Resource Planning and Economies of scale
Community healthcare programs in uMkhanyakude are often implemented or supported by ward-based outreach teams (WBOTs)[24]. A WBOT consists of a professional nurse, a staff nurse and community care givers (CCGs)[24]. If the simulation treatment team consists of the ward-based outreach team (WBOT) and one pediatric specialist, the average cost, per child, of treating 500 children in a schistosomiasis control MDA program for children aged below five years in uMkhanyakude District would be estimated to be US$60. If the model treatment team consists of a Medical Officer and WBOT the estimated average cost per child treating 500 children drops to US$57 indicating a decline of 5%. However, a WBOT only model treatment team requires US$27 which is 20% less per child compared to when a pediatrician is part of the treatment team. In the simulation, if the number of children treated increased to 2500, the average cost per child reduced to US$30 (51% drop) when a pediatrician is part of the treatment team; reduced by 49% when a medical officer is part of the treatment team instead of a pediatrician; and by 53% when the treatment team is the WBOT. If the number of children is increased to 18 500, the average cost of treatment per child reduces by 42% from US$60 to US$23, by 62% for a pediatrician led team, by 52% for a Medical Officer led team and 53% for a WBOT only treatment team. Table 2 shows the project’s simulated economies of scale.
Table 2
Program’s economies of scale analysis and resource planning.
| Paediatric Specialist and WBOT | Medical Officer and WBOT. | WBOT only | |
500 children | 0% | -5% | -20% | |
2500 children | -51% | -49% | -53% | |
13500 children | -62% | -52% | -53% | |
Descriptive Statistics | |
| Max (US$) | Max Scenario | Min (US$) | Min Scenario |
500 children | 60 | Paediatric Specialist and WBOT | 48 | WBOT only |
2500 children | 30 | Paediatric Specialist and WBOT | 22 | WBOT only |
13500 children | 23 | Paediatric Specialist and WBOT | 17 | WBOT only |
If only the WBOT is used to treat 2500 children, and laboratory diagnosis is limited to a sample of 500 children, the average cost of treatment per child in the MDA program is 18% lower than when all the children are screened and treated for schistosomiasis. If 18 500 children are treated by a WBOT based on results of testing 500 samples, the cost of the MDA program would be 26% lower than when all the children are tested. A scenario in which only a sample of 500 children was tested for schistosomiasis using laboratory methods was used for further calculations. Figure 1 depicts economies of scale for each treatment model.
Figure 1: Economies of scale per treatment model
As shown in Fig. 1, the average cost per child in a schistosomiasis control MDA program decreases sharply when the number of children treated are increased from less than 500 children to about 2500 children. A gradual decrease in the cost of treatment per child was observed if the number of children to be treated was increased to more than 2500.
Implementation strategy and economies of scope.
uMkhanyakude district has fixed clinics and School Health Mobile Clinics where the vaccination program is done. In comparing the cost of using the fixed clinics and mobile clinics, we assumed that four additional community caregivers would be required in the mobile clinics to make up for the absence of the parents at the schools when the School Health Mobile Clinic is used in crèches and early childhood development centers. It cost 14% more per child to treat the children in the School Health Mobile Clinic than it would cost in the fixed clinics when 500 children were treated. If 2500 children are treated, it costs 6% more to treat children in the School Health Mobile Clinic compared to the fixed clinic. Figure 2 shows the economies of scope for the program based on simulations.
Currently, the vaccination program in uMkhanyakude District is done in the fixed clinics while the school health mobile clinics are used for the deworming program. The deworming program is integrated with the vitamin A supplementation program. If the schistosomiasis control MDA is in integrated with the vaccination program, it costs 33% less to treat 500 than it would to treat 500 children if the MDA is implemented independently in a fixed clinic. This cost difference reduces to 14% when 2 500 are treated. If the schistosomiasis control program is integrated with the deworming and vitamin A supplementation program, the cost of treating 500 children becomes 47% lower than treating the children in an independent schistosomiasis control MDA program using a mobile clinic. The cost difference reduces to 22% when 2 500 children are treated.
If the schistosomiasis control MDA for children aged five years and below is integrated to the fixed clinic, it costs 9% more to treat 500 children than when the MDA program is integrated with the deworming and vitamin A supplementation program. The cost difference reduced to 3% when 2 500 were treated. There was no difference in the cost of using either of the options to treat at 17 000 or more.
Total Costs and Cost Effectiveness Analysis
Based on the WHO recommended coverage of 75%, the study found that the estimated total cost of implementing the MDA is US$1.087 million when the schistosomiasis control MDA program for children aged five years and below is integrated with the immunization program. Integrating the schistosomiasis control MDA program for children aged five years and below with the deworming and vitamin A supplementation programs was US$1.056 million indicating a 3% reduction in costs from the former.
At present, coverage for the immunization program in uMkhanyakude district is 85% while that of the deworming and Vitamin A program is 74%[21]. The cost effectiveness is calculated based on the average cost per additional child above or to reach the 75% treatment coverage recommended by WHO[28, 29]. If the schistosomiasis control MDA program is integrated with the immunization program, 75% coverage would require US$100 per additional child to reach that level. When the MDA program is integrated with the deworming and vitamin A supplementation program, the additional cost per child is US$1,246 to reach the 75% coverage. Assuming that deworming and vitamin A supplementation program reaches the 85% coverage similar to that of the immunization program, the additional cost per child to achieve the WHO coverage of 75% would be US$97. Table 2 shows the total cost and cost effectiveness analysis of the different options for treatment programs.
Cost Ratios
PZQ was the main cost driver of the MDA program and accounted for 59% of the costs of the schistosomiasis control MDA program for children aged five years and below when either the fixed clinics or mobile clinics were used. For both the fixed clinics and the mobile clinics, dose syringes contributed 26% of the costs, food contributed 13% while labor and laboratory costs contributed 1% each to the total costs of the schistosomiasis control MDA program as shown in Figs. 3 below.
Sensitivity Analysis
The main cost driver of the treatment program was the cost of PZQ. The sensitivity of the total costs to the use of generic drugs is detailed in Table 3:
Table 3
Percentage difference in cost of PZQ (brand to Generic) | 39% | 45% | 60% | 100% |
Percentage difference in total cost of treatment | -23% | -27% | -35% | -59% |
If the average cost of generic PZQ is less than the branded PZQ, the total cost of the schistosomiasis control MDA program for children aged five years and below would reduce by 23%. When the cost of generic drugs is less than the branded drug by 45%, there is a 27% reduction in the cost of the MDA program. A 60% reduction in the generic PZQ compared to the branded drug gave a 35% reduction in the total cost of the MDA program. In the case of donated PZQ the treatment program costs 59% less that when branded PZQ is used to treat schistosomiasis in an MDA program targeting children aged five years and below.