A cost-effectiveness assessment of an ambulance-based referral system for emergencies: the case of Beira, Mozambique

We set out to estimate the cost-effectiveness of an ambulance-based referral system for emergencies, connecting primary care health centres to a central hospital in a sub-Saharan low-income context. We adopted an observational retrospective study design in the setting of the Beira District (Sofala Region, Mozambique) and classified effective referrals based on the triage emergency codes assigned during transfer. We focused solely on referral running costs required to run the ambulance and complete safe and effective transfer, including staff (nurses and drivers) and communication costs between health centres, ambulance operators and the central hospital. A total of 7849 referrals were included in the analysis, 6295 of which were deemed effective. The total running cost of the intervention (11 months) was $172.071. The cost-per-effective referral was $27,33, which is below the acceptability benchmarks that can be considered “very attractive” ($58,20) and that we defined as 1/10 of the national GDP per capita of Mozambique ($582). Sensitivity analysis corroborates our findings, which confirm and extend previous evidence on the high cost-effectiveness of ambulance-based referral systems for emergencies in sub-Saharan low-income countries.