Role of community health workers in improving cost efficiency in an active case finding tuberculosis programme: an operational research study from rural Bihar, India

Abstract

Objectives: Cost-efficient active case finding (ACF) approaches are needed for their large-scale adoption in national tuberculosis (TB) programmes. Our aim was to assess if community health workers' (CHW) knowledge about families' health status can improve the cost efficiency of the ACF programme without adversely affecting the delivery of other health services for which they are responsible.

Design: Quasi-experimental design.

Interventions: We evaluated an ACF programme in the Samastipur district in Bihar, India, between July 2017 and June 2018. CHWs called Accredited Social Health Activists generated referrals of individuals at risk of TB and conducted symptom-based screening to identify patients with presumptive TB. They also helped them undergo testing and provided treatment support for confirmed TB cases.

Primary and secondary outcome measures: We compared the notification rate from the intervention region with that from a control region in the same district with similar characteristics. We analysed operational data to calculate the cost per TB case diagnosed. We used routine programmatic data from the public health system to estimate the impact on other services provided by CHWs.

Findings: CHWs identified 9895 patients with presumptive TB. Of these, 5864 patients were tested for TB, and 1236 were confirmed as TB cases. Annual public case notification rate increased sharply in the intervention region from 45.8 to 105.8 per 100 000 population, whereas it decreased from 50.7 to 45.3 in the control region. There was no practically or statistically significant impact on other output indicators of the CHWs, such as institutional deliveries (-0.04%). The overall cost of the intervention was about US$134 per diagnosed case. Main cost drivers were human resources, and commodities (drugs and diagnostics), which contributed 37.4% and 32.5% of the cost, respectively.

Conclusions: ACF programmes that use existing CHWs in the health system are feasible, cost efficient and do not adversely affect other healthcare services delivered by CHWs.

Keywords: community health worker; health economics; international health services; organisation of health services; public health; tuberculosis.

Figure 1

Map indicating the blocks in intervention and control region in Samastipur district, Bihar.

Figure 2

The diagnostic protocol used in the active case-finding project. CXR, chest X-ray; DRTB, drug-resistant tuberculosis; DSTB, drug-sensitive TB; EPTB, extrapulmonary TB; F/U, follow-up; PLHIV, people living with HIV; T/T: treatment.

Figure 3

The organisation chart in the active case-finding project.

Figure 4

The patient care cascade from Q3 2017 to Q2 2018. *All percentages are calculated as a proportion of the number of participants entering the previous step of the cascade.