Budgeting for comprehensive sexual and reproductive health and rights under universal health coverage

Figures & data

Table 1. Ingredients example: essential care for all women with routine vaginal delivery

Drug/supply	% receiving	Note	No.	Times per day	Days per case	Total units per case	Unit cost (any country)	Cost per avg. case (any country)
Drawsheet, plastic	100	Assumes cleaned and reused at least 2 times*	0.3	1	1	0.3	$0.84	$0.28
Gloves, latex, disposable, pair	100	One per health care worker*	1	4	1	4	$0.05	$0.19
Chlorhexidine surgical scrub, 5ml	100	Antiseptic*	1	1	1	1	$0.02	$0.02
Cotton swab	100	For application of antiseptic^†	1	1	1	1	$0.10	$0.10
Partograph	100	For monitoring*	1	1	1	1	$0.04	$0.04
Delivery record	100	For documenting*	1	1	1	1	$0.18	$0.18
Identification bracelet	100	For the woman^†	1	1	1	1	$0.03	$0.03
Paracetamol, tablet, 500 mg	100	For pain relief*	1	4	3	12	$0.01	$0.11
Episiotomy
Lidocaine HCl (in dextrose 7.5%), ampoule 2ml	50^ǂ	Local anaesthesia for episiotomy /repair of tears*	1	1	1	1	$0.13	$0.06
Syringe, needle and swab	50^ǂ	For lidocaine injection*	1	1	1	1	$0.07	$0.04
Suture, catgut, chromic, needle	50^ǂ	Suture of episiotomy or tear*	1	1	1	1	$0.29	$0.15
Gauze pad, sterile	50^ǂ	Dressing for episiotomy/tears*	1	1	1	1	$0.06	$0.03
Staff Type	% treated by			Min’s^†	No. of days	Total min’s	Unit cost (example: Bangladesh)	Cost per avg. case (example: Bangladesh)
Nurse/Midwife	50^§	Monitoring of labour, assistance during delivery*		120	1	120	$0.06	$3.75
Assistant Nurse	50	Monitoring of labour, assistance during delivery^§		120	1	120	$0.05	$2.88
Obstetrician	100	During delivery*		20	1	20	$0.08	$1.54
Auxiliary/ Attendant	100	During hospital stay^§		30	2	60	$0.05	$2.88
Hospital food cost	% hospitalised				No. of days	Total days	Unit cost (example: Bangladesh)	Cost per avg. case (example: Bangladesh)
Food costs per day	100*				2		$0.56	$1.12

No., number; Min’s, minutes; Avg., average.

* These assumptions follow those included in the OneHealth Tool.⁴⁶. Note that some delivery-related items included in OneHealth are included as essential care for newborns in the Adding It Up model.

^†Assumptions based on advice from clinicians and health system costing experts.

^ǂAssumptions based on information contained in Clesse et al.⁵⁶

^§Assumptions based on the WHO’s guidance for task-shifting for maternal and child health.⁴⁹

Table 2. Interlinked services and analysis parameters by scenario

Preventive service(s)	Impacted service(s)	Assumptions/mechanism by scenario
		(1) Current service levels	(2) All-needs-met: Impacted service(s)	(3) All-needs-met: Preventive & impacted services
Chlamydia (CT) and gonorrhoea (NG) treatment	Pelvic inflammatory disease (PID) treatment	Level of treatment is country-specific. However, many women with CT and NG go untreated, 40% of untreated women progress to PID, ^Citation57 and many of these PID cases go untreated	Level of treatment is country-specific. Women with CT and NG go untreated, 40% of untreated women progress to PID,^Citation57 and all of these PID are treated	All incident CT and NG infections are treated, eliminating the PID that results from untreated infections
Safe abortion services	Unsafe abortion* and postabortion care (PAC)	Levels of safe and unsafe abortion services are country-specific. We used estimates from country-specific studies, prior AIU estimates, and abortion safety classifications to make assumptions about estimated abortion complications that require PAC. More details can be found elsewhere.^Citation24	Levels of safe and unsafe safe services remain at current country-specific levels. All need for abortion-related PAC is met.	We hypothetically assumed that all abortions are provided safely. Need for abortion-related PAC is greatly reduced.^† All PAC cases receive treatment.
Safe childbirth services^ǂ	Services for managing/treating: - Maternal sepsis - Post-partum haemorrhage (PPH) - Obstetric fistula - Local infections in newborns - Newborn sepsis	The level of facility-based, safe deliveries is country-specific. The level of care provided for the following complications requiring treatment is also country-specific: 2.5% of vaginal deliveries in facilities, 5.3% of caesarean deliveries and 5% of deliveries outside of facilities progress to maternal sepsis.^Citation58 Among women delivering vaginally, including assisted vaginal deliveries (AVDs), among those receiving active management of third-stage labour (AMSTL), 9.5% experience post-partum haemorrhage (PPH). Among women delivering vaginally who do not receive AMSTL, PPH occurs at a rate of 21.9%.^Citation59 2.15% of women with untreated obstructed labour experience obstructed fistula 10% of newborns experience local infections,^Citation60, and 10% of newborns develop sepsis.^Citation61 90% of newborns with sepsis can be treated with injectable antibiotics, and 10% require full supportive care.^Citation62	Facility-based, safe deliveries remain at current country-specific levels. However, care for complications a-d increases to meet all need	We assume all women giving birth have facility-based, safe delivery care. We also assume all newborns are delivered with safe, clean delivery practices and all receive immediate newborn care. As a result, complications drop as noted below. All complications receive treatment. All women undergoing caesarean section receive prophylactic antibiotics, reducing maternal sepsis to 2.9% of caesarean deliveries and 2.5% of vaginal deliveries in facilities.^Citation58 All women delivering vaginally receive AMSTL, reducing PPH to 9.5% of these deliveries. We assume all obstetric fistula is eliminated due to all cases of obstructed labour receiving treatment. Occurrence of newborn infections and newborn sepsis is reduced by 50%.^Citation60 The sepsis treatment needs (injection or full care) remain split at 90%/10%

CP, contraception; PRNC, pregnancy-related and newborn care; CT, Chlamydia trachomatis (chlamydia); NG, Neisseria gonorrhoeae (gonorrhoea) PID, pelvic inflammatory disease.

*Unsafe abortion comprises both less safe and least safe abortion.

^†A low level of need for PAC persists due to complications from safe abortion.

^ǂ Essential care for all women with routine vaginal delivery, assisted vaginal delivery or caesarean section plus essential care for all newborns

Table 3. Number (000s) or proportion of women aged 15–49 requiring and receiving service in all LMICs in 2019, by scenario*

Scenario:	(1) Current service levels	(2) All-needs-met: Impacted service(s)	(3) All-needs-met: Preventive & impacted services
Cluster 1: STI treatment for women aged 15–49
Number of women with chlamydia and gonorrhoea infections	87,194	87,194	87,194
Number of women who receive chlamydia and gonorrhoea treatment	10,986	10,986	87,194
% of all chlamydia and gonorrhoea infections that go untreated	87%	87%	0%
Number of women with PID	30,483	30,483	0
Number of women with PID who receive treatment	16,285	30,483	0
% of PID infections that go untreated	47%	0%	NA
Cluster 2: Induced abortion and postabortion care
Number of safe abortions	33,099	33,099	68,518
Number of less safe abortions	24,268	24,268	0
Number of least safe abortions	11,151	11,151	0
Number of women requiring PAC^†	20,882	20,882	1,655
Number of women receiving PAC^†	12,340	20,882	1,655
% of women who need but do not receive PAC^†	41%	0%	0%
Cluster 3: Safe childbirth services
Number of live births in LMICs	127,362		127,362
Preventive
Number of births with facility deliveries	96,644		127,362
Number of newborns receiving immediate care	96,644		127,362
Impacted
Obstetric fistula repair^ǂ
Number needing	68		0
Number receiving	22		0
Maternal sepsis management^ǂ
Number needing	4,673		3,251
Number receiving	2,811		3,251
Postpartum haemorrhage treatment^ǂ
Number needing	13,274		7,939
Number receiving	6,524		7,939
Newborn local infections treatment
Number needing	12,736		6,368
Number receiving	9,664		6,368
Newborn sepsis treatment (injectable antibiotics and full supportive care)
Number needing	12,736		6,368
Number receiving	9,489		6,368

LMIC, low- and middle-income country; PID, pelvic inflammatory disease; NA, not applicable; PAC, postabortion care.

*Regional outcomes can be found in Supplementary Table 3.

^†For abortion complications (i.e. not including PAC for miscarriage).

^ǂThese costs are only for women needing these interventions who have live births. Those needing these interventions who have a stillbirth are excluded here.

Table 4. Total direct cost (USD) per recipient of selected interventions in LMICs in 2019, by region*

Intervention	Africa	Asia	East and Southern Europe	Latin America and the Carribean	Oceania	All LMICs
Cluster 1: STI treatment for women aged 15–49
Chlamydia treatment	4.97	4.65	6.96	6.94	4.46	5.02
Gonorrhea treatment	4.93	4.61	6.92	6.89	4.42	4.98
Syphilis treatment	7.29	6.97	9.28	9.26	6.78	7.34
Trichomonas treatment	4.94	4.62	6.94	6.91	4.44	4.99
PID from chlamydia or gonorrhoea	7.09	6.78	9.09	9.06	6.59	7.15
Cluster 2: Induced Abortion and Postabortion Care (PAC)
Induced abortion services for safe abortions
Abortion - Manual or electric vacuum aspiration (safe)	4.69	4.42	6.36	6.19	4.26	4.72
Abortion - Dilation and evacuation (safe)	8.09	7.55	11.52	11.22	7.23	8.16
Abortion - Mifepristone and misoprostol (<12 weeks or 84 days) (safe)	19.19	18.76	21.88	21.28	18.50	19.20
Abortion - Mifepristone and misoprostol (≥12 weeks) (safe)	24.94	24.13	30.05	29.23	23.65	25.01
Abortion - Misoprostol (<12 weeks) (safe)	6.48	6.05	9.18	8.94	5.80	6.53
Abortion - Misoprostol (≥12 weeks) (safe)	8.69	8.26	11.39	11.08	8.01	8.74
Induced abortion services for less safe abortions
Abortion - Manual or electric vacuum aspiration (less safe)	4.86	4.58	6.62	6.59	4.41	4.90
Abortion - Dilation and currettage (less safe)	8.47	7.93	11.90	11.86	7.61	8.56
Abortion - Mifepristone and misoprostol (<12 weeks or 84 days) (less safe)	13.81	13.81	13.81	13.81	13.81	13.81
Abortion - Mifepristone and misoprostol (≥12 weeks) (less safe)	14.91	14.91	14.91	14.91	14.91	14.91
Abortion - Misoprostol (<12 weeks) (less safe)	1.10	1.10	1.10	1.10	1.10	1.10
Abortion - Misoprostol (≥12 weeks) (less safe)	3.31	3.31	3.31	3.31	3.31	3.31
Least safe abortion (all gestations)
No health systems costs included	0.00	0.00	0.00	0.00	0.00	0.00
Postabortion care (PAC) for induced abortion or miscarriage complications
PAC for incomplete abortion and nonsevere bleeding
PAC - Treating Incomplete abortion with manual vacuum aspiration (MVA)	11.07	10.28	15.99	15.92	9.82	11.20
PAC - Treating incomplete abortion with misoprostol	15.61	14.62	21.86	21.77	14.03	15.78
PAC - Management of non-severe haemorrhage	6.21	6.19	6.36	6.36	6.17	6.22
PAC for abortion complications needing comprehensive emergency obstetric care (EmOC)
PAC - Shock	40.03	38.41	49.44	49.36	37.51	40.20
PAC - Sepsis	77.34	74.83	91.57	91.48	73.46	77.56
PAC - Uterine perforation/cervical laceration	69.26	66.19	86.61	86.50	64.52	69.52
PAC - Severe hemorrhage	119.86	117.34	134.09	134.00	115.97	120.08
Prereferral management of abortion complications
PAC - Prereferral management of abortion complications	28.91	27.46	38.07	37.94	26.60	29.16
Cluster 3: Safe childbirth services^†
Maternal care
Obstetric fistula repair	82.45	76.87	114.84	114.57	73.77	83.04
Maternal sepsis case management	109.31	105.07	134.06	133.84	102.70	109.77
Postpartum hemorrhage (PPH) treatment	105.51	100.87	132.71	132.47	98.27	106.03
Newborn care
Newborn local infections treatment	1.95	1.81	2.83	2.81	1.72	1.97
Newborn sepsis treatment with injectable antibiotics	27.97	25.88	38.30	38.34	24.86	27.96
Newborn sepsis treatment with full supportive care	87.20	81.26	121.75	121.45	77.96	87.84

LMIC, low- and middle-income country; CEmOC, comprehensive emergency management of obstetric complications; PID, pelvic inflammatory disease.

* These costs are the sum of the components found in Supplementary Table 2.

^† Several interventions contribute to reductions in need for the impacted services (listed here). These include in-facility delivery and provision of essential newborn care, but many others are also included, such as management of obstructed labour, etc. Because of the complex nature of the linkages between these interventions we have not provided preventive service costs here.

Table 5. Total cost (000s) (USD) for providing care by intervention and within linked category in all LMICs in 2019, by scenario*

Scenario:	(1) Current service levels	(2) All-needs-met: Impacted service(s)	(3) All-needs-met: Preventive & impacted services
STI treatment
Chlamydia treatment	29,293	29,293	298,972
Gonorrhoea treatment	31,738	31,738	167,352
PID treatment	127,364	227,188	0
Total	188,395	288,219	466,324
Induced abortion and postabortion care
Safe abortion services	353,002	353,002	642,872
Less safe abortion services	172,888	172,888	0
Least safe abortion services	0	0	0
Postabortion care^†	869,437	1,479,415	119,355
Total	1,395,327	2,005,306	762,227
Safe childbirth services
Preventive - all services^ǂ	-	-	-
Impacted
Obstetric fistula repair^§	1,431	-	0
Maternal sepsis case management^§	315,300	-	347,236
Postpartum haemorrhage (PPH) treatment^§	711,573	-	841,409
Newborn local infections treatment	18,846	-	11,874
Newborn sepsis treatment (injectable antibiotics + full supportive care)	313,075	-	206,746
Total	1,360,226	-	1,407,265

LMIC, low- and middle-income country; PID, pelvic inflammatory disease; PPH, post-partum haemorrhage.

* Regional outcomes can be found in Supplementary Table 4.

^† For abortion complications (i.e. not including PAC for miscarriage).

^ǂ Several interventions contribute to reductions in need for the impacted services. These include in-facility delivery and provision of essential newborn care, but many others are also included, such as management of obstructed labour, etc. Because of the complex nature of the linkages between these interventions, we have omitted providing costs for all the preventive services here.

^§ These costs are only for women needing these interventions who have live births. Those needing these interventions who have a stillbirth are excluded here.

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Data availability

The data that support the findings of this study are available at https://gu.tt/AddingItUp. The survey data used in the analysis include the Demographic and Health Surveys (DHS); Multiple Indicator Cluster Surveys (MICS); U.S. Centers for Disease Control and Prevention Reproductive Health Surveys (RHS); Performance Monitoring for Action (PMA) surveys; and Pan Arab Project for Family Health (PAPFAM) surveys. Restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are available for free from many of the source websites (e.g. the DHS Program, UNICEF and PMA websites), respectively, or by request from country statistical offices.