Contextual factors for understanding the heterogeneity of outcomes of a policy of exemption from payment for care in Chad / Les facteurs contextuels pour comprendre l'hétérogénéité des résultats d'une politique d'exemption du paiement des soins au Tchad

Chad has one of the highest maternal and infant mortality rates in the world. Efforts to reduce these rates have led to the introduction of fee exemption and community involvement initiatives to further encourage the use of health services. Despite the introduction of these initiatives, inequalities in access to and use of health facilities persist. The aim of this study is to understand why and how the same action, implemented in a quasi-homogeneous way, produced contrasting results in different health centers. A multiple, contrasting case study was used to analyze the outcomes of pediatrics consultations and deliveries in four health centers in the Bénoye and Beinamar districts. Data were collected through individual interviews (n=26) and focus groups (n=22) with women beneficiaries, community health workers, and health care providers. The qualitative software QDA Miner was used to process the data. The study revealed that the organizational and managerial capacities of the providers and community actors would explain the heterogeneity of the results observed. Contextual factors such as the remoteness of services or the impassability and dangerousness of roads accentuated the disparities in the results observed. The results of this study show that human and contextual factors would explain the heterogeneity of the observed effects.

Le Tchad a l'un des taux de mortalité maternelle et infantile les plus élevés au monde. Les efforts visant à réduire ces taux ont conduit à la mise en place d'une politique d'exemption du paiement des soins, associée à l'implication des communautés pour encourager l'utilisation des services. Malgré l'introduction de cette initiative, des inégalités dans l'accès et l'utilisation des établissements de santé persistent. L'objectif de cette étude est de comprendre pourquoi et comment cette politique d'exemption, mise en œuvre de manière quasi homogène, a donné des résultats contrastés dans plusieurs centres de santé. Une étude de cas multiples contrastés a été utilisée pour analyser les résultats des consultations pédiatriques et des accouchements dans quatre centres de santé des districts de Bénoye et Beinamar. Les données ont été recueillies lors des entretiens individuels (n=26) et des groupes de discussion (n=22) auprès des femmes bénéficiaires, des agents de santé communautaire et des prestataires de soins. Le logiciel QDA Miner a été utilisé pour traiter les données. L'étude a révélé que les capacités organisationnelles et managériales des prestataires et des acteurs communautaires expliqueraient l'hétérogénéité des résultats observés. Des facteurs contextuels tels que l'éloignement des services ou l'impraticabilité et la dangerosité des routes ont accentué les disparités des résultats observés. Dans la mise en place des politiques de santé, il est important de tenir compte des facteurs humains et contextuels, car ils participent à l'explication de l'hétérogénéité des effets observés et renforcent la pertinence de ce type d'études.

Health economic evaluation of strategies to eliminate gambiense human African trypanosomiasis in the Mandoul disease focus of Chad.

Human African trypanosomiasis, caused by the gambiense subspecies of Trypanosoma brucei (gHAT), is a deadly parasitic disease transmitted by tsetse. Partners worldwide have stepped up efforts to eliminate the disease, and the Chadian government has focused on the previously high-prevalence setting of Mandoul. In this study, we evaluate the economic efficiency of the intensified strategy that was put in place in 2014 aimed at interrupting the transmission of gHAT, and we make recommendations on the best way forward based on both epidemiological projections and cost-effectiveness. In our analysis, we use a dynamic transmission model fit to epidemiological data from Mandoul to evaluate the cost-effectiveness of combinations of active screening, improved passive screening (defined as an expansion of the number of health posts capable of screening for gHAT), and vector control activities (the deployment of Tiny Targets to control the tsetse vector). For cost-effectiveness analyses, our primary outcome is disease burden, denominated in disability-adjusted life-years (DALYs), and costs, denominated in 2020 US$. Although active and passive screening have enabled more rapid diagnosis and accessible treatment in Mandoul, the addition of vector control provided good value-for-money (at less than $750/DALY averted) which substantially increased the probability of reaching the 2030 elimination target for gHAT as set by the World Health Organization. Our transmission modelling and economic evaluation suggest that the gains that have been made could be maintained by passive screening. Our analysis speaks to comparative efficiency, and it does not take into account all possible considerations; for instance, any cessation of ongoing active screening should first consider that substantial surveillance activities will be critical to verify the elimination of transmission and to protect against the possible importation of infection from neighbouring endemic foci.

Gini index decomposition by deprivation in multidimensional poverty: evidence from Chad.

OBJECTIVE: This paper aims the decomposition of the multidimensional Gini coefficient by deprivation to investigate how aggregate multidimensional poverty inequality translates into inequality within each of its components. This approach provides a better understanding of the distribution of deprivations held, the standard of living of the population and makes recommendations on government policies. METHOD: We use the method of Lerman and Yitzhaki (1985), which allows us to identify the impact of marginal changes on multidimensional inequality (fuzzy poverty inequality). RESULTS: The data used come from the Household Budget and Consumption Surveys of 2003 of 6695 households, 2011 of 9259 households and 2018 of 7493 households. Empirical findings suggest that the Gini index in 2003 is 0.229, 0.215 in 2011 and 0.180 in 2018. CONCLUSIONS: The different social policies to reduce multi-inequalities must mainly be oriented towards health policies and access to drinking water, which are unequally distributed during the three periods. And social policies to reduce inequality in education, sanitation and housing are also to be taken into account.

Use of and barriers to maternal health services in southeast Chad: results of a population-based survey 2019.

OBJECTIVES: Chad reports the second highest maternal mortality worldwide. We conducted a survey in Sila region in southeast Chad to estimate the use of maternal health services (MHS) and to identify barriers to access MHS. DESIGN: Retrospective cross-sectional, population-based survey using two-stage cluster sampling methodology. The survey consisted of two strata, Koukou Angarana and Goz Beida district in Sila region. We conducted systematic random sampling proportional to population size to select settlements in each strata in the first sampling stage; and in the second stage we selected households in the settlements using random walk procedure. We calculated survey-design-weighted proportions with 95% CIs. We performed univariate analysis and multivariable logistic regression to identify impact factors associated with the use of MHS. SETTING: We interviewed women in selected households in Sila region in 2019. PARTICIPANTS: Women at reproductive age, who have given birth in the previous 2 years and are living in Koukou Angarana and Goz Beida district. PRIMARY OUTCOMES: Use of and access barriers to MHS including antenatal care (ANC), delivery care in a health facility (DC), postnatal care (PNC) and contraceptive methods. RESULTS: In total, 624 women participated. Median age was 28 years, 95.4% were illiterate and 95.7% married. Use of ANC, DC and PNC was reported by 57.6% (95% CI: 49.3% to 65.5%), 22.5% (95% CI: 15.7% to 31.1%) and 32.9% (95% CI: 25.8% to 40.9%), respectively. Use of MHS was lower in rural compared with urban settings. Having attended ANC increased the odds of using DC by 4.3 (1.5-12.2) and using PNC by 6.4 (3.7-11.1). Factors related to transport and to culture and belief were the most frequently stated access barriers to MHS. CONCLUSION: In Sila region, use of MHS is low and does not meet WHO-defined standards regarding maternal health. Among all services, use of ANC was better than for other MHS. ANC usage is positively associated with the use of further life-saving MHS including DC and could be used as an entry point to the community. To increase use of MHS, interventions should include infrastructural improvements as well as community-based approaches to overcome access barriers related to culture and belief.

The cost of tsetse control using 'Tiny Targets' in the sleeping sickness endemic forest area of Bonon in Côte d'Ivoire: Implications for comparing costs across different settings.

BACKGROUND: Work to control the gambiense form of human African trypanosomiasis (gHAT), or sleeping sickness, is now directed towards ending transmission of the parasite by 2030. In order to supplement gHAT case-finding and treatment, since 2011 tsetse control has been implemented using Tiny Targets in a number of gHAT foci. As this intervention is extended to new foci, it is vital to understand the costs involved. Costs have already been analysed for the foci of Arua in Uganda and Mandoul in Chad. This paper examines the costs of controlling Glossina palpalis palpalis in the focus of Bonon in Côte d'Ivoire from 2016 to 2017. METHODOLOGY/PRINCIPAL FINDINGS: Some 2000 targets were placed throughout the main gHAT transmission area of 130 km2 at a density of 14.9 per km2. The average annual cost was USD 0.5 per person protected, USD 31.6 per target deployed of which 12% was the cost of the target itself, or USD 471.2 per km2 protected. Broken down by activity, 54% was for deployment and maintenance of targets, 34% for tsetse surveys/monitoring and 12% for sensitising populations. CONCLUSIONS/SIGNIFICANCE: The cost of tsetse control per km2 of the gHAT focus protected in Bonon was more expensive than in Chad or Uganda, while the cost per km2 treated, that is the area where the targets were actually deployed, was cheaper. Per person protected, the Bonon cost fell between the two, with Uganda cheaper and Chad more expensive. In Bonon, targets were deployed throughout the protected area, because G. p. palpalis was present everywhere, whereas in Chad and Uganda G. fuscipes fuscipes was found only the riverine fringing vegetation. Thus, differences between gHAT foci, in terms of tsetse ecology and human geography, impact on the cost-effectiveness of tsetse control. It also demonstrates the need to take into account both the area treated and protected alongside other impact indicators, such as the cost per person protected.

Assessment of the Chad guinea worm surveillance information system: A pivotal foundation for eradication.

BACKGROUND: In the absence of a vaccine or pharmacological treatment, prevention and control of Guinea worm disease is dependent on timely identification and containment of cases to interrupt transmission. The Chad Guinea Worm Eradication Program (CGWEP) surveillance system detects and monitors Guinea worm disease in both humans and animals. Although Guinea worm cases in humans has declined, the discovery of canine infections in dogs in Chad has posed a significant challenge to eradication efforts. A foundational information system that supports the surveillance activities with modern data management practices is needed to support continued program efficacy. METHODS: We sought to assess the current CGWEP surveillance and information system to identify gaps and redundancies and propose system improvements. We reviewed documentation, consulted with subject matter experts and stakeholders, inventoried datasets to map data elements and information flow, and mapped data management processes. We used the Information Value Cycle (IVC) and Data-Information System-Context (DISC) frameworks to help understand the information generated and identify gaps. RESULTS: Findings from this study identified areas for improvement, including the need for consolidation of forms that capture the same demographic variables, which could be accomplished with an electronic data capture system. Further, the mental models (conceptual frameworks) IVC and DISC highlighted the need for more detailed, standardized workflows specifically related to information management. CONCLUSIONS: Based on these findings, we proposed a four-phased roadmap for centralizing data systems and transitioning to an electronic data capture system. These included: development of a data governance plan, transition to electronic data entry and centralized data storage, transition to a relational database, and cloud-based integration. The method and outcome of this assessment could be used by other neglected tropical disease programs looking to transition to modern electronic data capture systems.

[Improving provision of mother-and-child care in Chad at the community level: A quasi-experimental study]. / Amélioration de l'offre et de la demande de soins de santé maternelle et infantile au Tchad : une étude quasi-expérimentale.

BACKGROUND: Chad is among the countries with the highest maternal and infant mortality rates in the world. An initiative aimed at improving mother-and-child health services was implemented from 2016 to 2019 in three rural health districts in southern Chad, with strong community input, while concomitantly increasing the supply and demand for care. The objective of this study is to evaluate the effects of this program on health service use. METHODS: Interrupted time-series analyses with a control group was used to measure the effects of the intervention by applying a quasi-experimental approach. Monthly attendance data were collected from the registries of the 18 health centres that participated in the program and 18 centres that did not participate (control group), before (18 months) and after (24 months) the start of implementation. RESULTS: On average, there were 10.98 (95% CI: 6.57-15.39, P<0.001) additional paediatric visits and 0.68 additional deliveries (95% CI: 0.42-0.95, P<0.001) each month in the participation group compared to the control group. Community involvement decisively contributed to the change. CONCLUSION: During the 24 months of implementation, the initiative significantly increased the use of essential mother-and-child health services in Chad. This study highlights the benefits of a strong partnership with communities trained and involved in health system activities, with the objective of achieving universal health coverage.

Proximate, intermediate, and distal predictors of under-five mortality in Chad: analysis of the 2014-15 Chad demographic and health survey data.

BACKGROUND: Under-five mortality in Chad reached a minimum value of 119 deaths per 1000 live births in 2018, compared with a maximum of 250 in 1972. Despite this decline in the  mortality trend, for every six children in Chad, one dies before the age of five. This study, therefore, investigated the proximate, intermediate, and distal determinants of under-five mortality in Chad. METHODS: We used data from the 2014-15 Chad's Demographic and Health Survey. Data of 7782 children below 5 years were used for the study. Both descriptive and multivariable hierarchical logistic regression analyses were performed. Statistical significance was declared at p < 0.05. RESULTS: Under-five mortality was found to be 130 deaths per 1000 live births in Chad, with variations across the various population sub-groups. For distal predictors, the likelihood of death was higher in children born in the FChari Baguirmi region (AOR = 3.83, 95% CI: 1.81-8.14). Children whose mothers belonged to the Baguirmi/Barma ethnic group (AOR = 8.04, 95% CI: 1.75-36.99) were more likely to die before the age of five. On the contrary, the likelihood of under-five mortality was low among children born in rural areas (AOR = 0.73, 95% CI: 0.55-0.97). With the intermediate predictors, the likelihood of under-five deaths was higher among children whose mothers had no formal education (AOR = 1.72, 95% CI: 1.06-2.77). Regarding the proximate predictors, the odds of under-five deaths was higher among male children (AOR = 1.03, 95% CI: 1.05-1.63) and first rank children (AOR = 1.58, 95% CI: 1.13-2.21). CONCLUSION: The study found that the determinants of under-five mortality in Chad are region of residence, place of residence, ethnicity, education, sex of child, and birth rank. These findings show that both socio-economic and proximate factors explain the disparities in under-five mortality in Chad. The identification of these factors can be pivotal towards the design of evidence-based interventions intended to improve child survival. Therefore, improving maternal education while refocusing and re-packaging existing strategies to target selected sub-regional populations with high under-five mortality is urgently required.

Delivering 'tiny targets' in a remote region of southern Chad: a cost analysis of tsetse control in the Mandoul sleeping sickness focus.

BACKGROUND: Since 2012, the World Health Organisation and the countries affected by the Gambian form of human African trypanosomiasis (HAT) have been committed to eliminating the disease, primarily through active case-finding and treatment. To interrupt transmission of Trypanosoma brucei gambiense and move more rapidly towards elimination, it was decided to add vector control using 'tiny targets'. Chad's Mandoul HAT focus extends over 840 km2, with a human population of 39,000 as well as 14,000 cattle and 3000 pigs. Some 2700 tiny targets were deployed annually from 2014 onwards. METHODS: A protocol was developed for the routine collection of tsetse control costs during all field missions. This was implemented throughout 2015 and 2016, and combined with the recorded costs of the preliminary survey and sensitisation activities. The objective was to calculate the full costs at local prices in Chad. Costs were adjusted to remove research components and to ensure that items outside the project budget lines were included, such as administrative overheads and a share of staff salaries. RESULTS: Targets were deployed at about 60 per linear km of riverine tsetse habitat. The average annual cost of the operation was USD 56,113, working out at USD 66.8 per km2 protected and USD 1.4 per person protected. Of this, 12.8% was an annual share of the initial tsetse survey, 40.6% for regular tsetse monitoring undertaken three times a year, 36.8% for target deployment and checking and 9.8% for sensitisation of local populations. Targets accounted for 8.3% of the cost, and the cost of delivering a target was USD 19.0 per target deployed. CONCLUSIONS: This study has confirmed that tiny targets provide a consistently low cost option for controlling tsetse in gambiense HAT foci. Although the study area is remote with a tsetse habitat characterised by wide river marshes, the costs were similar to those of tiny target work in Uganda, with some differences, in particular a higher cost per target delivered. As was the case in Uganda, the cost was between a quarter and a third that of historical target operations using full size targets or traps.

The State of Maternal and Infant Health and Mortality in Chad.

The level of Chad's government expenditure on health is a predictor of the general health of the population and, consequently, life expectancy. We used data from the World Bank's World Development Indicators and publications from the World Health Organization to assess the state of maternal and infant health and mortality. The primary objective of this research was to investigate whether Chad had reduced the risk of maternal and infant mortality after signing the Abuja Declaration in 2001. We hypothesised that increased general government health expenditure was associated with improved health mediated by increased numbers of skill health workers and minimum out-of-pocket health expenditure. Our secondary objective was to assess effective implementations of health policies in line with the Millennium Development Goals that Chad has agreed to achieve by 2015. We observed that, as of 2015, the government health expenditure was only 6.28% and the population out-of-pocket spending was over 56%. Furthermore, only 20% of women give birth in a hospital. These results led to three major policies recommendations in order to improve maternal and infant health in Chad: skilled birth attendants training, enhanced social status of nurses, and the development of a supplemental nutrition care program for women.

The late arrival of coronavirus disease 2019 (COVID-19) in Chad: mitigating spread in Ndjamena focused on specific target population.

The novel coronavirus disease 2019 (COVID-19) has rapidly spread to all 7 continents. Due to yet unknown reasons, the African continent has remained relatively unaffected, especially Chad. We discuss the importance of mitigating spread in Ndjamena focused on specific target population.

Small area estimation of under-5 mortality in Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia using spatially misaligned data.

BACKGROUND: The under-5 mortality rate (U5MR) is an important metric of child health and survival. Country-level estimates of U5MR are readily available, but efforts to estimate U5MR subnationally have been limited, in part, due to spatial misalignment of available data sources (e.g., use of different administrative levels, or as a result of historical boundary changes). METHODS: We analyzed all available complete and summary birth history data in surveys and censuses in six countries (Bangladesh, Cameroon, Chad, Mozambique, Uganda, and Zambia) at the finest geographic level available in each data source. We then developed small area estimation models capable of incorporating spatially misaligned data. These small area estimation models were applied to the birth history data in order to estimate trends in U5MR from 1980 to 2015 at the second administrative level in Cameroon, Chad, Mozambique, Uganda, and Zambia and at the third administrative level in Bangladesh. RESULTS: We found substantial variation in U5MR in all six countries: there was more than a two-fold difference in U5MR between the area with the highest rate and the area with the lowest rate in every country. All areas in all countries experienced declines in U5MR between 1980 and 2015, but the degree varied both within and between countries. In Cameroon, Chad, Mozambique, and Zambia we found areas with U5MRs in 2015 that were higher than in other parts of the same country in 1980. Comparing subnational U5MR to country-level targets for the Millennium Development Goals (MDG), we find that 12.8% of areas in Bangladesh did not meet the country-level target, although the country as whole did. A minority of areas in Chad, Mozambique, Uganda, and Zambia met the country-level MDG targets while these countries as a whole did not. CONCLUSIONS: Subnational estimates of U5MR reveal significant within-country variation. These estimates could be used for identifying high-need areas and positive deviants, tracking trends in geographic inequalities, and evaluating progress towards international development targets such as the Sustainable Development Goals.

Cost-estimate and proposal for a development impact bond for canine rabies elimination by mass vaccination in Chad.

Close to 69,000 humans die of rabies each year, most of them in Africa and Asia. Clinical rabies can be prevented by post-exposure prophylaxis (PEP). However, PEP is commonly not available or not affordable in developing countries. Another strategy besides treating exposed humans is the vaccination of vector species. In developing countries, the main vector is the domestic dog, that, once infected, is a serious threat to humans. After a successful mass vaccination of 70% of the dogs in N'Djaména, we report here a cost-estimate for a national rabies elimination campaign for Chad. In a cross-sectional survey in four rural zones, we established the canine : human ratio at the household level. Based on human census data and the prevailing socio-cultural composition of rural zones of Chad, the total canine population was estimated at 1,205,361 dogs (95% Confidence interval 1,128,008-1,736,774 dogs). Cost data were collected from government sources and the recent canine mass vaccination campaign in N'Djaména. A Monte Carlo simulation was used for the simulation of the average cost and its variability, using probability distributions for dog numbers and cost items. Assuming the vaccination of 100 dogs on average per vaccination post and a duration of one year, the total cost for the vaccination of the national Chadian canine population is estimated at 2,716,359 Euros (95% CI 2,417,353-3,035,081) for one vaccination round. A development impact bond (DIB) organizational structure and cash flow scenario were then developed for the elimination of canine rabies in Chad. Cumulative discounted cost of 28.3 million Euros over ten years would be shared between the government of Chad, private investors and institutional donors as outcome funders. In this way, the risk of the investment could be shared and the necessary investment could be made available upfront - a key element for the elimination of canine rabies in Chad.

Coordination as a best practice from the polio eradication initiative: Experiences from five member states in the African region of the World Health Organization.

BACKGROUND: As part of the efforts to eradicate polioviruses in the African Region, structures were put in place to ensure coordinated mobilization and deployment of resources within the framework of the global polio eradication initiative (PEI). The successes of these structures made them not only attractive to other public health interventions, but also caused them to be deployed to the response efforts of other diseases interventions, without any systematic documentation. This article documents the contributions of PEI coordination units to other public health interventions in the African Region of World Health Organization METHODS: We reviewed the contributions of PEI coordination units to other public health interventions in five countries in the African Region. RESULTS: The analysis identified significant involvement of PEI coordination structures in the implementation of routine immunization programs in all the countries analyzed. Similarly, maternal and child health programs were planned, implemented, monitored and evaluation the Inter-Agency Coordination Committees of the PEI programs in the different countries. The hubs system used in PEI in Chad facilitated the efficient coordination of resources for immunization and other public health interventions in Chad. Similarly, in the Democratic Republic of Congo PEI led coordination activities benefited other public health programs like disease control and the national nutrition program, the national malaria control program, and the tuberculosis control program. In Nigeria, the polio Expert Review Committee effectively deployed the Emergency Operation Center for the implementation of prioritized strategies and activities of the National Polio Eradication Emergency Plan, and it was utilized in the response to Ebola Virus Disease outbreak in the country. CONCLUSIONS: The PEI-led coordination systems are thus recognized as having made significant contribution to the coordination and delivery of other public health interventions in the African Region.

The contribution of the polio eradication initiative to narrowing the gaps in the health workforce in the African Region.

INTRODUCTION: The Global Polio Eradication Initiative (GPEI) massively invested to overcome the crippling disease in countries of the WHO African Region. In the context of economic crisis, almost all countries in the Region lack an adequate health workforce. Large amounts were invested by GPEI in human resources. This paper shows how the human resources funded by polio contributed to narrowing the gaps in health workforce and helped strengthening and supporting other priority health programmes in Angola, Chad, DRC, Nigeria, Tanzania, and Togo. METHODS: The health workforce strengthening methods used in the five different countries included the following: policy development and strategic planning, microplanning, capacity building of public health and community workers, implementation and services, monitoring and evaluation, advocacy and social mobilization, and programme review. RESULTS: Staff funded by polio helped with achieving good coverage in vitamin A and insecticide-treated mosquito nets (Angola, Chad); improvement of EPI and integrated disease surveillance indicators, improved quality of data (all five countries), administrative support, smooth introduction of new vaccines, increased case detection, and early isolation of patients suffering from the Guinea worm (Chad); reduction of cholera, extension of directly observed TB short course treatment (Democratic Republic of Congo); significant staff performance improvement (Nigeria). DISCUSSION: GPEI investment achieved far beyond its primary goal, and contributed to narrowing the gaps in the health workforce in countries of the African Region, as demonstrated by the best practice documentation exercise. We recommend that expertise and experience of polio funded staff should be leveraged to strengthen, expand and support other public health programmes.

The actual and potential costs of meningitis surveillance in the African meningitis belt: Results from Chad and Niger.

BACKGROUND: The introduction of serogroup A meningococcal conjugate vaccine in the African meningitis belt required strengthened surveillance to assess long-term vaccine impact. The costs of implementing this strengthening had not been assessed. METHODOLOGY: The ingredients approach was used to retrospectively determine bacterial meningitis surveillance costs in Chad and Niger in 2012. Resource use and unit cost data were collected through interviews with staff at health facilities, laboratories, government offices and international partners, and by reviewing financial reports. Sample costs were extrapolated to national level and costs of upgrading to desired standards were estimated. RESULTS: Case-based surveillance had been implemented in all 12 surveyed hospitals and 29 of 33 surveyed clinics in Niger, compared to six out of 21 clinics surveyed in Chad. Lumbar punctures were performed in 100% of hospitals and clinics in Niger, compared to 52% of the clinics in Chad. The total costs of meningitis surveillance were US$ 1,951,562 in Niger and US$ 338,056 in Chad, with costs per capita of US$ 0.12 and US$ 0.03, respectively. Laboratory investigation was the largest cost component per surveillance functions, comprising 51% of the total costs in Niger and 40% in Chad. Personnel resources comprised the biggest expense type: 37% of total costs in Niger and 26% in Chad. The estimated annual, incremental costs of upgrading current systems to desired standards were US$ 183,299 in Niger and US$ 605,912 in Chad, which are 9% and 143% of present costs, respectively. CONCLUSIONS: Niger's more robust meningitis surveillance system costs four times more per capita than the system in Chad. Since Chad spends less per capita, fewer activities are performed, which weakens detection and analysis of cases. Countries in the meningitis belt are diverse, and can use these results to assess local costs for adapting surveillance systems to monitor vaccine impact.