European and Developing Countries Clinical Trials Partnership.

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Summaryobjectives To estimate the incremental cost-effectiveness of a large-scale urban hygiene promotion programme in terms of reducing the incidence of childhood diarrhoeal disease in Bobo-Dioulasso, Burkina Faso.methods Total and incremental costs of the programme were estimated retrospectively from the perspectives of the provider, from the households who change their behaviour as a result of the programme and from society (the sum of the two). The programme effects were derived from an intervention study that estimated the impact on handwashing with soap after handling child stools through a time-series method of observing 37 319 mothers. Using data from the literature, the associated reductions in childhood morbidity and mortality were estimated. The direct medical savings and indirect savings of caregiver time and lost productivity associated with child death were estimated from interviews with households and health workers. The cost and outcome data were combined to provide an estimate of the cost per mother who starts handwashing with soap as a result of the programme and the cost per case of childhood diarrhoea averted.results The total provider cost (including start-up and 3-year running costs) was $302 507. Core programme activities accounted for 31% of the cost, administration 40%. The total cost to the 7286 households associated with changing behaviour during the 3 years of programme implementation was $160 125 ($7.3 per year per household). An estimated 8638 cases of diarrhoea, 864 outpatient consultations, 324 hospital referrals and 105 deaths were averted by the programme during this time.Savings to the provider from reduced treatment costs were estimated at $10 716 and savings to the households from averted treatment cost were $9136, resulting in a total saving to society of $19 852, increasing to $393 967 if indirect savings are included. The incremental provider cost per case of diarrhoea averted was $33.8. The incremental cost to society was $51.3 falling to $7.9 if indirect savings are included. If the programme were to be replicated elsewhere, savings in the international research input and start-up costs could reduce provider costs to $26.9 per case of diarrhoea averted. The annual cost of the programme represents 0.001% of the national health budget for Burkina Faso. The direct annual cost of implementing the programme at the household level represents 1.3% of annual household income.conclusion Hygiene promotion reduces the occurrence of childhood diarrhoea in Burkina Faso at less than 1% of the Ministry of Health budget and less than 2% of the household budget, and could be widely replicated at lower cost.keywords diarrhoeal disease, hygiene promotion, cost-effectiveness analysis correspondence Josephine Borghi, Health Policy Unit,

Abstract

Background

Ahmedabad is an industrial city in Gujarat, India. In 2003, the HIV prevalence among commercial sex workers (CSWs) in Ahmedabad reached 13.0%. In response, the Jyoti Sangh HIV prevention programme for CSWs was initiated, which involves outreach, peer education, condom distribution, and free STD clinics. Two surveys were performed among CSWs in 1999 and 2003. This study estimates the cost-effectiveness of the Jyoti Sangh HIV prevention programme.

Methods

A dynamic mathematical model was used with survey and intervention-specific data from Ahmedabad to estimate the HIV impact of the Jyoti Sangh project for the 51 months between the two CSW surveys. Uncertainty analysis was used to obtain different model fits to the HIV/STI epidemiological data, producing a range for the HIV impact of the project. Financial and economic costs of the intervention were estimated from the provider's perspective for the same time period. The cost per HIV-infection averted was estimated.

Results

Over 51 months, projections suggest that the intervention averted 624 and 5,131 HIV cases among the CSWs and their clients, respectively. This equates to a 54% and 51% decrease in the HIV infections that would have occurred among the CSWs and clients without the intervention. In the absence of intervention, the model predicts that the HIV prevalence amongst the CSWs in 2003 would have been 26%, almost twice that with the intervention. Cost per HIV infection averted, excluding and including peer educator economic costs, was USD 59 and USD 98 respectively.

Conclusion

This study demonstrated that targeted CSW interventions in India can be cost-effective, and highlights the importance of replicating this effort in other similar settings.