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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:
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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:
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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 35-74
By age and sex
UN Population Division
Distribution of risk factors
Region specific
Global Burden of Disease Project
Ten-year risk of CVD events
Framingham Risk Score
Annual probability of nonCVD death
Based on life tables
WHO

Fatal or nonfatal CVD
events
Costs: Global Markov CVD Model
Likelihood of hospitalization
or secondary treatment
WHO PREMISE
Cost of medications
Management Sciences for Health
Cost of clinic visits and
hospitalizations
WHO 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
Conclusions
A 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.