Costs of community-wide mass drug administration and school-based deworming for soil-transmitted helminths: evidence from a randomised controlled trial in Benin, India and Malawi

Abstract

ObjectivesCurrent guidelines for the control of soil-transmitted helminths (STH) recommend deworming children and other high-risk groups, primarily using school-based deworming (SBD) programmes. However, targeting individuals of all ages through community-wide mass drug administration (cMDA) may interrupt STH transmission in some settings. We compared the costs of cMDA to SBD to inform decision-making about future updates to STH policy.DesignWe conducted activity-based microcosting of cMDA and SBD for 2 years in Benin, India and Malawi within an ongoing cMDA trial.SettingField sites and collaborating research institutions.Primary and secondary outcomesWe calculated total financial and opportunity costs and costs per treatment administered (unit costs in 2019 USD ($)) from the service provider perspective, including costs related to community drug distributors and other volunteers.ResultsOn average, cMDA unit costs were more expensive than SBD in India ($1.17 vs $0.72) and Malawi ($2.26 vs $1.69), and comparable in Benin ($2.45 vs $2.47). cMDA was more expensive than SBD in part because most costs (~60%) were ‘supportive costs’ needed to deliver treatment with high coverage, such as additional supervision and electronic data capture. A smaller fraction of cMDA costs (~30%) was routine expenditures (eg, drug distributor allowances). The remaining cMDA costs (~10%) were opportunity costs of staff and volunteer time. A larger percentage of SBD costs was opportunity costs for teachers and other government staff (between ~25% and 75%). Unit costs varied over time and were sensitive to the number of treatments administered.ConclusionscMDA was generally more expensive than SBD. Accounting for local staff time (volunteers, teachers, health workers) in community programmes is important and drives higher cost estimates than commonly recognised in the literature. Costs may be lower outside of a trial setting, given a reduction in supportive costs used to drive higher treatment coverage and economies of scale.Trial registration numberNCT03014167.

Cost and cost-effectiveness analysis of mass drug administration compared to school-based targeted preventive chemotherapy for hookworm control in Dak Lak province, Vietnam

“…On the other hand, a cost survey which was part of a multi-country trial in India, Benin, and Malawi found that the cost per person was higher for MDA than for school-based targeted PC in India and Malawi but not in Benin. 10 However, this study also found that when “supportive” activities designed to optimise PC coverage were excluded, such as supervision from a non-governmental organisation, the cost per person was lower for MDA than for school-based targeted PC in all countries. 10 Real-world cost survey data and effectiveness data derived from experimental epidemiological studies are required to provide accurate evidence to determine if MDA is cost-effective compared to school-based targeted PC for STH control.…”

“…Interviewer administered questionnaires were developed to collect information on cost, resource use, and time spent on the implementation of annual school-based targeted PC and MDA programs using albendazole (400 mg), which were assumed to be donated for school-age children and purchased for other population groups. Costs were categorised according to the components of PC implementation 7 , 10 , 19 : albendazole procurement (which includes its purchase, transport, and storage), training, community sensitisation, albendazole administration, and PC monitoring and evaluation ( Appendix p 2). The questionnaires were translated from English to Vietnamese and were pre-tested and revised with the research assistants who conducted the interviews.…”

“…9 MDA, however, is more costly overall as additional resources are required to reach the entire population. 10 …”

Community-based deworming for hookworm benefits children treated within schools and is cost-effective due to economies of scale: the CoDe-STH trial

“…Cost-effectiveness of community-based MDA was due to economies of scale—as treatment programmes expand and treat more people there are administrative costs that are not reincurred or that max out and the incremental cost of treating another person decreases as more people are treated. Other studies 9 , 10 have shown that cost-effectiveness can be influenced by STH prevalence and consideration of costs for supportive activities such as advocacy campaigns.…”

Finding realistic solutions to NTD target delays

“…The cost of reaching an individual through a house-to-house drug distribution approach is, on average, five to ten times higher than that incurred by reaching a child through school distribution 5 , 6 , 7 in which the school is used as support infrastructure and the drugs are distributed within each class by teachers at minimal cost. 6 On the contrary, the house-to-house approach faces important costs due to the increased complexity of the activity and the need to recruit distributors.…”