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Table 3 Economic evaluation results of included studies

From: A systematic review of economic evaluations of CHW interventions aimed at improving child health outcomes

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
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