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Quang Vo LN, Forse RJ, Tran J, Dam T, Driscoll J, Codlin AJ, Creswell J, Sidney-Annerstedt K, Van Truong V, Thi Minh HD, Huu LN, Nguyen HB, Nguyen NV. Economic evaluation of a community health worker model for tuberculosis care in Ho Chi Minh City, Viet Nam: a mixed-methods Social Return on Investment Analysis. BMC Public Health 2023; 23:945. [PMID: 37231468 DOI: 10.1186/s12889-023-15841-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 05/08/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND There is extensive evidence for the cost-effectiveness of programmatic and additional tuberculosis (TB) interventions, but no studies have employed the social return on investment (SROI) methodology. We conducted a SROI analysis to measure the benefits of a community health worker (CHW) model for active TB case finding and patient-centered care. METHODS This mixed-method study took place alongside a TB intervention implemented in Ho Chi Minh City, Viet Nam, between October-2017 - September-2019. The valuation encompassed beneficiary, health system and societal perspectives over a 5-year time-horizon. We conducted a rapid literature review, two focus group discussions and 14 in-depth interviews to identify and validate pertinent stakeholders and material value drivers. We compiled quantitative data from the TB program's and the intervention's surveillance systems, ecological databases, scientific publications, project accounts and 11 beneficiary surveys. We mapped, quantified and monetized value drivers to derive a crude financial benefit, which was adjusted for four counterfactuals. We calculated a SROI based on the net present value (NPV) of benefits and investments using a discounted cash flow model with a discount rate of 3.5%. A scenario analysis assessed SROI at varying discount rates of 0-10%. RESULTS The mathematical model yielded NPVs of US$235,511 in investments and US$8,497,183 in benefits. This suggested a return of US$36.08 for each dollar invested, ranging from US$31.66-US39.00 for varying discount rate scenarios. CONCLUSIONS The evaluated CHW-based TB intervention generated substantial individual and societal benefits. The SROI methodology may be an alternative for the economic evaluation of healthcare interventions.
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Affiliation(s)
- Luan Nguyen Quang Vo
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam.
| | - Rachel Jeanette Forse
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jacqueline Tran
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Thu Dam
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Jenny Driscoll
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | - Andrew James Codlin
- Friends for International TB Relief, 6th Floor, 1/21 Le Van Luong St., Nhan Chinh Ward, Thanh Xuan District, Ha Noi, Viet Nam
| | | | - Kristi Sidney-Annerstedt
- Department of Global Public Health, WHO Collaboration Centre on Tuberculosis and Social Medicine, Karolinska Institutet, Solna, Sweden
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Minwyelet Terefe M, Eyob H, Letta T, Nadew E, Assefa T, Hailu B, Cunnama L, Garcia Baena I, Vassall A, Sweeney S, Laurence YV. Efficiency of TB service provision in the public and private health sectors in Ethiopia. Int J Tuberc Lung Dis 2022; 26:1128-1136. [PMID: 36447315 PMCID: PMC9728951 DOI: 10.5588/ijtld.21.0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: The Ethiopian Government has identified efficiency of TB services as a key priority in planning and budgeting. Understanding the magnitude and sources of inefficiencies is key to ensuring value for money and improved service provision, and a requirement from donors to justify resource needs. This study identifies the cost of providing a wide range of TB services in public and private facilities in Ethiopia.METHODS: Financial and economic unit costs were estimated from a health provider´s perspective, and collected retrospectively in 26 health facilities using both top-down (TD) and bottom-up (BU) costing approaches for each TB service output. Capacity inefficiency was assessed by investigating the variation between TD and BU unit costs where the factor was 2.0 or more.RESULTS: Overall, TD unit costs were two times higher than BU unit costs. There was some variation across facility ownership and level of care. Unit costs in urban facilities were on average 3.8 times higher than in rural facilities.CONCLUSION: We identified some substantial inefficiencies in staff, consumable and capital inputs. Addressing these inefficiencies and rearranging the TB service delivery modality would be important in ensuring the achievement of the country´s End TB strategy.
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Affiliation(s)
| | - H Eyob
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - T Letta
- National Tuberculosis and Leprosy Control Programme, Ethiopia Federal Ministry of Health, Addis Ababa, Ethiopia
| | - E Nadew
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - T Assefa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - B Hailu
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - L Cunnama
- Health Economics Unit and Division, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - I Garcia Baena
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - A Vassall
- Global Health Economics Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - S Sweeney
- Global Health Economics Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Y V Laurence
- Global Health Economics Centre, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Sweeney S, Laurence YV, Cunnama L, Gomez GB, Garcia-Baena I, Bhide P, Capeding TJ, Chatterjee S, Chikovani I, Eyob H, Kairu A, Terefe MM, Shengelia N, Toshniwal M, Saadi N, Bergren E, Vassall A. Cost of TB services: approach and summary findings of a multi-country study (Value TB). Int J Tuberc Lung Dis 2022; 26:1006-1015. [PMID: 36281042 PMCID: PMC9621303 DOI: 10.5588/ijtld.22.0096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND: There are currently large gaps in unit cost data for TB, and substantial variation in the quality and methods of unit cost estimates. Uncertainties remain about sample size, range and comprehensiveness of cost data collection for different purposes. We present the methods and results of a project implemented in Kenya, Ethiopia, India, The Philippines and Georgia to estimate unit costs of TB services, focusing on findings most relevant to these remaining methodological challenges.METHODS: We estimated financial and economic unit costs, in close collaboration with national TB programmes. Gold standard methods included both top-down and bottom-up approaches to resource use measurement. Costs are presented in 2018 USD and local currency unit.RESULTS: Cost drivers of outputs varied by service and across countries, as did levels of capacity inefficiency. There was substantial variation in unit cost estimates for some interventions and high overhead costs were observed. Estimates were subject to sampling uncertainty, and some data gaps remain.CONCLUSION: This paper describes detailed methods for the largest TB costing effort to date, to inform prioritisation and planning for TB services. This study provides a strong baseline and some cost estimates may be extrapolated from this data; however, regular further studies of similar quality are needed to add estimates for remaining gaps, or to add new or changing services and interventions. Further research is needed on the best approach to extrapolation of cost data. Costing studies are best implemented as partnerships with policy makers to generate a community of mutual learning and capacity development.
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Affiliation(s)
- S Sweeney
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - Y V Laurence
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - L Cunnama
- University of Cape Town, Cape Town, South Africa
| | - G B Gomez
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK, Global Access, International Aids Vaccine Initiative, Amsterdam, The Netherlands
| | | | - P Bhide
- The George Institute for Global Health, New Delhi, India
| | - T J Capeding
- University of the Philippines Manila, Manila, The Philippines
| | - S Chatterjee
- The George Institute for Global Health, New Delhi, India
| | - I Chikovani
- Curatio International Foundation, Tbilisi, Georgia
| | - H Eyob
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - A Kairu
- Health Economics Research Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - M M Terefe
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - N Shengelia
- Curatio International Foundation, Tbilisi, Georgia
| | | | - N Saadi
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK, University of Oslo, Oslo, Norway
| | - E Bergren
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
| | - A Vassall
- Global Health Economics Centre, London School of Hygiene & Tropical Medicine, London, UK
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Kairu A, Orangi S, Oyando R, Kabia E, Nguhiu P, Ong Ang O J, Mwirigi N, Laurence YV, Kitson N, Garcia Baena I, Vassall A, Barasa E, Sweeney S, Cunnama L. Cost of TB services in healthcare facilities in Kenya (No 3). Int J Tuberc Lung Dis 2021; 25:1028-1034. [PMID: 34886934 PMCID: PMC8675875 DOI: 10.5588/ijtld.21.0129] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/08/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND: The reduction of Kenya´s TB burden requires improving resource allocation both to and within the National TB, Leprosy and Lung Disease Program (NTLD-P). We aimed to estimate the unit costs of TB services for budgeting by NTLD-P, and allocative efficiency analyses for future National Strategic Plan (NSP) costing.METHODS: We estimated costs of all TB interventions in a sample of 20 public and private health facilities from eight counties. We calculated national-level unit costs from a health provider´s perspective using bottom-up (BU) and top-down (TD) approaches for the financial year 2017-2018 using Microsoft Excel and STATA v16.RESULTS: The mean unit cost for passive case-finding (PCF) was respectively US$38 and US$60 using the BU and TD approaches. The unit BU and TD costs of a 6-month first-line treatment (FLT) course, including monitoring tests, was respectively US$135 and US$160, while those for adult drug-resistant TB (DR-TB) treatment was respectively US$3,230.28 and US$3,926.52 for the 9-month short regimen. Intervention costs highlighted variations between BU and TD approaches. Overall, TD costs were higher than BU, as these are able to capture more costs due to inefficiency (breaks/downtime/leave).CONCLUSION: The activity-based TB unit costs form a comprehensive cost database, and the costing process has built-in capacity within the NTLD-P and international TB research networks, which will inform future TB budgeting processes.
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Affiliation(s)
- A Kairu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - S Orangi
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - R Oyando
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - E Kabia
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - P Nguhiu
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - J Ong Ang O
- Centre for Respiratory Diseases Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - N Mwirigi
- Ministry of Health, Division of National Tuberculosis, Leprosy, and Lung Disease Program, Nairobi, Kenya
| | - Y V Laurence
- Department of Global Health and Development, Faculty of Public Health and Policy, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - N Kitson
- Department of Global Health and Development, Faculty of Public Health and Policy, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - I Garcia Baena
- TB Monitoring and Evaluation, Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - A Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - E Barasa
- Health Economics Research Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - S Sweeney
- Department of Global Health and Development, Faculty of Public Health and Policy, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - L Cunnama
- Health Economics Unit and Division, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Chatterjee S, Toshniwal MN, Bhide P, Sachdeva KS, Rao R, Laurence YV, Kitson N, Cunnama L, Vassall A, Sweeney S, Baena IG. Costs of TB services in India (No 1). Int J Tuberc Lung Dis 2021; 25:1013-1018. [PMID: 34886932 PMCID: PMC8675874 DOI: 10.5588/ijtld.21.0105] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND: There is a dearth of economic analysis required to support increased investment in TB in India. This study estimates the costs of TB services from a health systems’ perspective to facilitate the efficient allocation of resources by India’s National Tuberculosis Elimination Programme. METHODS: Data were collected from a multi-stage, stratified random sample of 20 facilities delivering TB services in two purposively selected states in India as per Global Health Cost Consortium standards and using Value TB Data Collection Tool. Unit costs were estimated using the top-down (TD) and bottom-up (BU) methodology and are reported in 2018 US dollars. RESULTS: Cost of delivering 50 types of TB services and four interventions varied according to costing method. Key services included sputum smear microscopy, Xpert® MTB/RIF and X-ray with an average BU costs of respectively US$2.45, US$17.36 and US$2.85. Average BU cost for bacille Calmette-Guérin vaccination, passive case-finding, TB prevention in children under 5 years using isoniazid and first-line drug treatment in new pulmonary and extrapulmonary TB cases was respectively US$0.76, US$1.62, US$2.41, US$103 and US$98. CONCLUSION: The unit cost of TB services and outputs are now available to support investment decisions, as diagnosis algorithms are reviewed and prevention or treatment for TB are expanded or updated in India.
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Affiliation(s)
- S Chatterjee
- George Institute for Global Health, New Delhi, India, University of New South Wales, Sydney, NSW, Australia, Manipal Academy of Higher Education, Manipal, India
| | - M N Toshniwal
- Independent consultant, Public Health Division, Durga Clinic, Akola, India
| | - P Bhide
- George Institute for Global Health, New Delhi, India
| | - K S Sachdeva
- Central TB Division, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - R Rao
- Central TB Division, Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Y V Laurence
- Department of Global Health and Development, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - N Kitson
- Department of Global Health and Development, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - L Cunnama
- Health Economics Unit & Health Economics Division, University of Cape Town, Cape Town, South Africa
| | - A Vassall
- Department of Global Health and Development, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - S Sweeney
- Department of Global Health and Development, Centre for Health Economics in London, London School of Hygiene & Tropical Medicine, London, UK
| | - I Garcia Baena
- Global TB Programme, World Health Organization, Geneva, Switzerland
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Garg T, Bhardwaj M, Deo S. Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India. BMJ Open 2020; 10:e036625. [PMID: 33004390 PMCID: PMC7536783 DOI: 10.1136/bmjopen-2019-036625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Cost-efficient active case finding (ACF) approaches are needed for their large-scale adoption in national tuberculosis (TB) programmes. Our aim was to assess if community health workers' (CHW) knowledge about families' health status can improve the cost efficiency of the ACF programme without adversely affecting the delivery of other health services for which they are responsible. DESIGN Quasi-experimental design. INTERVENTIONS We evaluated an ACF programme in the Samastipur district in Bihar, India, between July 2017 and June 2018. CHWs called Accredited Social Health Activists generated referrals of individuals at risk of TB and conducted symptom-based screening to identify patients with presumptive TB. They also helped them undergo testing and provided treatment support for confirmed TB cases. PRIMARY AND SECONDARY OUTCOME MEASURES We compared the notification rate from the intervention region with that from a control region in the same district with similar characteristics. We analysed operational data to calculate the cost per TB case diagnosed. We used routine programmatic data from the public health system to estimate the impact on other services provided by CHWs. FINDINGS CHWs identified 9895 patients with presumptive TB. Of these, 5864 patients were tested for TB, and 1236 were confirmed as TB cases. Annual public case notification rate increased sharply in the intervention region from 45.8 to 105.8 per 100 000 population, whereas it decreased from 50.7 to 45.3 in the control region. There was no practically or statistically significant impact on other output indicators of the CHWs, such as institutional deliveries (-0.04%). The overall cost of the intervention was about US$134 per diagnosed case. Main cost drivers were human resources, and commodities (drugs and diagnostics), which contributed 37.4% and 32.5% of the cost, respectively. CONCLUSIONS ACF programmes that use existing CHWs in the health system are feasible, cost efficient and do not adversely affect other healthcare services delivered by CHWs.
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Affiliation(s)
- Tushar Garg
- Research, Innovators In Health, Patna, Bihar, India
| | | | - Sarang Deo
- Operations Management, Indian School of Business, Hyderabad, Telangana, India
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