Cost-effectiveness of task-shifting in resource-constrained settings
Authors: Mary Lou Chatterton, Yared Belete Belay
Journal: The Lancet Global Health (2024)

Despite the considerable burden on global health, mental health care is under-resourced in low-income and middle-income countries (LMICs), resulting in undertreatment and sparse access to care.1Antiporta DA Bruni A Emerging mental health challenges, strategies, and opportunities in the context of the COVID-19 pandemic: perspectives from South American decision-makers.Rev Panam Salud Publica. 2020; 44: e154Crossref PubMed Scopus (4) Google Scholar Task-shifting, in which a diverse range of health professionals and community members share responsibilities, is increasingly preferred. This approach is expected to improve patient health outcomes and be cost-effective for health-care payers.2Seidman G Atun R Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries.Hum Resour Health. 2017; 15: 29Crossref PubMed Scopus (134) Google Scholar However, there is little evidence on the cost-effectiveness of the broad implementation of task-shifting, particularly in resource-constrained settings. The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity-Building Scale-Up trial addresses this gap in the evidence for implementing depression care strategies in Malawi. The SHARP trial demonstrated the effectiveness of integrating an enhanced implementation strategy of non-specialist-led depression screening and treatment in achieving higher depression treatment follow-up and 3-month remission from depression relative to a basic implementation strategy.3Pence BW Gaynes BN Udedi M et al.Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial.Lancet Glob Health. 2024; (published online Feb 23.)https://doi.org/10.1016/S2214-109X(23)00592-2Summary Full Text Full Text PDF Scopus (2) Google Scholar In The Lancet Global Health, Juan Yanguela and colleagues4Yanguela J Pence BW Udedi M et al.Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation.Lancet Glob Health. 2024; (published online Feb 23.)https://doi.org/10.1016/S2214-109X(23)00597-1Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar report on an additional economic evaluation that estimated the cost-effectiveness of the basic and enhanced implementation strategies compared with the status quo (ie, no treatment). Considering the strengths and limitations of the economic evaluation methods as well as the policy context is important when interpreting the study's findings for Malawi and other LMICs. The economic evaluation used a decision-tree model model combining data from the trial with additional information from the literature, such as the probability of spontaneous remission from depression for the status-quo comparator. The choice of a no-treatment comparator is sensible within this context, in which depression care is absent from the health system, and avoids overestimating the burden averted by the interventions. However, the SHARP trial used Patient Health Questionnaire 9 to assess diagnosis and remission from depression, whereas the meta-analysis reporting spontaneous remission of depression for the no-treatment comparator used the Beck Depression Inventory and Hamilton Rating Scale for Depression scores to assess remission status. The different outcome measures across the comparators add to the uncertainty in the economic evaluation results, as exhibited by the remission rate for the basic implementation approach at 12 months being lower that the spontaneous remission rate attributed to the status quo.3Pence BW Gaynes BN Udedi M et al.Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial.Lancet Glob Health. 2024; (published online Feb 23.)https://doi.org/10.1016/S2214-109X(23)00592-2Summary Full Text Full Text PDF Scopus (2) Google Scholar, 5Whiteford HA Harris MG McKeon G et al.Estimating remission from untreated major depression: a systematic review and meta-analysis.Psychol Med. 2013; 43: 1569-1585Crossref PubMed Scopus (242) Google Scholar A key issue when interpreting a cost-effectiveness analysis is the cost-effectiveness threshold (CET), which is the upper limit of the incremental cost per outcome that a funder designates as representing value for money. The CET represents societal willingness to pay for additional health gain, an important consideration in resource allocation decisions.6Drummond MF Sculpher MJ Claxton K Stoddart GL Torrance GW Methods for the economic evaluation of health care programmes. Oxford University Press, Oxford2015Google Scholar CETs can be set by a jurisdiction's policy makers, but it is common practice to use gross domestic product (GDP) per capita in a CET for LMICs.7Edejer TT-T Baltussen R Adam T et al.Making choices in health: WHO guide to cost-effectiveness analysis. World Health Organization, Geneva2003Google Scholar However, there are limitations to using per-capita GDP thresholds and several studies recommend exploring alternative approaches.8Iino H Hashiguchi M Hori S Estimating the range of incremental cost-effectiveness thresholds for healthcare based on willingness to pay and GDP per capita: a systematic review.PLoS One. 2022; 17e0266934Crossref Scopus (24) Google Scholar The cost-effectiveness analysis conducted from the SHARP trial data considers the adoption of a locally determined CET by policy makers, stated as US$65 per disability-adjusted life-year (DALY) averted, in addition to the commonly used threshold of 1–3 times per-capita GDP per DALY averted. The cost-effectiveness findings—that the enhanced or basic implementation strategies are not cost-effective under the current CET used by Malawian decision makers but are cost-effective under the threshold of 3-times per-capita GDP per DALY averted—require careful consideration. The findings imply that Malawi might view doing nothing as an appropriate choice given that neither strategy would be viewed as providing value for money using their locally defined CET. However, if one of the implementation strategies was to be chosen, the enhanced strategy would be the most efficient as highlighted by the direct comparison of the enhanced implementation to the basic implementation strategy (presented in appendix 1 pp 25–30 of the main Article), resulting in an incremental ratio of $81 per DALY averted for the enhanced strategy.4Yanguela J Pence BW Udedi M et al.Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluation.Lancet Glob Health. 2024; (published online Feb 23.)https://doi.org/10.1016/S2214-109X(23)00597-1Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Policy makers might want to reconsider the CET or use additional second-stage filter criteria previously used in priority setting frameworks, such as the assessing cost-effectiveness (ACE) approach. The second-stage filters from ACE include: (1) the intervention's role in reducing inequality, (2) stakeholder acceptability, (3) implementation feasibility, (4) evidence strength, (5) sustainability, and (6) the intervention's impact on community health and cultural acceptability.9Kan K Jörg F Lokkerbol J et al.More than cost-effectiveness? Applying a second-stage filter to improve policy decision making.Health Expect. 2021; 24: 1413-1423Crossref PubMed Scopus (2) Google Scholar In this context, the evidence supports task-shifting as a culturally accepted and sustainable strategy in low-income settings, with support from international stakeholders such as WHO.2Seidman G Atun R Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from low-income and middle-income countries.Hum Resour Health. 2017; 15: 29Crossref PubMed Scopus (134) Google Scholar, 10Keynejad R Spagnolo J Thornicroft G WHO mental health gap action programme (mhGAP) intervention guide: updated systematic review on evidence and impact.Evid Based Ment Health. 2021; 24: 124-130Crossref PubMed Scopus (55) Google Scholar The main trial findings support the feasibility and evidence strength of the enhanced intervention package.3Pence BW Gaynes BN Udedi M et al.Two implementation strategies to support the integration of depression screening and treatment into hypertension and diabetes care in Malawi (SHARP): parallel, cluster-randomised, controlled, implementation trial.Lancet Glob Health. 2024; (published online Feb 23.)https://doi.org/10.1016/S2214-109X(23)00592-2Summary Full Text Full Text PDF Scopus (2) Google Scholar In conclusion, the economic evaluation from the SHARP trial is important in the context of LMICs, where there is a pressing need for practical and feasible depression care. The study provides valuable data on the cost-effectiveness of implementing depression screening and care using task-shifting approaches, which are potentially generalisable to other resource-limited settings. We declare no competing interests. Implementation strategies to build mental health-care capacity in Malawi: a health-economic evaluationInvesting in supporting champions might be an appropriate use of resources. Although not currently cost-effective by Malawian willingness-to-pay standards compared with the status quo, the IC + ES package would probably be a cost-effective way to build mental health-care capacity in resource-constrained settings in which decision makers use higher willingness-to-pay thresholds. Full-Text PDF Open Access