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: ClinicalTrials.gov, 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.