Valuing the Unpaid Contribution of Community Health Volunteers to Mass Drug Administration Programs

Value is Gendered: The Need for Sex and Gender Considerations in Health Economic Evaluations

Economic evaluations play a crucial role in health resource allocation by assessing the costs and effects of various interventions. However, existing methodologies often overlook significant differences related to sex and gender, leading to a 'blind spot' in understanding patient heterogeneity. This paper highlights how biological and social factors influence costs and health outcomes differently for women, emphasising the need for a more explicit consideration of these differences in economic evaluations to ensure efficient and equitable resource allocation. The paper is structured to first outline how sex and gender factors impact costs and outcomes. It then identifies biases in current economic evaluation methods and practices, using real-world examples to illustrate the implications of these biases on policymaking and health equity. Notably, we argue that neglecting gender considerations can lead to inefficiencies and inequities in healthcare resource distribution. Key areas of gender bias include the estimation of productivity losses, quality of life variations and the secondary household effects of interventions. The analysis reveals that women often face higher healthcare costs and experience different health outcomes due to systemic biases in treatment and care. The paper concludes with practical recommendations for analysts, decision makers and research funders, advocating for the integration of sex and gender-responsive methodologies in health economic evaluations. Ultimately, this work calls for a paradigm shift in health economics to better reflect the complexities of sex and gender and improve health outcomes for all.

Cost of implementing a doxycycline test-and-treat strategy for onchocerciasis elimination among settled and semi-nomadic groups in Cameroon

BACKGROUND

Onchocerciasis is a neglected tropical disease with 217.5 million people globally at risk of having the infection. In both settled and semi-nomadic communities of Massangam Health District in Cameroon, Sightsavers has been carrying out test-and-treat with doxycycline and twice-yearly ivermectin distribution. This paper focuses on the cost of test-and-treat with doxycycline in the two community contexts of settled and semi-nomadic.

METHODS

For the valuation, a combination of gross or micro-costing was used to identify cost components, as well as bottom-up and top-down approaches. The opportunity costs of vehicle and equipment use were estimated and included. Not included, however, were the opportunity costs of building use and Ministry of Public Health staff salaries. We only captured the incremental costs of implementing test-and-treat activities as part of a functional annual community-directed treatment with the ivermectin programme.

RESULTS

We estimate the economic cost per person tested and cost per person treated in Massangam to be US$135 and US$667 respectively. Total implementation cost in the settled community was US$79,409, and in the semi-nomadic community US$69,957. Overall, the total economic cost of implementing the doxycycline test-and-treat strategy for onchocerciasis elimination in Massangam came to US$168,345. Financial costs represented 91% of total costs.

CONCLUSIONS

Unit costs of test-and-treat in both settled and semi-nomadic communities are higher than unit costs of community-directed treatment with ivermectin. However, it is critical to note that a two-year implementation shows a significantly larger reduction in infection prevalence than the preceding 20 years of annual community-directed treatment with ivermectin. Test-and-treat with doxycycline may be a cost-effective intervention in places where the prevalence of microfilaria is still high, or in hard-to-reach areas where community-directed treatment with ivermectin and MDA coverage are not high enough to stop transmission or where marginalised populations consistently miss treatment.

What are economic costs and when should they be used in health economic studies?

Economic analyses of healthcare interventions are an important consideration in evidence-based policymaking. A key component of such analyses is the costs of interventions, for which most are familiar with using budgets and expenditures. However, economic theory states that the true value of a good/service is the value of the next best alternative forgone as a result of using the resource and therefore observed prices or charges do not necessarily reflect the true economic value of resources. To address this, economic costs are a fundamental concept within (health) economics. Crucially, they are intended to reflect the resources' opportunity costs (the forgone opportunity to use those resources for another purpose) and they are based on the value of the resource's next-best alternative use that has been forgone. This is a broader conceptualization of a resource's value than its financial cost and recognizes that resources can have a value that may not be fully captured by their market price and that by using a resource it makes it unavailable for productive use elsewhere. Importantly, economic costs are preferred over financial costs for any health economic analyses aimed at informing decisions regarding the optimum allocation of the limited/competing resources available for healthcare (such as health economic evaluations), and they are also important when considering the replicability and sustainability of healthcare interventions. However, despite this, economic costs and the reasons why they are used is an area that can be misunderstood by professionals without an economic background. In this paper, we outline to a broader audience the principles behind economic costs and when and why they should be used within health economic analyses. We highlight that the difference between financial and economic costs and what adjustments are needed within cost calculations will be influenced by the context of the study, the perspective, and the objective.

Cost of community-based human papillomavirus self-sampling in Peru: A micro-costing study

Background

Cost data of human papillomavirus (HPV) self-sampling programs from low-and-middle-income countries is limited. We estimated the total and unit costs associated with the Hope Project, a community-based HPV self-sampling social entrepreneurship in Peru.

Methods

We conducted a micro-costing analysis from the program perspective to determine the unit costs of (1) recruitment/training of community women (Hope Ladies); (2) Hope Ladies distributing HPV self-sampling kits in their communities and the laboratory testing; and (3) Hope Ladies linking screened women with follow-up care. A procedural manual was used to identify the program's activities. A structured questionnaire and in-depth interviews were conducted with administrators to estimate the resource/time associated with activities. We obtained unit costs for each input previously identified from budgets and expenditure reports.

Findings

From November 2018 to March 2020, the program recruited and trained 62 Hope Ladies who distributed 4,882 HPV self-sampling kits in their communities. Of the screened women, 586 (12%) tested HPV positive. The annual cost per Hope Lady recruited/trained was $147·51 (2018 USD). The cost per HPV self-sampling kit distributed/tested was $45·39, the cost per woman followed up with results was $55·64, and the cost per HPV-positive woman identified was $378·14. Personnel and laboratory costs represented 56·1% and 24·7% of the total programmatic cost, respectively.

Interpretation

Our findings indicate that implementation of a community-based HPV self-sampling has competitive prices, which increases its likelihood to be feasible in Peru. Further economic evaluation is needed to quantify the incremental benefits of HPV self-sampling compared to more established options such as Pap tests.

Funding

Thomas Francis Jr. Fellowship provided funding for data collection. The Hope Project was funded by grants from Grand Challenges Canada (TTS-1812-21131), Uniting for Health Innovation, Global Initiative Against HPV and Cervical Cancer, University of Manitoba, and the John E. Fogarty International Center (5D43TW009375-05).

A mixed-methods exploration into the resilience of community drug distributors conducting mass drug administration for preventive chemotherapy of lymphatic filariasis and onchocerciasis in Côte d'Ivoire and Uganda

Volunteer community drug distributors (CDDs) have been vital to progress made in the elimination of onchocerciasis and lymphatic filariasis; two neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). However, formative work in Côte d'Ivoire and Uganda revealed that CDDs can encounter considerable challenges during mass drug administration (MDA). CDDs must be resilient to overcome these challenges, yet little is known about their resilience. This mixed-methods study explored the resilience of CDDs in Côte d'Ivoire and Uganda. The characteristics and experiences of 248 CDDs involved in the 2018 MDAs in Côte d'Ivoire (N = 132) and Uganda (N = 116) were assessed using a micronarrative survey. Thematic analysis of CDDs' micronarratives was used to identify challenges they encountered during MDA. Resilience was assessed using the Connor-Davidson Resilience Scale 25 (CD-RISC-25). Variables from the micronarrative survey found to be individually associated with mean CD-RISC-25 score (P<0.05) through bivariate analyses were included in a multiple linear regression model. Post-hoc, country-specific analyses were then conducted. Thematic analysis showed that CDDs encountered a wide range of challenges during MDA. The aggregate model revealed that CDDs who had positive relationships or received support from their communities scored higher on the CD-RISC-25 on average (P<0.001 for both), indicating higher resilience. These trends were also observed in the country-specific analyses. Mean CD-RISC-25 scores were unaffected by variations in district, age, gender, and length of involvement with the NTD program. Community support during MDA and positive community-CDD relationships appear to be associated with CDDs' personal capacity to overcome adversity. Involving communities and community leadership in the selection and support of CDDs has the potential to benefit their well-being. This study establishes the CD-RISC-25 as a useful tool for assessing the resilience of CDDs. Further research is needed to understand, promote, and support the resilience of this valuable health workforce, upon which NTD programs depend.

Are current preventive chemotherapy strategies for controlling and eliminating neglected tropical diseases cost-effective?

Neglected tropical diseases (NTDs) remain a significant cause of morbidity and mortality in many low-income and middle-income countries. Several NTDs, namely lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH) and trachoma, are predominantly controlled by preventive chemotherapy (or mass drug administration), following recommendations set by the WHO. Over one billion people are now treated for NTDs with this strategy per year. However, further investment and increased domestic healthcare spending are urgently needed to continue these programmes. Consequently, it is vital that the cost-effectiveness of preventive chemotherapy is understood. We analyse the current estimates on the cost per disability-adjusted life year (DALY) of the preventive chemotherapy strategies predominantly used for these diseases and identify key evidence gaps that require further research. Overall, the reported estimates show that preventive chemotherapy is generally cost-effective, supporting WHO recommendations. More specifically, the cost per DALY averted estimates relating to community-wide preventive chemotherapy for lymphatic filariasis and onchocerciasis were particularly favourable when compared with other public health interventions. Cost per DALY averted estimates of school-based preventive chemotherapy for schistosomiasis and STH were also generally favourable but more variable. Notably, the broader socioeconomic benefits are likely not being fully captured by the DALYs averted metric. No estimates of cost per DALY averted relating to community-wide mass antibiotic treatment for trachoma were found, highlighting the need for further research. These findings are important for informing global health policy and support the need for continuing NTD control and elimination efforts.

Recognition of factors affecting the use of volunteer clinical forces in hospitals in Tehran: A qualitative study

INTRODUCTION

Volunteers are valuable human resources for service-providing organizations. Health system requires their participation and cooperation in all sectors to achieve more success. The present study was conducted to recognize factors influencing the use of volunteer clinical forces (VCFs) in Tehran hospitals from 2018 to 2020.

METHODS

This is a qualitative study, based on grounded theory approach, and was done through semi-structured interviews. The studied population included the experts, managers of hospitals, and high-ranking managers in the Ministry of Health, Iranian Red Crescent Organization, and health nongovernmental organizations (NGOs). Nineteen persons were selected by purposeful sampling method and interviewed. The achieved data were analyzed by content analysis method.

RESULTS

The results showed that using VCFs in Tehran's hospitals was affected by eight following factors: organizational, legal, policy-making, economic, social, security, personal, and cultural dimensions. These findings illustrated the necessity of making changes in the structures, the rules, and the culture of health system to fit the bases with new approaches.

CONCLUSION

VCFs amplify the quality and structure of service providing for patients in hospitals. The focus of policymakers and high-ranking managers in health system is on accelerating their use permanently and legally. Developing health-centered NGOs facilitates the access to VCF, lessens nonclinical loads of hospitals, and improves the organization of human forces. The experiences and knowledge of VCFs cause to develop hospitals' resilience, develop social participation, and improve social capitals in medical field.

Lessons learned for surveillance strategies for trachoma elimination as a public health problem, from the evaluation of approaches utilised by Guinea worm and onchocerciasis programmes: A literature review

Introduction

A number of neglected tropical diseases are targeted for elimination or eradication. An effective surveillance system is critical to determine if these goals have been achieved and maintained. Trachoma has two related but morphologically different presentations that are monitored for elimination, the active infectious form of trachoma and trachomatous trichiasis (TT), the progression of the disease. There are a number of lessons learnt from the Guinea worm surveillance system that are particularly compatible for TT surveillance and the onchocerciasis surveillance system which can provide insights for surveillance of the infectious form of trachoma.

Methods/Principal findings

A literature search of peer-reviewed published papers and grey literature was conducted using PUBMED and Google Scholar for articles relating to dracunculiasis or Guinea worm, onchocerciasis and trachoma, along with surveillance or elimination or eradication. The abstracts of relevant papers were read and inclusion was determined based on specified inclusion and exclusion criteria. The credibility and bias of relevant papers were also critically assessed using published criteria. A total of 41 papers were identified that were eligible for inclusion into the review.

The Guinea worm programme is designed around a surveillance-containment strategy and combines both active and passive surveillance approaches, with a focus on village-based surveillance and reporting. Although rumour reporting and a monetary incentive for the identification of confirmed Guinea worm cases have been reported as successful for identifying previously unknown transmission there is little unbiased evidence to support this conclusion. More rigorous evidence through a randomised controlled trial, influenced by motivational factors identified through formative research, would be necessary in order to consider applicability for TT case finding in an elimination setting. The onchocerciasis surveillance strategy focuses on active surveillance through sentinel surveillance of villages and breeding sites. It relies on an entomological component, monitoring infectivity rates of black flies and an epidemiological component, tracking exposure to infection in humans. Challenges have included the introduction of relatively complex diagnostics that are not readily available in onchocerciasis endemic countries and target thresholds, which are practically unattainable with current diagnostic tests. Although there is utility in monitoring for infection and serological markers in trachoma surveillance, it is important that adequate considerations are made to ensure evidence-based and achievable guidelines for their utility are put in place.

Conclusions/Significance

The experiences of both the Guinea worm and onchocerciasis surveillance strategies have very useful lessons for trachoma surveillance, pre- and post-validation. The use of a monetary reward for identification of TT cases and further exploration into the use of infection and serological indicators particularly in a post-validation setting to assist in identifying recrudescence would be of particular relevance. The next step would be a real-world evaluation of their relative applicability for trachoma surveillance.

The design of a surveillance system needs to be carefully thought out to ensure it provides sufficient evidence to determine if a disease or infection is eliminated or eradicated. If inappropriate it can lead to on-going transmission and resurgence of infection or disease or the unnecessary continuation of interventions, wasting valuable resources. Guinea worm is a disease that is painful and debilitating, for which there is no drug or vaccine. The aim is to eradicate the disease and as such the Guinea worm programme is designed around a strategy of identification of cases and their containment to prevent onward transmission. Onchocerciasis if left untreated can lead to blindness. The aim is to eliminate the disease through the interruption of transmission. A literature review was conducted to determine available evidence and identify lessons that can be learnt from the surveillance of both diseases for the design of trachoma surveillance strategies in the endgame. The potential utility of rumour reporting and a monetary incentive for the identification of a confirmed case of Guinea worm could be explored for trichiasis case finding. Trichiasis is the progression of trachoma and leads to significant ocular morbidity. The introduction of tests for infection and antibodies and the utility of sentinel surveillance as utilised for onchocerciasis are interesting considerations for active trachoma surveillance post-validation and has potential to identify recrudescence cost-effectively. The experiences of both the Guinea worm and onchocerciasis surveillance strategies have very useful lessons that can be trialled for trachoma surveillance. However, their real-world applicability and implications for trachoma need to be evaluated before any changes in guidelines are proposed.

Vaccination or mass drug administration against schistosomiasis: a hypothetical cost-effectiveness modelling comparison

Background

Schistosomiasis is a neglected tropical disease, targeted by the World Health Organization for reduction in morbidity by 2020. It is caused by parasitic flukes that spread through contamination of local water sources. Traditional control focuses on mass drug administration, which kills the majority of adult worms, targeted at school-aged children. However, these drugs do not confer long-term protection and there are concerns over the emergence of drug resistance. The development of a vaccine against schistosomiasis opens the potential for control methods that could generate long-lasting population-level immunity if they are cost-effective.

Methods

Using an individual-based transmission model, matched to epidemiological data, we compared the cost-effectiveness of a range of vaccination programmes against mass drug administration, across three transmission settings. Health benefit was measured by calculating the heavy-intensity infection years averted by each intervention, while vaccine costs were assessed against robust estimates for the costs of mass drug administration obtained from data. We also calculated a critical vaccination cost, a cost beyond which vaccination might not be economically favorable, by benchmarking the cost-effectiveness of potential vaccines against the cost-effectiveness of mass drug administration, and examined the effect of different vaccine protection durations.

Results

We found that sufficiently low-priced vaccines can be more cost-effective than traditional drugs in high prevalence settings, and can lead to a greater reduction in morbidity over shorter time-scales. MDA or vaccination programmes that target the whole community generate the most health benefits, but are generally less cost-effective than those targeting children, due to lower prevalence of schistosomiasis in adults.

Conclusions

The ultimate cost-effectiveness of vaccination will be highly dependent on multiple vaccine characteristics, such as the efficacy, cost, safety and duration of protection, as well as the subset of population targeted for vaccination. However, our results indicate that if a vaccine could be developed with reasonable characteristics and for a sufficiently low cost, then vaccination programmes can be a highly cost-effective method of controlling schistosomiasis in high-transmission areas. The population-level immunity generated by vaccination will also inevitably improve the chances of interrupting transmission of the disease, which is the long-term epidemiological goal.

The division of labour between community medicine distributors influences the reach of mass drug administration: A cross-sectional study in rural Uganda

Background

Despite decades of community-based mass drug administration (MDA) for neglected tropical diseases, it remains an open question as to what constitutes the best combination of community medicine distributors (CMDs) for achieving high (>65%/75%) treatment rates within a village.

Methods

Routine community-based MDA was evaluated in Mayuge District, Uganda. For one month, we tracked 6,148 individuals aged 1+ years in 1,118 households from 28 villages. Praziquantel, albendazole, and ivermectin were distributed to treat Schistosoma mansoni, lymphatic filariasis, and soil-transmitted helminths. The similarity/diversity between CMDs was observed and used to predict the division of labour and overall village treatment rates. The division of labour was calculated by dividing the lowest treatment rate by the highest treatment rate achieved by two CMDs within a village. CMD similarity was measured for 16 characteristics including friendship network overlap, demographic and socioeconomic factors, methods of CMD selection, and years as CMD. Relevant variables for MDA outcomes were selected through least absolute shrinkage and selection operators with leave-one-out cross validation. Final models were run with ordinary least squares regression and robust standard errors.

Results

The percentage of individuals treated with at least one drug varied across villages from 2.79–89.74%. The only significant predictor (p-value<0.05) of village treatment rates was the division of labour. The estimated difference between a perfectly equal (a 50–50 split of individuals treated) and unequal (one CMD treating no one) division of labour was 39.69%. A direct tie (close friendship) between CMDs was associated with a nearly twofold more equitable distribution of labour when compared to CMDs without a direct tie.

Conclusions

An equitable distribution of labour between CMDs may be essential for achieving treatment targets of 65%/75% within community-based MDA. To improve the effectiveness of CMDs, national programmes should explore interventions that seek to facilitate communication, friendship, and equal partnership between CMDs.

Community-based mass drug administration (MDA) uses volunteers within at-risk communities to distribute preventive chemotherapies en masse for neglected tropical diseases. Treatment rates achieved by community medicine distributors (CMDs) vary widely and can undermine morbidity control. We studied routine community-based MDA in 28 villages near Lake Victoria in Uganda. There were two CMDs per village who were tasked with moving from home-to-home to administer praziquantel, albendazole, and ivermectin for schistosomiasis, lymphatic filariasis, and soil-transmitted helminths. We observed treatment outcomes for 6,148 eligible individuals aged 1+ years. Here we identified the best combination of CMD characteristics for achieving high village-level treatment rates. We found that a more equal division of labour (e.g. 50–50 split between how many people each CMD treated) was associated with higher treatment rates when compared to CMDs with an unequal division of labour (e.g. one CMD treating no one). CMDs who were friends were more likely to have a division of labour that was nearly twofold more equal than CMDs who were not friends. The similarity of CMDs with respect to network, demographic, or socioeconomic characteristics did not influence village treatment rates. National programmes should explore interventions that seek to facilitate communication, friendship, and equal partnership between CMDs.

Economic evaluations of onchocerciasis interventions: a systematic review and research needs

OBJECTIVE

To provide a systematic review of economic evaluations that has been conducted for onchocerciasis interventions, to summarise current key knowledge and to identify research gaps.

METHOD

A systematic review of the literature was conducted on the 8th of August 2018 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. No date or language stipulations were applied to the searches.

RESULTS

We identified 14 primary studies reporting the results of economic evaluations of onchocerciasis interventions, seven of which were cost-effectiveness analyses. The studies identified used a variety of different approaches to estimate the costs of the investigated interventions/programmes. Originally, the studies only quantified the benefits associated with preventing blindness. Gradually, methods improved and also captured onchocerciasis-associated skin disease. Studies found that eliminating onchocerciasis would generate billions in economic benefits. The majority of the cost-effectiveness analyses evaluated annual mass drug administration (MDA). The estimated cost per disability-adjusted life year (DALY) averted of annual MDA varies between US$3 and US$30 (cost year variable).

CONCLUSIONS

The cost benefit and cost effectiveness of onchocerciasis interventions have consistently been found to be very favourable. This finding provides strong evidential support for the ongoing efforts to eliminate onchocerciasis from endemic areas. Although these results are very promising, there are several important research gaps that need to be addressed as we move towards the 2020 milestones and beyond.