Economic Evaluation of the Zika Contraception Access Network—A Primary Public Health Intervention to Increase Access to Contraception in Puerto Rico during the 2016–17 Zika Virus Outbreak

Research Objective Zika virus infection during pregnancy can cause severe brain abnormalities, including microcephaly. During the 2016‐2017 Zika outbreak, Puerto Rico had the most cases of Zika virus among US states and territories. Contraception to prevent unintended pregnancies was identified as a primary strategy to prevent birth defects during the Zika outbreak. The Zika Contraception Access Network (Z‐CAN), an intervention implemented between April 2016 and September 2017, provided women in Puerto Rico with access to the full range of reversible contraception at no cost. Prior to implementation, a cost‐effectiveness analysis (CEA) of a contraceptive access intervention based on assumptions was conducted and showed that the intervention was cost‐saving. The objective of the study was to estimate the cost‐effectiveness of the Z‐CAN program using actual program data. Study Design We evaluated the costs and outcomes of increased access to contraception as a result of the Z‐CAN intervention compared with no intervention using a decision tree model from a societal perspective. Health outcome measures included the number of Zika‐associated microcephaly (ZAM) cases (consisting of live‐born and stillborn infants and pregnancy losses with microcephaly) and unintended pregnancies. The economic benefits of the Z‐CAN intervention included Zika virus–associated costs avoided, including lifetime costs avoided from ZAM cases prevented and costs avoided from monitoring Zika virus–exposed pregnancies and infants born from Zika virus–infected mothers, and the cost avoided from prevention of unintended pregnancies as a result of increased contraception access through the Z‐CAN intervention. Population Studied 29 211 women participated in Z‐CAN. Principal Findings The Z‐CAN intervention costs a total of $27.7 million, including $19.6 million for the full range of reversible contraceptive methods, $3.6 million for contraception‐related services, and $4.6 million for programmatic activities (such as training, administrative costs, and a health communication campaign). The program potentially prevented 34 cases of ZAM among unintended pregnancies avoided. The incremental intervention cost of US $23.5 million (ie, $805 per women participated) in Z‐CAN relative to no intervention (status quo) is more than offset by $88.4 million in avoided Zika virus–associated costs, including $3.8 million from avoided testing and monitoring for Zika virus–exposed pregnancies and $84.6 million from ZAM cases prevented. The net savings from avoided Zika virus–associated costs alone is $64.9 million. The additional savings from avoided unintended pregnancies were $54.8 million. Conclusions Our findings demonstrate that Z‐CAN was cost‐saving in the context of a public health emergency response setting during the 2016‐2017 Zika virus outbreak in Puerto Rico. Implications for Policy or Practice Our study has two important contributions. First, the cost data for a real‐world large‐scale public health intervention during an emergency are valuable for planning and implementing similar programs in the future. Second, we had a unique opportunity to conduct a CEA for a hypothetical intervention prior to implementation, and conduct another economic evaluation using actual costs of the real‐world intervention. The findings are consistent and validate modeling as a useful way to inform decision making in an emergency setting with many uncertainties.