Saving lives, saving costs Investment Case for

Saving lives, saving costs

Investment Case for

Community Health Workers

In South Africa

What costs and what benefits

For the health sector, for the economy and

For society?

Emmanuelle Daviaud

Donela Besada

South African Medical Research Council

Debbie Budlender

Kate Kerber

David Sanders

June 2017

Table of Contents

Table of Figures 3

Executive Summary 4

Methodology 4

Results 5

Benefits for the health sector 5

Benefits for economy and society 7

Costing of the platform 7

Discussion 8

Background 9

Benefits for the health sector 11

Mother and Child Health 11

Table 1.Estimated proportionate causes of death in South Africa for neonates, infants and children, 2015 11

The potential impact of interventions supported by Community Health Workers 12

Table 2.Additional deaths prevented in with a 10 percentage point increase from 2016 coverage levels 13

Cost per DALY averted 13

HIV-AIDS 14

State of HIV/AIDS in South Africa 14

CHW interventions and impact related to HIV 16

Modelling CHWs impact 22

Table 3.Impact of CHWs for HIV/AIDS 24

References 24

TB 29

CHW TB case-finding 29

CHWs and TB treatment 30

Modelling 31

Results 32

Table 4.TB Deaths and DALYs averted by CHWs interventions 32

Table 5.Impact on MDR cases 33

Table 6.Cost per TB DALY averted with CHW intervention 34

Sensitivity analysis 35

Table 7.Impact of varying success rates for TB 35

Table 8.Impact of varying DOTs treatment by CHWs 35

References 36

Burden of Hypertension and Diabetes in South Africa 38

South Africa’s National Strategic Plan for NCDs 39

Hypertension 40

Evidence for CHW/lay workers-related interventions in hypertensive care 41

Table 9.Summary of hypertension related outcomes with CHWs interventions 42

Hypertension Modelling 45

Table 10.Modelling of CHWs impact on hypertension 46

References 46

Diabetes 48

Evidence for CHW/lay worker-related interventions for diabetes care 49

Diabetes Modelling: 59

Table 11.Modelling of diabetic costs with CHW scenario 61

References 61

Palliative Care 66

Palliative Modelling 66

Table 12.Palliative care modelling 67

References 68

Benefits for the economy and society 69

Estimating the multiplier of a current injection of CHW expenditure 69

Table 13.Impact of additional salaries injection on GDP 71

Creating female-dominated jobs 72

Productivity 73

Invisible economic benefits 74

Additional productivity of increased health status of the population 74

Table 14.Additional productivity due to avoided deaths 74

References 75

COSTING 77

Methods 77

Results 78

Table 15.Cost of the WBOT platform 78

Cost-effectiveness, costs and savings of the CHW platform 79

Table 16.Cost-effectiveness of the CHW platform 79

Table 17.Costs and savings of the CHW platform 79

Sensitivity analysis 80

Discussion 81

Table of Figures

Executive Summary

Community health workers (CHWs) are increasingly shown to have the potential to improve the health status of the population, in particular that of the more disadvantaged or those living in hard to reach areas. Their involvement in mother and child programmes, HIV/AIDs and TB programmes as well as chronic diseases and palliative care has been documented across many countries. Many studies have documented impressive impacts due to better prevention through health education, to significantly higher case-finding than in standard care, better support for treatment adherence and increased control or cure rate, to better support for palliative care allowing patients to remain with their families at the end of their lives. However, in many low income countries the CHW platform has been very patchy with inadequate training, inadequate support and supervision, uncertain funding and low morale amongst CHWs. This weak system then leads to underperformance and disappointing results.

In South Africa in 2012 the government launched the PHC re-engineering approach which placed the WBOTs system (Ward-based outreach teams) firmly in the continuum of PHC services with strong linkages with PHC facilities and district hospitals to improve access, detection and support in the community. The roll-out of WBOTs has been uneven and this platform is generally under-resourced. A new study on WBOTs in 2 provinces, with more developed WBOTs system, showed that expenditure on WBOTs represented under 4% of their respective PHC expenditures.

The purpose of this investment case commissioned by the National Department of Health is to assess the return on investment of a strong CHW platform in South Africa.

This report reflects the potential of a high performing CHW platform based on findings from South African or international literature. The first part focusses on the impact of CHWs on the health sector. It follows a life course model and focusses on mother and child health, HIV/AIDs, TB, Hypertension, Diabetes and Palliative care. It estimates deaths averted, DALYs averted, cost per additional DALY averted and whether the intervention is cost-effective or even cost-saving.

The second part of the report focusses on the benefits for the economy and society of the stronger CHW platform. It first looks at the multiplier effect of the CHW platform on increased employment, and at the impact on the economy of employing mainly poor women. It then estimates the productivity impact of improved health status of the population through CHWs interventions.

Finally the report presents the costing of an adequately resourced and supported CHW platform. It first presents absolute yearly costs, then the additional costs of this platform since some aspects of this platform already exist and are paid for.