The Costs of Volunteering: Quantifying the Economic Value of Community Resources Contributed to an Integrated Neglected Tropical Disease Control Program in Nigeria Public

Abstract

Background/Objective
Neglected tropical disease (NTD) control programs in Africa typically rely on community volunteers to carry out drug distribution and other essential tasks. Although the benefits of using volunteer labor have been demonstrated from a programmatic perspective, little is known about the costs that are imposed on volunteers themselves. This research aimed to quantify the financial and opportunity costs incurred by community volunteers contributing to the Carter Center-supported NTD program in north central Nigeria between 2009 and 2010.

Methodology/Principal Findings
Retrospective data on inputs were collected from a sample of community-directed distributors (CDDs) and village heads (VHs) using a survey instrument. Programmatic data were used to make inferences about the study population. While performing NTD activities each year, the average CDD worked 15.5 days and incurred financial costs of $5.36 (USD, 2010), while the average VH worked 5 days and had costs of $4.09. When volunteer time was valued in monetary units and combined with financial costs, the total value of resources contributed was estimated at $.06 per treatment distributed and $72.60 per community. For opportunity costs related to NTD activities, a downward trend was observed between study years. However, when inputs to insecticide-treated bed net (ITN) distribution in 2010 were included, this trend was reversed due to significantly higher costs among those distributing ITNs. The sum total of economic costs incurred by communities in the study area was estimated at $259,630 per year for NTD activities, and $337,527 for NTD and ITN activities combined in 2010.

Conclusion
This study finds that significant and wide-ranging economic costs were imposed on community members contributing to an NTD program. CDDs in particular bore the brunt of these economic costs, although community support played a role in redistributing them more broadly. The data suggest that while integration of preexisting interventions may have contributed to modest reductions in communities' economic costs, the addition of a new intervention led to substantial cost increases. Overall, the findings raise concerns about whether integrated NTD programs can sustainably expand the scale and scope of their services without providing commensurate incentives to CDDs.

Table of Contents

Chapter 1: Introduction................................................................................................................ 1

Introduction/Rationale................................................................................................................. 1

Problem Statement....................................................................................................................... 4

Purpose........................................................................................................................................ 6

Research Goals............................................................................................................................ 6

Significance.................................................................................................................................. 7

Definition of Terms..................................................................................................................... 7

Chapter 2: Comprehensive Review of the Literature............................................................... 9

Background.................................................................................................................................. 9

Description of CHWs.............................................................................................................. 9

Global distribution and characteristics of CHWs.................................................................. 10

Use of CHWs by multiple programs..................................................................................... 11

Integration of NTD programs................................................................................................ 12

Results of Integration............................................................................................................ 13

Financing................................................................................................................................ 14

Incentives and Community Financing in NTD MDA Programs........................................... 16

Motivation and Performance................................................................................................. 19

Methods for the economic evaluation of CHW programs......................................................... 21

Economic evaluations in health care...................................................................................... 21

Transfers................................................................................................................................ 22

Cost distribution.................................................................................................................... 23

Community economic costs.................................................................................................. 23

Valuation of donated goods................................................................................................... 23

Valuation of paid labor.......................................................................................................... 24

Valuation of volunteer labor.................................................................................................. 24

Economic evaluations of CHW programs in the literature........................................................ 27

Overview............................................................................................................................... 27

Economic evaluations of CHW programs in higher income countries................................... 28

Economic evaluations of TB programs using CHWs............................................................ 28

Economic evaluations of child survival interventions using CHWs...................................... 30

Economic evaluations of MDA interventions utilizing CHWs............................................. 31

Other relevant economic evaluations..................................................................................... 33

Conclusion................................................................................................................................. 34

Chapter 3: Methodology............................................................................................................. 35

Introduction............................................................................................................................... 35

Research Design......................................................................................................................... 35

Study Setting............................................................................................................................. 35

Population and Sample.............................................................................................................. 36

Instruments................................................................................................................................ 36

Data entry and analysis............................................................................................................. 37

Valuation of Time Inputs.......................................................................................................... 39

Limitations and Delimitations................................................................................................... 40

Chapter 4: Results...................................................................................................................... 41

Summary of Programmatic Data................................................................................................ 41

Respondent Characteristics....................................................................................................... 44

Time Inputs for NTD Activities............................................................................................... 44

Time Inputs by NTD Programmatic Activity.......................................................................... 48

Comparison of Time Inputs for Integrated and Non-Integrated NTD Treatment.................... 49

Costs and Transfers: Financial and In-Kind.............................................................................. 50

Inputs per NTD Treatments Distributed in the Study Population.......................................... 52

Inputs for ITN Distribution...................................................................................................... 54

Total Value of Economic Costs................................................................................................. 56

Chapter 5...................................................................................................................................... 59

Discussion................................................................................................................................. 59

Areas of further study............................................................................................................... 62

Recommendations...................................................................................................................... 64

Conclusion................................................................................................................................. 65

References...................................................................................................................................... 66

Appendices..................................................................................................................................... 70

About this Master's Thesis

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School	Rollins School of Public Health
Department	Hubert Department of Global Health
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health Economics, General
Mot-clé	community-directed distributor (CDD) community health worker (CHW) neglected tropical disease (NTD) volunteer economic costs
Committee Chair / Thesis Advisor	McFarland, Deborah A, Emory University
Partnering Agencies	Emory University schools, faculty or affiliated programs International Non-governmental organization (e.g., CARE, Inc.)

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