Incremental costs of scaling up kangaroo mother care: Results from implementation research in Ethiopia and India

Aim: To estimate incremental costs of an implementation model for scaling up

In 2018, a study found that 56% of the 25 countries examined had a KMC policy or guideline in place, but only 9% of eligible babies born in health facilities with KMC had received such care. 3 Another study in India showed that KMC coverage in the community (control group) was 4.4%. 5 The WHO "Every Newborn Action Plan" includes the goal of scaling up KMC to 75% of babies with birth weight <2000 g by 2025. 6 To support the achievement of these goals and targets, a multisite research project was conducted in Ethiopia and India from 2016-19 with the aim to develop a delivery model that would result in a high population based KMC coverage (80% or greater). The results of this study have been published and show that implementation models developed in all sites resulted in KMC initiation in 68%-86% of eligible infants in the population in Ethiopia sites and 86.5%-87.4% in India sites. 7 At discharge, effective KMC (defined as at least 8 hours of skin-to-skin contact per day and exclusive breastfeeding) was provided to 68% of eligible infants in Ethiopia and to 55% of eligible infants in India. The details of the design and implementation of the delivery models are discussed elsewhere. 7 Literature on costs for KMC interventions is limited (discussed later). [8][9][10] In this paper, we estimate incremental costs per newborn <2000 g in the population for implementation of interventions required to scale up quality KMC initiated in public health facilities and continued at home after discharge in study districts in Ethiopia and India.

| ME THODS
The main study developed and tested implementation models for scaling up KMC through an iterative process until a promising model that resulted in close to 80% of effective KMC coverage was found. The study was conducted in four regions in Ethiopia -Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples' Region (SNNPR) (3-5 woredas at each site) and three states in India-Haryana, Karnataka, and Uttar Pradesh (one district at each site). Details of the study methodology and outcomes achieved are reported elsewhere. 7 The major similarities and differences in the models for delivery of KMC across the study sites are presented in Table S1. The KMC implementation models had three components: The "pre-KMC facility" component aimed to maximise correct identification, screening, and referral of LBW babies; the "KMC-facility" component aimed to initiate and maintain effective KMC, and the "post-facility" component aimed to ensure continuation of KMC at home post-discharge.

| Overall approach to costing
The additional activities and related inputs that were required for providing quality KMC under each of the three components mentioned above were identified to estimate incremental costs. The recurrent costs items under each activity included only incremental human resources, supplies and operational costs necessary for implementing the models as shown in Table 1. Additionally, incremental start-up costs (for infrastructure, communications, and training) were also estimated.
Costs of research staff hired for the study, research data collection and management, and vehicles or other equipment purchased for research activities were not included in calculating the KMC costs. Health system costs that were not included in the analysis are also shown in Table 1.
Financial costs as opposed to economic costs were calculated.
This implied that the costs of shared resources such as providers or equipment or discounted present value of capital was not included in cost estimates. Furthermore, marginal or incremental financial costs were estimated, that is only those items that supported scaled-up services for the final KMC implementation model were added.
The average costs at each site were calculated by using the price times quantity approach where the quantities were only for the items listed in Table 1 and which were additional during the scale up of the project. The recurrent incremental costs were estimated by adding costs for the additional time for human resources, consumable and non-consumable items and the operational costs. The costs were derived from programme perspective and not from societal perspective implying that the out-of-pocket expenditures and the opportunity costs to mothers and caregivers were not included.

Correct weighing, recording and identification of LBW babies
Costs of digital weighing scales, which replaced spring scales at facilities where births occurred in the study area, and training costs for staff to accurately weigh and record birth weight were included.
Costs of staff time used for weighing was not included as this was an ongoing activity not specific to KMC implementation.

Referral of LBW babies to KMC-implementing facilities
Transportation costs for all referrals for infants <2000 g from home or lower-level facilities to KMC-implementing facilities in the study district were included. Transportation costs were calculated based on number of newborns referred and average cost per trip. Furthermore, cost of the time spent by health workers to facilitate referral was included. Costs of communication materials used for facilitating referral, community awareness and counselling about KMC were also included.

Key Notes
The coverage of Kangaroo Mother Care (KMC) globally is low, despite its benefits for survival and health of lowbirth-weight babies. Improved coverage and survival can be achieved at low costs through better identification and follow up, strengthening human resource availability; training health workers; and educating and motivating mothers and families about KMC. These costs must be included in programme budgets.

Initial training costs
Actual costs of organising training as well as time costs for trainees and trainers were calculated.

Communication material costs
Costs of development of materials such as videos, educational booklets, job aids were included in the start-up costs.

Recurrent costs
Included staff time for activities such as reassessing weight, assessing for stability, counselling, motivating, and supporting mothers to place the baby in KMC position by trained nurses and physicians, monitoring progress and regular assessments for hours of skin-to-skin contact, breastfeeding, weight, type of feeding; and problem solving in the KMC facility. The cost of supplies included KMC garments (mothers' front open clothing to provide skin-to-skin contact and easily breastfeed, baby wraps/slings), bedding, eating, and cooking utensils, food for the mother (if provided); stationary such as KMC follow up record sheets, registers; and KMC education materials provided to families.

Support continuation of KMC after discharge
After discharge, mothers were encouraged and supported to continue KMC, including support for continued skin-to-skin care and exclusive breastfeeding or breast milk feeding at home for as long as the newborn tolerated or up to 28 days after birth. At some sites, a

| Data collection
Costing data were directly collected by research teams through

| Analysis of costing data
The data for costs were compiled for a full one year in all sites,

| Ethical approvals
Ethical approvals were received from the committees of the World Health Organisation and the participating research institutions for the main study of which this costing study was a subsidiary. 7

| RE SULTS
The number of KMC implementing facilities, health staff at these facilities, number of newborns <2000 g in the study area (inborn or referred into the KMC facilities), newborns who were initiated on KMC, newborns who received effective KMC at discharge and newborns who continued to receive KMC at home are shown in

| Main results
Our results show that the incremental total costs per newborn

| Strengths and limitations of the study
We did not conduct a full economic analysis or cost effectiveness analysis because the purpose of the costing analysis was to inform policy makers about the costs of scaling up KMC for <2000 g neo- limitation is that we could not provide comparative costs of care of newborns <2000 g without KMC. Also, some of the infants initiated into KMC were from outside the study area but we used only the study population for pre-KMC and post-KMC implementation activities. Also, in one site, KMC was provided to all babies <2500 g and not only to those babies <2000 g. This implies that at the KMC facility, the costs are distributed over a larger population of LBW infants treated. The time of the mothers during the stay in the facility and community events have not been considered for costing purposes.
While some of the LBW newborns received KMC in private facilities in India, these were not included in the cost analysis as the data on resources and costs at private facilities could not be reliably obtained.
Furthermore, the main purpose of this study was to know the cost to the public sector so that it could be used for program budgeting.

| CON CLUS IONS/P OLIC Y IMPLIC ATIONS
While the estimated costs of KMC seem feasible, acceptable, and affordable for most health system settings, they must be included in budgets while planning KMC scale up. Our study provides a basis for policy makers and programme managers to budget incremental costs for planning the scaling up of KMC services in a district, based on the expected number of births and those with birthweight <2000 g.

ACK N OWLED G EM ENTS
The country teams would like to acknowledge the state government, facility staff for their support and the study participants, newborns, mothers, and family members for providing the information.

CO N FLI C T O F I NTE R E S T
None declared.

D I SCL A I M ER
The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated.