1. ESTIMATING THE RETURNS OF INVESTING IN RMNCH Malcolm Bryant and Susan Foster

2. Overview  Why calculate ROI  Overall approach  Developing a framework for policy-makers  How it will work  Challenges 2

3. Why calculate returns on investment for RMNCH?  Economic benefits of investing in health have been calculated for a range of populations and diseases  Identification of the economic benefits of investing in HIV, TB, malaria—presented persuasive cases  Financing agencies understood these arguments, and as a result, increased funding  RMNCH have not benefitted from the same form of detailed analysis  Country-level decision-makers require tools to understand and support RMNCH 3

4. Overall approach  Review and list the RMNCH challenges faced by women and their children in low-income environments  Identify the major health, social, and other impacts of each challenge  Identify the economic impact of each challenge 4

5. Creating a framework  Identify the most important costs associated with each impact  Use an expanded cost-of-illness approach;  Capture direct and indirect costs;  Individuals  Households  Healthcare systems  Societies 5

6. Populate the framework  What data is required to estimate each cost at the national level?  What are the possible sources of such data in typical country settings?  Current burden of morbidity and mortality  Unit costs to estimate the cost of illness  Estimate current costs of providing RMNCH interventions and services  Identify data needed to calculate productivity losses 6

7. How will it work? 1. What are the RMNCH challenges?  All common maternal, neonatal, and childhood illnesses and conditions!  How to make sense of them?  The Continuum of Care 7

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9. Adolescence and before pregnancy Stage/EventChallengesOutcomesImpacts Menarche and before Rituals – e.g. FGM Pain, shame, fear, psychological and mental illness, dyspareunia, perineal tears during labor Burden on health system Marital discord+/- divorce Neonatal deaths and asphyxia, postpartum hemorrhage and death MenstruationPain, inconvenience Early marriage Lost days at school, lost days at work, Decreased female literacy; increased child mortality; Lost productivity Early Sexual Activity Unwanted pregnancy, STI, HIV/AIDS Social rejection, dystocia in young girls, Infertility, divorce, early end of schooling Burden on health system Neonatal death and asphyxia, decreased female literacy, increased child mortality 9

10. Selecting priorities  RMNCH is infinitely complex (it makes HIV, TB, and Malaria seem simple). We have to make rational choices about which impacts to address  Proposed Criteria:  Must be proven interventions to address impact  Feasibility  Political visibility Attractive to politicians and can be understood by them  Evidence of cost-effectiveness 10

11. Possible criteria that could be used  Health services costs averted  Lives saved – RMNCH is unique in being able to save more than one life with one treatment episode, e.g. a mother and the baby  Long term sequelae of birth injuries, e.g. asphyxia - need for lifetime of care, low or no income earning, etc.  Long term sequelae of maternal injuries e.g. fistula – divorce, stigma  Indirectly, loss of a mother often means poor survival of remaining children  Increasing under five survival has a disproportionate effect on national life-expectancy  Societal costs – low morale, fatalism, orphans, widowers 11

12. Who is our target audience  International funding agencies?  Politicians and policymakers at national level  Ministry of Finance  Ministry of Health  National medical and nursing staff and thought leaders  Local politicians and funding groups in decentralized settings 12

13. How closely to link with health and non- health solutions Where does female education fit in with this? 13

14. Next Steps  Link RMNCH challenges to health, social, economic and other impacts  Estimate the costs to the individual, household, community, health system, and country of each impact  Create a simple tool that can be used to estimate the costs  Simple is key. Methodological soundness is required, but a balance must be maintained between the perfect and the practical 14