Cost-effectiveness of a Community-based Hypertension Improvement Project (ComHIP) in Ghana: results from a modelling study

Abstract

ObjectiveTo undertake a cost-effectiveness analysis of a Community-based Hypertension Improvement Project (ComHIP) compared with standard hypertension care in Ghana.DesignCost-effectiveness analysis using a Markov model.SettingLower Manya Krobo, Eastern Region, Ghana.InterventionWe evaluated ComHIP, an intervention with multiple components, including: community-based education on cardiovascular disease (CVD) risk factors and healthy lifestyles; community-based screening and monitoring of blood pressure by licensed chemical sellers and CVD nurses; community-based diagnosis, treatment, counselling, follow-up and referral of hypertension patients by CVD nurses; telemedicine consultation by CVD nurses and referral of patients with severe hypertension and/or organ damage to a physician; information and communication technologies messages for healthy lifestyles, treatment adherence support and treatment refill reminders for hypertension patients; Commcare, a cloud-based health records system linked to short-message service (SMS)/voice messaging for treatment adherence, reminders and health messaging. ComHIP was evaluated under two scale-up scenarios: (1) ComHIP as currently implemented with support from international partners and (2) ComHIP under full local implementation.Main outcome measuresIncremental cost per disability-adjusted life-year (DALY) averted from a societal perspective over a time horizon of 10 years.ResultsComHIP is unlikely to be a cost-effective intervention, with current ComHIP implementation and ComHIP under full local implementation costing on average US$12 189 and US$6530 per DALY averted, respectively. Results were robust to uncertainty analyses around model parameters.ConclusionsHigh overhead costs and high patient costs in ComHIP suggest that the societal costs of ensuring appropriate hypertension care are high and may not produce sufficient impact to achieve cost-effective implementation. However, these results are limited by the evidence quality of the effectiveness estimates, which comes from observational data rather than from randomised controlled study design.

The economic burden of treating uncomplicated hypertension in Sub-Saharan Africa: a systematic literature review

“…Regarding the economic study design, 21 studies followed a partial economic evaluation (nine cost descriptions [33, 35-38, 44, 47, 49, 56], eight cost analyses [41,45,46,48,50,57,58,64] and four cost-outcome descriptions [32,34,43,63]. The remaining studies followed a full economic evaluation design (seven cost effectiveness analyses [39,40,54,[59][60][61][62], three cost utility analyses [42,51,52] and two cost minimization analysis [53,55]). The following costing approaches were used: Bottom up [32-39, 41, 42, 44-49, 51, 54, 55, 58-60, 63], top down [40,43,50,52,56,57,61,62] and a combination of both [53,64], human capital [35,38,44], replacement value [38] and willingness to pay [46].…”

“…Figure 2 displays the countries with research on economic burden of hypertension. Nine studies were conducted in Nigeria [35][36][37][38][47][48][49][50][51][52][53][54][55], five in South Africa [59][60][61][62][63], four in Kenya [41][42][43][44], four in Ethiopia [35][36][37][38], two in Rwanda [56,57] and Cameroon [32,33] and one each in the Democratic Republic of Congo [34], Ghana [39], Guinea [40], Mali [45], the Seychelles [58] and Uganda [64]. Overall, we identified ten studies [34-38, 40, 45, 56, 57, 64] from low-income countries (LIC) according to the World Bank classification [21] as well as 22 studies [32, 33, 39, 41-44, 47-55, 58-63] from middle income countries (MIC).…”

“…One study had a global focus [46]. Most studies focused on a rural setting [32, 44, 52-54, 56, 57] or had a mixed urban-rural focus [35,37,38,41,50,61,64] with data collected from hospitals [33, 35-38, 45, 47-49, 53-57], health care or community centers [32,40,43,58,61,63] and a mix of facility types [34,39,41,44,50,64].…”

“…We found that the definition of hypertension was heterogeneous. Thirteen studies only considered patients diagnosed with hypertension [32, 34, 36-38, 40, 45, 47, 49, 53, 55-57], five studies included only patients who were actually receiving some form of treatment for hypertension [33,39,44,48,63], and five studies did not provide any specific information other than referring to patients living with hypertension or hypertensive disease [41,50,59,61,64].…”

“…Most studies focused on the public sector [33, 34, 36, 38, 40, 44, 45, 47-49, 54-58, 63] or used a mixed approach also including private, non-governmental or missionary facilities [32,35,37,39,41,43,50,52,59,64]. Only one study had a sole focus on the private health system sector [53].…”