Using Community Health Workers to Manage

Hypertension in Urban India:A Cost-Effectiveness Analysis

Adrianna Murphy, M.Sc. London School of Hygiene and Tropical Medicine; Harvard School of

Public Health

Joshua Schulman-Marcus, M.D. Columbia University Medical School

Dorairaj Prabhakaran, M.D., M.P.H.

Centre for Chronic Disease Control

Tom Gaziano, M.D., PhD.Harvard Medical School; Harvard School of Public Health

Burden of CVD in India

Source: KS Reddy. 2007. ”India wakes up to the threat of cardiovascular diseases" Journal of the American College of Cardiology. Oct 2;50(14):1370-2

A potential role for Community Health Workers ?

The Evidence:

•Lin, T. et al; 2004•Yuchi, Taiwan•6 visits by CHWs•3.8 mm/Hg reduction for men•7.1 mm/Hg reduction for women

The Evidence:

•Levin, et al.; 2003•Inner City Baltimore•1 visit from CHW•6.5 mm/Hg reduction

To analyse cost-effectiveness:

• Estimate risk of CVD events (fatal and non)

• Estimate cost of CVD events

• Design hypothetical CHW intervention

• Estimate costs of CHW intervention

Risk: Global Markov CVD Model

Population estimates Adults ages 35-74By age and sex

UN Population Division

Distribution of risk factors

Region specific Global Burden of Disease

ProjectTen-year risk of CVD events Framingham Risk

ScoreAnnual probability of non-CVD death

Based on life tables WHO

Fatal or non-fatal

CVD events

Costs: Global Markov CVD Model

Likelihood of hospitalization or

secondary treatmentWHO PREMISE

Cost of medicationsManagement Sciences for

Health

Cost of clinic visits and hospitalizationsWHO CHOICE

Cost of CVD

CHW intervention: design

+

= 3 mm/Hg reduction in systolic blood pressure

CHW intervention: costs

• Cost estimates from WHO-CHOICE; expert opinion

• CHW salary = 3,908 USD/year

• Total cost of intervention for one year =

$ 141, 904; $6.44/patient, $3.22/visit

Results

• $141,000 cost offset by $110,000 saved

• 65 DALYs averted annually

• $475/DALY averted

Results: sensitivity analysis

• +/-25% of overall program costs

• $140-1600 per DALY averted

• CHW salary below $1,400 or number of visits reduced = intervention cost-saving

Results: sensitivity analysis

• 3 to 7 mm/Hg decrease

• At 5mm/Hg ICER = $180/DALY averted

• Anything above 5.3 mm/Hg reduction = intervention cost-saving

ConclusionsA hypothetical intervention for which CHWs are paid $3900 annually, and achieve a 3 mm/Hg reduction in blood pressure is very cost-effective.

At higher estimates of blood pressure reduction the intervention becomes cost-saving.

CHW intervention may also lead to improvements in other CVD risk factors and reductions in CVD-related morbidity would likely lead to increases in work productivity.