Discussion
MINOR
In Uganda, the Ministry of Health assumes leadership and is responsible for resource mobilization, operating under the following hierarchical structure: National referral hospitals, Regional referral hospitals, Health center IV at the Sub-district level, Health center III, Health center II, and the Village Health Teams.Planning and decision-making are integral responsibilities of the District Health Management teams. However, the decision-making process is ad hoc and dependent on the availability of funds [The main objective of this cost effectiveness analysis was to aid potential decision-makers and stake-holders by providing an economic evaluation of health outcomes and costs. This study considered important concerns with respect to a future large-scale implementation of the education intervention. One significant aspect was that this education intervention was largely managed and implemented by local personnel, using local village health teams. Thus, the cost-effectiveness findings of this intervention would have the potential to be replicated in other low-resource, community-based settings.Health promotion for parenting programs has consistently been linked with early childhood development and cognitive development [Our results show that the mean cognitive composite score increased with 16.11 units in the intervention group relative to the control group. Similar cost-effectiveness analyses of education interventions delivered to mothers to enhance children’s cognitive development are rare and we have only found one, which was conducted in Pakistan. That study reported that the cognitive composite score difference between the group with responsive stimulation and that without responsive stimulation was 7.6 (the average scores were 81.7 and 74.1, respectively) [Our estimated ICER indicates that the education intervention would be a cost-effective strategy if the willingness to pay threshold is above $16.50 per cognitive composite score gained. However, it has not been stated an explicit official willingness to pay threshold for cognitive development in Uganda. When used to guide high-level decision makers, cost-effectiveness analyses preferably include generic health measures such as DALY. In our study, it was not possible to translate the cognitive composite score to DALYs because both the DALY weight and the duration of the health effect were unknown. However, we present numerical examples in the In the probabilistic sensitivity analysis, the estimated mean ICER was $14.61 (95% decision model interval $9.14-$21.48) per unit of cognitive composite score, and all individual simulations were distributed in the top right quadrant. The deterministic one-way sensitivity analysis (High personnel costs are common in educational intervention programs and tend to decrease marginally over time with increasing number of participants [Relative to personnel costs, the remaining cost categories had minor impact on the ICER (One main strength of this study is that the analysis was based on a cluster-RCT; a rigorous study design that reduces selection bias [