The effects of selected neglected tropical diseases on economic performance at the macrolevel in Africa.

BACKGROUND: Neglected tropical diseases (NTDs) such as leprosy, lymphatic filariasis (LF), schistosomiasis and onchocerciasis are endemic in several African countries. These diseases can lead to severe pain and permanent disability, which can negatively affect the economic productivity of the affected person(s), and hence resulting into low economic performance at the macrolevel. Nonetheless, empirical evidence of the effects of these NTDs on economic performance at the macrolevel is sparse. This study therefore investigates the effects of the above-mentioned NTDs on economic performance at the macrolevel in Africa. METHODS: The study employs a panel design with data comprising 24 to 45 African countries depending on the NTD in question, over the period, 2002 to 2019. Gross domestic product (GDP) is used as the proxy for economic performance (Dependent variable) and the prevalence of the above-mentioned NTDs are used as the main independent variables. The random effects (RE), fixed effects (FE) and the instrumental variable fixed effects (IVFE) panel data regressions are used as estimation techniques. RESULTS: We find that, an increase in the prevalence of the selected NTDs is associated with a fall in economic performance in the selected African countries, irrespective of the estimation technique used. Specifically, using the IVFE regression estimates, we find that a percentage increase in the prevalence of leprosy, LF, schistosomiasis and onchocerciasis is associated with a reduction in economic performance by 0.43%, 0.24%, 0.28% and 0.36% respectively, at either 1% or 5% level of significance. CONCLUSION: The findings highlight the need to increase attention and bolster integrated efforts or measures towards tackling these diseases in order to curb their deleterious effects on economic performance. Such measures can include effective mass drug administration (MDA), enhancing access to basic drinking water and sanitation among others.

An Updated Economic Assessment of Moxidectin Treatment Strategies for Onchocerciasis Elimination.

BACKGROUND: Concerns that annual mass administration of ivermectin, the predominant strategy for onchocerciasis control and elimination, may not lead to elimination of parasite transmission (EoT) in all endemic areas have increased interest in alternative treatment strategies. One such strategy is moxidectin. We performed an updated economic assessment of moxidectin- relative to ivermectin-based strategies. METHODS: We investigated annual and biannual community-directed treatment with ivermectin (aCDTI, bCDTI) and moxidectin (aCDTM, bCDTM) with minimal or enhanced coverage (65% or 80% of total population taking the drug, respectively) in intervention-naive areas with 30%, 50%, or 70% microfilarial baseline prevalence (representative of hypo-, meso-, and hyperendemic areas). We compared programmatic delivery costs for the number of treatments achieving 90% probability of EoT (EoT90), calculated with the individual-based stochastic transmission model EPIONCHO-IBM. We used the costs for 40 years of program delivery when EoT90 was not reached earlier. The delivery costs do not include drug costs. RESULTS: aCDTM and bCDTM achieved EoT90 with lower programmatic delivery costs than aCDTI with 1 exception: aCDTM with minimal coverage did not achieve EoT90 in hyperendemic areas within 40 years. With minimal coverage, bCDTI delivery costs as much or more than aCDTM and bCDTM. With enhanced coverage, programmatic delivery costs for aCDTM and bCDTM were lower than for aCDTI and bCDTI. CONCLUSIONS: Moxidectin-based strategies could accelerate progress toward EoT and reduce programmatic delivery costs compared with ivermectin-based strategies. The costs of moxidectin to national programs are needed to quantify whether delivery cost reductions will translate into overall program cost reduction.

Zoonotic and vector-borne parasites and epilepsy in low-income and middle-income countries.

Zoonotic and vector-borne parasites are important preventable risk factors for epilepsy. Three parasitic infections - cerebral malaria, Taenia solium cysticercosis and onchocerciasis - have an established association with epilepsy. Parasitoses are widely prevalent in low-income and middle-income countries, which are home to 80% of the people with epilepsy in the world. Once a parasitic infection has taken hold in the brain, therapeutic measures do not seem to influence the development of epilepsy in the long term. Consequently, strategies to control, eliminate and eradicate parasites represent the most feasible way to reduce the epilepsy burden at present. The elucidation of immune mechanisms underpinning the parasitic infections, some of which are parasite-specific, opens up new therapeutic possibilities. In this Review, we explore the pathophysiological basis of the link between parasitic infections and epilepsy, and we consider preventive and therapeutic approaches to reduce the burden of epilepsy attributable to parasitic disorders. We conclude that a concerted approach involving medical, veterinary, parasitological and ecological experts, backed by robust political support and sustainable funding, is the key to reducing this burden.

Economic evaluations of onchocerciasis interventions: a systematic review and research needs.

OBJECTIVE: To provide a systematic review of economic evaluations that has been conducted for onchocerciasis interventions, to summarise current key knowledge and to identify research gaps. METHOD: A systematic review of the literature was conducted on the 8th of August 2018 using the PubMed (MEDLINE) and ISI Web of Science electronic databases. No date or language stipulations were applied to the searches. RESULTS: We identified 14 primary studies reporting the results of economic evaluations of onchocerciasis interventions, seven of which were cost-effectiveness analyses. The studies identified used a variety of different approaches to estimate the costs of the investigated interventions/programmes. Originally, the studies only quantified the benefits associated with preventing blindness. Gradually, methods improved and also captured onchocerciasis-associated skin disease. Studies found that eliminating onchocerciasis would generate billions in economic benefits. The majority of the cost-effectiveness analyses evaluated annual mass drug administration (MDA). The estimated cost per disability-adjusted life year (DALY) averted of annual MDA varies between US$3 and US$30 (cost year variable). CONCLUSIONS: The cost benefit and cost effectiveness of onchocerciasis interventions have consistently been found to be very favourable. This finding provides strong evidential support for the ongoing efforts to eliminate onchocerciasis from endemic areas. Although these results are very promising, there are several important research gaps that need to be addressed as we move towards the 2020 milestones and beyond.

OBJECTIF: Fournir une analyse systématique des évaluations économiques réalisées pour les interventions contre l'onchocercose, résumer les principales connaissances actuelles et identifier les lacunes de la recherche. MÉTHODE: Une revue systématique de la littérature a été menée le 8 août 2018 en utilisant les bases de données électroniques PubMed (Medline) et ISI Web of Science. Aucune indication de date ou de langue n'a été appliquée aux recherches. RÉSULTATS: Nous avons identifié 14 études principales rapportant sur les résultats d'évaluations économiques d'interventions contre l'onchocercose, dont 7 étaient des analyses coût-efficacité. Les études identifiées ont utilisé diverses approches pour estimer les coûts des interventions/programmes étudiés. A l'origine, les études ne mesuraient que les avantages associés à la prévention de la cécité. Progressivement, les méthodes se sont améliorées et ont également capturé les maladies de la peau associées à l'onchocercose. Les études ont montré que l'élimination de l'onchocercose générerait des milliards de bénéfices économiques. La majorité des analyses coût-efficacité ont évalué l'administration annuelle en masse de médicaments (AMD). Le coût estimé par année de vie ajustée par rapport à l'incapacité (DALY) corrigé pour l'AMD annuelle varie entre 3 et 30 USD (variable de l'année de coût). ConclusionsLe rapport coût-efficacité et la rentabilité des interventions contre l'onchocercose se sont toujours avérés très favorables. Cette constatation fournit un solide appui probant aux efforts en cours pour éliminer l'onchocercose des zones d'endémie. Bien que ces résultats soient très prometteurs, plusieurs lacunes importantes en matière de recherche doivent être comblées à mesure que nous nous approchons des étapes clés pour 2020 et au-delà.

Equity and efficiency in the scaled-up implementation of integrated neglected tropical disease control: the health economics protocol of the COUNTDOWN multicountry observational study in Ghana, Cameroon and Liberia.

INTRODUCTION: Worldwide, millions of individuals are affected by neglected tropical diseases (NTDs). They are frequently the poorest and most marginalised members of society. Their living conditions, among other things, make them susceptible to such diseases. Historically, several large-scale treatment programmes providing mass drug administrations (MDAs) were carried out per single disease but over the last decade there has been an increasing trend towards co-implementation of MDA activities given the resources used for such programmes are often the same. The COUNTDOWN multicountry studies focus on scaled-up implementation of integrated control strategies against four diseases: lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis. The objective of the COUNTDOWN economic study is to assess the multicountry implementation of control interventions in terms of equity, impact and efficiency. METHODS: The health economic study uses different analytical methods to assess the relationship between NTDs and poverty and the cost-effectiveness of different large-scale intervention options. Regression analysis will be used to study the determinants of NTD occurrence, the impact of NTDs on poverty, factors that hinder access to MDAs and the effect of NTDs on quality-of-life of those affected, including disability. Cost-effectiveness analyses of various integration methods will be performed using health economic modelling to estimate the cost and programme impact of different integration options. Here, cost-effectiveness ratios will be calculated, including multivariate sensitivity analyses, using Bayesian analysis. ETHICS AND DISSEMINATION: Ethics approval has been received both at the Liverpool School of Tropical Medicine and in all participating countries. Results of the various substudies will be presented for publication in peer-reviewed journals. STUDY DATES: 1 July 2016 to 30 June-October 2019.

Audit of the community-directed treatment with ivermectin (CDTI) for onchocerciasis and factors associated with adherence in three regions of Cameroon.

BACKGROUND: After more than 15 years of community-directed treatment with ivermectin (CDTI) in the Centre 1, Littoral 2 and West CDTI projects in Cameroon, the epidemiological evaluation conducted in 2011 revealed that onchocerciasis endemicity was still high in some communities. To investigate the potential reasons explaining this high endemicity, a cluster coverage survey was conducted in April-May 2015 in three health districts (HD), to assess the implementation of the CDTI, the 2014 therapeutic coverage and the five-year adherence to treatment. A two-stage cluster design was considered during analyses, with data weighted proportionally to age and gender distribution in the population. RESULTS: In the three HDs, 69 community leaders, 762 heads of households, 83 community drug distributors (CDD) and 2942 household members were interviewed. The CDTI organization and the involvement of heads of households were in average weak, with 84.0% (95% CI: 81.2-86.4%) of them who had not participated in activities during the 2014 mass drug administration (MDA). On average, six of ten community leaders declared that the period of treatment was decided by the health personnel while the CDDs selection was made during a community meeting for only 43.4% of them. The 2014 weighted therapeutic coverage was 64.1% (95% CI: 56.8-70.9%), with no significant difference in the three HDs. The survey coverages were lower than the reported coverages with a significant difference varying from 14.1% to 22.0%. Among those aged 10 years and above, 57.8% (95% CI: 50.2-65.1%) declared having taken the treatment each time during the last five MDAs with no significant difference among HDs, while 9.8% (95% CI: 7.5-12.8%) declared that they had never taken the drug. In multivariate analysis, the most important factors associated with the five-year adherence to treatment were high involvement in CDTI and age (40+ years). CONCLUSIONS: Despite more than 15 years of CDTI, there was still weak community participation and ownership, a lower coverage than reported and an average five-year adherence in the surveyed HDs. The reinforcement of the community ownership by the Ministry of Public Health officials and the timely procurement of ivermectin as requested by the communities are some measures that should be implemented to improve the therapeutic coverage, adherence to treatment and hence achieve onchocerciasis elimination. Further anthropological and entomological studies would provide better insights into our understanding of the persistence of the disease in these three CDTI projects.

Feasibility of utilizing the SD BIOLINE Onchocerciasis IgG4 rapid test in onchocerciasis surveillance in Senegal.

As effective onchocerciasis control efforts in Africa transition to elimination efforts, different diagnostic tools are required to support country programs. Senegal, with its long standing, successful control program, is transitioning to using the SD BIOLINE Onchocerciasis IgG4 (Ov16) rapid test over traditional skin snip microscopy. The aim of this study is to demonstrate the feasibility of integrating the Ov16 rapid test into onchocerciasis surveillance activities in Senegal, based on the following attributes of acceptability, usability, and cost. A cross-sectional study was conducted in 13 villages in southeastern Senegal in May 2016. Individuals 5 years and older were invited to participate in a demographic questionnaire, an Ov16 rapid test, a skin snip biopsy, and an acceptability interview. Rapid test technicians were interviewed and a costing analysis was conducted. Of 1,173 participants, 1,169 (99.7%) agreed to the rapid test while 383 (32.7%) agreed to skin snip microscopy. The sero-positivity rate of the rapid test among those tested was 2.6% with zero positives 10 years and younger. None of the 383 skin snips were positive for Ov microfilaria. Community members appreciated that the rapid test was performed quickly, was not painful, and provided reliable results. The total costs for this surveillance activity was $22,272.83, with a cost per test conducted at $3.14 for rapid test, $7.58 for skin snip microscopy, and $13.43 for shared costs. If no participants had refused skin snip microscopy, the total cost per method with shared costs would have been around $16 per person tested. In this area with low onchocerciasis sero-positivity, there was high acceptability and perceived value of the rapid test by community members and technicians. This study provides evidence of the feasibility of implementing the Ov16 rapid test in Senegal and may be informative to other country programs transitioning to Ov16 serologic tools.

Benchmarking the Cost per Person of Mass Treatment for Selected Neglected Tropical Diseases: An Approach Based on Literature Review and Meta-regression with Web-Based Software Application.

BACKGROUND: Advocacy around mass treatment for the elimination of selected Neglected Tropical Diseases (NTDs) has typically put the cost per person treated at less than US$ 0.50. Whilst useful for advocacy, the focus on a single number misrepresents the complexity of delivering "free" donated medicines to about a billion people across the world. We perform a literature review and meta-regression of the cost per person per round of mass treatment against NTDs. We develop a web-based software application (https://healthy.shinyapps.io/benchmark/) to calculate setting-specific unit costs against which programme budgets and expenditures or results-based pay-outs can be benchmarked. METHODS: We reviewed costing studies of mass treatment for the control, elimination or eradication of lymphatic filariasis, schistosomiasis, soil-transmitted helminthiasis, onchocerciasis, trachoma and yaws. These are the main 6 NTDs for which mass treatment is recommended. We extracted financial and economic unit costs, adjusted to a standard definition and base year. We regressed unit costs on the number of people treated and other explanatory variables. Regression results were used to "predict" country-specific unit cost benchmarks. RESULTS: We reviewed 56 costing studies and included in the meta-regression 34 studies from 23 countries and 91 sites. Unit costs were found to be very sensitive to economies of scale, and the decision of whether or not to use local volunteers. Financial unit costs are expected to be less than 2015 US$ 0.50 in most countries for programmes that treat 100 thousand people or more. However, for smaller programmes, including those in the "last mile", or those that cannot rely on local volunteers, both economic and financial unit costs are expected to be higher. DISCUSSION: The available evidence confirms that mass treatment offers a low cost public health intervention on the path towards universal health coverage. However, more costing studies focussed on elimination are needed. Unit cost benchmarks can help in monitoring value for money in programme plans, budgets and accounts, or in setting a reasonable pay-out for results-based financing mechanisms.

Exploring Consumer Perceptions and Economic Burden of Onchocerciasis on Households in Enugu State, South-East Nigeria.

INTRODUCTION: Onchocerciasis or river blindness constitutes a major burden to households especially in resource-poor settings, causing a significant reduction in household productivity. There has been renewed interest from policy makers to reduce the burden of Neglected Tropical Diseases (NTDs) such as onchocerciasis on individuals and households. This paper provides new information on the patient's perceptions of onchocerciasis and its economic burden on households in South-eastern Nigeria. The information will be useful to health providers and policy makers for evidence-informed resource allocation decisions. METHODS: Information was generated from a cross-sectional household survey conducted in Achi community, Oji River Local Government Area (LGA) of Enugu State, Southeast Nigeria. A pre-tested interviewer-administered questionnaire was used to collect data. A total of 747 households were visited randomly and data were collected using pre-tested interviewer administered questionnaire from 370 respondents. The respondents' knowledge of the cause of symptoms of the disease, costs incurred for seeking treatment and productivity losses were elicited. Data were analyzed using tabulations and inferential statistics. A socio-economic status (SES) index was used to disaggregate some key variables by SES quintiles for equity analysis. RESULTS: Many people had more than one type of manifestation of onchocerciasis. However, more than half of the respondents (57%) had no knowledge of the cause of their symptoms. Male respondents had significantly more knowledge of the cause of symptoms than females (P = 0.04) but knowledge did not differ across SES (P = 0.82). The average monthly treatment cost per respondent was US$ 14.0. Drug cost (US$10) made up about 72% of total treatment cost. The per capita productivity loss among patients was US$16 and it was higher in the poorest (Q1) (US$20) and the third SES quintiles (Q3) (US$21). The average monthly productivity loss among caregivers was US$3.5. CONCLUSION: Onchocerciasis still constitutes considerable economic burden on patients due to the high cost of treatment and productivity loss. Prioritizing domestic resource allocation for the treatment of onchocerciasis is important for significant and sustained reduction in the burden of the disease. In addition, focused health promotion interventions such as health education campaigns should be scaled up in onchocerciasis-endemic communities.

The potential impact of moxidectin on onchocerciasis elimination in Africa: an economic evaluation based on the Phase II clinical trial data.

BACKGROUND: Spurred by success in several foci, onchocerciasis control policy in Africa has shifted from morbidity control to elimination of infection. Clinical trials have demonstrated that moxidectin is substantially more efficacious than ivermectin in effecting sustained reductions in skin microfilarial load and, therefore, may accelerate progress towards elimination. We compare the potential cost-effectiveness of annual moxidectin with annual and biannual ivermectin treatment. METHODS: Data from the first clinical study of moxidectin were used to parameterise the onchocerciasis transmission model EPIONCHO to investigate, for different epidemiological and programmatic scenarios in African savannah settings, the number of years and in-country costs necessary to reach the operational thresholds for cessation of treatment, comparing annual and biannual ivermectin with annual moxidectin treatment. RESULTS: Annual moxidectin and biannual ivermectin treatment would achieve similar reductions in programme duration relative to annual ivermectin treatment. Unlike biannual ivermectin treatment, annual moxidectin treatment would not incur a considerable increase in programmatic costs and, therefore, would generate sizeable in-country cost savings (assuming the drug is donated). Furthermore, the impact of moxidectin, unlike ivermectin, was not substantively influenced by the timing of treatment relative to seasonal patterns of transmission. CONCLUSIONS: Moxidectin is a promising new drug for the control and elimination of onchocerciasis. It has high programmatic value particularly when resource limitation prevents a biannual treatment strategy, or optimal timing of treatment relative to peak transmission season is not feasible.

Onchocerciasis control in the Democratic Republic of Congo (DRC): challenges in a post-war environment.

OBJECTIVE: To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12 years of community-directed treatment with ivermectin (CDTI). METHODS: Data from the National Programme for Onchocerciasis (NPO) provided by the National Onchocerciasis Task Force (NOTF) through the annual reports of the 21 CDTI projects for the years 2001-2012 were reviewed retrospectively. A hypothetical-inputs-process-outputs-outcomes table was constructed. RESULTS: Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39 100 communities by 2012 while the number of community-directed distributors (CDD) and health workers (HW) multiplied. By 2012, there were ratios of 1 CDD per 262 persons and 1 HW per 2318 persons at risk. More than 80% of the funding came from the fiduciary funds of the African Programme for Onchocerciasis Control. The cost of treatment per person treated fell from US$ 1.1 in 2001 to US$ 0.1 in 2012. The therapeutic coverage increased from 2.7% (2001) to 74.2% (2012); the geographical coverage, from 4.7% (2001) to 93.9% (2012). Geographical coverage fell in 2005 due to deaths in loiasis co-endemic areas, and the therapeutic coverage fell in 2008 due to insecurity. CONCLUSIONS: Challenges to CDTI in DRC have been serious adverse reactions to ivermectin in loiasis co-endemic areas and political conflict. Targets for personnel or therapeutic and geographical coverages were not met. Longer term funding and renewed efforts are required to achieve control and elimination of onchocerciasis in DRC.

Lymphatic filariasis and onchocerciasis prevention, treatment, and control costs across diverse settings: a systematic review.

The control and eventual elimination of neglected tropical disease (NTD) requires the expansion of interventions such as mass drug administration (MDA), vector control, diagnostic testing, and effective treatment. The purpose of this paper is to present the evidence base for decision-makers on the cost and cost-effectiveness of lymphatic filariasis (LF) and onchocerciasis prevention, treatment, and control. A systematic review of the published literature was conducted. All studies that contained primary or secondary data on costs or cost-effectiveness of prevention and control were considered. A total of 52 papers were included for LF and 24 papers were included for onchocerciasis. Large research gaps exist on the synergies and cost of integrating NTD prevention and control programs, as well as research on the role of health information systems, human resource systems, service delivery, and essential medicines and technology for elimination. The literature available on costs and cost-effectiveness of interventions is also generally older, extremely focal geographically and of limited usefulness for developing estimates of the global economic burden of these diseases and prioritizing among various intervention options. Up to date information on the costs and cost-effectiveness of interventions for LF and onchocerciasis prevention are needed given the vastly expanded funding base for the control and elimination of these diseases.

Disease control priorities for neglected tropical diseases: lessons from priority ranking based on the quality of evidence, cost effectiveness, severity of disease, catastrophic health expenditures, and loss of productivity.

BACKGROUND: In the context of limited health care budgets in countries where Neglected Tropical Diseases (NTDs) are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost-effectiveness analyses may lead to biased and insufficiently justified priorities. OBJECTIVES: The objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi-criteria decision-making matrix, and 3) discuss the conditions under which this decision-making procedure should be carried out in a real-world decision-making context. METHODS: This paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi-criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases. DISCUSSION: Our in vitro multi-criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil-transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision-making process and we stress the limitations of this study exercise. CONCLUSION: By exploring how several criteria relevant to the multi-facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised.

Where would I be without ivermectin? Capturing the benefits of community-directed treatment with ivermectin in Africa.

OBJECTIVES: To document peoples' perceptions of the benefits of taking ivermectin, as an important predictor of sustained compliance with long-term ivermectin treatment, and to identify the socio-demographic correlates of perceived benefits of ivermectin treatment. METHODS: Multisite study in Cameroon, DRC, Nigeria and Uganda. A structured questionnaire was administered to 1600 persons randomly selected from household treatment records. Community leaders, community-directed drug distributors (CDDs) and health workers were interviewed using in-depth interview guides, while focus group discussions (FGDs) were held with community members to capture factors that reflected their perception of benefits of community-directed treatment with ivermectin (CDTI). Case histories of persons with special experiences with onchocerciasis were collected. RESULTS: In this study, 84.7% of respondents indicated that ivermectin treatment has many benefits. The social benefits of CDTI included improved ability to work, peer acceptance and improved school attendance. Other individual benefits included self-respect/esteem, election to political office and improved relationship in the homes. The health benefits included improved skin texture and less ill health. Important demographic factors that influenced perception of the benefits of taking ivermectin, include marital status (P=0.012), age (P=0.029) and length of stay in onchocerciasis-endemic communities (P<0.001). Another factor was individual perception of susceptibility to onchocerciasis infection (P<0.0001). CONCLUSION: A programmatic focus on the benefits of CDTI could provide a basis for motivating communities to comply with long-term treatment with ivermectin. The results illustrate the importance of capturing beneficiaries' perceptions towards CDTI as a resource for producing health education materials for increasing the sustainability ivermectin distribution in endemic countries.

Economic evaluation of Mectizan distribution.

The distribution of ivermectin has dramatically altered the nature of onchocerciasis control. Existing economic analyses of ivermectin distribution programmes show that these programmes have a highly beneficial impact. Most analyses have estimated the economic benefits in terms of increased labour productivity as a result of reductions in blindness, and in terms of additional land-availability because of a reduced transmission of the parasite. Economic evaluations of the Onchocerciasis Control Program (OPC) in West Africa have calculated a net present value - equivalent discounted benefits minus discounted costs - of $485 million for the programme over a 39-year period, using a conservative 10% rate to discount future health and productivity gains. The net present value for the African Program for Onchocerciasis Control (APOC) is calculated at 88 million US dollars over a 21-year time period, also using a 10% discount rate. Cost-effectiveness analyses of ivermectin distribution have found a cost of 14-30 US dollars per disability-adjusted life-year prevented - estimates comparable with other priority disease control programmes. However, the economic success of ivermectin distribution is sensitive to the fact that the drug itself has been donated free of charge. The market value of Merck's donations to the APOC for just 1 year considerably outweighs the benefits calculated for both the OPC and the APOC over the life of these projects. Pending the development of an effective macrofilaricide, the distribution of ivermectin will remain a public health priority into the foreseeable future.

Profitable gifts: a history of the Merck Mectizan donation program and its implications for international health.

A unique public/private partnership situated around a pharmaceutical, Merck's Mectizan donation program stands out as an example of corporate philanthropy in the history of the pharmaceutical industry and provides insight into future public/private partnerships in public health. This paper considers the issues Merck faced in the decision to donate Mectizan (ivermectin) and in the subsequent development of the Mectizan donation program, delineating the moral and financial debates that arose within the company. Coming after almost 15 years of donation, this assessment of the program's strengths and shortcomings suggests how the pharmaceutical industry can better serve as a viable partner in improving international health.

Community-directed treatment with ivermectin in two Nigerian communities: an analysis of first year start-up processes, costs and consequences.

OBJECTIVES: To determine the start-up processes, costs and consequences of community-directed treatment with ivermectin (CDTI) in two onchocerciasis endemic rural towns of Southeast Nigeria; namely Achi and Nike. The other objectives were to discover the community-financing mechanisms, local ivermectin distribution strategies and communities' organisational capacity to handle the programme. METHODS: Structured questionnaires, informal interviews, observations, discussions with community members at general village assemblies and community outreach lectures were used at different stages of the study. RESULT: The towns had the organisational capacity to implement the programme. Coverage with ivermectin was between 31-73% in Achi (mean = 58.6%), and 36.6-72% in Nike (mean = 61.95%). The unit financial costs were $0.17 in Nike and $0.13 in Achi, but the unit aggregate cost was $0.37 in Nike and $0.39 in Achi. When research costs were removed, the unit aggregate cost was $0.22 in Achi and $0.20 in Nike. Provider's financial costs and communities' non-financial costs were the biggest contributors to the aggregate cost. The cost would decrease in subsequent years since the research cost and parts of the mobilisation and training costs would not be incurred after the first year. CONCLUSION: Governments and sponsors of CDTI should find means of continuously strengthening the programme and providing technical support to the communities. As both CDTI and communities are dynamic entities, continuous health education campaigns are needed to keep reminding the people of the benefit of long-term ivermectin distribution, together with the need for community ownership of the programme.

Onchocerciasis control in Nigeria: will households be able to afford community-directed treatment with ivermectin?

OBJECTIVES: To determine the level of affordability of community-directed treatment with ivermectin (CDTI) to households living in two onchocerciasis endemic Nigerian communities namely Toro in the north and Nike in the south. METHODS: The proportion of the cost of treating people with ivermectin will deplete in average monthly/projected annual household expenditure on food and health care, and on average monthly and projected annual household income were respectively calculated and used to determine the level of affordability of CDTI. Questionnaires administered to heads of households or their representatives were used to collect information on the household expenditures and income. The suggested unit CDTI cost of $0.20 was used. However, as a test of sensitivity, we also used the unit cost of $0.056 which some community based distributors are charging per treatment. RESULT: Using $0.20 as the unit treatment cost, this will consume less than 0.05% of average annual household income in both communities. It will equally deplete 0.05% of combined annual household expenditures on food and health care in both communities. However, using $0.056 as the unit treatment cost, then 0.02% of average annual household expenditure on health care, 0.01% average annual expenditure on combined health care and food, and 0.01% of average annual household income will be depleted. CONCLUSION: The households living in both communities may be able to afford CDTI schemes. However, the final decision on levels of affordability lies with the households. They will decide whether they can afford to trade-off some household income for ivermectin distribution.

The community-directed, ivermectin-treatment programme for onchocerciasis control in Uganda--an evaluative study (1993-1997).

The first 5 years of a community-directed, ivermectin-treatment programme, to control onchocerciasis in 1805 endemic communities in 10 districts in Uganda, are evaluated. Each year, the desired treatment coverage of the population eligible to take invermectin (90%) was achieved in 42.6%-51% of the 1713 communities for which complete data were available; 67%-74.8% achieved 80% coverage. The annual cost per person treated with ivermectin (ACPTI) was much higher in the districts with small populations to be treated (< 15,000) than in those with large populations (> 40,000) (U.S.$0.40 v. U.S.$0.10 or less). The community members' acceptance of the programme was related to their attendance at health-education sessions (P = 0.009), and their participation in the mobilisation of other community members increased greatly when they were allowed to take part in the selection of the community-based distributors (CBD) and the choice of treatment sites. The overall target ratio of one CBD/71 families was attained by 1997. However, the failure of some trained CBD to participate in the treatment exercise prevented some communities achieving 90% treatment coverage. Providing CBD with cash incentives or externally derived incentives 'in kind' proved counter-productive whereas locally generated incentives 'in kind' were simply regarded as the normal obligations of the community. District health staff successfully integrated the programme with their other health commitments, but the involvement of CBD in other programmes proved detrimental to their performance. Other constraints identified were rebel insurgency in some areas, and abnormally heavy rains in hilly areas with poor roads.