# Protocol for the economic evaluation of integrated community-based care compared with integrated facility-based care for HIV, hypertension and diabetes in Tanzania and Uganda (INTE-COMM trial)

## TL;DR

This study compares the costs and benefits of community-based versus facility-based care for HIV, hypertension, and diabetes in Tanzania and Uganda to help policymakers make informed decisions.

## Contribution

The study introduces a protocol for evaluating the cost-effectiveness of integrated community-based care for multiple chronic conditions in sub-Saharan Africa.

## Key findings

- The study will estimate costs and outcomes from both provider and patient perspectives.
- It will calculate incremental cost-effectiveness ratios for health outcomes like viral load suppression and blood pressure control.
- Equity impacts will be assessed by analyzing outcomes across socio-economic groups.

## Abstract

The number of people living with multiple chronic conditions in sub-Saharan Africa is increasing, but health facilities are unable to meet demand. To improve health system capacity and access to care, community models of HIV care have been trialled in countries such as Tanzania and Uganda. However, no evidence exists to inform policymakers on the effectiveness and cost-effectiveness of integrated community-based models of care for HIV and chronic non-communicable conditions. This protocol outlines a within-trial economic evaluation to address this gap.

We will estimate the costs and cost-effectiveness of integrated community-based care for HIV, hypertension and diabetes compared with facility-based care within the INTE-COMM pragmatic cluster-randomised trial in Tanzania and Uganda. Analyses will adopt a 52-week time horizon, the duration of trial follow-up. The full enrolled trial sample will be analysed from a societal perspective, comprising provider and patient perspectives. Economic costs will be estimated, which includes valuing inputs such as donated goods or time foregone by participants because of receiving care. For provider costs, participant case report forms will inform resource use along with data from facilities and community sites. Resources will be valued using project accounts, facility spending, and locally available cost data. Patient costs will be estimated based on a care-seeking and cost questionnaire administered to participants. Estimated costs will be analysed with co-primary trial outcomes on plasma viral load suppression, glycaemia and blood pressure control to calculate incremental cost-effectiveness ratios (ICER). We will also calculate ICERs for secondary trial outcomes related to health-related quality of life and wellbeing. Cost drivers and outcomes will be varied within confidence bounds in a two-way sensitivity analysis. We will investigate equity impact by estimating the mean difference in outcomes between integrated community-based and facility-based care across household socio-economic quintiles and by measuring whether participants incurred catastrophic health expenditures.

The ISRCTN Registry: ISRCTN15319595. Registered on 07 June 2022:
https://doi.org/10.1186/ISRCTN15319595

Our study aims to evaluate the type of HIV, diabetes and hypertension care which offers the best value for money in sub-Saharan African settings. This will involve comparing the costs and benefits among patients attending integrated community-based or facility-based care in Tanzania and Uganda. Unlike usual care, where patients attend separate clinics for different health conditions, integrated care means patients receive care in one place by the same health workers regardless of their health condition. The study will be carried out across community sites, primary healthcare clinics and hospitals in both countries.

Costs will be collected and estimated from different perspectives. The costs to healthcare providers will be estimated separately for facilities and community sites. Alongside provider costs, the study will evaluate the financial burden incurred by patients from illness and seeking care in community sites and facilities. To estimate benefits to patients receiving community-based or facility-based care, we will capture outcome changes specific to each health condition in addition to changes in quality of life and wellbeing.

Policymakers are faced with difficult decisions on how to use limited resources to improve social welfare. Ultimately, our study seeks to inform policymakers in Tanzania, Uganda and sub-Saharan Africa more widely on how to allocate resources for HIV, diabetes and hypertension care based on the options available to them.