Cost effectiveness analysis of strategies for maternal and neonatal he
http://www.100md.com
《英国医生杂志》
1 Health Systems Financing, Evidence and Information for Policy, World Health Organization, Switzerland, 2 School of Population Health, University of Queensland, Australia, 3 Health Effects Institute, Boston, USA, 4 Aga Khan University, Karachi, Pakistan, 5 Department of Making Pregnancy Safer, World Health Organization, 6 Department of International Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
Correspondence to: S S Lim s.lim@sph.uq.edu.au
Objective To determine the costs and benefits of interventions for maternal and newborn health to assess the appropriateness of current strategies and guide future plans to attain the millennium development goals.
Design Cost effectiveness analysis.
Setting Two regions classified by the World Health Organization according to their epidemiological grouping: Afr-E, those countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, comprising countries in South East Asia with high adult and high child mortality.
Data sources Effectiveness data from several sources, including trials, observational studies, and expert opinion. For resource inputs, quantities came from WHO guidelines, literature, and expert opinion, and prices from the WHO choosing interventions that are cost effective database.
Main outcome measures Cost per disability adjusted life year (DALY) averted in year 2000 international dollars.
Results The most cost effective mix of interventions was similar in Afr-E and Sear-D. These were the community based newborn care package, followed by antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth, offering first level maternal and neonatal care around childbirth; and emergency obstetric and neonatal care around and after birth. Screening and treatment of maternal syphilis, community based management of neonatal pneumonia, and steroids given during the antenatal period were relatively less cost effective in Sear-D. Scaling up all of the included interventions to 95% coverage would halve neonatal and maternal deaths.
Conclusion Preventive interventions at the community level for newborn babies and at the primary care level for mothers and newborn babies are extremely cost effective, but the millennium development goals for maternal and child health will not be achieved without universal access to clinical services as well.
Each year more than 500 000 women die during pregnancy or childbirth1 and more than 4 million babies die in the first 28 days of life, accounting for 38% of mortality in children aged less than 5 worldwide.2 The contrast between countries is stark. Of every 1000 children born in Africa and South East Asia, 44 and 38 die in the neonatal period, respectively, compared with four in high income countries. A similar gulf exists for maternal mortality, with rates in sub-Saharan Africa more than 2.5 times those in Asia, which are in turn more than 20 times those in developed countries.1 Effective interventions to reduce maternal and neonatal deaths exist,3 but they are not available to people living in the poorest parts of the world.4
The member countries of the United Nations agreed to reduce child mortality by two thirds and maternal mortality by three quarters by 2015 as part of the millennium development goals (goals 4 and 5, respectively). To aid decisions on how to more effectively reach these goals that have thus far shown poor progress, information on the costs and impact on health of current and possible new interventions is critical to show what improvements in health could be achieved with different options for expenditure.5 Cost effectiveness analyses of maternal and newborn interventions have, however, usually been restricted to the analysis of individual interventions,6-8 with considerable variation in the analytical methods used. This, combined with variability in the settings in which the analyses were undertaken, limits the value of the existing literature.
Recently, as part of a series on neonatal survival, the cost effectiveness of antenatal, intrapartum, and postnatal interventions of proved benefit for reducing neonatal mortality was estimated.3 The series used standardised methods and a form of analysis that allows existing interventions to be evaluated at the same time as possible new interventions.3 We develop this work further by including a more comprehensive list of maternal interventions provided during pregnancy, childbirth, and the neonatal period.
We examined the costs and impact on health of interventions that target the health related millennium development goals. This paper provides policy makers with the necessary information to enable them to evaluate if they are using the resources currently available for maternal and neonatal conditions effectively and efficiently, and how they can best achieve millennium development goals 4 and 5 as new resources become available. A summary paper considers the overall implications of the results presented in this series.9
Methods
The paper by Evans et al provides details on the standardised methods of the WHO choosing interventions that are cost effective (CHOICE) project that were used in this analysis.10 Here we provide additional detail on methods exclusive to this paper.
Interventions
The analysis included 21 interventions and all possible combinations of interventions, taking into account interactions in costs or effectiveness when interventions are implemented together. Table 1 lists the interventions, categorised according to the level of care required to deliver them (first level maternal and newborn care, referral level maternal and newborn care, community based newborn care), and the period of implementation (antenatal, intrapartum, post partum, newborn).
Table 1 Description of maternal and neonatal intervention packages and components
Intervention effects
The effectiveness of the interventions listed in table 1 and the estimated coverage levels in 2000 are listed in tables A and B on bmj.com. Effects are estimated through their impact on incidence, remission, and case fatality of the maternal and neonatal conditions specified in table D on bmj.com. We include the impact of interventions on maternal mortality and morbidity and on neonatal mortality, when available. A lack of reliable data prevents inclusion of the impact on neonatal morbidity or stillbirths, so the benefits of some interventions are under-estimated. Using the population model PopMod, we assessed the health effects on the population of the interventions compared with the no intervention scenario,11 with effects measured as the number of disability adjusted life years (DALYs) averted.
Intervention costs
The quantities of resources used for the interventions listed in table 1 are based on WHO evidence based guidelines12-15 as well as on information obtained from the studies used for the estimates of effectiveness (see table A on bmj.com), to ensure consistency between costs and effectiveness. When these could not be used, we sought expert opinion on the resources needed to introduce and run a programme. See table E on bmj.com for details on the costing methods and the main assumptions on use of resources.
Results
The costs, population health effects, and cost effectiveness for all 300 combinations of individual interventions analysed by WHO epidemiological subregions are available from www.who.int/choice. Tables F and G on bmj.com provide the full results for Afr-E (countries in sub-Saharan Africa with very high adult and high child mortality) and for Sear-D (countries in South East Asia with high adult and high child mortality). We present here the results of the most cost effective set of interventions. Tables 2 and 3 show the order in which interventions would be purchased at given levels of availability of resources, if cost effectiveness is the only consideration. This is called the "expansion path" (figs 1 and 2). The paper by Evans et al provides a detailed description on the construction and interpretation of the expansion path.10
Table 2 Annual costs, effects, and cost effectiveness of intervention packages on optimal expansion path for Afr-E in 2000
Table 3 Annual costs, effects, and cost effectiveness of intervention packages on optimal expansion path for Sear-D in 2000
Fig 1 Expansion path of most cost effective mix of interventions in Afr-E (countries in sub-Saharan Africa with very high adult and high child mortality) in 2000
Fig 2 Expansion path of most cost effective mix of interventions in Sear-D (countries in South East Asia with high adult and high child mortality) in 2000
The expansion paths for both regions suggest that interventions for newborn care at the community level are highly cost effective (for example, promotion of breast feeding), followed by selected antenatal care interventions (for example, tetanus toxoid), interventions deliverable by a skilled attendant at birth in a health facility (for example, normal delivery care by a skilled attendant), then by more complex interventions that require referral to a higher level health facility. Important differences do, however, exist between the regions. Screening and treatment of syphilis in Sear-D is relatively less cost effective than in Afr-E owing to its lower prevalence. Community based management of neonatal pneumonia is relatively more cost effective in Afr-E than in Sear-D because of its higher prevalence.
The expansion path not only shows the relative cost effectiveness of interventions but also allows decision makers to see the absolute value of resources necessary to move to the next point on the expansion path. Sometimes, however, there may be insufficient resources to move to the next point. For example, if A9 is not affordable a decision maker may choose to implement a lower cost but less cost effective package such as B2 (referral care of postpartum haemorrhage), B3 (referral care of maternal sepsis and postpartum haemorrhage), or B4 (referral care of maternal sepsis and postpartum haemorrhage and antibiotics for preterm premature rupture of membranes). See tables H and I on bmj.com for further examples of alternative interventions for scaling up maternal and newborn health services in the event that the preferred intervention is unaffordable.
Considerable uncertainty surrounds the inputs used in this analysis, but rather than undertake a complex multivariate uncertainty analysis, for practical policy purposes we prefer to interpret the results by ICER (incremental cost effectiveness ratios) bands, using international dollars (a hypothetical unit of currency with the same purchasing power that the dollar has in the United States at a given time). For example, in Afr-E it is difficult to say with certainty that tetanus toxoid (ICER $Int22 per DALY averted) is more cost effective than other antenatal care interventions (ICER $Int27 per DALY averted). We can be more certain, however, that interventions costing less than $Int50 per DALY, such as community care of newborn babies, antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis), and skilled maternal and newborn care, are more cost effective than those costing more than $Int100 per DALY averted, such as antibiotics for preterm premature rupture of membranes. This means that the order in which the most cost effective interventions are introduced is up to the specific circumstances of a country. The important thing is to obtain high coverage with the group of cost effective interventions before implementing those of high cost and low effectiveness.
Eliminating discounting for health benefits resulted in about 2.5 times more DALYs averted, whereas removing age weighting decreased DALYs averted by 10-15% (data not shown). Costs were 5-20% higher without discounting. Although removing age weighting and discounting of DALYs favours interventions for newborn babies over those for mothers, the ranking of interventions and the expansion path, on the whole, remains the same.
Implementation of all the interventions covered in this analysis at 95% coverage would avert 52% of the year 2000 neonatal deaths and 51% of maternal deaths in Afr-E, and 56% of neonatal deaths and 51% of maternal deaths in Sear-D.
Discussion
World Health Organization (Department of Reproductive Health and Research). Maternal mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2004.
Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 2005;365: 891-900.
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365: 977-88.
World Health Organization. The world health report 2005: make every mother and child count. Geneva: WHO, 2005.
Evans DB, Adam T, Tan-Torres Edejer T, Lim SS, Cassels A, Evans TG, et al. Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries? BMJ 2005;331: 1133-6.
Terris-Prestholt F, Watson-Jones D, Mugeye K, Kumaranayake L, Ndeki L, Weiss H, et al. Is antenatal syphilis screening still cost effective in sub-Saharan Africa. Sex Transm Infect 2003;79: 375-81.
Griffiths UK, Wolfson LJ, Quddus A, Younus M, Hafiz RA. Incremental cost-effectiveness of supplementary immunization activities to prevent neonatal tetanus in Pakistan. Bull World Health Organ 2004;82: 643-51.
Nakhaee N, Mirahmadizadeh AR, Gorji HA, Mohammadi M. Assessing the cost-effectiveness of contraceptive methods in Shiraz, Islamic Republic of Iran. East Mediterr Health J 2002;8: 55-63.
Evans DB, Lim SS, Adam T, Tan-Torres Edejer T, the WHO-CHOICE Millennium Development Goals Team. Achieving the millennium development goals for health: Evaluation of current health intervention strategies and future priorities in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38658.675243.94).
Evans DB, Tan-Torres Edejer T, Adam T, Lim S, the WHO-CHOICE Millennium Development Goals Team. Achieving the millennium development goals for health: Methods to assess the costs and health effects of interventions for improving health in developing countries. BMJ 2005;331: 1137-40.
Lauer JA, Rohrich K, Wirth H, Charette C, Gribble S, Murray CJL. PopMod: a longitudinal population model with two interacting disease states. Cos Eff Resour Alloc 2003; 1.
World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. WHO document WHO/RHR/00.7. Geneva: WHO, 2003.
World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva: WHO, 2003.
World Health Organization. Managing newborn problems: a guide for doctors, nurses and midwives. Geneva: WHO, 2003.
World Health Organization. WHO antenatal care randomized trial: manual for the implementation of the new model. WHO document WHO/RHR/01.30. Geneva: WHO, 2002.
Stevens TP, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2004;3: CD003063.
Kulier R, Gumodoka AM, Hofmeyr GJ, Cheng LN, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev 2004;2: CD002855.
Nanda G, Switlick K, Lule E. Accelerating progress towards achieving the MDG to improve maternal health: a collection of promising approaches. Health, Nutrition and Population (HNP) discussion paper. Washington, DC: International Bank for Reconstruction and Development and the World Bank, 2005.
Baltussen R, Knai C, Sharan M. Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world. J Nutr 2004;134: 2678-84.
Tan-Torres Edejer T, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies in developing countries for child health. BMJ 2005 Nov 10; epub ahead of print (doi: 1136/bmj.38652.550278.7C).
Baltussen R, Floyd K, Dye C. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies for tuberculosis control in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38645.660093.68).
Morel C, Lauer J, Evans DB. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies to combat malaria in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38639.702384.AE).
Hogan DR, Baltussen R, Hayashi C, Lauer JA, Salomon JA. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies to combat HIV/AIDS. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38643.368692.68).
Horton S, Sanghvi T, Phillips M, Fiedler J, Perez-Escamilla R, Lutter C, et al. Breastfeeding promotion and priority setting in health. Health Policy Plan 1996;11: 156-68.(Taghreed Adam, health economist1, Stephe)
Correspondence to: S S Lim s.lim@sph.uq.edu.au
Objective To determine the costs and benefits of interventions for maternal and newborn health to assess the appropriateness of current strategies and guide future plans to attain the millennium development goals.
Design Cost effectiveness analysis.
Setting Two regions classified by the World Health Organization according to their epidemiological grouping: Afr-E, those countries in sub-Saharan Africa with very high adult and high child mortality, and Sear-D, comprising countries in South East Asia with high adult and high child mortality.
Data sources Effectiveness data from several sources, including trials, observational studies, and expert opinion. For resource inputs, quantities came from WHO guidelines, literature, and expert opinion, and prices from the WHO choosing interventions that are cost effective database.
Main outcome measures Cost per disability adjusted life year (DALY) averted in year 2000 international dollars.
Results The most cost effective mix of interventions was similar in Afr-E and Sear-D. These were the community based newborn care package, followed by antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis); skilled attendance at birth, offering first level maternal and neonatal care around childbirth; and emergency obstetric and neonatal care around and after birth. Screening and treatment of maternal syphilis, community based management of neonatal pneumonia, and steroids given during the antenatal period were relatively less cost effective in Sear-D. Scaling up all of the included interventions to 95% coverage would halve neonatal and maternal deaths.
Conclusion Preventive interventions at the community level for newborn babies and at the primary care level for mothers and newborn babies are extremely cost effective, but the millennium development goals for maternal and child health will not be achieved without universal access to clinical services as well.
Each year more than 500 000 women die during pregnancy or childbirth1 and more than 4 million babies die in the first 28 days of life, accounting for 38% of mortality in children aged less than 5 worldwide.2 The contrast between countries is stark. Of every 1000 children born in Africa and South East Asia, 44 and 38 die in the neonatal period, respectively, compared with four in high income countries. A similar gulf exists for maternal mortality, with rates in sub-Saharan Africa more than 2.5 times those in Asia, which are in turn more than 20 times those in developed countries.1 Effective interventions to reduce maternal and neonatal deaths exist,3 but they are not available to people living in the poorest parts of the world.4
The member countries of the United Nations agreed to reduce child mortality by two thirds and maternal mortality by three quarters by 2015 as part of the millennium development goals (goals 4 and 5, respectively). To aid decisions on how to more effectively reach these goals that have thus far shown poor progress, information on the costs and impact on health of current and possible new interventions is critical to show what improvements in health could be achieved with different options for expenditure.5 Cost effectiveness analyses of maternal and newborn interventions have, however, usually been restricted to the analysis of individual interventions,6-8 with considerable variation in the analytical methods used. This, combined with variability in the settings in which the analyses were undertaken, limits the value of the existing literature.
Recently, as part of a series on neonatal survival, the cost effectiveness of antenatal, intrapartum, and postnatal interventions of proved benefit for reducing neonatal mortality was estimated.3 The series used standardised methods and a form of analysis that allows existing interventions to be evaluated at the same time as possible new interventions.3 We develop this work further by including a more comprehensive list of maternal interventions provided during pregnancy, childbirth, and the neonatal period.
We examined the costs and impact on health of interventions that target the health related millennium development goals. This paper provides policy makers with the necessary information to enable them to evaluate if they are using the resources currently available for maternal and neonatal conditions effectively and efficiently, and how they can best achieve millennium development goals 4 and 5 as new resources become available. A summary paper considers the overall implications of the results presented in this series.9
Methods
The paper by Evans et al provides details on the standardised methods of the WHO choosing interventions that are cost effective (CHOICE) project that were used in this analysis.10 Here we provide additional detail on methods exclusive to this paper.
Interventions
The analysis included 21 interventions and all possible combinations of interventions, taking into account interactions in costs or effectiveness when interventions are implemented together. Table 1 lists the interventions, categorised according to the level of care required to deliver them (first level maternal and newborn care, referral level maternal and newborn care, community based newborn care), and the period of implementation (antenatal, intrapartum, post partum, newborn).
Table 1 Description of maternal and neonatal intervention packages and components
Intervention effects
The effectiveness of the interventions listed in table 1 and the estimated coverage levels in 2000 are listed in tables A and B on bmj.com. Effects are estimated through their impact on incidence, remission, and case fatality of the maternal and neonatal conditions specified in table D on bmj.com. We include the impact of interventions on maternal mortality and morbidity and on neonatal mortality, when available. A lack of reliable data prevents inclusion of the impact on neonatal morbidity or stillbirths, so the benefits of some interventions are under-estimated. Using the population model PopMod, we assessed the health effects on the population of the interventions compared with the no intervention scenario,11 with effects measured as the number of disability adjusted life years (DALYs) averted.
Intervention costs
The quantities of resources used for the interventions listed in table 1 are based on WHO evidence based guidelines12-15 as well as on information obtained from the studies used for the estimates of effectiveness (see table A on bmj.com), to ensure consistency between costs and effectiveness. When these could not be used, we sought expert opinion on the resources needed to introduce and run a programme. See table E on bmj.com for details on the costing methods and the main assumptions on use of resources.
Results
The costs, population health effects, and cost effectiveness for all 300 combinations of individual interventions analysed by WHO epidemiological subregions are available from www.who.int/choice. Tables F and G on bmj.com provide the full results for Afr-E (countries in sub-Saharan Africa with very high adult and high child mortality) and for Sear-D (countries in South East Asia with high adult and high child mortality). We present here the results of the most cost effective set of interventions. Tables 2 and 3 show the order in which interventions would be purchased at given levels of availability of resources, if cost effectiveness is the only consideration. This is called the "expansion path" (figs 1 and 2). The paper by Evans et al provides a detailed description on the construction and interpretation of the expansion path.10
Table 2 Annual costs, effects, and cost effectiveness of intervention packages on optimal expansion path for Afr-E in 2000
Table 3 Annual costs, effects, and cost effectiveness of intervention packages on optimal expansion path for Sear-D in 2000
Fig 1 Expansion path of most cost effective mix of interventions in Afr-E (countries in sub-Saharan Africa with very high adult and high child mortality) in 2000
Fig 2 Expansion path of most cost effective mix of interventions in Sear-D (countries in South East Asia with high adult and high child mortality) in 2000
The expansion paths for both regions suggest that interventions for newborn care at the community level are highly cost effective (for example, promotion of breast feeding), followed by selected antenatal care interventions (for example, tetanus toxoid), interventions deliverable by a skilled attendant at birth in a health facility (for example, normal delivery care by a skilled attendant), then by more complex interventions that require referral to a higher level health facility. Important differences do, however, exist between the regions. Screening and treatment of syphilis in Sear-D is relatively less cost effective than in Afr-E owing to its lower prevalence. Community based management of neonatal pneumonia is relatively more cost effective in Afr-E than in Sear-D because of its higher prevalence.
The expansion path not only shows the relative cost effectiveness of interventions but also allows decision makers to see the absolute value of resources necessary to move to the next point on the expansion path. Sometimes, however, there may be insufficient resources to move to the next point. For example, if A9 is not affordable a decision maker may choose to implement a lower cost but less cost effective package such as B2 (referral care of postpartum haemorrhage), B3 (referral care of maternal sepsis and postpartum haemorrhage), or B4 (referral care of maternal sepsis and postpartum haemorrhage and antibiotics for preterm premature rupture of membranes). See tables H and I on bmj.com for further examples of alternative interventions for scaling up maternal and newborn health services in the event that the preferred intervention is unaffordable.
Considerable uncertainty surrounds the inputs used in this analysis, but rather than undertake a complex multivariate uncertainty analysis, for practical policy purposes we prefer to interpret the results by ICER (incremental cost effectiveness ratios) bands, using international dollars (a hypothetical unit of currency with the same purchasing power that the dollar has in the United States at a given time). For example, in Afr-E it is difficult to say with certainty that tetanus toxoid (ICER $Int22 per DALY averted) is more cost effective than other antenatal care interventions (ICER $Int27 per DALY averted). We can be more certain, however, that interventions costing less than $Int50 per DALY, such as community care of newborn babies, antenatal care (tetanus toxoid, screening for pre-eclampsia, screening and treatment of asymptomatic bacteriuria and syphilis), and skilled maternal and newborn care, are more cost effective than those costing more than $Int100 per DALY averted, such as antibiotics for preterm premature rupture of membranes. This means that the order in which the most cost effective interventions are introduced is up to the specific circumstances of a country. The important thing is to obtain high coverage with the group of cost effective interventions before implementing those of high cost and low effectiveness.
Eliminating discounting for health benefits resulted in about 2.5 times more DALYs averted, whereas removing age weighting decreased DALYs averted by 10-15% (data not shown). Costs were 5-20% higher without discounting. Although removing age weighting and discounting of DALYs favours interventions for newborn babies over those for mothers, the ranking of interventions and the expansion path, on the whole, remains the same.
Implementation of all the interventions covered in this analysis at 95% coverage would avert 52% of the year 2000 neonatal deaths and 51% of maternal deaths in Afr-E, and 56% of neonatal deaths and 51% of maternal deaths in Sear-D.
Discussion
World Health Organization (Department of Reproductive Health and Research). Maternal mortality in 2000: estimates developed by WHO, UNICEF, UNFPA. Geneva: WHO, 2004.
Lawn JE, Cousens S, Zupan J. 4 million neonatal deaths: when? Where? Why? Lancet 2005;365: 891-900.
Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005;365: 977-88.
World Health Organization. The world health report 2005: make every mother and child count. Geneva: WHO, 2005.
Evans DB, Adam T, Tan-Torres Edejer T, Lim SS, Cassels A, Evans TG, et al. Achieving the millennium development goals for health: Time to reassess strategies for improving health in developing countries? BMJ 2005;331: 1133-6.
Terris-Prestholt F, Watson-Jones D, Mugeye K, Kumaranayake L, Ndeki L, Weiss H, et al. Is antenatal syphilis screening still cost effective in sub-Saharan Africa. Sex Transm Infect 2003;79: 375-81.
Griffiths UK, Wolfson LJ, Quddus A, Younus M, Hafiz RA. Incremental cost-effectiveness of supplementary immunization activities to prevent neonatal tetanus in Pakistan. Bull World Health Organ 2004;82: 643-51.
Nakhaee N, Mirahmadizadeh AR, Gorji HA, Mohammadi M. Assessing the cost-effectiveness of contraceptive methods in Shiraz, Islamic Republic of Iran. East Mediterr Health J 2002;8: 55-63.
Evans DB, Lim SS, Adam T, Tan-Torres Edejer T, the WHO-CHOICE Millennium Development Goals Team. Achieving the millennium development goals for health: Evaluation of current health intervention strategies and future priorities in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38658.675243.94).
Evans DB, Tan-Torres Edejer T, Adam T, Lim S, the WHO-CHOICE Millennium Development Goals Team. Achieving the millennium development goals for health: Methods to assess the costs and health effects of interventions for improving health in developing countries. BMJ 2005;331: 1137-40.
Lauer JA, Rohrich K, Wirth H, Charette C, Gribble S, Murray CJL. PopMod: a longitudinal population model with two interacting disease states. Cos Eff Resour Alloc 2003; 1.
World Health Organization. Managing complications in pregnancy and childbirth: a guide for midwives and doctors. WHO document WHO/RHR/00.7. Geneva: WHO, 2003.
World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice. Geneva: WHO, 2003.
World Health Organization. Managing newborn problems: a guide for doctors, nurses and midwives. Geneva: WHO, 2003.
World Health Organization. WHO antenatal care randomized trial: manual for the implementation of the new model. WHO document WHO/RHR/01.30. Geneva: WHO, 2002.
Stevens TP, Blennow M, Soll RF. Early surfactant administration with brief ventilation vs selective surfactant and continued mechanical ventilation for preterm infants with or at risk for respiratory distress syndrome. Cochrane Database Syst Rev 2004;3: CD003063.
Kulier R, Gumodoka AM, Hofmeyr GJ, Cheng LN, Campana A. Medical methods for first trimester abortion. Cochrane Database Syst Rev 2004;2: CD002855.
Nanda G, Switlick K, Lule E. Accelerating progress towards achieving the MDG to improve maternal health: a collection of promising approaches. Health, Nutrition and Population (HNP) discussion paper. Washington, DC: International Bank for Reconstruction and Development and the World Bank, 2005.
Baltussen R, Knai C, Sharan M. Iron fortification and iron supplementation are cost-effective interventions to reduce iron deficiency in four subregions of the world. J Nutr 2004;134: 2678-84.
Tan-Torres Edejer T, Aikins M, Black R, Wolfson L, Hutubessy R, Evans DB. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies in developing countries for child health. BMJ 2005 Nov 10; epub ahead of print (doi: 1136/bmj.38652.550278.7C).
Baltussen R, Floyd K, Dye C. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies for tuberculosis control in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38645.660093.68).
Morel C, Lauer J, Evans DB. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies to combat malaria in developing countries. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38639.702384.AE).
Hogan DR, Baltussen R, Hayashi C, Lauer JA, Salomon JA. Achieving the millennium development goals for health: Cost effectiveness analysis of strategies to combat HIV/AIDS. BMJ 2005 Nov 10; epub ahead of print (doi: 10.1136/bmj.38643.368692.68).
Horton S, Sanghvi T, Phillips M, Fiedler J, Perez-Escamilla R, Lutter C, et al. Breastfeeding promotion and priority setting in health. Health Policy Plan 1996;11: 156-68.(Taghreed Adam, health economist1, Stephe)