Economic evaluation of delivering integrated school-based health programmes in Cambodia and Ghana

• In Event: Strengthening data for better education systems

Proposal

The School Health Integrated Programming (SHIP) project was developed to demonstrate how schools can be an effective platform to deliver integrated health interventions, using deworming and vision screening as examples. From January to December 2016, the Project was successfully implemented in four focus countries: Cambodia, Ethiopia, Ghana and Senegal. The economic evaluation of SHIP in Cambodia and Ghana offered the possibility to compare cost of implementing a similar programme in different settings, analyse the affordability of scaling up, and add to the scarce existing evidence of school health economics. Moreover, the projection model developed could be used to estimate the cost of such intervention in other countries, hence generating the necessary evidence for policy maker to promote the use of school as health delivery platforms and practitioner to plan its implementation.

This analysis assessed the incremental costs and cost-effectiveness of vision screening and treating uncorrected refractive error as part of an integrated school-based health programme, as well as discuss budget implications for its scale up in Cambodia and Ghana. Three sets of cost estimates were calculated: i) SHIP project actual cost, ii) standard costs of implementing integrated school based vision screening, and iii) budget impact analysis of implementing a national integrated school-based vision screening programme. One-way and multi-way sensitivity analyses were used to test the robustness and identified parameters of the model, which have the largest influence on the budget of the scale up.

As a result, SHIP project actual costs analysis showed that in country implementation, expenditure amounted to $61,019 in Cambodia and $61,257 in Ghana (in USD 2016). Teacher training (38%, $23,384) and coordination activities (26%, $15,753) accounted for the largest share of expenditure in Cambodia (64%), whereas, in Ghana, capacity building and partnership strengthening was the largest expenditure (29%, $17,840) followed by project coordination (24%, $14,840) (53% combined).
Standard project expenditures were calculated to allow cross-country comparisons and model parameters. Standard unit costs were similar for most activities in Cambodia and Ghana with some exceptions, such as cost of capacity and partnership strengthening ($76 per participant/day in Cambodia vs $396 in Ghana), and cost of custom-made spectacles ($6 per pair in Cambodia vs $25 in Ghana), explained in part by variations in salary levels, per diems rates and accommodation costs between the two countries .

Based on the budget impact estimates for implementing national school-based vision screening programmes, the overall cost of the programme over five academic years (2018/19-2022/23) is projected to be $7,285,244 in Cambodia and $16,706,133 in Ghana for children and teachers in all public primary and lower secondary schools. The first year is the most expensive for both countries, representing over a third of the overall programme budget for each country (40% in Cambodia and 44% in Ghana). In terms of affordability, the five years programme would represents, in Cambodia, about 0.9% of the education and 1.5% of the health sector budget, or 0.5% of the combined budgets ($1.333 billion) and, in Ghana, 0.8% of the education sector and 1.7% of the health sector government budget of 2018. The results of the multivariate sensitivity analysis showed that the projected total cost of the screening programme over 5 years in Cambodia would range from $5,025,655 to $10,304,335. In Ghana, the estimated range is between $11,678,041 and $23,526,227.

The five-year national programme would result in vision screening of 5,477,614 schoolchildren and 64,712 teachers, 31,703 children with refractive error (RE) receiving a pair of spectacles and 9,687 children referred to eye care services for further examination and treatment in Cambodia. In addition, 38,827 teachers would receive spectacles for presbyopia. In Ghana, the programme would result in 9,098,192 schoolchildren and 221,486 teachers being screened, 70,270 children and 132,892 teachers receiving a pair of spectacles and 66,667 children referred to eye care services. In terms of cost-effectiveness of the programme, the average cost per child screened is $1.33 across all provinces (ranging from $0.56 per child in Phnom Penh to $6.38 in Kep province). The cost per child with corrected refractive error is $230 on average, ranging from $97 in Phnom Penh to $1,103 in Kep province.

There is a lack of quality evidence on the cost of school-based vision screening programme in resource-poor settings. This study had the ambition to, in part, filling the evidence gap in assessing the costs of the screening pilots in Ghana and Cambodia and estimating the cost-effectiveness and budget impact for the scale up of such programmes. Results confirmed that vision screening of schoolchildren, as part of a school-based health package, is a cost-effective way to identify and provide spectacles to children with URE. The analysis suggested that the scale up of the programmes in Cambodia and Ghana is affordable for the current health and education budgets, if there is sufficient in-country capacity to deliver such interventions at scale. The study highlights a number of policy and programme implications and provides suggestions for minimising costs and maximising efficiencies of vision screening in a school setting. Integrating vision screening with other school-based interventions identified in the essential package for school age child health and delivering it at scale can maximize the economies of scale and scope, ultimately reducing the unit cost of delivering vision screening and other school-based health interventions. Findings from this analysis contribute to the evidence base to enable education planners and international partners to improve their planning and budgeting processes for school-based interventions to improve health and learning outcomes for children in low- and middle-income countries.

Authors

• Guillaume Trotignon, Sightsavers

• Imran Khan, Sightsavers