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Table 1 Full list of citations included in systematic review

From: Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries

Author and year Country Intervention Indicator type Main indicator Result Quality data
Clarke, M., et al. (2006) [39] South Africa Training of lay health workers (LHWs) to support treatment and management of TB on farms, instead of clinic nurses or enrolled (non-professional) nurses Input/process Cost per minute of health worker time 91% reduction in cost from clinic nurses ($0.12 per minute) to LHWs ($0.01 per minute) and 87.5% reduction from enrolled nurses ($0.08 per minute) to LHWs Farms with LHWs supporting had 42% better case finding rate and 10% better cure rate
Datiko, D. G. and B. Lindtjorn (2010) [35] Ethiopia Comparison of Health Facility-based DOT (HFDOT) program for TB compared with community DOT (CDOT) program using health extension workers Outcome Cost per successfully treated patient 63% reduction in costs from HFDOT model ($16.19) to CDOT model ($6.07) 74.8% cure rate for CDOT compared with 68.2% for HFDOT
Dick, J., et al. (2007) [37] South Africa Evaluation of a lay health worker project overseen by primary healthcare nurses aimed at treating TB on farms Outcome Cost per case detected and cured 74% cost reduction to the District Health Authority on farms with LHW program compared to control farms (absolute cost figures not reported) Treatment completion rate for smear-positive TB patients 18.7% higher in intervention group compared to controls (p < .05)
Floyd, K., et al. (2003) [41] Malawi Community-based outpatient treatment for smear-positive pulmonary patients (instead of inpatient treatment) Outcome Cost per patient cured 62% reduction from hospital-based treatment ($786) to community-based treatment ($296) Cure rate was 68% for community-based strategy and 58% for hospital-based strategy
Islam, M. A., et al. (2002) [36] Bangladesh BRAC TB control program using CHWs, compared to government-run program Input/process; outcome Total annual cost for TB control program at the subdistrict (thana) level; Cost per patient cured 31% reduction in total annual costs from government program ($10,697) to BRAC program ($7,351); 32% reduction in cost per patient cured 84.1% cure rate in BRAC TB program compared to 82.2% in government program
Khan, M. A., et al. (2002) [40] Pakistan Comparison of DOTS by health workers at health centers, DOTS by family members, and “DOTS without direct observation” Outcome Cost per case cured 45% reduction from health center DOTS ($310) to CHW DOTS ($172); unsupervised DOTS cost $164 Cure rates were 62% for unsupervised DOTS, 55% for family member DOTS, 67% for CHW DOTS, and 58% for Health Center DOTS
Okello, D., et al. (2003) [38] Uganda Comparison of conventional hospital-based care with community-based care for DOTS, including management by a sub-county public health worker Outcome Cost per smear-positive patient successfully treated 57% reduction in costs from conventional care ($911) to community-based care ($391) Treatment success rate for smear-positive cases was 56% for conventional care and 74% within community-based care
Prado, T. N., et al. (2011) [42] Brazil Comparison of DOTS overseen by guardians with standard of care treatment by CHWs Output Total cost for DOTS course 28% reduction in costs from CHW DOTS ($547) to guardian-supervised DOTS ($389) 98% treatment completion in guardian-supervised DOTS compared to 83% treatment completion with CHW-supervised DOTS (p = .01)
Sinanovic, E., et al. (2003) [43] South Africa Comparison of clinic-based care with community-based observation by lay person with community-based care for smear-positive pulmonary and retreatment TB patients Outcome Cost per patient successfully treated 62% reduction in costs for new smear-positive patients from clinic-based care ($1302) to community-based care ($392); 62% reduction in costs for retreatment patients from clinic-based care ($2008) to community-based care ($766) 80% treatment success rate for community-based care, compared to 54% treatment success rate for clinic-based care
Babigumira, J. B., et al. (2011) [46] Uganda Comparison of a Pharmacy-only Refill Program (PRP) to Standard of Care for treatment for HIV/AIDS patients Output Cost per person per year from societal and Ministry of Health perspective 21% reduction in societal costs from Standard of Care ($665) to PRP ($520) and 17% reduction in MoH costs from Standard of Care ($610) to PRP ($496) No statistically significant difference in favorable immune response among patients in two groups
Bemelmans, M., et al. (2014) [48] South Africa Adherence club for ARVs led by lay counselor and offered to all clinically stable patients who had been on ARVs for greater than 12 months; Club met every 2 months for essential medical tasks (e.g., weighing and health assessment) and distribution of ARVs Output Cost per patient per year 46% reduction from mainstream model of care ($108) to ARV club model ($58) <1% mortality at 40 months, and 2.8% loss to follow up at 40 months in ARV club
Fatti, G., et al. (2015) [45] South Africa Indirectly Supervised Pharmacist Assistant (ISPA) program compared to nurse-managed models for providing ARTs Input/process Human resource costs and costs per item dispensed 29% reduction in human resource costs from nurse-managed program ($1.89 per patient visit) compared to ISPA model ($1.35 per patient visit); 49% reduction in cost per item dispensed from nurse-managed program ($0.83) to ISPA model ($0.43) Cumulative attrition lower at ISPA sites (20.7% compared to 31.5%); proportion of patients achieving virological suppression higher at ISPA sites (89.6% compared to 85.9%)
Foster, N. and D. McIntyre (2012) [47] South Africa Indirectly Supervised Pharmacist Assistant (ISPA) program and nurse-managed models compared to full-time pharmacist for providing ARTs Input/process Cost per patient visit 43% reduction in cost from nurse-driven model ($10.16) to ISPA model ($5.74) and 12% reduction in cost from full-time pharmacist model ($6.55)  
Johns, B. and E. Baruwa (2015) [31] Nigeria Comparison of hospital-based distribution of ART (by doctors) with clinic-based distribution of ART (by nurses and/or community pharmacists) for stable patients who had been on ART for at least 1 year, in two states aiming to decentralize health services Output Total cost per person per year Total costs increased in one state by 31% and decreased in one state by 32%; In both cases, the largest difference in costs between the hospital and clinic sites was staff cost/patient visit Few statistically significant differences found in service utilization indicators between patients going to clinic sites versus hospital sites; Patients in the state that achieved cost savings had 3.7× more visits per year than in hospitals (p < .01)
Johns, B., et al. (2014) [30] Ethiopia Comparison of minimal, moderate, and maximal task shifting for ARV responsibilities away from physicians with hospital-based ARV distribution . Minimal = nonphysicians clinicians (NPC) monitor ART; Moderate = NPC initiate and monitor ART; Maximal = NPCs initiate, monitor, treat side effects, and switch ARTs Output Cost per patient year No statistically significant changes in cost/patient per year between models of task shifting or between all task shifting models and hospitals Almost no statistically significant differences in patient retention from different levels of task shifting
Yan, H., et al. (2014) [44] China Evaluation of shifting HIV preventive intervention and care for men who have sex with men (MSM) from government facilities to community-based organizations (CBOs) Outcome Unit cost per HIV case detected 97% reduction in cost from government health facilities ($14,906) to community-based organizations ($315) Within 4 years, total % of HIV cases reported increased from ~10 to ~50%, despite “a very low share of HIV tests by CBOs out of the total HIV tests performed each year during the pilot,” which indicates effective targeting of HIV patients for tests by CBOs
Chanda, P., et al. (2011) [49] Zambia Comparison of home management (using CHW) with facility-based management of uncomplicated malaria Output Cost per case appropriately diagnosed and treated 31% reduction from facility-based management ($6.12) to home management ($4.22) 100% of cases treated appropriately through home management, and 43% of cases treated appropriately in facility
Hamainza, B. M., et al. (2014) [50] Zambia Comparison of CHW program to test and treat malaria with facility-based testing and treatment Output Total cost per confirmed case treated 60% reduction in cost from facility-based approach ($10.75) to CHW approach ($4.34) 78% of CHW contacts received appropriate testing and treatment, while 53% of facility-based patients received appropriate testing and treatment based on guidelines
Mbonye, A., et al. (2008) [32] Uganda Community-based administration of intermittent preventive treatment (IPTp) for malaria by traditional birth attendants, drug-shop vendors, community reproductive health workers, and adolescent peer mobilizers Output Cost per patient of providing a full regimen of IPTp 9% increase in costs from health center care (4093 shillings) to community-based care (4491 shillings)  
Patouillard, E., et al. (2011) [51] Ghana Comparison of IPT administration by village health workers (VHWs), facility-based nurses working in outpatient departments of health centers or EPI outreach clinics Outcome Economic cost per child fully covered and fully adherent to treatment 11% reduction from using facility-based strategy ($8.51) to VHW strategy ($7.56) 69.1% of children in VHW strategy completed course, 63.8% of children in facility-based strategy completed course
Ruebush, T. K., 2nd, et al. (1994) [52] Guatemala Change to the supervision and distribution model of unpaid Volunteer Collaborators (VC) in the surveillance and treatment of malaria, including treatment for malaria without taking a blood smear, removal of literacy requirement for VC, and reduced supervision from once every 4 weeks to once every 8 weeks Output Cost per patient treated 75% reduction in cost per patient treated in modified model of VCs ($0.61) versus control network of VCs ($2.45) Average time from examination to initiation of treatment was 6.6 days in modified model areas, compared to 14.6 days in control areas
Sikaala, C. H., et al. (2014) [53] Zambia Community-based (CB) mosquito surveillance and trapping using light traps (LT) and Ifakara tent traps (ITT) compared to centrally supervised quality assurance (QA) trapping teams, including human-landing catch (HLC) teams, for the prevention of malaria Output Cost per specimen of Anopheles funestus captured 96% reduction in costs from using QA-LT ($141) to CB-LT ($5.3); 83% reduction in costs from using QA-ITT ($168) to CB-ITT ($28); QA-HLC method cost $10.5  
Other diseases and health systems strengthening activities
Aung, T., et al. (2013) [62] Myanmar Comparison of costs to treat diarrhea by CHW, government facility, and private provider Input/process Total patient cost for consultation and correct ORS 7% reduction from private providers ($5.40) to CHWs ($5) and 67% reduction from government facilities ($15) to CHWs CHWs provided appropriate ORS and amount of drinking water in 57.6% of cases, private providers in 47.1% of cases, and government facilities in 71.4% of cases
Buttorff, C., et al. (2012) [57] India Comparison of “collaborative care” model using full-time physician, lay health worker (LHW), and mental health specialist with “enhanced usual care” by full-time physician only for treatment of depression and anxiety disorders Output Average annual cost per subject 23% reduction in costs from collaborative care model ($177) compared to physician-only care model ($229) Patients in collaborative care improved 3.84 points more on the Revised Clinical Interview Schedule (to measure psychiatric symptoms) compared to physician-only care model
Chuit, R., et al. (1992) [60] Argentina Surveillance to reduce transmission of Chagas disease using Primary Health Care (PHC) agents compared to a vertically oriented program run by trained entomological professionals Output Cost of surveillance per house 80% reduction in cost from vertical surveillance ($17) to PHC surveillance ($3.40) Surveillance rates and levels of infestation detection were comparable across intervention and control arms
Cline, B. L. and B. S. Hewlett (1996) [61] Cameroon Diagnosis and treatment for schistosomiasis by CHWs identified by the community Output Average cost of diagnosis and treatment of a child 90% reduction in cost from treatment at nearest pharmacy (approx. $15) to CHW model ($1.50) 7% prevalence in school children after participating in program, compared to 71% in children who did not participate in program
Fiedler, J. L., et al. (2008) [63] Honduras Community-based integrated child care (AIN-C) program that uses volunteers to help mothers monitor and maintain adequate growth of young children Input/process Cost for one child growth and development consultation 86% reduction from facility-based consultation (105.1 lempiras) to community-based program (14.67 lempiras)  
Hounton et al., (2009) [33] Burkina Faso Training of obstetricians, general practitioners, and clinical officers to lead surgical teams for caesarian sections Outcome Incremental cost of one newborn life saved Compared to clinical officers, one newborn life saved cost $200 for general practitioners, and $3,235 for obstetricians Higher newborn and maternal case fatality rates among clinical officers than other types of practitioners
Jafar, T. H., et al. (2011) [54] Pakistan Home-health education (HHE) by CHWs, home-health education plus general practitioner (GP) supervision (combined group), or general practitioner-supervision only to control blood pressure Output Total cost per patient over 2 years for each group 7% reduction in costs from GP-only group ($537) to combined group ($500); 27% reduction in costs from GP-only group to HHE-only group ($393) Decline in systolic BP was highest in the combined group (p = .001)
Kruk, M. E., et al. (2007) [58] Mozambique Comparison of surgically trained assistant medical officers and specialist physicians Input/process Cost per major obstetric surgical procedure 72% reduction in costs using assistant medical officers ($39) compared to specialist physicians ($144)  
Laveissiere, C., et al. (1998) [56] Cote d'Ivoire Detection of sleeping sickness using conventional mobile teams compared to integration of activity into CHW duties Output Cost of surveillance per person 81% reduction in costs using CHWs ($0.10) instead of using mobile teams ($0.55)  
Puett, C., et al. (2013) [55] Bangladesh Community-based management of severe acute malnutrition by CHWs compared to inpatient treatment Outcome Cost per DALY averted 98% reduction in costs/DALY averted from observed inpatient treatment costs ($1344) to community treatment ($26) and in costs/death averted from observed inpatient treatment costs ($45,688) to community treatment ($869) 91.9% of children in community treatment area recovered, compared to only 1.4% in inpatient treatment
Sadruddin, S., et al. (2012) [59] Pakistan Comparison of home treatment of severe pneumonia by lady health workers with referred cases treated by other practitioners Output Cost per treatment of severe pneumonia 81% reduction in costs using lady health workers ($1.46) compared to referred cases ($7.60) 93.4% of cases successfully treated by lady health workers with a 5-day course of amoxicillin, and remaining cases referred for further treatment
Munyaneza, F., et al. (2014) [34] Rwanda Use of CHWs and nurses to collect geographic coordinates using GIS systems instead of trained and dedicated GIS teams Input/process Total cost of mapping activities 51% reduction in costs from using dedicated GIS teams ($60,112) to CHWs ($29,692)