Trial-based economic evaluation of the system-integrated activation of community health volunteers in rural Ghana

ABSTRACT

Background

Globally, steps to revitalise programmes deploying community health workers (CHWs) on a national scale have been growing, but few economic evaluations have been done on system-integrated CHW programmes. Ghana has dual cadres of CHWs: community health officers (CHOs) and community health volunteers (CHVs). CHO plays a major role in primary health services but has suffered from chronic staff shortages. We activated CHVs in communities to mitigate the negative impact due to CHO shortages. The CHVs conducted home visits and provided health education to prevent childhood diseases.

Objective

We evaluated the cost-effectiveness and cost-benefit of activating CHVs.

Methods

In a cluster-randomised trial with 40 communities in rural Ghana, the changes in disease incidence were inferred from a statistical model using a Bayesian generalised linear multilevel model. We evaluated the total incremental cost, benefit, and effectiveness for the intervention from an economic model. In cost-effectiveness analysis, disability-adjusted life years (DALYs) were estimated using a decision tree model. In the cost-benefit analysis, the cost-benefit ratio and net present value of benefit were estimated using a decision tree model, and a standardised sensitivity analysis was conducted. The decision tree model was a one-year cycle and run over 10-years. Costs, benefits, and effectiveness were discounted at a rate of 3% per year.

Results

According to the cost-effectiveness analysis, the programme was highly likely to exceed the WHO-CHOICE threshold (1–3 times GDP per capita), but it was unlikely to exceed the conservative threshold (10–50% of GDP per capita). In the cost-benefit analysis, the mean and median cost-benefit ratios were 6.4 and 4.8, respectively.

Conclusion

We found the potential economic strengths in the cost-benefit analysis. To integrate CHW programmes with national health systems, we need more research to find the most effective scope of work for CHWs.

KEYWORDS:

• Community health volunteers
• Ghana
• economic feasibility
• cost benefit
• cost effectiveness

Responsible Editor Stig Wall

Responsible Editor Stig Wall

Acknowledgments

The authors thank the project team members for their efforts and contributions to improving maternal and child health in the Volta Region, Ghana. They extend their appreciation to the CHVs and CHNs, community members, the Ketu South District Assembly, the Ketu South DHMT, and the Ghana Health Service. Special thanks go to Dr. Joseph Teye Nuertey and Dr. Yaw Ofori Yeboah, Director and Deputy Director of Public Health, Volta Regional Health Directorate, respectively.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors’ contributions

Conceptualisation: Y.C., S.C. Data curation: Y.C., D.J. Formal analysis: Y.C., D.J. Funding acquisition: Y.C. Investigation: Y.C., S.C. Methodology: Y.C., D.J. S.C. C.O. Supervision: S.C. C.O. K.A. Validation: D.J. Writingoriginal: Y.C. Writing-review & editing: D.J. K.A.C.O.S.C. All authors read and approved the final manuscript.

Ethics and consent

Ethical approval for the trial was obtained from the Ghana Health Service Ethics Review Committee (GHS-ERC:07/01/15), and the evaluation was supplementarily approved by the Harvard T.H. Chan School of Public Health (IRB17–2051). Informed consent was obtained from caregivers in written form for participation.

Paper context

Activating community health volunteers in Ghana to induce disease reduction in children did not meet the realistic cost-effectiveness thresholds in low- and middle-income countries. Although, there was a high probability that one dollar’s investment in activating community health volunteers in Ghana would yield more than 3 dollars return in cost-benefit analysis. This study provides valuable insights to specify the optimal scope of work for the dual cadres of community health workers in the resource-scarce setting.

International Standard Randomized Controlled Trial Registry, ISRCTN49236178. https://doi.org/10.1186/ISRCTN49236178. Registered 16 May 2015 - Retrospectively registered.

Supplementary data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/16549716.2023.2203541.

Additional information

Funding

This study is supported by the Korea International Cooperation Agency (KOICA) under the “Project for Improving Maternal and Child Healthcare in Volta Region, Ghana (P2013-00192-1)”. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.