title: Cost-Effectiveness of Community-Based Strategies for Blood Pressure Control in a Low-Income Developing Country: Findings From a Cluster-Randomized, Factorial-Controlled Trial Coverage, Adherence and Costs of Intermittent Preventive Treatment of Malaria in Children Employing Different Delivery Strategies in Jasikan, Ghana Household Costs for Treatment of Severe Pneumonia in Pakistan Economic Analysis of Delivering Primary Health Care Services through Community Health Workers in 3 North Indian States Cost of delivering child health care through community level health workers: how much extra does IMNCI program cost? Economic assessment of a women's group intervention to improve birth outcomes in rural Nepal Economic evaluation of a task-shifting intervention for common mental disorders in India. Cost Effectiveness of Seasonal Intermittent Preventive Treatment Using Amodiaquine & Artesunate or Sulphadoxine-Pyrimethamine in Ghanaian Children Costs and Cost-Effectiveness of Training Traditional Birth Attendants to Reduce Neonatal Mortality in the Lufwanyama Neonatal Survival Study (LUNESP) Cost and Cost-Effectiveness of Smear-Positive Tuberculosis Treatment by Health Extension Workers in Southern Ethiopia: A Community Randomized Trial Costs and cost-effectiveness of different DOT strategies for the treatment of tuberculosis in Pakistan. Directly Observed Treatment. Incidence of pediatric diarrhea and public-private preferences for treatment in rural Myanmar: a randomized cluster survey. Cost-effectiveness analysis of an alternative tuberculosis management strategy for permanent farm dwellers in South Africa amidst health service contraction Is home management of fevers a cost-effective way of reducing under-five mortality in Africa? The case of a rural Ghanaian District. Implementation and Operational Research: A Comparison of Two Task-Shifting Models of Pharmaceutical Care in Antiretroviral Treatment Programs in South Africa Primary health care nurses implement and evaluate a community outreach approach to health care in the South African agricultural sector.
abstract: Background — Evidence on economically efficient strategies to lower  blood pressure ( BP )  from low- and middle-income countries remains scarce . The Control of Blood Pressure and Risk Attenuation ( COBRA ) trial r and omized 1341 hypertensive subjects in 12 r and omly selected communities in Karachi , Pakistan , to 3 intervention programs : ( 1 ) combined home health education ( HHE ) plus trained general practitioner ( GP ) ; ( 2 ) HHE only ; and ( 3 ) trained GP only . The comparator was no intervention ( or usual care ) . The reduction in BP was most pronounced in the combined group . The present study examined the cost-effectiveness of these strategies . Methods and Results — Total costs were assessed at baseline and 2 years to estimate incremental cost-effectiveness ratios based on ( 1 ) intervention cost ; ( 2 ) cost of physician consultation , medications , diagnostics , changes in lifestyle , and productivity loss ; and ( 3 ) change in systolic BP . Precision of the incremental cost-effectiveness ratio estimates was assessed by 1000 bootstrapping replications . Bayesian probabilistic sensitivity analysis was also performed . The annual costs per participant associated with the combined HHE plus trained GP , HHE alone , and trained GP alone were $ 3.99 , $ 3.34 , and $ 0.65 , respectively . HHE plus trained GP was the most cost-effective intervention , with an incremental cost-effectiveness ratio of $ 23 ( 95 confidence interval , 6–99 ) per mm Hg reduction in systolic BP compared with usual care , and remained so in 97.7 of 1000 bootstrapped replications . Conclusions — The combined intervention of HHE plus trained GP is potentially affordable and more cost-effective for BP control than usual care or either strategy alone in some communities in Pakistan , and possibly other countries in Indochina with similar healthcare infrastructure . Clinical Trial Registration — http://www . clinical trials.gov . Unique identifier : NCT00327574 Background Intermittent preventive treatment of malaria in children ( IPTc ) involves the administration of a course of anti-malarial drugs at specified time intervals to children at risk of malaria regardless of whether or not they are known to be infected .  IPTc provides a high level of protection against uncomplicated and severe malaria , with monthly sulphadoxine-pyrimethamine plus amodiaquine ( SP&AQ ) and sulphadoxine-pyrimethamine plus piperaquine being the most efficacious regimens . A key challenge is the identification of a cost-effective delivery strategy . Methods A community r and omized trial was undertaken in Jasikan district , Ghana to assess IPTc effectiveness and costs using SP&AQ delivered in three different ways . Twelve villages were r and omly selected to receive IPTc from village health workers ( VHWs ) or facility-based nurses working at health centres ' outpatient departments ( OPD ) or EPI outreach clinics . Children aged 3 to 59 months-old received one IPT course ( three doses ) in May , June , September and October . Effectiveness was measured in terms of children covered and adherent to a course and delivery costs were calculated in financial and economic terms using an ingredient approach from the provider perspective . Results The economic cost per child receiving at least the first dose of all 4 courses was US$ 4.58 when IPTc was delivered by VHWs , US$ 4.93 by OPD nurses and US$ 5.65 by EPI nurses . The unit economic cost of receiving all 3 doses of all 4 courses was US$ 7.56 and US$ 8.51 when IPTc was delivered by VHWs or facility-based nurses respectively . The main cost driver for the VHW delivery was supervision , reflecting re sources used for travelling to more remote communities rather than more intense supervision , and for OPD and EPI delivery , it was the opportunity cost of the time spent by nurses in dispensing IPTc . Conclusions VHWs achieve higher IPTc coverage and adherence at lower costs than facility-based nurses in Jasikan district , Ghana . Trial Registration Clinical Trials.gov NCT00119132 Current World Health Organization ( WHO ) guidelines for severe pneumonia treatment of under-5 children recommend hospital referral . However , high treatment cost is a major barrier for communities . We compared household costs for referred cases with management by lady health workers ( LHWs ) using oral antibiotics . This study was nested within a cluster r and omized trial in Haripur , Pakistan . Data on direct and indirect costs were collected through interviews and record review s in the 14 intervention and 14 control clusters . The average household cost/case for a LHW managed case was $ 1.46 compared with $ 7.60 for referred cases . When the cost of antibiotics provided by the LHW program was excluded from the estimates , the cost/case came to $ 0.25 and $ 7.51 for the community managed and referred cases , respectively , a 30-fold difference . Exp and ing severe pneumonia treatment with oral amoxicillin to community level could significantly reduce household costs and improve access to the underprivileged population , preventing many child deaths Background We assessed overall annual and unit cost of delivering package of services and specific services at sub-centre level by CHWs and cost effectiveness of Government of India ’s policy of introducing a second auxiliary nurse midwife ( ANM ) at the sub-centre compared to scenario of single ANM sub-centre . Methods We undertook an economic costing of health services delivered by CHWs , from a health system perspective . Bottom-up costing method was used to collect data on re sources spent in 50 r and omly selected sub-centres selected from 4 districts .  Mean unit cost along with its 95 % confidence intervals were estimated using bootstrap method . Multiple linear regression model was used to st and ardize cost and assess its determinants . Results Annually it costs INR 1.03 million ( USD 19,381 ) , or INR 187 ( USD 3.5 ) per capita per year , to provide a package of preventive , curative and promotive services through community health workers . Unit costs for antenatal care , postnatal care , DOTS treatment and immunization  were INR 525 ( USD 10 ) per full ANC care , INR 767 ( USD 14 ) per PNC case registered , INR 974 ( USD 18 ) per DOTS treatment completed and INR 97 ( USD 1.8 ) per child immunized in routine immunization respectively . A 10 % increase in human re source costs results in 6 % rise in per capita cost . Similarly , 10 % increment in the ANC case registered per provider through-put results in a decline in unit cost ranging from 2 % in the event of current capacity utilization to 3 % reduction in case of full capacity utilization . Incremental cost of introducing 2nd ANM at sub-centre level per unit percent increase ANC coverage was INR 23,058 ( USD 432 ) . Conclusion Our estimates would be useful in undertaking full economic evaluations or equity analysis of CHW programs . Government of India ’s policy of hiring 2nd ANM at sub-centre level is very cost effective from Indian health system perspective BACKGROUND AND METHODS In the setting of a cluster r and omized study to assess impact of the  Integrated Management of Neonatal and Childhood Illnesses ( IMNCI ) program in the district of Faridabad in India , we r and omly selected auxiliary nurse midwives ( ANM ) , anganwadi workers ( AWW ) and accredited social health activists ( ASHA ) from intervention and control areas to collect cost data using an economic perspective . Bootstrap method was used to estimate 95 % confidence interval . RESULTS The annual per-child cost of providing health services through an ANM , AWW and ASHA is INR 348 ( USD 7.7 ) , INR 588 ( USD 13.1 ) and INR 87 ( USD 1.9 ) , respectively . The annual per-child incremental cost of delivering IMNCI is INR 124.8 ( USD 2.77 ) , INR 26 ( USD 0.6 ) and INR 31 ( USD 0.7 ) at the ANM , AWW and ASHA level , respectively . CONCLUSION Implementation of IMNCI imposes additional costs to the health system . A comprehensive economic evaluation of the IMNCI is imperative to estimate the net cost implication s in India We did a cost-effectiveness analysis alongside a cluster-r and omised controlled trial of a participatory intervention with women 's groups  to improve birth outcomes in rural Nepal . The average provider cost of the women 's group intervention was US0.75 dollars per person per year ( 0.90 dollars with health-service strengthening ) in a population of 86,704 . The incremental cost per life-year saved ( LYS ) was 211 dollars ( 251 dollars ) , and expansion could rationalise on start-up costs and technical assistance , reducing the cost per LYS to 138 dollars ( 179 dollars ) . Sensitivity analysis showed a variation from 83 dollars to 263 dollars per LYS for most variables . This intervention could provide a cost-effective way of reducing neonatal deaths OBJECTIVE To carry out an economic evaluation of a task-shifting intervention for the treatment of depressive and anxiety disorders in primary -care setting s in Goa , India . METHODS Cost-utility and cost-effectiveness analyses based on generalized linear models were performed within a trial set in 24 public and private primary -care facilities . Subjects were r and omly assigned to an intervention or a control arm . Eligible subjects in the intervention arm were given psycho-education , case management , interpersonal psychotherapy and /or antidepressants by lay health workers . Subjects in the control arm were treated by physicians . The use of health-care re sources , the disability of each subject and degree of psychiatric morbidity , as measured by the Revised Clinical Interview Schedule , were determined at 2 , 6 and 12 months . FINDINGS Complete data , from all three follow-ups , were collected from 1243 ( 75.4 % ) and 938 ( 81.7 % ) of the subjects enrolled in the study facilities from the public and private sectors , respectively . Within the public facilities , subjects in the intervention arm showed greater improvement in all the health outcomes investigated than those in the control arm . Time costs were also significantly lower in the intervention arm than in the control arm , whereas health system costs in the two arms were similar . Within the private facilities , however , the effectiveness and costs recorded in the two arms were similar . CONCLUSION Within public primary -care facilities in Goa , the use of lay health workers in the care of subjects with common mental disorders was not only cost-effective but also cost-saving Background Intermittent preventive treatment for malaria in children ( IPTc ) involves the administration of a full course of an anti-malarial treatment to children under 5 years old at specified time points regardless of whether or not they are known to be infected , in areas where malaria transmission is seasonal . It is important to determine the costs associated with IPTc delivery via community based volunteers and also the potential savings to health care providers and caretakers due to malaria episodes averted as a consequence of IPTc . Methods Two thous and four hundred and fifty-one children aged 3–59 months were r and omly allocated to four groups to receive : three days of artesunate plus amodiaquine ( AS+AQ ) monthly , three days of AS+AQ bimonthly , one dose of sulphadoxine-pyrimethamine ( SP ) bi-monthly or placebo . This paper focuses on incremental cost effectiveness ratios ( ICERs ) of the three IPTc drug regimens as delivered by community based volunteers ( CBV ) in Hohoe , Ghana compared to current practice , i.e. case management in the absence of IPTc . Financial and economic costs from the publicly funded health system perspective are presented . Treatment costs borne by patients and their caretakers are also estimated to present societal costs . The costs and effects of IPTc during the intervention period were considered with and without a one year follow up . Probabilistic sensitivity analysis was undertaken to account for uncertainty . Results Economic costs per child receiving at least the first dose of each course of IPTc show SP bimonthly , at US$ 8.19 , is the cheapest to deliver , followed by AS+AQ bimonthly at US$ 10.67 and then by AS+AQ monthly at US$ 14.79 . Training , drug delivery and supervision accounted for approximately 20–30 % each of total unit costs . During the intervention period AS & AQ monthly was the most cost effective IPTc  drug regimen at US$ 67.77 ( 61.71–74.75 , CI 95 % ) per malaria case averted based on intervention costs only , US$ 64.93 ( 58.92–71.92 , CI 95 % ) per malaria case averted once the provider cost savings are included and US$ 61.00 ( 54.98 , 67.99 , CI 95 % ) when direct household cost savings are also taken into account . SP bimonthly was US$ 105.35 ( 75.01–157.31 , CI 95 % ) and AS & AQ bimonthly US$ 211.80 ( 127.05–399.14 , CI 95 % ) per malaria case averted based on intervention costs only . The incidence of malaria in the post intervention period was higher in children who were < 1 year old when they received AS+AQ monthly compared to the placebo group leading to higher cost effectiveness ratios when one year follow up is included . The cost per child enrolled fell considerably when modelled to district level as compared to those encountered under trial conditions . Conclusions We demonstrate how cost-effective IPTc  is using three different drug regimens and the possibilities for reducing costs further if the intervention was to be scaled up to the district level . The need for effective training , drug delivery channels and supervision to support a strong network of community based volunteers is emphasised Background The Lufwanyama Neonatal Survival Project ( “ LUNESP ” ) was a cluster r and omized , controlled trial that showed that training traditional birth attendants ( TBAs ) to perform interventions targeting birth asphyxia , hypothermia , and neonatal sepsis reduced all-cause neonatal mortality by 45 % . This companion analysis was undertaken to analyze intervention costs and cost-effectiveness , and factors that might improve cost-effectiveness . Methods and Findings We calculated LUNESP 's financial and economic costs and the economic cost of implementation for a forecasted ten-year program ( 2011–2020 ) . In each case , we calculated the incremental cost per death avoided and disability-adjusted life years ( DALYs ) averted in real 2011 US dollars . The forecasted 10-year program analysis included a base case as well as ‘ conservative ’ and ‘ optimistic ’ scenarios . Uncertainty was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis . The estimated financial and economic costs of LUNESP were $ 118,574 and $ 127,756 , respectively , or $ 49,469 and $ 53,550 per year . Fixed costs accounted for nearly 90 % of total costs . For the 10-year program , discounted total and annual program costs were $ 256,455 and $ 26,834 respectively ; for the base case , optimistic , and conservative scenarios , the estimated cost per death avoided was $ 1,866 , $ 591 , and $ 3,024 , and cost per DALY averted was $ 74 , $ 24 , and $ 120 , respectively . Outcomes were robust to variations in local costs , but sensitive to variations in intervention effect size , number of births attended by TBAs , and the extent of foreign consultants ' participation . Conclusions Based on established guidelines , the strategy of using trained TBAs to reduce neonatal mortality was ‘ highly cost effective ’ . We strongly recommend consideration of this approach for other remote rural population s with limited access to health care by HEWs in the health posts and general health workers at health facility were compared along a community-r and omized trial . Costs were analysed from societal perspective in 2007 in US $ using st and ard methods . We prospect ively enrolled smear positive patients , and calculated cost-effectiveness as the cost per patient successfully treated . The total cost for each successfully treated smear-positive patient was higher in health facility ( $ 158.9 ) compared with community ( $ 61.7 ) . Community-based treatment reduced the total , patient and caregiver cost by 61.2 % , 68.1 % and 79.8 % , respectively . Involving HEWs added a total cost of $ 8.80 ( 14.3 % of total cost ) on health service per patient treated in the community . Conclusions / Significance Community-based treatment by HEWs costs only 39 % of what treatment by general health workers costs for similar outcomes . Involving HEWs in TB treatment is a cost effective treatment alternative to the health service , to the patients and the family . There is an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia . However , community-based treatment requires initial investment to start its implementation , training and supervision . Trial Registration Clinical Trials.gov An economic study was conducted alongside a clinical trial at three sites in Pakistan to establish the costs and effectiveness of different strategies for implementing directly observed treatment ( DOT ) for tuberculosis . Patients were r and omly allocated to one of three arms : DOTS with direct observation by health workers ( at health centres or by community health workers ) ; DOTS with direct observation by family members ; and DOTS without direct observation . The clinical trial found no statistically significant difference in cure rate for the different arms . The economic study collected data on the full range of health service costs and patient costs of the different treatment arms . Data were also disaggregated by gender , rural and urban patients , by treatment site and by economic categories , to investigate the costs of the different strategies , their cost-effectiveness and the impact that they might have on patient compliance with treatment . The study found that direct observation by health centre-based health workers was the least cost-effective of the strategies tested ( US dollars 310 per case cured ) . This is an interesting result , as this is the model recommended by the World Health Organization and International Union against Tuberculosis and Lung Disease . Attending health centres daily during the first 2 months generated high patient costs ( direct and in terms of time lost ) , yet cure rates for this group fell below those of the non-observed group ( 58 % , compared with 62 % ) . One factor suggested by this study is that the high costs of attending may be deterring patients , and in particular , economically active patients who have most to lose from the time taken by direct observation . Without stronger evidence of benefits , it is hard to justify the costs to health services and patients that this type of direct observation imposes . The self-administered group came out as most cost-effective ( 164 dollars per case cured ) . The community health worker sub-group achieved the highest cure rates ( 67 % ) , with a cost per case only slightly higher than the self-administered group ( 172 dollars per case cured ) . This approach should be investigated further , along with other approaches to improving patient compliance UNLABELLED The incidence of pediatric diarrhea in countries neighboring Myanmar is high ( > 9 % ) . No national data exist in Myanmar , however hospital treatment data indicate that diarrhea is a major cause of morbidity . OBJECTIVE This study seeks to determine diarrhea incidence among children in rural Myanmar and document health-seeking behavior and treatment costs . METHODS We surveyed 2033 caregivers in households with under-five children , in 104 r and omly selected villages in rural Myanmar . FINDINGS The incidence of diarrhea in the 2 weeks prior to the survey was 4.9 % . Home treatment  was common ( 50.6 % ) ; among those who consulted a professional 35.6 % went to government clinics , 28.8 % to private clinics and 28.0 % to a community health worker . The cost of treatment was highest ( $ 15 ) at government clinics and lowest ( $ 1.3 ) for self-treatment at home . CONCLUSION Pediatric diarrhea is an important cause of morbidity in rural Myanmar .  Self-treatment and treatment by private providers is common Aim : To establish the cost-effectiveness of  lay health workers ( LHWs )  in conjunction with the current , local tuberculosis ( TB ) control programme , amidst health service contraction . Method : A cost-effectiveness analysis , comparing direct time costs of the current TB management strategy among permanent farm dwellers , with an intervention , whereby LHWs are involved in TB control activities on farms . Measure of effectiveness was case finding and cure rates of adult new smear-positive ( NSP ) TB cases , alongside a r and omized control trial ( RCT ): Results : The observed cost reduction to the Bol and Health District was 74 % per case detected and cured on the intervention farms relative to the control farms . Intervention farms reached 83 % successful treatment completion rate , control farms 65 % . Although the successful treatment adherence was significantly different ( 18 % letter ) . The improved case detection and cure rates were not statistically significant ( chisquared test ) . Direct LHW costs are borne by farmers . Farmers were motivated to bear costs by reduced job absenteeism and other positive side-effects . Even without outcome improvements costs per case cured were 59 % lower on the intervention farms . Conclusion : TB control has suffered from budget reductions in South Africa . It is critically important to develop cost-effective strategies to reduce the TB burden . Costs to public budgets can be substantially reduced while maintaining or improving case detection and treatment outcomes , by using farm-based LHWs OBJECTIVE To assess the cost-effectiveness of two strategies of home management of under-five fevers in Ghana - treatment using antimalarials only ( artesunate-amodiaquine - AAQ ) and combined treatment using antimalarials and antibiotics ( artesunate-amodiaquine plus amoxicillin - AAQ + AMX ) . METHODS We assessed the costs and cost-effectiveness of AAQ and AAQ + AMX compared with a control receiving st and ard care . Data were collected as part of a cluster r and omised controlled trial with a step-wedged design . Approximately , 12,000 children aged 2 - 59 months in Dangme West District in southern Ghana were covered . Community health workers delivered the interventions . Costs were analysed from societal perspective , using anaemia cases averted , under-five deaths averted and disability-adjusted life years ( DALYs ) averted as effectiveness measures . RESULTS Total economic costs for the interventions were US$ 204,394.72 ( AAQ ) and US$ 260,931.49 ( AAQ + AMX ) . Recurrent costs constituted 89 % and 90 % of the total direct costs of AAQ and AAQ + AMX , respectively . Deaths averted were 79.1 ( AAQ ) and 79.9 ( AAQ + AMX ) , with DALYs averted being 2264.79 ( AAQ ) and 2284.57 ( AAQ + AMX ) . The results show that cost per anaemia case averted were US$ 150.18 ( AAQ ) and US$ 227.49 ( AAQ + AMX ) and cost per death averted was US$ 2585.58 for AAQ and US$ 3272.20 for AAQ + AMX . Cost per DALY averted were US$ 90.25 ( AAQ ) and US$ 114.21 ( AAQ + AMX ) . CONCLUSION Both AAQ and AAQ + AMX approaches were cost-effective , each averting one DALY at less than the st and ard US$ 150 threshold recommended by the World Health Organisation . However , AAQ was more cost-effective . Home management of under-five fevers in rural setting s is cost-effective in reducing under-five mortality Background : The severe shortage of pharmacists is an important limitation to providing antiretroviral treatment ( ART ) in re source -limited countries . Two task-shifting pharmaceutical care models have been developed to address this in South Africa , namely indirectly supervised pharmacist assistant ( ISPA ) and nurse-managed models . This study compared pharmaceutical care quality , patient clinical outcomes , and provider staff costs between these models . Methods : An analysis of  pharmaceutical quality audits , patient clinical data , and staff costing data collected at 7 ISPA and 8 nurse-managed facilities was undertaken .  Pharmaceutical audits  were conducted by pharmacists using a st and ardized tool . Routine clinical data were collected prospect ively at patient visits , and staff human re sources costs were analyzed . Results : Overall pharmaceutical care quality scores were higher at ISPA sites than nurse-managed sites ; 88.8 % vs. 79.9 % , respectively ; risk ratio ( ISPA vs. nurse ) = 1.11 ( 95 % confidence interval : 1.09 to 1.13 ; P < 0.0001 ) . Mean provider pharmaceutical-related human re sources costs per patient visit and per item dispensed were 29 % and 49 % lower , respectively , at ISPA facilities . At ISPA facilities , patient attrition was observed to be lower and viral suppression higher than at nurse-managed sites . Conclusion : The ISPA model had a higher quality of pharmaceutical care and was less costly to implement . Further expansion of this model or integrating it with nurse-managed ART may enhance the cost-efficient scale-up of ART programs in Sub-Saharan Africa BACKGROUND Early detection and effective case management of tuberculosis ( TB ) among a high-risk group of material ly poor farm workers in an area of the Cape Winel and s , South Africa , presents special challenges to the health community , where re source constraints lead to service reduction . In order to address this problem , local nurses established a collaborative partnership between permanent farm workers and their families , their employers , selected non-governmental organizations and the public health sector . In consultation with stakeholders , they developed an intervention primarily focusing on having peer selected trained lay health workers ( LHWs ) on farms , mentored and managed by nurses . PURPOSE To describe the complex process of implementation and evaluation of the LHW project , and provide a summary of a number of discrete studies evaluating the effectiveness , cost implication s , and the perceptions and experiences of key stakeholders of the intervention . METHODS Quantitative and qualitative research methods conducted within the context of a pragmatic unblinded community cluster r and omized control trial were used . Emphasis was placed on an iterative participatory interaction between the research ers and key stakeholders . RESULTS The intervention contributed to significantly better successful treatment completion rates among adult new smear-positive TB cases . The process implemented proved cost-effective and was pivotal in initiating a community-based social development programme . CONCLUSIONS The use of peer-selected LHWs within a wider programme of integrated care design ed to merge technical biomedical approaches to disease management with more holistic social development activities , appears essential to meet the complex health needs in conjunction with public health of the rural poor
target: We found that substantial evidence exists for achieving cost savings and efficiency improvements from task shifting activities related to tuberculosis and HIV/AIDS , and additional evidence exists for the potential to achieve cost savings from activities related to malaria , NCDs , NTDs , childhood illness , and other disease areas , especially at the primary health care and community levels .
  Conclusions Task shifting presents a viable option for health system cost savings in LMICs .
background: Background Task shifting has become an increasingly popular way to increase access to health services , especially in low-re source setting s. Research has demonstrated that task shifting , including the use of community health workers ( CHWs ) to deliver care , can improve population health .
  This systematic review investigates whether task shifting in low-income and middle-income countries ( LMICs ) results in efficiency improvements by achieving cost savings .