Costs of community-wide mass drug administration and school-based deworming for soil-transmitted helminths: evidence from a randomised controlled trial in Benin, India and Malawi

Abstract

Objectives: Current guidelines for the control of soil-transmitted helminths (STH) recommend deworming children and other high-risk groups, primarily using school-based deworming (SBD) programmes. However, targeting individuals of all ages through community-wide mass drug administration (cMDA) may interrupt STH transmission in some settings. We compared the costs of cMDA to SBD to inform decision-making about future updates to STH policy.

Design: We conducted activity-based microcosting of cMDA and SBD for 2 years in Benin, India and Malawi within an ongoing cMDA trial.

Setting: Field sites and collaborating research institutions.

Primary and secondary outcomes: We calculated total financial and opportunity costs and costs per treatment administered (unit costs in 2019 USD ($)) from the service provider perspective, including costs related to community drug distributors and other volunteers.

Results: On average, cMDA unit costs were more expensive than SBD in India ($1.17 vs $0.72) and Malawi ($2.26 vs $1.69), and comparable in Benin ($2.45 vs $2.47). cMDA was more expensive than SBD in part because most costs (~60%) were 'supportive costs' needed to deliver treatment with high coverage, such as additional supervision and electronic data capture. A smaller fraction of cMDA costs (~30%) was routine expenditures (eg, drug distributor allowances). The remaining cMDA costs (~10%) were opportunity costs of staff and volunteer time. A larger percentage of SBD costs was opportunity costs for teachers and other government staff (between ~25% and 75%). Unit costs varied over time and were sensitive to the number of treatments administered.

Conclusions: cMDA was generally more expensive than SBD. Accounting for local staff time (volunteers, teachers, health workers) in community programmes is important and drives higher cost estimates than commonly recognised in the literature. Costs may be lower outside of a trial setting, given a reduction in supportive costs used to drive higher treatment coverage and economies of scale.

Trial registration number: NCT03014167.

Keywords: health economics; public health; tropical medicine.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.

Figures

Figure 1

Flow of DeWorm3 activities conducted in intervention and control clusters. Activities include: census, prevalence survey, school-based deworming, community-wide mass drug administration, and coverage survey. Acronyms: quarter (Q), school-based deworming (SBD), community-wide mass drug administration (cMDA). a In India, SBD is also conducted in quarter 2, prior to the coverage survey. b In Malawi, no prevalence survey was conducted in year 2.

Figure 2

One-way and two-way sensitivity analyses of unit costs (2019 USD ($)). (A) community-wide mass drug administration (cMDA) costs in Benin; (B) school-based deworming (SBD) costs in Benin; (C) cMDA costs in India; (D) SBD costs in India; (E) cMDA costs in Malawi; (F) SBD costs in Malawi. Details on how each parameter was varied can be found in online supplemental appendix 4.