Depression is a major contributor to morbidity and mortality in sub-Saharan Africa. Due to low system capacity, three in four patients with depression in sub-Saharan Africa go untreated. Despite this, little attention has been paid to the cost-effectiveness of implementation strategies to scale up evidence-based depression treatment in the region. In this study, we investigate the cost-effectiveness of two different implementation strategies to integrate the Friendship Bench approach and measurement-based care in non-communicable disease clinics in Malawi. The two implementation strategies tested in this study are part of a trial, in which ten clinics were randomly assigned (1:1) to a basic implementation package consisting of an internal coordinator acting as a champion (IC-only group) or to an enhanced package that complemented the basic package with quarterly external supervision, and audit and feedback of intervention delivery (IC + ES group). We included material costs, training costs, costs related to project-wide meetings, transportation and medication costs, time costs related to internal champion activities and depression screening or treatment, and costs of external supervision visits if applicable. Outcomes included the number of patients screened with the patient health questionnaire 2 (PHQ-2), cases of remitted depression at 3 and 12 months, and disability-adjusted life-years (DALYs) averted. We compared the cost-effectiveness of both packages to the status quo (ie, no intervention) using a micro-costing-informed decision-tree model. Relative to the status quo, IC + ES would be on average US$10 387 ($1349–$17 365) more expensive than IC-only but more effective in achieving remission and averting DALYs. The cost per additional remission would also be lower with IC + ES than IC-only at 3 months ($119 $223) and 12 months ($210 for IC + ES; IC-only dominated by the status quo at 12 months). Neither package would be cost-effective under the willingness-to-pay threshold of $65 per DALY averted currently used by the Malawian Ministry of Health. However, the IC + ES package would be cost-effective in relation to the commonly used threshold of three times per-capita gross domestic product per DALY averted. Investing 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. National Institute of Mental Health.

中文翻译：

---

马拉维精神卫生保健能力建设的实施战略：卫生经济评估

抑郁症是撒哈拉以南非洲地区发病率和死亡率的主要原因。由于系统容量低，撒哈拉以南非洲地区四分之三的抑郁症患者得不到治疗。尽管如此，很少有人关注该地区扩大循证抑郁症治疗实施策略的成本效益。在这项研究中，我们调查了马拉维非传染性疾病诊所中两种不同实施策略的成本效益，以整合友谊长凳方法和基于测量的护理。本研究中测试的两种实施策略是一项试验的一部分，其中 10 家诊所被随机分配 (1:1) 到一个基本实施包，该包由一名内部协调员充当冠军（仅 IC 组）或一个增强型实施包。通过季度外部监督、干预实施的审计和反馈（IC + ES 小组）补充基本方案的一揽子计划。我们包括材料成本、培训成本、与项目范围会议相关的成本、交通和药品成本、与内部冠军活动和抑郁症筛查或治疗相关的时间成本，以及外部监督访问的成本（如果适用）。结果包括通过患者健康问卷 2 (PHQ-2) 筛查的患者人数、3 个月和 12 个月时抑郁症缓解的病例以及避免的伤残调整生命年 (DALY)。我们使用微观成本决策树模型将这两个方案的成本效益与现状（即无干​​预）进行了比较。相对于现状，IC + ES 平均比单纯 IC 贵 10 387 美元（1349 美元至 17 365 美元），但在实现缓解和避免 DALY 方面更有效。在 3 个月（119 美元、223 美元）和 12 个月（IC + ES 为 210 美元；仅 IC 在 12 个月时以现状为主），使用 IC + ES 的每次额外缓解的成本也将低于仅 IC。在马拉维卫生部目前采用的每避免伤残调整生命年 65 美元的支付意愿门槛下，这两种方案都不具有成本效益。然而，相对于通常使用的每可避免伤残调整生命年人均国内生产总值三倍的阈值而言，IC + ES 一揽子计划将具有成本效益。投资支持冠军可能是资源的适当利用。虽然与现状相比，目前马拉维的支付意愿标准并不具有成本效益，但 IC + ES 一揽子计划可能是在资源有限的环境中建设精神卫生保健能力的一种经济有效的方式，决策者可以在其中使用更高的支付意愿门槛。国家心理健康研究所。