Effectiveness and efficiency of integrating delivery of neglected tropical disease programs

Abstract

Background: Neglected tropical diseases (NTDs) affect over one billion people globally, resulting in severe disability and disfigurement. With recent calls to eliminate or control many of the NTDs, experts and policy makers recommend integrating NTD programs in co-endemic areas to achieve greater health impact and efficiency. While some evidence supports the beneficial effects of integrating NTD programs to optimize coverage and reduce costs in research settings, there is minimal information regarding when or how to effectively operationalize program integration. The lack of systematic analyses of integration experiences and of integration processes may act as an impediment to achieving more effective NTD programming. We aimed to learn about the experiences of a range of NTD stakeholders and their perceptions of integration (Chapter 2), evaluate the effectiveness and synergy of multisectorial approaches to NTD control (Chapter 3), and determine the costs and cost drivers of a sub-national integrated NTD program operating at scale (Chapter 4). Methodology: We used a multi-disciplined approach to study how NTD integration is implemented and the effects of integration in terms of the key programmatic outcomes of effectiveness and efficiency. Chapter 2: We evaluated differences in the definitions, roles, perceived effectiveness, and implementation experiences of integrated NTD programs among a variety of NTD stakeholder groups, including multilateral organizations, funding partners, implementation partners, national Ministry of Health (MOH) teams, district MOH teams, volunteer rural health workers, and community members participating in NTD campaigns. Semi-structured key informant interviews were conducted. Coding of themes involved a mix of applying in-vivo open coding and a priori thematic coding from a start list. Chapter 3: We conducted a cohort study nested within a randomized trial of empiric deworming of HIV-infected adults in Kenya to evaluate the potential synergistic influence of dual access to deworming medications and water, sanitation, and hygiene (WASH) resources. Helminth infections, including soil transmitted helminths (STH) and schistosomiasis, and infection intensity were diagnosed using semi-quantitative real-time PCR. We conducted a manual forward stepwise model building approach to identify the package of interventions most protective against a helminth infection of any species (combined outcome) and each helminth species individually. We conducted secondary analyses relevant only to individuals with no exposure to antihelminithics and used interaction terms to test for intervention synergy. Chapter 4: We utilized a bottom-up microcosting approach to identify all financial and economic costs associated with implementing an integrated NTD program at scale in two Nigerian States: Abia State and Cross River State. We used an established costing tool, the Tool for Integrated Planning and Costing, to collect costs and evaluate tool functionality. We used societal and provider (government) perspectives. We conducted a series of univariate sensitivity analyses to identify cost drivers within and across States and changes in unit costs associated with increasingly comprehensive program integration. We also conducted scenario analyses to identify the affordability of the NTD program under circumstances in which governments assume all program costs without the assistance of non-governmental organizations or in which governments assume all drug purchasing costs. Findings: Chapter 2: In total, 41 interviews were conducted. Salient themes varied by stakeholder, however dominant themes on integration included: significant variations in definitions, differential effectiveness of specific integrated NTD activities, community member perceptions of NTD programs, the influence of funders, perceived facilitators, perceived barriers, and the effects of integration on health system strength. In general, stakeholder groups provided unique perspectives, rather than contrarian points of view, on the same topics. The stakeholders identified more advantages to integration than disadvantages, however there are a number of both unique facilitators and challenges to integration from the perspective of each stakeholder group. Chapter 3: Approximately 22% of the 701 stool samples provided were helminth-infected, most of which were of low to moderate intensity. The odds of infection with any STH species were lower for individuals who were treated with albendazole (adjusted odds ratio, aOR: 0.11, 95%CI: 0.05, 0.20, p<0.001). Although most WASH interventions demonstrated minimal additional benefit in reducing the probability of infection with any STH species, access to safe flooring did appear to offer some additional protection (aOR:0.34, 95%CI: 0.20, 0.56, p<0.001). Only treatment with praziquantel was protective for schistosomiasis (aOR:0.30 95%CI: 0.14, 0.60, p=0.001). Amongst individuals who were not treated with albendazole or praziquantel, the most protective intervention package to reduce probability of STH infections included safe flooring (aOR:0.34, 95%CI: 0.20, 0.59, p<0.001) and latrine access (aOR:0.59, 95%CI: 0.35, 0.99, p=0.05). Across all species, there was no evidence of synergy or antagonism between anthelmintic chemotherapy with albendazole or praziquantel and WASH interventions. Chapter 4: From the provider (MOH, not inclusive of NGO costs) perspective, the average financial cost per treatment delivered was $0.42 and $0.34 in Abia and Cross River States, respectively. From the societal perspective, the average financial cost per treatment delivered in Abia State was $0.46 while in Cross River State it was $0.64. Economic unit costs accounting for programmatic and community-level opportunity costs were $4.73 and $4.04 per treatment delivered while total costs per treatment delivered were $5.09 and $4.68 in Abia and Cross River States, respectively. Total costs per case averted were $14.10 and $10.85. In sensitivity analyses, variations in lymphatic filariasis (LF) treatment coverage exhibited the strongest influence on potential reductions in the average financial cost per treatment delivered, with up to a 39% reduction in costs. Variations in the cost of ivermectin tablets for onchocerciasis control had a large potential effect on average total costs per treatment delivered, with the potential to increase costs by up to 81%. Changes to baseline estimated disease prevalence, particularly onchocerciasis, also had a large effect on average total cost per case averted in each State, where the lower the disease prevalence the higher the average unit cost. Integration of activities that minimize the time CDDs spent on training and MDA delivery activities did not have a large influence on average total unit costs per person treated or per case averted. However ensuring that programs are fully integrated for community members could reduce total unit costs per person treated and cases averted up to 12%. Under a variety of scenarios and using several relevant benchmarks of affordability, it is evident that programs are not affordable for State governments without substantial support from NGOs (at least 25% of program costs) and donated drugs. Conclusions: This dissertation indicates that integration of NTD programs is an anecdotally promising policy for increasing the effectiveness and efficiency of NTD programs in pursuit of global elimination goals, but there is mixed evidence regarding what aspects of the programs to integrate, how to operationalize integration, and what outcomes may realistically be expected. Chapter 2: Qualitative data suggest several structural, process, and technical opportunities that could be addressed to promote more effective and efficient integrated NTD elimination programs. We highlight a set of ten recommendations that may address stakeholder concerns and perceptions regarding these key opportunities. For example, public health stakeholders should embrace a broader perspective of community-based health needs, including and beyond NTDs, and available platforms for addressing those needs. Chapter 3: Deworming is highly effective in reducing the probability of helminth infections amongst HIV-infected adults. With the exception of safe flooring, WASH interventions offer minimal additional benefit in our study. However, WASH does appear to significantly reduce infection prevalence in adults who are not treated with deworming medications. These findings suggest that multisectoral integration of deworming and WASH is difficult to measure and may not result in synergies. However there may be political or strategic rationale for pursuing multisectoral integration, and appropriate outcome metrics should be identified accordingly without assumptions regarding heightened health impact. Chapter 4: The average total cost per treatment delivered were far more expensive in this study than most estimates currently available in the literature due to the inclusion of opportunity costs for volunteer drug distributors, community members, and donated drugs. This demonstrates the need for future studies to engage in a more nuanced and comprehensive approach to NTD program costing to understand the totality of integrated NTD program costs. To increase the efficiency of programs, local governments should focus on increasing treatment coverage (i.e. economies of scale) and ensuring that activities are maximally integrated for volunteers and program beneficiaries, without compromises to program quality.