We estimated the cost-effectiveness of an operational CL treatment program in Kabul, Afghanistan. This was done for internal program evaluation purposes (i.e. to assess program impact), but also to yield comparative data that would be of use for the local MoH and other health sector NGOs and stakeholders. Such data and exercises are rare [
10], despite repeated calls for health interventions in complex emergencies to be evidence-based and assessed for their cost-effectiveness [
23‐
25]. In our approach we extrapolate results from published clinical research trials to a defined operational setting, estimating the cost-effectiveness of the currently used combination of intralesional and intramuscular SSG in Kabul, Afghanistan (i.e. 'standard treatment'). We express results as realistic ranges rather than simple point estimates, thereby including the uncertainty surrounding used input parameters.
The cost-effectiveness of current leishmaniasis treatment in Kabul, Afghanistan and its comparison to alternative treatment protocols
Using chosen input parameters, we estimate that the current cost per patient treated and cured in HNTPO's operational program in Kabul is US$ 27. The cost per patient treated and cured with SSG we report here was lower than expected, and is much lower than the SbV treatment costs reported in other CL-endemic countries, notably US$ 280 in Guatemala [
26], US$ 300 in Peru [
27], and US$ 5500 in the USA. (Aronson,
pers. comm.). This outcome is due to the difference in drug purchasing price (e.g. use of generic versus branded SbV [Pentostam
® or Glucantime
®]), therapy protocol (e.g. intralesional versus intramuscular versus intravenous administration of SbV), labor costs (e.g. Afghan versus American health staff), and patient care (i.e. treatment is on an out-patient basis in Afghanistan versus an in-patient basis in the USA.).
For the first time, the cost-effectiveness of CL treatment is evaluated. Using parameter estimates listed in Table
1 we estimate that the cost-effectiveness of CL treatment in Kabul is approximately US$ 1,200 per DALY averted.
Policy implications for cutaneous leishmaniasis treatment in Kabul and elsewhere
According to WHO-CHOICE criteria health interventions are 'very cost-effective' and 'cost-effective' if within one and three times a country's per capita GDP, respectively [
28]. The per capita GDP for Afghanistan was US$ 165 in 2004 and US$ 232 in 2006 [
29]. Hence, with US$ 1,200 per DALY averted CL treatment in Kabul is not a 'cost-effective' health intervention, and based on above criteria it cannot be argued that it is a justified health expenditure.
Although the methods to estimate an intervention's cost-effectiveness may not be strictly comparable, we can set our figures into context, with other CEA having found the cost-effectiveness of supplemental tetanus immunization in Pakistan to be US$ 2 – 6 per DALY averted [
30], melarsoprol treatment for late stage African trypanosomiasis in Uganda US$ 8 [
31], SSG treatment for fatal visceral leishmaniasis US$18 [
32], ivermectin distribution for onchocerciasis control US$ 14 – 30 [
33], malaria chloroquine chemoprophylaxis US$ 14 – 93 [
22], integrated water supply and sanitation US$ 20 – 1,152 [
34], and the mass-treatment of trachoma patients with azythromycin US$ 9,000 – 65,000 [
35].
In many leishmaniasis-endemic countries, the standard recommended treatment for CL is the intramuscular administration with SbV [
13]. Had patients been treated with intramuscular SSG only, 6,492 patients could have been treated due to available staff man-hrs (i.e. due to the higher number of patient-clinic visits required when following this regimen), which would have yielded an estimate of US$ 3,718 per DALY averted (data not shown). Clearly, in those countries increased use of intralesional SbV as treatment regimen as in HNTPO's operational program would increase the cost-effectiveness of anti-leishmanial treatment dramatically.
However, whilst our analyses appear to demonstrate that CL treatment in Kabul is not cost-effective according to WHO-CHOICE criteria, several caveats of our analysis have to be highlighted. First, as with any CEA, some of the model input parameters are debatable. For example, we arbitrarily chose a lesion duration of 12 months even though many patients can have lesions of longer duration [
2]; undeniably, by doing so, we may have underestimated true lesion duration due to
L. tropica infection. As shown in Figure
2, a longer lesion duration can have a significant impact on the cost-effectiveness ratio. Unfortunately, we are unaware of any published data on the natural course of
L. tropica infections, and used data represents our best estimate. Similarly, data used for clinical efficacy in our evaluation has been extrapolated from studies on two SbV, i.e. meglumine antimoniate and SSG. No data has been published demonstrating that both drugs have varying degree of efficacy in treating CL and used data, again, represents our best estimate of minimum and maximum values of the treatment efficacy distribution.
Second, as has been the case for schistosomiasis [
36] and other communicable diseases [
37], the disability weighting for CL as set by the Global Burden of Disease study [
7,
15] is debatable and should be re-evaluated. CL can cause significant scarring as well as chronic pathology, which in some cultural contexts such as Afghanistan can lead to severe ostracism of the affected population [
3], especially when scars are located on the face. In such instances, DALY should not only be estimated for the duration of active leishmaniasis lesions, but for the duration of scars as well. Inclusion of disability incurred due to leishmaniasis scars in our DALY estimates would have significantly altered our estimated cost-effectiveness range. Thus, a disability weight similar to a cleft lip (i.e. 0.049), Bancroftian filariasis (i.e. 0.106) or debilitating leprosy (i.e. 0.152) [
15], the cost-effectiveness of CL treatment in Kabul would have been US$ 541, US$ 250, and US$ 174 per DALY averted, respectively (see also Figure
2).
Third, once patients cure from leishmaniasis they tend to be immune to re-infection [
38]. Thus, unlike other infectious diseases such as dengue or malaria there will be no recurrent DALY or treatment costs per person.
Fourth, CL in Kabul is transmitted anthroponotically with active cases presumed to be highly infectious to sandfly vectors [
4]. Although epidemiological data investigating the impact of mass treatment on anthroponotic CL transmission does not exist, it is likely that treating and curing leishmaniasis patients will reduce the size of the reservoir and therefore avert further new cases (i.e. DALY). How many cases would be prevented by treating one active case is difficult to quantify, but it would reduce the cost-effectiveness ratio.
Fifth, it is clear that our study only applies to the given, local conditions in Kabul, with analyses being based on chosen input parameters and care should be given not to generalize the conclusions. Cost figures were primarily based on an operational program implemented locally and are likely to vary when compared to programs elsewhere.
In future work we plan to carry out a range of sensitivity analyses to investigate the effect of a range of cost and clinical parameters on estimated treatment cost-effectiveness. For example, cost-effectiveness ratios would have been higher had estimates been based on fewer patients attending the clinics.
Whilst it is clear that not all patients can be treated with intralesional SbV (e.g. due to the painful route of drug administration patients with lesions close to the eyes or lips tend to be given intramuscular SbV instead) our results show that costs to treat CL patients could be substantially reduced were a treatment strategy implemented that would largely adopt the localized treatment of CL lesions.
Difficulties associated with cost-effectiveness analyses in complex emergencies
It is surprising that cost-effectiveness analyses of health interventions in complex emergencies are very scarce [
10,
32], highlighting a major gap in the evidence-based implementation of humanitarian programs [
23]. Whilst it is true that there are many logistical constraints in collecting reliable financial and operational data in complex emergencies (e.g. due to the absence of established health information systems) [
39], health interventions in these settings are often vertical with program-allocated budgets allowing for easy data collection. CEA should enable local stakeholders to set health intervention priorities, use results as leverage to obtain funding as well as make implementing partners more accountable in front of donor organizations. The drawback is that the CEA will be based on local circumstances, which can vary considerably between and within emergencies. However, it is clear that within a local context, CEA will assist priority setting of health interventions, whether for comparative purposes between different diseases or a single disease [
40].
Thus, for example, despite the findings reported here, HNTPO's treatment activities currently implemented in Kabul are still substantially more cost-effective than a household latrine revision intervention to reduce diarrheal disease [
10].