Study | Costs measured | Measure of effectiveness or benefit | Economic results | Author conclusions |
---|---|---|---|---|
Tozan, 2010 [14] | Direct medical | Deaths DALYs averted | Low intervention uptake—low referral compliance scenario averts 1 death, 19 DALYs, at incremental cost of I$ 17 466, cost per DALY averted = 1 173 Full intervention uptake—full referral compliance scenario averts 37 deaths, 967 DALYs, at incremental cost of I$7 1 166, cost per DALY averted = 77 | Pre-referral artesunate is cost-effective in rural African settings when referral compliance and intervention uptake are moderate or higher The intervention was cost-effective under all scenarios. |
Gonzalez, 2000 [13] | Direct medical Direct non-medical Indirect costs | Years of life lost DALYs | All three intervention strategies cost-effective. Deltaprim administered by VHWs twice as effective as a combination of Deltaprim + iron administered by mothers | Results favour inclusion of malaria chemoprophylaxis and iron supplementation delivered through EPI |
Conteh et al. 2010 [15] | Direct medical Direct intervention Indirect/productivity losses | Rebound in malaria morbidity Malaria cases averted | Intervention cost-effectiveness of the 2 drug therapies artesunate plus amodiaquine (AS + AQ) and sulphadoxine-pyrimethamine ranged from $61/malaria case averted (societal perspective) to $65/malaria case averted (provider perspective). Cost per child enrolled fell considerably when modelled to district level as compared to those encountered under trial conditions | Potential for the different treatment approaches to be cost-effective at district level when implemented by CHWs |
Nonvignon et al. 2013 | Direct Indirect costs | Malaria cases averted Deaths averted DALYs averted | Cost-effectiveness was better when CHWs managed fevers with antimalarial only without antibiotics. Compared to control arm : Each malaria case averted cost US$ 150.18 (antimalarial) and US$ 227.49 (antimalarial + antibiotic) Each death averted cost US$ 2 585.58 (antimalarial) and US$ 3 272.20 (antimalarial + antibiotic). Each DALY cost US$ 90.25 (antimalarial) and US$ 114.21 (antimalarial + antibiotic) | Home management of under-5 fevers by CHWs in rural settings is cost-effective in reducing under-5 mortality and cost less than the WHO threshold of $150/DALY averted |
Pagnoni et al. 1997 [18] | Direct programme costs | Primary: proportional reduction in severe malaria cases Secondary: proportion of women who self-diagnosed malaria and sought “medical treatment” care from CHWs pre- and post-intervention period | Slight decrease in severe malaria cases reported Proportion of women who sought help from CHWs increased from 5 to 76% Proportion of mothers using modern tablets to treat malaria in children almost doubled Appropriate treatment increased from 3 to 49% Adequacy of length of treatment increased from 21 to 72% Costs: average net cost per resident child = US$ 0.06 | Low-cost community-based intervention aimed at providing children with prompt and adequate treatment for malaria is possible Intervention could reduce morbidity of severe malaria |
Chola et al. 2011 [19] | Direct costs | N/A | Total project costs = US$ 56 308; 53% of costs attributed to peer supervision (38% of costs due to transport); 26% attributed to peer support Alternative community EBF programme = $14 per visit; $74 per mother Cost of scaling up programme on population of 1 million = $2 590 000 Total cost per individual counselling visit = $26 Total cost per mother counselled = $139 Costs of alternative modelled intervention 80% lower | Costs of $139 per mother considered expensive. High costs driven by personnel salaries |
Desmond et al. 2008 [17] | Direct costs | Months of EBF | Incremental costs per month of EBF associated with moving from the less effective scenarios to the more effective scenarios: Nothing—basic R616 ($88) Basic—simplified R162 ($23) Simplified—Full R879 ($126) | Modelled scenarios indicate that there is a possibility that costs and outcomes may differ in real-life setting The simplified scenario, with a combination of clinic and home visits, is the most efficient in terms of cost per increased month of EBF and has the lowest incremental cost-effectiveness ratio. |
Frick et al. 2012 [28] | Partial direct costs (transport, personnel time) | Number of visits to a clinic Number of formula feedings Number of prescription medicines taken | The cost of the personnel and travel required for the intervention was $296 per woman. Health care use savings were significant for clinic visits at 4 weeks with intervention group expensing 40% less clinic visits | Support for breastfeeding by community health nurses and peer counsellors is partially offset by reducing medical care utilization and formula feeding costs |
Pugh et al. 2002 [29] | Direct costs Indirect costs | Primary outcome: EBF rates at 3, 6 months; Secondary: frequency of illness | At 3 months: 45% EBF in intervention arm versus 25% in usual care; at 6 months, 30% EBF in intervention arm versus 15% in usual care. Infants in intervention group had fewer sick visits; intervention cost $301/mother. No incremental cost-effectiveness ratios | CHWs can increase BF duration and reduce costs especially costs of support |
Morrell et al. 2006 | Direct medical costs | Primary outcome: general health perception at 6 weeks. Secondary outcomes: mean Edinburgh Postnatal Depression Scale (EPDS), Duke Functional Social Support (DUFSS) scores, and breastfeeding rates | No significant differences in health outcomes between intervention and control group. The total mean NHS cost to 6-month follow-up for the intervention group was £180 per woman greater than for the control group (confidence interval, £79.60, £272.40). | Added cost of intervention at no benefit made intervention unfavourable though the service was valued by women |
Margellos-Anast 2012 [30] | Direct medical costs | Asthma-related quality of life and number of urgent medical visits averted | Intervention saves US$ 2 561/participant, i.e. for every $1 spent on intervention, you save $5 Urgent HRU decreased from median of 4 to 1 (75% decline) Activity-limited days reduced from median of 7 to 3.5 (50% decline) Regular clinic visits increased from 2.5 to 3.5 | CHW model is effective in improving asthma management Intervention decreased the need to use emergency health services by 75% CHW model improves asthma knowledge, quality of life Cultural competence key to success of intervention |
Puett et al. 2013 [24] | Direct medical; direct non-medical; indirect costs | DALYS averted Deaths averted Child recovered Child treated | The community-based strategy cost US$ 26/DALY averted, compared with US$ 1 344 per DALY averted for inpatient treatment. The average cost to participant households for their child to recover from SAM in community treatment was one-sixth that of inpatient treatment | Community-based management of acute malnutrition (CMAM) delivered by community health workers (CHWs) is a cost-effective strategy compared with inpatient treatment and compares well with the cost-effectiveness of other common child survival interventions. In this context, inpatient treatment performed poorly in comparison with community treatment; even if performance was improved by 20%, it would remain over eight times less cost-effective than the CMAM intervention. |
Melville et al. 1995 [27] | Direct costs | Percentage of children who gained adequate weight between May 1990 and Apr 1992 | Cost per child of intervention = US$ 31.1 (annual cost of US$ 14.50); personnel comprised 75% of costs Malnutrition declined by 34.5% | CHVs can play a vital role in primary health care settings in developing countries |
Gowani et al. 2014 [21] | Direct programme costs | Primary: cognitive, language, and motor development scores as measured by the BSID III criterion | Statistically significant improvements in primary outcome measures reported at 12 and 24 months when responsive stimulation (RS) was integrated into package but no additive benefits with RS + enhanced nutrition. CER ranged from $15–$19 per year (CER = annualized cost per LHW divided by composite scores of language, cognitive, or motor skills development) | With further refinement, integrating early stimulation with nutrition support can be scaled up effectively; on the basis of existing data in other settings, the cost-benefit to the country could be very significant. |
Aracena et al. 2009 [26] | Direct medical costs | Linguistic skills development Nutritional state of mother Mental health of mother | Only the following showed statistically significant differences: (1) development of children’s language skills, (2) nutritional state of the mother, and (3) mental health of the mother. Cost of standard care = US$ 50 per adolescent over a period of 15 months, median cost of intervention for the home visit programme was US$ 90 per adolescent over a period of 15 months; total incremental cost of the home visit programme versus standard care US$ 40 per day over the same time period, i.e. the standard programme costs US$ 3.30 per month per adolescent, whilst the home visit programme costs US$ 6. | Intervention more effective at improving maternal outcomes. |
Barzgar et al. 1997 [20] | Direct medical and non-medical | Proportional reduction in infant mortality, maternal mortality, increase in vaccination coverage | Costs per person = $0.39 for capital costs and $1.13 per person for recurrent costs. 50% reduction in infant mortality (from 130/1 000 at baseline to 64/1 000 after intervention) >50% reduction in maternal mortality—(596 per 100 000 at base line to 246 per 100 000 after intervention) >50% reduction in infant diarrheal deaths >97% reduction in neonatal tetanus No impact on low birth weight/malnutrition and pneumonia Immunization coverage increased by 80% in Chakwal, 70% Mastung and 100% in Malir | Capital and recurrent costs per person were lower than the allocations for public sector outlay in the same period of $1.87 |
Hafeez et al. 2011 [22] | Direct intervention costs | Key maternal and child health indicators: Contraceptive prevalence Fully immunized children Skilled birth attendance | CHW programme versus national averages: Fully immunized children—80 vs 47% IMR—51 vs 39% MMR—180 vs 276 Costs: average cost of each CHW = US$ 570 per year; salary costs comprised 50% of total | Focused mainly on impact rather than costs—CHWs effective in reducing MMR and improving vaccination coverage in rural areas. CHWs provide an important link between community and first level care. No detailed costs analysis reported—makes it difficult to judge cost-effectiveness of programme |
Borghi, 2005 [23] | Direct costs | Neonatal mortality rate Life years saved (LYS) | Average annual cost per woman of reproductive age = $4.38 ($5.22 with health service strengthening) Average annual cost per newborn infant = US$ 22.51 ($26.82 with health systems strengthening (HSS)) Cost per neonatal death averted = $5 801 ($6 912 with HSS) Cost per life year saved = 211 (251 with HSS) | Intervention most suited to settings like Nepal where supply-side interventions may not be feasible due to resource requirements Personnel costs account for largest costs—70% Intervention likely to be more CE when replicated elsewhere due to lower start-up costs Intervention more CE when maternal LYS are included |
San Sebastian et al. 2001 [25] | Direct intervention Indirect costs/productivity losses | Proportional increase in fully vaccinated children | Existent (Department of Health) strategy—$3 888 versus $3 618 for CHWs (no significance tests) Coverage of DPT3/polio was 22.6-fold higher in CHW strategy vs DH strategy | CHW strategy dominates the existent strategy Costs of averting disease not calculated which would have presented a stronger case for CHW model |