Health Economics: Cameroon & Ghana

Equity and Efficiency in the Implementation and Scale-up of Integrated Neglected Tropical Disease Control

The main goal of the health economics (MST 3) component of the COUNTDOWN project relates to the project’s first two over-arching questions:

  • • What are the most effective, cost effective, sustainable, equitable, and acceptable current and complementary strategies to both implement scale-up to meet the country goals strengthening integrated approaches and health systems?
  • • What are the present economic impacts at household level by socio-economic status in terms of income, wellbeing, and service coverage? 
  • • What are efficient and equitable strategies to improve these impacts at the household and health system level?
  • • What are new, innovative, attractive (efficient and equitable) approaches to up-scale NTD control for typical country situations (early, advancing, established levels of NTD control)?

The project aims to look at the generalisable factors which influence the acceptance, effectiveness, efficiency, and equity impact of scale-up from a health systems approach. It will also explore the most effective strategies to work with Community Drug Distributers (CDDs) and Community Health Workers to extend the scaling up of MDA to include hard-to-reach communities and build the resilience of vulnerable and marginalized groups. The project will look at ways of integrating NTD programmes strengthen health systems, foster cross-sector working (e.g. sanitation, water resources and agriculture) to deliver a sustainable impact to overcome the vulnerability of NTD affected populations.

The health economics component of the project has three main aims:

  1. Situational analyses of the economic burden of NTDs at household level, carrying out household level surveys, at baseline and (selective) post-implementation of NTD efforts.
  2. Study the value-for-money of the investment on NTDs interventions, carrying out costing surveys, using information from the household survey and existing economic models and available reference prices.  This information will be used to derive cost-effectiveness information and budget impact estimates at local and national level.
  3. Identify opportunities for planning, upscaling, and integrated implementation at the national, and district and community level.

These three aims will form the basis of the objectives that concern field-based empirical and model-based studies. It is envisaged that these objectives will be attempted fully in Cameroon. This will be achieved through the following specific objectives:

1. To estimate the household-level impact of the four NTDs in COUNTDOWN project areas on income, income status, out-of-pocket health expenditure, service use, and well-being by socio-economic status.

  1. To estimate the change of household-level impact of these NTDs after the implementation of COUNTDOWN scale-up efforts on income, income status, out-of-pocket health expenditure, service use, and well-being by socio-economic status, in selected country settings.
  2. To estimate the cost-effectiveness of selected scaling-up activities of COUNTDOWN under Aim1 and Aim2 and other options and alternative approaches, from a societal perspective, as compared to the counterfactual, to inform national and international policy makers.

Hypothesis

For the health economics component of this project we hypothesise that:

1. Households that do not seek treatment for NTDs and those not taking part in the annual MDAs are more likely to have low incomes, less access to NTD control, more infected children, and less likely to attend school. They are also more likely to face catastrophic health expenditures. Those from low-income household who do attend school are less likely to perform well.

2. COUNTDOWN scale-up efforts will lead to an increase in household access to NTD control, reduction of NTD prevalence - hence increase equity in access, increase labour market participation, and an increase in household wealth. The increase will be significantly higher for those at the lower end of the income distribution (increased coverage among the right groups).

3. The QoL among the low-income households will be low. Among those with NTDs it will be increasingly lower. For those who receive the COUNTDOWN intervention QoL will be will be better compared to those who receive the standard treatment/intervention and those who receive none.

4. Proposed MDA and other specific COUNTDOWN intervention packages for the four NTDs will be cost-effective as compared to current interventions i.e. provide value-for-money.

5. Integration and scale-up of NTD control will be more cost-effective compared to the current vertical intervention for each NTD programme.

Research Design and Methodology

The research will be made up of two main studies: 1) a household level microeconomic population case-control study, stratified by NTD severity, to examine the equity effects of NTD infections by various variable and 2) observational economic evaluations of the proposed COUNTDOWN interventions, carrying out local costing studies, and economic NTD modelling.  We adopt a case-control approach for the former due to the rarity of NTDs and because some infected individuals might remain asymptomatic for a period of time after becoming infected.

Sub-Study 1: Neglected Tropical Diseases: Determinants and Consequences

The main goal of Study 1 is to analyse issues around NTD-related health inequalities. The focus will be on the bi-directional relationship between health and poverty as well as the effect of NTDs on disability and mental health. The study will be composed of 6 sub-studies: 1) NTDs in Cameroon – Determinants of community prevalence, 2) A poverty assessment of households affected by NTDs in Cameroon, 3) The relationship between poverty and NTDs: Evidence from Cameroon, 4) Catastrophic Health Spending and NTDs: Evidence from Cameroon 5) Inequalities in accessing NTD treatment: Evidence from MDAs in Cameroon, and 6) Mental health and disability: The effects of NTDs.

Sub-Study 2: The Relationship between Poverty and NTDs: Evidence from Cameroon Sampling Strategy

The goal of this sub-study is to examine in a detailed manner the relationship between poverty and NTDs at the household level. The goal is to analyse whether poverty does lead to NTDs. To this effect, the study will use data from the ECAM4 (Quatrième Enquête Camerounaise auprès des Ménages) and those collected during the COUNTDOWN interventions. The sampling frame will be the communities where the COUNTDOWN interventions are taking place.

Sub-Study 3: A Poverty Assessment of Households Affected by NTDs in Cameroon Study Goals and Methodology

This sub-study is a complement to sub-study 1 and sub-study 3 discussed later and looks at the socio-economic profile of households living in communities (health areas) affected by the four COUNTDOWN NTDs and compares it to that of the general population at the health district.

STUDY SITES

With the exception of the first sub-study, this study will be carried out in the communities where the different ICST1 (link to this theme) and ICST2 (link to this theme) COUNTDOWN interventions will be taking place, supplemented with costing studies elsewhere.