Costs and coverage of community health worker-led hypertension and diabetes screening in rural Lesotho (ComBaCaL): cost–consequence analysis of a cohort study

Background Community health workers (CHWs) could increase access to hypertension and diabetes screening and diagnosis in low-income and middle-income countries, particularly in rural areas.However, evidence from largerscale real-world projects on the costs and reach of CHW-led combined hypertension and diabetes screening is scarce.We aimed to assess the coverage and costs of a combined hypertension and diabetes screening intervention run by CHWs in Lesotho by use of a clinical decision support application run on an electronic tablet. MethodsThis is a prespecified cost-consequence analysis of the prospective Community-Based Chronic Care Lesotho (ComBaCaL) cohort study.CHWs in 103 villages in rural Lesotho were trained and equipped to offer hypertension and diabetes screening, by use of a specifically developed clinical decision support application (ComBaCaL app) based on the open-source Community Health Toolkit run on an electronic tablet.Each village had a median of 49 households (IQR 41-61) and was managed by one CHW.For this cost-consequence analysis, we assessed the screening coverage among eligible participants (aged 18 years for hypertension screening; aged 40 years or aged 18 years with BMI 25 kg/m 2 for diabetes screening) and costs per person screened and diagnosed.We used a combined bottom-up and top-down approach for the cost analysis, using financial records of local implementing organisations.We subsequently developed two costing models: the project model included all research expenses and the routine model reflected real-world implementation costs.The main endpoints of this analysis were coverage of hypertension and diabetes screening and diagnosis by CHWs 6 months after training, cost per person screened, and cost per person diagnosed, considering all eligible participants.The ComBaCaL study was registered with ClinicalTrials.gov(NCT05596773) and is ongoing.Findings Between Feb 1, 2023, and June 30, 2024, 9221 adults (aged 18 years) were enrolled in the cohort, of whom, 9053 (982%) were eligible for hypertension screening and were included in the analysis; 5175 (572%) were female and 3878 (428%) were male.A total of 7706 (851%) of 9053 eligible participants were screened for hypertension, corresponding to an adjusted coverage of 88% (95% CI 87-89).Among the 9221 enrolled participants, 6345 (688%) were either aged at least 40 years or aged at least 18 years with BMI at least 25 kg/m 2 , of whom, 6045 (952%) were eligible for diabetes screening and were included in the analysis; 3873 (641%) were female and 2172 (359%) were male.In total, 5507 (911%) of 6045 eligible participants were screened for diabetes, corresponding to an adjusted coverage of 95% (95% CI 94-96).In the project model, the costs were US$332 per diagnosis and $41 per person screened.In the routine model, the costs were $137 per diagnosis and $17 per person screened.Interpretation CHWs, by use of a clinical decision support application run on an electronic tablet, provided high hypertension and diabetes screening coverage at moderate costs.Our findings support the integration of CHW-led hypertension and diabetes screening and diagnosis into routine programmes in similar settings.