Cost-benefit and extended cost-effectiveness analysis of a comprehensive adolescent pregnancy prevention program in Zambia: study protocol for a cluster randomized controlled trial


Background: Early marriages, pregnancies and births are the major cause of school drop-out among adolescent

girls in sub-Saharan Africa. Birth complications are also one of the leading causes of death among adolescent girls.

This paper outlines a protocol for a cost-benefit analysis (CBA) and an extended cost-effectiveness analysis (ECEA) of

a comprehensive adolescent pregnancy prevention program in Zambia. It aims to estimate the expected costs,

monetary and non-monetary benefits associated with health-related and non-health outcomes, as well as their

distribution across populations with different standards of living.

Methods: The study will be conducted alongside a cluster-randomized controlled trial, which is testing the hypothesis

that economic support with or without community dialogue is an effective strategy for reducing adolescent childbearing

rates. The CBA will estimate net benefits by comparing total costs with monetary benefits of health-related and

non-health outcomes for each intervention package. The ECEA will estimate the costs of the intervention

packages per unit health and non-health gain stratified by the standards of living. Cost data include program

implementation costs, healthcare costs (i.e. costs associated with adolescent pregnancy and birth complications

such as low birth weight, pre-term birth, eclampsia, medical abortion procedures and post-abortion complications) and

costs of education and participation in community and youth club meetings. Monetary benefits are returns to education

and averted healthcare costs. For the ECEA, health gains include reduced rate of adolescent childbirths and non-health

gains include averted out-of-pocket expenditure and financial risk protection. The economic evaluations will

be conducted from program and societal perspectives.

Discussion: While the planned intervention is both comprehensive and expensive, it has the potential to produce

substantial short-term and long-term health and non-health benefits. These benefits should be considered seriously

when evaluating whether such a program can justify the required investments in a setting with scarce resources. The

economic evaluations outlined in this paper will generate valuable information that can be used to guide large-scale

implementation of programs to address the problem of the high prevalence of adolescent childbirth and school

drop-outs in similar settings.

Trial registration:, NCT02709967. Registered on 2 March 2016. ISRCTN, ISRCTN12727868.

Registered on 4 March 2016.

Keywords: Adolescent pregnancy, Early marriage, School drop-out, Cost-benefit analysis, Extended cost-effectiveness

analysis, Cash transfer, Catastrophic health expenditure, Cluster randomized controlled trial.

Publisher's Version