Cost comparison of school-based mass drug administration of albendazole and ivermectin versus albendazole alone for soil-transmitted helminth control in Uganda

The co-administration of albendazole and ivermectin (ALB-IVM) is recommended for the treatment of soil-transmitted helminth (STH) infections, especially where the prevalence of Trichuris trichiura is high. Before large-scale implementation can be considered, feasibility, acceptability and required resources and investments for the mass drug administration (MDA) of ALB-IVM compared with albendazole (ALB) alone should be assessed. This study, conducted in two districts in south-western Uganda, aimed to assess and compare the costs of school-based MDA with ALB-IVM (MDA-ALB-IVM) versus the routinely used ALB alone (MDA-ALB) on a small scale (targeting around 2,500 children per treatment arm per district). We applied a micro-costing (mixed top-down and bottom-up) approach to assess the financial costs from a health system perspective, as well as the opportunity costs of donated ALB. The total (financial and opportunity) costs of MDA-ALB-IVM were higher than those of MDA-ALB ($10,793 for MDA-ALB-IVM versus $4,458 for MDA-ALB in Kabale district and $14,445 versus $5,765 in Kisoro, respectively). The presence of informed consent and assent required for MDA-ALB-IVM (as ALB-IVM is still considered a new therapy for STH infections in Uganda) increased the number of days and resources including personnel requirements for training and drug distribution. Furthermore, adequate community sensitization and the involvement of community health workers (i.e., village health teams in Uganda) and local community leaders appeared to be essential to achieve high treatment coverage. The scenario analysis showed that, in the absence of the informed consent and assent process, the total incremental costs of MDA-ALB-IVM compared with MDA-ALB could decrease by 31%-36% in the two districts. This study identifies key cost drivers and offers insights for the wider implementation of ALB-IVM co-administration.