Evidence Action’s Deworm the World Initiative calculates what it costs to deworm a child in the countries where we work. You might have seen the ‘cost per child per year’ to treat for parasitic worms cited in our materials and that of others.
So how do we calculate that cost? In the spirit of transparency (and in hopes of clearing up any misconceptions about how we determine our supported deworming programs’ cost per child), let’s talk costing!
Why Calculate the Cost of Deworming?
Miguel and Kremer’s 2004 seminal study analyzed the costs of school-based deworming and determined that it was less than $0.50 per child per year. At this low cost, deworming in schools is considered a ‘best buy for development’ given the long-term benefits that deworming provides to individuals and entire societies.
Of course, it’s now more than ten years later. Costs have evolved and programs have grown to reach millions more children in additional countries. So let’s take another look at this figure.
It’s important to note that understanding what a program costs does not measure its impact, and therefore our cost analysis is not used for a cost-benefit analysis. We don’t argue here that “with this amount of money we can cause a particular health benefit or educational outcome for a child.”
Rather, we simply say, “in this particular deworming program, here’s the total cost for each child treated” (the impact following from that treatment has been discussed at great length elsewhere). Because Evidence Action’s Deworm the World Initiative provides technical assistance and is one of a number of partners involved in a deworming program, we also consider costs incurred by other stakeholders such as implementing governments. We also track the costs of donated drugs when these are provided.
The school-based deworming programs we support are implemented by governments and vary greatly in scope. Thus, costs can be very different from state to state or country to country, as fixed costs are spread across a different number of children. Other variations also drive costs: the required drug(s) and frequency of their administration vary across countries depending on local worm infection prevalence and intensity. Some areas administer parasitic worm treatment alongside other health programs. This leverages existing infrastructure for deworming, potentially decreasing costs. In Delhi, the government has integrated treatment with its iron and folic acid supplementation program, requiring fewer resources dedicated to deworming alone. Another variation between countries is simply the cost of doing business — operating costs in Kenya, for example, are higher than those in India.
What Do We Include In Our Cost Analysis For Deworming And Why?
We follow J-PAL’s 2012 framework that offers guidance on costing large-scale programs in developing countries.
While we do include all partners’ expenditures in costing the deworming programs, we do not consider spending that would already be incurred without deworming taking place. Maintaining health departments and education systems creates costs that would exist even in the absence of deworming. We do not include these expenses in our analysis but focus instead on the additional costs resulting directly from implementing a deworming program.
Following a similar logic, we assume that teachers come to school on deworming day and the same amount of work gets done, in addition to the deworming activity. We thus do not calculate the value of alternative activities that teachers or government officials could be engaging in if not for the deworming program. Although this type of government contribution is not quantified in the model, we note that the existing platforms and infrastructure leveraged by school-based deworming is instrumental to the low-cost nature of these programs.
We also, as we noted, do not attempt to calculate the associated benefits of deworming to society in this analysis. So, what do we include in our calculation?
Teachers’ and principals’ allowances: Our calculation includes per diems and travel allowances paid to teachers and principals when they attend deworming-specific trainings. Teachers’ and principals’ general salaries are not included because they do not spend additional time on deworming beyond what they are already compensated for by the government for regular classroom teaching.
Drugs: We include the value of drugs in our calculation, whether the drugs are procured through donation from pharmaceutical companies via the WHO or purchased by the government.
Prevalence surveys: We always include the cost of running prevalence surveys in our calculation because they are essential for informing treatment strategies and assessing the long-term impact of deworming. Surveys are done prior to deworming in a given geography to map worm prevalence and intensity and then, following rounds of deworming, subsequent surveys are conducted to understand the change in prevalence and intensity. Survey frequency varies across programs, but in general, survey costs are amortized across the treatment rounds they inform.
Technical implementation assistance: Direct costs such as Evidence Action/Deworm the World staff time (both in-country and global) are included in our calculation because these costs are incurred in direct relation to program implementation. Indirect costs are also counted to cover functions like finance and HR that contribute to our support of the program.
Community education and sensitization campaigns: We include all costs of designing and producing promotional materials in local languages. These are used to raise awareness about deworming and to encourage treatment participation and typically include TV or radio ads, village announcers, community parades, posters and fliers.
Training: We include all costs of conducting trainings through a multi-tier cascade to equip government personnel from the national level down to the schools (and sometimes preschools) administering treatment. These include hiring qualified trainers, developing and printing materials, and lots of text messages and phone calls for coordination. When there are specific costs associated with training venues, we include them in the calculation. However, when training (as well as program-related meetings and other events) takes place in spaces that are government-owned and covered by their regular operational costs, those are not included.
Monitoring and evaluation: We include all costs of data reporting, monitoring of deworming days and other critical events, and validating program coverage and results, including printing of forms, data entry and analysis, travel to school sites for activity monitoring, and outsourced or in-house data analysis.
TL;DR: Then What Is the Actual Deworming Cost Per Child Per Year?
Given all of this, what do we come up with when all is said and done? Here are our calculations for the most recently completed round of deworming in Kenya, and for the Indian states of Bihar, Rajasthan and Delhi where Evidence Action’s Deworm the World Initiative supports the national and state governments in their deworming programs.
We include in this calculation the total fully loaded costs of deworming a child in each program location including expenditures from all partners — Evidence Action, government ministries, the World Health Organization, and others. We also break down our per-child costs for the program.
What explains some of these large discrepancies? Per-child treatment costs are higher in Kenya in large part because the national program is treating for schistosomiasis in addition to STH. This requires additional disease mapping and provision of the more expensive drugs to treat for schistosomiasis. Kenya also has different norms for allowances for government officials than India, and higher costs of doing business relative to India. Per-child costs are higher in Delhi than other Indian states, as there are relatively fewer kids treated. We are able to take advantage of economies of scale in Bihar and Rajasthan. No matter where in the world, however, school-based deworming remains a highly effective and low-cost program.
This Post Has 3 Comments
This is very insightful and eye opening. The cost of deworming now appears to be so low to me compared to all factors that have to be considered. There are so many factors that we usually ignore like monitoring and evaluation (data collection, reporting and dissemination) which are key in any intervention. Thank you Katherine!
Thanks for this wonderful post! Very helpful.
How do you decide how much to allocate resources in Kenya vs. India, if the costs are so much different? You write that the cost in Kenya is significantly higher because the national deworming program includes schistosomiasis treatments as well, but does this explain a 5x discrepancy in cost?
Very curious to hear how you think through this ethical and programatic issue. Cheers!
Hi Scott – thanks for this thoughtful comment! I checked with our Deworm the World staff, so here you go!
We determine where to invest (our time, and donor resources) based on a variety of factors, primarily worm burden (need – both in terms of # kids and levels of infection), capacity of governments, demand by governments, and utility of the school-based approach (i.e., we need to work in places with decent enrollment, otherwise we won’t hit enough of the target population). we did our most sophisticated analysis for this in India where we developed a prioritization matrix for these criteria that has a large number of data points that feed into the analysis.
With regard to allocating resources to Kenya vs. India, both programs are funded by geography-specific grant agreements. With the exception of our unrestricted funds (which we use to fill in gaps), funding allocations are guided by these multi-year agreements that are developed ahead of program implementation, in collaboration with our donors and our partner governments.
To address the question of the cost discrepancy, the additional drugs are indeed an important factor. An annual dose of praziquantel, the drug used to treat schistosomiasis, costs >4 times more than an annual dose of albendazole, the drug used to treat STH (reference is JPAL’s "Best Buy" brief, 2012). Of course, as we mentioned, the difference is also largely driven by economies of scale; operating costs are much higher in Kenya than in India, including everything from office rent to supplies, to the development and transportation of program materials.
In terms of expanding to more countries, we are certainly looking at the WHO priority countries as one important factor, but that’s not the only one. Demand is critically important to our decisions because our strategy hinges on partnerships with governments in order to succeed. To that end, we have developed a ‘light’ technical assistance model with the flexibility to work in a variety of different places with varying set-ups so long as there is need and demand.