Incremental Costs of Transitioning from Four to Eight WHO-recommended Antenatal Care Visits in Uganda: A Costing Analysis from a Societal Perspective

Abstract Background In 2016, the World Health Organization revised its antenatal care (ANC) recommendation from four to eight visits. For low- and middle-income countries like Uganda, where achieving even four visits remains a challenge, this transition has significant cost implications for both the health system and households. This study estimated the incremental costs of adopting the eight-visit model from a societal perspective. Methods The study was conducted in six government health facilities in southwestern Uganda. A micro-costing approach estimated health facility costs (personnel, equipment, consumables, and overhead). Costs incurred at patients’ end (transport, ultrasound, medical expenses, and time) were collected from 785 women using a questionnaire, with all costs in 2025 USD. Results For an average of 4.3 visits, total cost per woman was $100.1: facility costs $43.7 (43.7%), and patient costs $56.4 (56.3%). Transitioning to eight visits would increase total cost by $57.8 (57.8%), of which $36.4 (63.0%) would fall on households, equivalent to 68.8% of average monthly household income. Total costs would rise by 55.4% ($115.5 to $179.5) at Health Center IVs and 64.3% ($102.3 to $168.1) at Health Center IIIs, with facility costs up 43.4% and 62.9% and patient costs up 61.2% and 65.7%, respectively. Conclusion Transitioning to eight ANC visits would impose a large financial burden on households, with the incremental patient cost equivalent to more than two-thirds of average monthly household income. Equitable implementation requires improving availability of medicines and diagnostics, subsidizing transport, exploring telemedicine or community-based models, and improving efficiency at lower-tier health centers. Highlights Evidence on the incremental costs of scaling up antenatal care services in low-income countries, especially from a societal perspective that captures household costs, remains limited. Transitioning to WHO-recommended eight antenatal care visits in Uganda would increase total cost per woman by 57.8% to $157.9, with 63% of the incremental cost ($36.4) falling on households, equivalent to more than two-thirds of average monthly household income, and 37% ($21.4) on health facilities. To ensure equitable scale-up, policy interventions should improve availability of medicines and diagnostics at public facilities, subsidize transport costs, and explore telemedicine or community-based models to reduce household financial burden.