Evaluating integrated neglected tropical disease (NTD) control strategies: cost, effectiveness and sustainability of the NTD control programme in Uganda.

The predicted costs and savings of integrated preventive chemotherapy (IPCT) for the Neglected Tropical Diseases (NTDs) have been proposed by a number of prior studies. The principle aims of the research presented in this thesis were to determine the cost, effectiveness and sustainability of the Ugandan integrated NTD Control Programme (NTDCP). Annual programme costs were prospectively and retrospectively collected at all levels of programme implementation in twelve districts over three years. Overall cost per person treated for IPCT were, financial (excluding purchased drugs) US0.17; economic (excluding purchased and donated) US0.65 and full economic cost per person (including value of all drugs) US12.06. When costs of the NTDCP were compared to the combined costs of the pre-integration stand-alone (SA) control programmes in Uganda, cost savings of 54% to 72% were achieved. The IPCT was also effective with over 43 million treatments delivered and 2,444,714 disability-adjusted life years (DALYs) averted; and highly cost-effective at an estimated economic cost of US16.50 per NTD case averted and US10.19 per DALY averted. Using a novel approach to measure community drug distributors (CDDs) involvement in IPCT; pictorial diaries collected prospective data on their time allocation. On average 2.5 working weeks were spent on NTDCP activities per year by a CDD. This meant a significant reduction in time available for subsistence and income generating engagements. With each incremental drug delivery required over a mass IPCT campaign i.e. the number of times a CDD delivered a NTD drug package to communities, economic costs increased. Moreover, as CDDs took more time to complete NTDCP activities their programme coverage performance decreased. Motivation for the programme was acknowledged as low and CDDs felt undervalued. Finally the applications and implications of the thesis results are discussed with regards to programme effectiveness and sustainability and in the context of NTD control and elimination.