive to the baseline risk of infection, cost of the kit and the relative risk of infection associated with iNCK use. Below a relative risk of infection of 0.83 and cost of the iNCK less than USD 32, the iNCK remained cost-effective compared to standard of care. Conclusions: The distribution of the iNCK dominated the current standard of care, i.e., is less costly and more effective, with most of the effectiveness attributable to a reduction in neonatal infection.