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1、Cost and cost-effectiveness of nationwideschool-based helminth control in Uganda intra-country variation and effects of scaling-upSimon Brooker,1* Narcis B Kabatereine,2 Fiona Fleming3 and Nancy Devlin4Accepted 13 August 2007Estimates of cost and cost-effectiveness are typically based on a limited n
2、umber of small-scale studies with no investigation of the existence of economies to scale or intra-country variation in cost and cost-effectiveness. This information gap hinders the efficient allocation of health care resources and the ability to generalize estimates to other settings. The current s
3、tudy investigates the intracountry variation in the cost and cost-effectiveness of nationwide school-based treatment of helminth (worm) infection in Uganda. Programme cost data were collected through semi-structured interviews with district officials and from accounting records in six of the 23 inte
4、rvention districts. Both financial and economic costs were assessed. Costs were estimated on the basis of cost in US$ per schoolchild treated, and an incremental cost-effectiveness ratio (cost in US$ per case of anaemia averted) was used to evaluate programme cost-effectiveness. Sensitivity analysis
5、 was performed to assess the effect of discount rate and drug price. The overall economic cost per child treated in the six districts was US$0.54 and the cost-effectiveness was US$3.19 per case of anaemia averted. Analysis indicated that estimates of both cost and cost-effectiveness differ markedly
6、with the total number of children who received treatment, indicating economies of scale. There was also substantial variation between districts in the cost per individual treated (US$0.410.91) and cost per anaemia case averted(US$1.709.51). Independent variables were shown to be statistically associ
7、ated with both sets of estimates. This study highlights the potential bias intransferring data across settings without understanding the nature of observedvariations.Keywords Cost analysis, cost-effectiveness, economic evaluation, variation, scaling up,helminth control, Uganda* Corresponding author.
8、 Department of Infectious and Tropical Disease,London School of Hygiene and Tropical Medicine, Keppel Street, LondonWC1E 7HT, UK. Tel: t44 (0) 207 927 2614. Fax: t44 (0) 207 927 2918.E-mail: simon.brookerlshtm.ac.uk1 Department of Infectious and Tropical Diseases, London School of Hygieneand Tropica
9、l Medicine, London, UK.2 Vector Control Division, Ministry of Health, Kampala, Uganda.3 Schistosomiasis Control Initiative, Department of Infectious DiseaseEpidemiology, Imperial College, London, UK.4 Department of Economics, City University, London, UK.Published by Oxford University Press in associ
10、ation with The London School of Hygiene and Tropical Medicine_ The Author 2007; all rights reserved. Advance Access publication 17 November 2007Health Policy and Planning 2008;23:2435doi:10.1093/heapol/czm041IntroductionCost-effectiveness analysis has become a principal tool to evaluate health inter
11、ventions, guiding health policy in both developed (McDaid et al. 2003) and developing countries (World Bank 1993; Jamison et al. 2006). Estimates of costeffectiveness are typically taken from a single study or a few small-scale studies in different countries (Walker and Fox-Rushby 2000), with no att
12、empt to review the possible variation in estimates. However, because both intervention costs and effectiveness differ among locations, a single estimate of costeffectiveness is unlikely to be universally applicable (Musgrove and Fox-Rushby 2006). More probable is that costs and cost-effectiveness wi
13、ll vary, even within a single country. For instance, intra-country variation in costs has been demonstrated in the delivery of routine immunization in Peru (Walker et al. 2004), antenatal care in Cuba and Thailand (Hutton et al. 2004), a bednet distribution programme in Malawi (Stevens et al. 2005)
14、and a lymphatic filariasis elimination programme in Egypt (Ramzy et al. 2005). Variations in average costs may arise in the short run from differences in the relative costs of inputs, differences in technical efficiency, or, in the long run, from factors associated with economies of scale (Folland e
15、t al. 2004). Differences may also reflect variation in respect to the demography and epidemiology of disease, availability of health care resources and system of health care delivery (Drummond and Pang 2001). Understanding how and whycosts vary can help in assessing the degree to which cost andcost-
16、effectiveness estimates can be reliably extrapolated acrossdifferent settings, and can also enable health planners and policy makers to discern what drives costs and to plan future budgets (Drummond et al. 1992; OBrien 1997; Bryan andBrown 1998; Spath et al. 1999; Drummond and Pang 2001; Walker et a
17、l. 2004). This understanding is particularly important for global health programmes which implement a common health package in a range of settings. For example, a number of initiatives are now underway which seek to control a number of tropical diseases, including those caused by parasitic helminth
18、(worm) infections (Albonico et al. 2006; Boatin and Richards 2006; Fenwick et al. 2006; Ottesen 2006). staff, also need information on how costs change as the programmes are gradually scaled-up. In economics, changes in the level of output may change average costs; as output increases, average costs
19、 either remain constant (constant returns to scale), decrease (economies of scale) or increase (diseconomies of scale) (Folland et al. 2004). Many studies assume constant returns to scale, and take average costs per recipient and multiply them by projected output levels (e.g. Fenwick et al. 2005; Br
20、ady et al. 2006). In practice, however, available studies demonstrate that average costs vary at different levels of output (Over 1998;Mansley et al. 2002; Valdmanis et al. 2003; Elbasha and Messonnier 2004).There is a clear need for empirical evidence to better understand variations in cost and cos
21、t-effectiveness, particularly in the context of large-scale control programmes. This paper assesses the variation in costs and cost-effectiveness of a nationwide helminth control programme, and the effect of scaling-up on costs. The specific aims are to: (1) investigate the intra-country variation i
22、n the cost and cost-effectiveness of a national school-based schistosomiasis and soil-transmitted helminth (STH) control programme in Uganda, (2) determine the effects of scaling-up on costs and cost-effectiveness, and (3) identify the main determinants of average costs.Description of the control pr
23、ogramme In 2003, the Ugandan Ministry of Health (MoH) launched its national schistosomiasis and STH control programme (Kabatereine et al. 2006a,b). Implemented vertically through the Vector Control Division (VCD) in Kampala, the programme provides anthelmintic (deworming) treatment to schools and co
24、mmunities at risk of morbidity due to helminth infection. In brief, the programme comprises the following activities: community sensitization, training of teachers and community drug distributors (CDDs), and school-based delivery of two anthelmintic drugs. Mass treatment with praziquantel to treat s
25、chistosomiasis and with albendazole to treat soil-transmittedhelminths was given to all schools and communities in targeted areas. Treatment in schools is carried out by teachers and in communities by CDDs. The programme manager and VCD headquarters staff have overall responsibility for the programm
26、e and regularly visit districts to monitor progress. Implementation of the programme at the district level is undertaken by District Vector Control Officers (DVCOs) and district health teams. To help create awareness and political engagement, a series of national workshops were held in Kampala betwe
27、en 2001 and 2005 (two in 2001, two in 2002 and one each in 2004 and2005). The implementation of control began with a pilot phase from April to October 2003 targeting 400 000 people, with one sub-county selected for mass treatment in each of the 18 most affected districts (Kabatereine et al. 2006a).
28、In 2004 the number of sub-counties targeted in each of theKEY MESSAGESIn Uganda, the costs and cost-effectiveness of delivering anthelmintics through schools as part of a nationwidehelminth control programme varied significantly for different years and for different districts. Average costs decrease
29、d with increasing total number of children treated in each district, indicating the existence of economies of scale as the programme was rolled-out.Using a single estimate of cost and cost-effectiveness is misleading and may lead to inaccurate cost projections in policyand planning. It is important
30、to carefully consider which costs can be reliably extrapolated across different settings.VARIATION IN COSTS AND COST-EFFECTIVENESS OF HELMINTH CONTROL 18 districts was increased, and in 2005 the programme was expanded to include 23 districts, targeting 2.3 million people (Kabatereine et al. 2006b).
31、In each district, training workshops provided teachers and CDDs with a basic understanding of schistosomiasis and STH, and of how to complete record forms and to administer tablets. The design of training and number of participants varied between districts. Health education messages were delivered t
32、hrough posters, booklets and audio and film media. All information, education and communication (IEC) material was translated into various local languages. Imported drugs were cleared at Entebbe airport by the Uganda National Medical Stores, who transported them to VCD headquarters. Drugs and IEC ma
33、terial were either transported to the districts by VCD or collected by the districts during routine visits to Kampala. Drug registration and treatment included compiling school enrolment data and community census information to determine the target population and drug needs. The number of tablets pr
34、ovided to each school was calculated on the basis of treatment registers completed by head teachers and CCDs. The drugs were delivered to each school by the DVCOs and were received bythe head teacher. Tablets were then administered by teachers on a specified day in all schools under the supervision
35、of the head teachers and community health workers. In communities, treatment was provided by CCDs. Praziquantel (25 mg/kg) was administered to individuals on the basis of height, using locally made height poles, and every individual was given a single dose of albendazole (400 mg). All unused tablets
36、 were recovered byDVCOs who also compiled a report of activities. Data and methodsOnly costs associated with school-based treatment are considered here because of the global focus of helminth control on the school-age child (Bundy et al. 2006) and the availability of detailed effectiveness data for
37、schoolchildren (Kabatereine et al.2007).Cost analysisCost data were collected retrospectively from the VCD team inKampala and from six of the 23 intervention districts. Districts were chosen to reflect differences in disease transmission (Kabatereine et al. 2004) and in socioeconomic and health serv
38、ice infrastructure. Data collection was carried out between February and June 2006. A semi-structured questionnaire was drafted and was revised and amended during joint discussions with MoH officials. Data were collected by interviews with district officials using the final questionnaire and by cons
39、ultation of the programme accounting system in Kampala. Documentation related to expenditure had been checked by each district accountant for accountability and cross-checked by the research team for accuracy. The perspective adopted in the evaluation was that of thegovernment, rather than society,
40、since the costs of accessing treatment were negligible as children were treated in their own schools. Both financial and economic costs were estimated. Financial costs represent cash expenditure paid for the implementation of the intervention on an annual basis. Economic costs include the opportunit
41、y cost of using existing Ministry of Health staff and school teachers as well as annuitized capital costs, and represent the true cost of any intervention. Opportunity costs for staff were calculated from salary costs, based on Ugandan civil service pay scales for 2005. Capital costs were annuitized
42、 over the useful life of each itemusing a discount rate of 3%, consistent with the recommendations of the World Bank (1993). Such annuitization enables an equivalent annual cost to be estimated and reflects the valuein- use of capital items, rather than reflecting when the item was purchased. The as
43、sumed useful life of buildings was 30 years, vehicles 7.5 years, motorcycles 4 years and computers 3 years. Vehicle running costs also included maintenance andinsurance. The purchase, freight and insurance of drugs was paid in foreign currency (US$). All other costs were paid in Uganda Shillings (US
44、h) and converted to US dollars using official exchange rates, based on average yearly exchange rate: 1 US$1777 USh in 2003, 1807 USh in 2004 and 1844 USh in 2005 ( Monetary costswere adjusted for inflation over time using the Gross Domestic Product (GDP) implicit price deflator ( logon.aspx) and exp
45、ressed in 2000 prices. Details on the resources employed, their unit costs and quantities consumed are provided in the appendix. All costs directly related to research activities were excluded. The cost data are organized into six main cost centres:(1) programme running costs; (2) community awarenes
46、s;(3) training; (4) imported drugs; (5) drug registration anddistribution; and (6) IEC material. The different cost components of the intervention were identified using an ingredients approach, considering both the number of units and the prices of units in local currency (Ugandan Shillings). The un
47、it cost data were combined with numbers treated to calculate, on a district-by-district basis, the average cost per child treated.The relationship between the cost per child treated and the percentage of overall costs due to different cost centres and other independent demographic and geographic var
48、iables was assessed using a non-parametric Spearman rank correlation. Figure 1 Map of Uganda showing districts selected for cost analysis 26 HEALTH POLICY AND PLANNINGEffectiveness Evidence of the programme effectiveness was measured interms of anaemia cases averted. Epidemiological data were collec
49、ted prospectively through longitudinal surveys conducted in 30 schools between 2003 and 2005. The details of the sampling strategy, survey design and procedures are providedelsewhere (Brooker et al. 2004; Kabatereine et al. 2007).Population-based measures of programme impact included parasitological and haematological data which were collected from randomly selected schoolchildren who were followed upover 3 years. Anaemi
