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Table 3 Summary of key methodological points and cost and cost-effectiveness results of included studies

From: Costs and cost-effectiveness of community health workers: evidence from a literature review

Study Country Type of CHW Description Type of study and perspective Programme costs included Patient costs included Narrative conclusion on cost and/or cost-effectiveness
Training Capital Recurrent Joint/overhead
Maternal health  
Alem et al. 2012 [27] Bangladesh CHWs Dissemination of health messages, identifying pregnancies, bringing pregnant women to birthing huts, accompanying them during their delivery and providing newborn care by CHWs. Costing of CHW dropout from a provider perspective. Yes Yes Yes Yes No CHW dropout after training and working for 1 month leads to foregone health services as well as recruitment and training of replacements. With an additional investment double the initial investment per CHW, the organization reduces dropout, can make additional cost savings (not recruiting and training a replacement) and fewer services are foregone in the community.
Sutherland and Bishai. 2009 [39] India Village health workers (VHWs) Simulation study on maternal health: prevention of PPH and anaemia by VHWs. Cost-effectiveness study from a provider perspective. Yes No Yes No No Misoprostol prevention and treatment provided by VHWs are both more cost-effective than standard care (although standard care is not defined). Treatment is significantly more cost-effective than prevention in terms of cost per life saved.
Sutherland et al. 2010 [40] India VHWs Simulation study on prevention of PPH by VHWs. Cost-effectiveness study from a provider perspective. Yes No Yes No No Misoprostol prevention and treatment provided by VHWs are both more cost-effective than standard care (although standard care is not defined). Treatment is significantly more cost-effective than prevention in terms of cost per life saved.
Chin-Quee 2013 [26] Zambia CHWs Family planning intervention by CHWs Costs and benefits of a single intervention from a programme perspective. Yes No Yes No No Provision of injectable contraceptives by CHWs can be done at low cost when added to an existing community-based distribution package.
Neonatal health
Borghi et al. 2005 [11] Nepal Women group facilitators Maternal health intervention with women’s groups. Economic evaluation with provider perspective alongside RCT Yes Yes Yes Yes No Women groups facilitated by lay health workers could provide a cost-effective way of reducing neonatal deaths compared to current practice.
Chola et al. 2011 [28] Uganda Peer supporters Breastfeeding intervention delivered by local women trained as peer supporters. Costing study from a local provider perspective Yes Yes Yes Yes No The use of local women trained as peer supporters to individually counsel women about exclusive breast feeding can be implemented in sub-Saharan Africa at a “sustainable cost”.
Sabin et al. 2012 [38] Zambia Traditional birth attendants (TBAs) Neonatal healthcare delivered by trained TBAs. Costing and cost-effectiveness study alongside RCT; financial analysis based on trial costs only then expanded to intervention economic costs from societal perspective Yes No Yes No No The strategy of using trained TBAs to perform the neonatal resuscitation protocol (NRP) and antibiotics with facilitated referral to a health centre (AFR) to reduce neonatal mortality was found to be highly cost-effective as compared to GDP per capita and per WHO guidelines in Zambia.
Child health
Fiedler 2003 [16] Honduras Monitors/CHWs Growth monitoring of children under two by CHWs. The CHW treats and refers children under five to health services. Costing study from a health service perspective. Yes Unclear Yes No No CHW programme cost 11% of the facility-based alternative while saving outpatient visits and costs.
Fiedler et al. 2008 [17] Honduras Monitors/CHWs Growth monitoring of children under two by CHWs. The CHW treats and refers children under five to health services. Costing study from a health service perspective Yes Unclear Yes No No CHW programme cost 11% of the facility-based alternative while saving outpatient visits and costs.
Nonvignon et al. 2012 [19] Ghana CHWs CHW home management of malaria using two different drugs, by voluntary community-based agents in Ghana. Cost-effectiveness study with a societal perspective Unclear Yes Yes Unclear Unclear Home management of under-five fevers by trained, unpaid community volunteers through diagnosis and dispensing of antimalarials and/or antibiotics was found to be a cost-effective strategy (in terms of cost per DALY averted compared with threshold recommended by WHO) for reducing under-five mortality in this setting.
Prinja et al. 2013 [36] India Auxiliary nurse midwives (ANM), anganwadi workers (AWW) and accredited social health activists (ASHA) Comparison of costs of integrated management of neonatal and childhood illnesses (IMNCI) and no IMNCI. Economic evaluation from a programme perspective nested in an effectiveness trial Yes Yes Yes Yes No Implementation of IMNCI imposes additional costs to the health system; cost-effectiveness needs to be assessed in a comprehensive economic evaluation.
Puett et al. 2013 [37] Bangladesh CHWs Comparison of home management of severe acute nutrition versus facility-based inpatient treatment. Cos-effectiveness study from a societal perspective Yes Yes Yes Yes Yes Treatment of severe acute malnutrition by CHWs is highly cost-effective compared to facility-based treatment.
Tozan et al. 2010 [23] Africa CHWs A community-based pre-referral artesunate treatment and referral programme by CHWs for children suspected to have severe malaria in areas with poor access to formal healthcare in rural Africa. Cost and effects of single intervention from a provider perspective Unclear No Yes No No Pre-referral artesunate treatment delivered by CHWs is a cost-effective (as compared to GDP per capita and per WHO guidelines), life-saving intervention, which can substantially improve the management of severe childhood malaria in rural African settings.
Tuberculosis
Clarke et al. 2006 [14] South Africa Lay health workers (LHWs) Tuberculosis treatment adherence and counselling by trained LHWs on farms. Cost-effectiveness analysis alongside RCT from a health district perspective No Unclear Yes No No Costs to public budgets can be substantially reduced while maintaining or improving case detection and treatment outcomes, by using farm-based LHWs.
Datiko and Lindtjørn 2010 [15] Ethiopia Health extension workers (HEWs) HEWs administered DOT for 2 months during intensive phase at health post, gave out drugs on monthly basis during continuation phase. Cost and cost-effectiveness as part of randomized trial from a societal perspective No Yes Yes Yes Yes Involving HEWs in TB treatment is cost-effective alternative to health facility delivery.
Floyd et al. 2003 [18] Malawi Guardians Out-patient DOT at health facilities (by CHW) or by community member guardian (only new smear-negative patients), handing out drugs in an urban setting. Cost and cost-effectiveness from a societal perspective No Yes Yes Yes Yes When new smear-positive and smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs compared with the strategy used until end of October 1997 which did not require any direct observation of treatment.
Okello et al. 2003 [20] Uganda Community volunteers DOT at community level by village-based volunteers. Cost-effectiveness study from a societal perspective Yes No Yes Yes Yes Findings suggest there is a strong economic case for replacing hospital admission for the first 2 months of treatment followed by 6 months of daily unsupervised outpatient treatment with community-based care in Uganda, provided it is accompanied by strong investment in activities such as training, community mobilization and programme supervision.
Prado et al. 2011 [21] Brazil Trained guardians and CHWs TB care in an urban setting. Cost-effectiveness study from a societal perspective Yes Yes Yes Yes Yes Guardian-supervised DOT is an attractive option to complement CHW-supervised DOT.
Sinanovic et al. 2003 [22] South Africa CHWs/LHWs New smear-positive pulmonary and retreatment patients receiving treatment for TB by CHWs/LHWs. Economic evaluation from a societal perspective as part of a prospective cohort study Yes No Yes Yes Yes Community-based care is a cost-effective strategy for TB treatment compared with the facility alternative.
Malaria
Chanda et al. 2011 [13] Zambia CHWs CHWs using rapid diagnostic test for malaria in Zambia. Complicated malaria cases and non-malaria febrile cases were referred to the nearest health facility for further management. Uncomplicated malaria cases were treated by the CHW using artemisinin-based combination therapy (ACT). Cost-effectiveness study from a provider perspective No Yes Yes Yes No Home management of uncomplicated malaria by CHWs was 36% more cost-effective than the standard of care at health facility level in this setting.
Conteh et al. 2010 [29] Ghana Community-based volunteers Community-based volunteers delivered three different intermittent preventive treatments for malaria in children (IPTc) drug regimens to children aged 3–59 months. Economic evaluation alongside RCT from a societal perspective Yes Yes Yes Unclear Yes Delivery of IPT for children by VVHWs is less costly than delivery by nurses working at outpatient departments or EPI outreach.
Hamainza et al. 2014 [24] Zambia CHWs Home-based case detection and treatment of malaria with rapid diagnostic tests (RDTs) by CHWs versus facility care. Costing study from a programme perspective alongside a longitudinal study. Unclear Unclear Yes Unclear No This way of delivering testing and treatment may be cost-effective at certain levels if community participation in regular testing is achieved.
Mbonye et al. 2008 [31] Uganda TBAs, drug-shop vendors, community reproductive health workers and adolescent peer mobilizers Directly observed sulfadoxine-pyrimethamine (SP) therapy delivered by trained community resource persons to pregnant women through home visits during second and third trimester in a rural setting. Cost-effectiveness study from both provider and patient perspectives Yes Yes Yes Yes Yes Community-based delivery of SP during pregnancy increased access and adherence to IPTp and was cost-effective according to World Bank criteria.
Onwujekwe et al. 2007 [41] Nigeria CHWs Community members conducted treatment of presumptive malaria in uncomplicated adults and children. Costs and benefits of a single intervention from both provider and community perspectives Yes Unclear Yes Unclear Unclear CHWs are an economically viable and “potentially cost-effective” (no comparator or benchmark given) source for providing timely, appropriate treatment of malaria in rural areas.
Patouillard et al. 2011 [33] Ghana VHWs VHWS dispensed IPTc during three consecutive scheduled days from a central point of each village. Costing study from a provider perspective alongside community randomized trial Yes Yes Yes Yes No Delivery of IPT for children by VHWs is less costly then delivery by nurses working at outpatient departments or EPI outreach.
Other or multiple disease areas
Bowser et al. 2015 [34] Mozambique CHWs Multi-year comparison of costs and benefits of delivery by CHWs of specialized targeted package of primary care interventions including family planning, maternal health, malaria, diarrhoea, pneumonia, TB, HIV, malnutrition and more. Cost-effectiveness study taking a programme perspective Yes Yes Yes Yes No Using CHWs to deliver a range of primary care services can be less costly than other community-based programmes.
Buttorf et al. 2012 [12] India LHWs LHWs/counsellors counselled on mental disorders. Economic evaluation from a societal perspective alongside RCT No Yes Yes Unclear Yes LHW intervention resulted in cost savings from both a provider and patient perspective and achieved the same outcomes, making it more cost-effective than standard care at public primary care facilities.
Gaziano et al. 2014 [42] South Africa CHWs This study compares CHWs visiting patients with uncontrolled hypertension two times a year with undefined usual care. Cost-utility study using a Markov model, perspective undefined Yes Unclear Yes Unclear No The intervention is cost-saving, with the life cost being less than the annual cost due to reductions in non-fatal cardiovascular disease-related events.
Jafar et al. 2011 [30] Pakistan CHWs CHWs provided advice at three monthly intervals on the importance of physical activity, diet and smoking cessation. Cost-effectiveness study from a societal perspective alongside RCT Yes Yes Yes Yes Yes A combined intervention of HHE plus training of general practitioners to control high blood pressure is the most cost-effective solution as compared with other options.
Mahmud et al. 2010 [25] Malawi CHWs CHWs using text messages delivered a variety of services including requesting medication deliveries, notifying patient deaths, sending appointment reminders, monitoring treatment adherence for TB DOTS and ART, queries and more. Costing study with unspecified perspective (seems to be hospital) No Unclear Yes Unclear No m-health intervention delivered by CHWs resulted in both professional worker time and monetary savings compared with previous practice (a CHW programme without the m-health intervention).
McCord et al. 2013 [32] Sub-Saharan Africa CHWs Various (diarrhoea, malaria, malnutrition, TB screening, pneumonia, management of pregnancy and health promotion). Costing study from unspecified perspective (seems to be programme) Yes Yes Yes Yes No Comprehensive CHW subsystems can be deployed across sub-Saharan Africa at a cost that is modest compared with project costs of primary healthcare system.
Prinja et al. 2014 [35] India Auxiliary nurse midwives (ANMs), multi-purpose health workers (MPHWs) and accredited social health activist (ASHA) workers Range of primary care services delivered by three types of CHWs at the sub-centre health facility level; study compares having one ANM with two ANMs. Costing and cost-effectiveness study from a health system perspective Unclear Yes Yes No No Hiring a second ANM at the sub-centre level is very cost-effective given the incremental cost per unit increase in ANC coverage.