Cost-effectiveness analysis of a cluster-randomized, culturally tailored, community health worker home-visiting diabetes intervention versus standard care in American Samoa.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is highly prevalent in American Samoa. Community health worker (CHW) interventions may improve T2DM care and be cost-effective. Current cost-effectiveness analyses (CEA) of CHW interventions have either overlooked important cost considerations or not been based on randomized clinical trials (RCTs). The Diabetes Care in American Samoa (DCAS) intervention which occurred in 2009-2010 was a cluster-randomized, culturally tailored, home-visiting CHW intervention and improved HbA1c levels. OBJECTIVE: To analyze the cost-effectiveness of the DCAS intervention against standard care using a RCT in a low-resource setting. METHODS: We collected clinical, utilization, and cost data over 2 years and modeled quality-adjusted life years (QALYs) gained based on the RCT glycated hemoglobin (HbA1c) improvements. We calculated an incremental cost-effectiveness ratio (ICER) from the societal perspective over a 2-year time horizon and reported all costs in 2012 USD ($). RESULTS: Two hundred sixty-eight American Samoans diagnosed with T2DM were cluster randomized into the CHW (n = 104) or standard care control (n = 164) arms. The CHW arm had a mean reduction of 0.53% in HbA1c, an increase of $594 in cost, and an increase of 0.05 QALYs. The ICER for the CHW arm compared to the control arm was $1121 per percentage point HbA1c reduced and $13 191 per QALY gained. CONCLUSIONS: Compared to a variety of willingness-to-pay thresholds from $39 000 to $154 353 per QALY gained, this ICER shows that the CHW intervention is highly cost-effective. Future studies of the cost-effectiveness of CHW T2DM interventions in similar settings should model lifetime costs and QALYs gained to better assess long-term cost-effectiveness. TRIAL REGISTRATION: ClinicalTrials.gov , ID NCT00850824. Registered 9 February 2009, https://clinicaltrials.gov/ct2/show/NCT00850824 .

Cost-effectiveness of the treatment of uncomplicated severe acute malnutrition by community health workers compared to treatment provided at an outpatient facility in rural Mali.

BACKGROUND: The Malian Nutrition Division of the Ministry of Health and Action Against Hunger tested the feasibility of integrating treatment of severe acute malnutrition (SAM) into the existing Integrated Community Case Management package delivered by community health workers (CHWs). This study assessed costs and cost-effectiveness of CHW-delivered care compared to outpatient facility-based care. METHODS: Activity-based costing methods were used, and a societal perspective employed to include all relevant costs incurred by institutions, beneficiaries and communities. The intervention and control arm enrolled different numbers of children so a modelled scenario sensitivity analysis was conducted to assess the cost-effectiveness of the two arms, assuming equal numbers of children enrolled. RESULTS: In the base case, with unequal numbers of children in each arm, for CHW-delivered care, the cost per child treated was 244 USD and cost per child recovered was 259 USD. Outpatient facility-based care was less cost-effective at 442 USD per child and 501 USD per child recovered. The conclusions of the analysis changed in the modelled scenario sensitivity analysis, with outpatient facility-based care being marginally more cost-effective (cost per child treated is 188 USD, cost per child recovered is 214 USD), compared to CHW-delivered care. This suggests that achieving good coverage is a key factor influencing cost-effectiveness of CHWs delivering treatment for SAM in this setting. Per week of treatment, households receiving CHW-delivered care spent half of the time receiving treatment and three times less money compared with those receiving treatment from the outpatient facility. CONCLUSIONS: This study supports existing evidence that the delivery of treatment by CHWs is a cost-effective intervention, provided that good coverage is achieved. A major benefit of this strategy was the lower cost incurred by the beneficiary household when treatment is available in the community. Further research is needed on the implementation costs that would be incurred by the government to increase the operability of these results.

Malaria community health workers in Myanmar: a cost analysis.

BACKGROUND: Myanmar has the highest malaria incidence and attributed mortality in South East Asia with limited healthcare infrastructure to manage this burden. Establishing malaria Community Health Worker (CHW) programmes is one possible strategy to improve access to malaria diagnosis and treatment, particularly in remote areas. Despite considerable donor support for implementing CHW programmes in Myanmar, the cost implications are not well understood. METHODS: An ingredients based micro-costing approach was used to develop a model of the annual implementation cost of malaria CHWs in Myanmar. A cost model was constructed based on activity centres comprising of training, patient malaria services, monitoring and supervision, programme management, overheads and incentives. The model takes a provider perspective. Financial data on CHWs programmes were obtained from the 2013 financial reports of the Three Millennium Development Goal fund implementing partners that have been working on malaria control and elimination in Myanmar. Sensitivity and scenario analyses were undertaken to outline parameter uncertainty and explore changes to programme cost for key assumptions. RESULTS: The range of total annual costs for the support of one CHW was US$ 966-2486. The largest driver of CHW cost was monitoring and supervision (31-60% of annual CHW cost). Other important determinants of cost included programme management (15-28% of annual CHW cost) and patient services (6-12% of annual CHW cost). Within patient services, malaria rapid diagnostic tests are the major contributor to cost (64% of patient service costs). CONCLUSION: The annual cost of a malaria CHW in Myanmar varies considerably depending on the context and the design of the programme, in particular remoteness and the approach to monitoring and evaluation. The estimates provide information to policy makers and CHW programme planners in Myanmar as well as supporting economic evaluations of their cost-effectiveness.

[Relations with emergency medical care and primary care doctor, home health care].

Medical care for an ultra-aging society has been shifted from hospital-centered to local community-based. This shift has yielded the so-called Integrated Community Care System. In the system, emergency medical care is considered important, as primary care doctors and home health care providers play a crucial role in coordinating with the department of emergency medicine. Since the patients move depending on their physical condition, a hospital and a community should collaborate in providing a circulating service. The revision of the medical payment system in 2014 clearly states the importance of "functional differentiation and strengthen and coordination of medical institutions, improvement of home health care". As part of the revision, the subacute care unit has been integrated into the community care unit, which is expected to have more than one role in community coordination. The medical fee has been set for the purpose of promoting the home medical care visit, and enhancing the capability of family doctors. In the section of end-of-life care for the elderly, there have been many issues such as reduction of the readmission rate and endorsement of a patient's decision-making, and judgment for active emergency medical care for patient admission. The concept of frailty as an indicator of prognosis has been introduced, which might be applied to the future of emergency medicine. As described above, the importance of a primary doctor and a family doctor should be identified more in the future; thereby it becomes essential for doctors to closely work with the hospital. Advancing the cooperation between a hospital and a community for seamless patient-centered care, the emergency medicine as an integrated community care will further develop by adapting to an ultra-aging society.

Exploring the context in which different close-to-community sexual and reproductive health service providers operate in Bangladesh: a qualitative study.

BACKGROUND: A range of formal and informal close-to-community (CTC) health service providers operate in an increasingly urbanized Bangladesh. Informal CTC health service providers play a key role in Bangladesh's pluralistic health system, yet the reasons for their popularity and their interactions with formal providers and the community are poorly understood. This paper aims to understand the factors shaping poor urban and rural women's choice of service provider for their sexual and reproductive health (SRH)-related problems and the interrelationships between these providers and communities. Building this evidence base is important, as the number and range of CTC providers continue to expand in both urban slums and rural communities in Bangladesh. This has implications for policy and future programme interventions addressing the poor women's SRH needs. METHODS: Data was generated through 24 in-depth interviews with menstrual regulation clients, 12 focus group discussions with married men and women in communities and 24 semi-structured interviews with formal and informal CTC SRH service providers. Data was collected between July and September 2013 from three urban slums and one rural site in Dhaka and Sylhet, Bangladesh. Atlas.ti software was used to manage data analysis and coding, and a thematic analysis was undertaken. RESULTS: Poor women living in urban slums and rural areas visit a diverse range of CTC providers for SRH-related problems. Key factors influencing their choice of provider include the following: availability, accessibility, expenses and perceived quality of care, the latter being shaped by notions of trust, respect and familiarity. Informal providers are usually the first point of contact even for those clients who subsequently access SRH services from formal providers. Despite existing informal interactions between both types of providers and a shared understanding that this can be beneficial for clients, there is no effective link or partnership between these providers for referral, coordination and communication regarding SRH services. CONCLUSION: Training informal CTC providers and developing strategies to enable better links and coordination between this community-embedded cadre and the formal health sector has the potential to reduce service cost and improve availability of quality SRH (and other) care at the community level.

A systematic review of the unit costs of allied health and community services used by older people in Australia.

BACKGROUND: An economic evaluation of interventions for older people requires accurate assessment of costing and consideration of both acute and long-term services. Accurate information on the unit cost of allied health and community services is not readily available in Australia however. This systematic review therefore aims to synthesise information available in the literature on the unit costs of allied health and community services that may be utilised by an older person living in Australia. METHOD: A comprehensive search of Medline, Embase, CINAHL, Google Scholar and Google was undertaken. Specialised economic databases were also reviewed. In addition Australian Government Department websites were inspected. The search identified the cost of specified allied health services including: physiotherapy, occupational therapy, dietetics, podiatry, counselling and home nursing. The range of community services included: personal care, meals on wheels, transport costs and domestic services. Where the information was not available, direct contact with service providers was made. RESULTS: The number of eligible studies included in the qualitative synthesis was fourty-nine. Calculated hourly rates for Australian allied health services were adjusted to be in equivalent currency and were as follows as follows: physiotherapy $157.75, occupational therapy $150.77, dietetics $163.11, psychological services $165.77, community nursing $105.76 and podiatry $129.72. CONCLUSIONS: Utilisation of the Medicare Benefits Scheduled fee as a broad indicator of the costs of services, may lead to underestimation of the real costs of services and therefore to inaccuracies in economic evaluation.

The human resource implications of improving financial risk protection for mothers and newborns in Zimbabwe.

BACKGROUND: A paradigm shift in global health policy on user fees has been evident in the last decade with a growing consensus that user fees undermine equitable access to essential health care in many low and middle income countries. Changes to fees have major implications for human resources for health (HRH), though the linkages are rarely explicitly examined. This study aimed to examine the inter-linkages in Zimbabwe in order to generate lessons for HRH and fee policies, with particular respect to reproductive, maternal and newborn health (RMNH). METHODS: The study used secondary data and small-scale qualitative fieldwork (key informant interview and focus group discussions) at national level and in one district in 2011. RESULTS: The past decades have seen a shift in the burden of payments onto households. Implementation of the complex rules on exemptions is patchy and confused. RMNH services are seen as hard for families to afford, even in the absence of complications. Human resources are constrained in managing current demand and any growth in demand by high external and internal migration, and low remuneration, amongst other factors. We find that nurses and midwives are evenly distributed across the country (at least in the public sector), though doctors are not. This means that for four provinces, there are not enough doctors to provide more complex care, and only three provinces could provide cover in the event of all deliveries taking place in facilities. CONCLUSIONS: This analysis suggests that there is a strong case for reducing the financial burden on clients of RMNH services and also a pressing need to improve the terms and conditions of key health staff. Numbers need to grow, and distribution is also a challenge, suggesting the need for differentiated policies in relation to rural areas, especially for doctors and specialists. The management of user fees should also be reviewed, particularly for non-Ministry facilities, which do not retain their revenues, and receive limited investment in return from the municipalities and district councils. Overall public investment in health needs to grow.

Street-level workers' criteria for identifying indigents to be exempted from user fees in Burkina Faso.

OBJECTIVES: Universal healthcare coverage cannot be achieved in Africa as long as the indigent, the poorest, are unable to access healthcare systems. This study was carried out in Burkina Faso to obtain street-level workers' perspectives on what criteria should be used to select indigents to be exempted from user fees. METHODS: Two group consensus techniques were used (Delphi and Concept Mapping). The participants were nurses (CM; n = 24), midwives (CM; n = 23) from a rural district and Social Action agents (CM; n = 31) and healthcare workers (Delphi n = 23) in training at two national schools. RESULTS: Altogether, 446 criteria were proposed. The nurses put forward criteria related to being ill without support and being a victim of society. The midwives focused more on the disabled poor and those who were ill and unsupported. The healthcare workers in training mentioned disabled persons and the elderly with no family support. The Social Action agents spoke about vulnerability related to illness or disability and the fact of being excluded or being a disaster victim. CONCLUSIONS: These criteria proposed by street-level workers add to other studies conducted in Burkina Faso and should help the State to improve indigents' access to care.

Child healthcare workers in resource-limited areas improve health with innovative low-cost projects.

Most child health workers in resource-limited communities are dedicated, imaginative, innovative practitioners with ideas that would improve the care of children and families. However, they often lack experience in seeking funds and implementing their ideas. In 2006, the Section on International Child Health in the American Academy of Pediatrics launched a program, I-CATCH to fill this gap. The program provides mentors to assist in writing a proposal for the community-conceived and community-driven idea to improve child health, makes a small amount of funds available to the selected proposals, and offers mentors to help with the project's implementation. To date, 29 projects in 20 different non-industrialized countries have been funded. The impressive results achieved by the four completed and three ongoing projects are presented.

Global Health: Preparation for Working in Resource-Limited Settings.

Trainees and clinicians from high-income countries are increasingly engaging in global health (GH) efforts, particularly in resource-limited settings. Concomitantly, there is a growing demand for these individuals to be better prepared for the common challenges and controversies inherent in GH work. This is a state-of-the-art review article in which we outline what is known about the current scope of trainee and clinician involvement in GH experiences, highlight specific considerations and issues pertinent to GH engagement, and summarize preparation recommendations that have emerged from the literature. The article is focused primarily on short-term GH experiences, although much of the content is also pertinent to long-term work. Suggestions are made for the health care community to develop and implement widely endorsed preparation standards for trainees, clinicians, and organizations engaging in GH experiences and partnerships.

Innovation in primary care: community health services in Mexico and the United States.

Providing adequate health care to a nation's citizens is a challenge in every country. Despite large differences in wealth, health care organization, and health politics, both Mexico and the United States undertook similar efforts to expand primary care to previously underserved populations during the past 30 years. This study analyzes common antecedents, contexts of change, elements of the innovations, problems with entrenched interests, and resources that have allowed both programs to survive in difficult environments. We show that new forms of primary health care can face similar problems and prospects in very different countries because of similar political, bureaucratic, and economic limitations.

Community-based health care in Kibwezi, Kenya: 10 years in retrospect.

In response to the interest of the Kenya government in community-based health care, the Kibwezi Rural Health Scheme was developed by the African Medical and Research Foundation (AMREF) in a semi-arid district in eastern Kenya. Based on a community co-operative philosophy and focussing on health promotion and prevention, the scheme includes the following: a health centre with a 15-bed in-patient unit including four maternity beds, out-patient services, and a 15-bed nutrition rehabilitation unit; a cadre of volunteer community health workers, trained by AMREF, who form the backbone of the project; maternal child health/family planning and nutrition services including an applied nutrition programme, a water project; and a mobile health unit. Designed as a replicable model health programme, the intention was that services would be gradually taken over by the Ministry of Health of Kenya. Much has been learned in the development of the project which should be meaningful to others considering similar endeavours. One of the first lessons learned was that the time taken to sensitize the community to community-based health care is critical to the success of the project and may need to be as long as 1-2 years. Another was that gaining the support of the community for the community health workers (CHW) requires a considerable effort on the part of project staff, but seems to be the only viable solution to the remuneration and recognition of the CHW's work. It also became apparent that preventive and promotive health services should be integrated structurally and operationally with curative health services to provide the most benefits for the community served. Finally, although there are some differences of opinion, it is felt that with some refinements, the project could be replicated in other parts of Kenya.