Integrated Surveys of Neglected Tropical Diseases in Southern Sudan: How Much Do They Cost and Can They Be Refined

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Integrated Surveys of Neglected Tropical Diseases in Southern Sudan: How Much Do They Cost and Can They Be Refined
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  Integrated Surveys of Neglected Tropical Diseases inSouthern Sudan: How Much Do They Cost and Can TheyBe Refined? Jan H. Kolaczinski 1,2 * , Kara Hanson 2 , Emily Robinson 1 , Diana Picon 3 , Anthony Sabasio 3 , MartinMpakateni 3 , Mounir Lado 4 , Stephen Moore 3 , Nora Petty 3 , Simon Brooker 2,5 1 Malaria Consortium – Africa Regional Office, Kampala, Uganda,  2 London School of Hygiene and Tropical Medicine, London, United Kingdom,  3 Malaria Consortium,Juba, Southern Sudan,  4 Ministry of Health, Government of Southern Sudan, Juba, Southern Sudan,  5 Kenya Medical Research Institute (KEMRI)-Wellcome Trust ResearchProgramme, Nairobi, Kenya Abstract Background:   Increasing emphasis on integrated control of neglected tropical diseases (NTDs) requires identification of co-endemic areas. Integrated surveys for lymphatic filariasis (LF), schistosomiasis and soil-transmitted helminth (STH) infectionhave been recommended for this purpose. Integrated survey designs inevitably involve balancing the costs of surveysagainst accuracy of classifying areas for treatment, so-called implementation units (IUs). This requires an understanding of the main cost drivers and of how operating procedures may affect both cost and accuracy of surveys. Here we report adetailed cost analysis of the first round of integrated NTD surveys in Southern Sudan. Methods and Findings:   Financial and economic costs were estimated from financial expenditure records and interviewswith survey staff using an ingredients approach. The main outcome was cost per IU surveyed. Uncertain variables weresubjected to univariate sensitivity analysis and the effects of modifying standard operating procedures were explored. Theaverage economic cost per IU surveyed was USD 40,206 or USD 9,573, depending on the size of the IU. The major costdrivers were two key categories of recurrent costs: i) survey consumables, and ii) personnel. Conclusion:   The cost of integrated surveys in Southern Sudan could be reduced by surveying larger administrative areas forLF. If this approach was taken, the estimated economic cost of completing LF, schistosomiasis and STH mapping inSouthern Sudan would amount to USD 1.6 million. The methodological detail and costing template provided here could beused to generate cost estimates in other settings and readily compare these to the present study, and may help budget forintegrated and single NTDs surveys elsewhere. Citation:  Kolaczinski JH, Hanson K, Robinson E, Picon D, Sabasio A, et al. (2010) Integrated Surveys of Neglected Tropical Diseases in Southern Sudan: How MuchDo They Cost and Can They Be Refined? PLoS Negl Trop Dis 4(7): e745. doi:10.1371/journal.pntd.0000745 Editor:  Narcis B. Kabatereine, Ministry of Health, Uganda Received  January 15, 2010;  Accepted  May 28, 2010;  Published  July 13, 2010 Copyright:    2010 Kolaczinski et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided the srcinal author and source are credited. Funding:  Start-up and scale-up of Southern Sudan’s national programme for integrated NTD control is largely funded by the United States Agency forInternational Development, through RTI International. Specific operational research components are being funded by COMDIS, a research programme consortiumled by the University of Leeds (http://www.comdis.org). These funders did not support the present cost analysis and hence had no role in study design, datacollection and analysis, decision to publish, or preparation of the manuscript. The cost associated with the staff time required to conduct the present work wascovered by Malaria Consortium, the MoH-GoSS, the London School of Hygiene and Tropical Medicine or the Kenya Medical Research Institute-Wellcome TrustResearch Programme, depending on the affiliation of the authors. SB is supported by a Research Career Development Fellowship (081673) from the WellcomeTrust. Competing Interests:  The authors have declared that no competing interests exist.* E-mail: j.kolaczinski@malariaconsortium.org Introduction Health intervention needs generally exceed available funds.Managers of disease control programmes therefore need to decidehow to allocate their resources most efficiently. This is particularlyso for the control and elimination of neglected tropical diseases(NTDs), which have been chronically underfunded [1,2]. In anattempt to increase the efficiency of NTD programmes, the co-administration of preventive chemotherapy (PCT) for lymphaticfilariasis (LF), onchocerciasis, schistosomiasis, soil-transmittedhelminth (STH) infections and trachoma is widely advocated, therationale being that in sub-Saharan Africa (SSA) the distributions of these diseases often overlap [3]. In areas of NTD co-endemicity onedelivery structure, instead of several, could therefore be used formass drug administration (MDA) of PCT [4,5]. Co-endemicity, the prerequisite for the anticipated efficiencygains of integrated control, applies not at the country level, but atsub-national levels where climatic and other determinants aresuitable for the transmission of more than one of above diseases[6,7]. For example, onchocerciasis is associated with fast flowing rivers [8], schistosomiasis occurs near calmer or stagnant water-bodies [9], whilst STH infection, trachoma and LF occur overrelatively large areas [10 – 12]. Because of these differing  transmission ecologies, prevalence data on each disease arerequired to identify areas of overlap and to target these withintegrated PCT delivery [13]. www.plosntds.org 1 July 2010 | Volume 4 | Issue 7 | e745  For large areas of SSA there are either no data to assess thepotential for integration, or they are incomplete or out of date.Only the distribution of onchocerciasis has been comprehensivelymapped, while LF mapping is ongoing in several countries and hasnot commenced in Chad and Eritrea [14]. In 2000, prevalencedata for schistosomiasis and STH infections were only available fora third of all districts in SSA [15] and, in spite of increasedresources for mapping, survey coverage remains patchy or absentin many areas [16]. No trachoma data were available for sevencountries in the Africa region in 2005, while only a few countrieshad undertaken national surveys [17]. Although more NTD dataare now being collected, the gaps in the known distributions arestill considerable.Given that funds are not just limited for intervention, but areparticularly hard to mobilize for apparent ‘research’, some controlprogrammes have started to survey multiple NTDs simultaneouslyinstead of mapping the different diseases separately [18,19]. Theunderlying rationale for such integrated surveys is the same as thatfor co-administration of PCT; reaching communities in SSA isoften challenging and associated with considerable costs, soavoiding repeated access to conduct similar activities is likely tominimize the investment required to achieve a desired outcome,be it classification of an administrative area (e.g. district) forintervention or curing people from NTD infection. As yet there islimited operational experience with integrated NTD surveys, but itis clear that their design needs to balance cost against the precisionand accuracy with which administrative areas are classifiedaccording to treatment needs.To improve on current designs it is important to understand themain drivers of survey costs and investigate potential effects of modifying standard operating procedures. One such modificationis altering the number of sites sampled, which is likely to affectboth the cost and accuracy of determining whether a geographicalarea needs to be targeted with interventions. Such cost analysesshould be undertaken using an approach that is ‘generalisable’,hence allowing comparison between settings and use of results toplan and budget for similar undertakings elsewhere [20,21]. Southern Sudan, along with the Democratic Republic of Congoand Central African Republic, possibly has the largest unmappedNTD burden in SSA and hence the greatest need for up-to-datedata. In 2008, based on available information [6,22], Southern Sudan developed a national strategy for the integrated control of onchocerciasis, LF, schistosomiasis, STH infection and trachoma. An essential component of this strategy is to generate data on thedistribution and co-distribution of the targeted NTDs (LF,schistosomiasis, STH infection nationwide, and trachoma inremaining regions). In 2009, an integrated NTD survey wasconducted in Northern Bahr-el-Ghazal State, the first of ten statesin the country [19], with completion of mapping in the remaining nine states planned for 2010/11.The aims of this paper are to analyse the costs of the 2009survey, to identify the main cost drivers, and to estimate theresources required to expand surveys to the whole of SouthernSudan. In addition, to help compare our results to those fromother settings and estimate the costs of integrated surveyselsewhere, we present a standardised approach to costing integrated NTD surveys. Methods Integrated NTD Control in Southern Sudan During 2007, the Ministry of Health, Government of SouthernSudan (MoH-GoSS), conducted a situation analysis of NTDs andtheir control in order to inform planning for NTD control andelimination. This analysis indicated that 12 NTDs were endemic,including all of the diseases for which MDA of PCT forms animportant component of control, namely onchocerciasis, LF,schistosomiasis, STH infection and trachoma [22]. At the time,only onchocerciasis and trachoma had benefitted from regularMDA in some endemic areas, while STH infections in childrenhad been treated through a number of deworming roundsalongside national immunization days. Although the need tocontrol all NTDs endemic to Southern Sudan’s was highlighted,an opportunity was identified to combine those diseases suitablefor MDA-based control under an umbrella National IntegratedNTD Control Programme. The aim of this undertaking was toincrease geographical PCT coverage and the number of diseasestreated in each location by expanding the scope of existing community-based delivery mechanisms, be it for NTDs or otherinterventions.Two delivery mechanisms were identified for initial integration,the volunteer networks for community-directed treatment withivermectin (CDTI, covering parts of the onchocerciasis endemicareas) and similar networks for Guinea worm eradication (which insome areas also delivers trachoma interventions). Given the lack of experience of expanding these networks into delivery platforms forPCT packages, the approach was to be piloted and graduallyscaled up building on implementation experience gained along theway. In areas where neither CDTI nor the Guinea worm volunteer network are present, other existing delivery structuresmay need to be supported to take on integrated NTD control. Alternatively a new platform may need to be established to deliverMDA amongst other public health interventions [22]. Implementation Units for Integrated NTD Control Southern Sudan has four administrative tiers: state (1 st  ), county(2 nd  ), payam (3 rd  ) and boma (4 th  ). A county is the administrativeunit most comparable to a district in other African countries. Themajority of counties include five or more payams. In 2005, Author Summary Control of neglected tropical diseases (NTDs) is suggestedto be more cost-effective when drugs are co-administeredthrough a single integrated delivery system rather thanseparate systems. An essential prerequisite for suchefficiency gains is sufficient geographical overlap of thetargeted diseases – lymphatic filariasis (LF), onchocerciasis,schistosomiasis, soil-transmitted helminth infection andtrachoma. Lack of data on geographical NTD distributioncurrently hampers the implementation of integratedcontrol in many African countries. To generate therequired data quickly and efficiently, integrated surveysof several NTDs simultaneously have been recommended.However, experience with integrated surveys is limited andrequires additional research on cost and effectiveness toinform improvements in methodology and to guide scale-up. Here we analyse costs of the first integrated NTDsurvey round in Southern Sudan, generating average costsper implementation unit surveyed. Cost estimates arepresented for use of the existing survey method and formodified versions. Key cost drivers were survey consum-ables and personnel, both of which are recurrent costs.These inputs could be reduced or put to more efficient useby modifying sampling for LF. To generate comparablecost estimates and identify key cost drivers in othersettings we provide detailed cost data and guidance onhow to replicate this work. Cost of Integrated NTD Surveys, Southern Sudanwww.plosntds.org 2 July 2010 | Volume 4 | Issue 7 | e745  Southern Sudan had 49 counties, the majority of which were , 10,000 km 2 in size (median of 8,033 km 2  ) and had a populationof 100,000 to 500,000 inhabitants. At the same time these countieswere divided into a total of approximately 308 payams that variedgreatly in population and size. The overall median population of payams was 31,607, but this ranged from 2,000 to 120,000inhabitants. The median payam size was 1,876 km 2 , ranging from126 km 2 (Cueibet in Lakes State) to 58,210 km 2 (Raja in WesternBahr-el-Ghazal State).The district, or an area of equivalent size, is the recommendedimplementation unit (IU) for LF elimination [23]. An area thissize, however, may be too large for co-administration of astandardized drug package, because schistosomiasis and oncho-cerciasis are unlikely to be endemic throughout. The MoH-GoSStherefore decided to consider both the payam and the county asIUs of the Integrated NTD Control Programme. Survey Description  A large-scale survey of LF, schistosomiasis, STH infection andloiasis was conducted in Northern Bahr-el-Ghazal State betweenFebruary and May 2009. Details of the study area and surveyprotocol are provided elsewhere [19,24]. In summary, quasi-random two-stage cluster sampling was used to select communitieson the basis of potential risk of LF and schistosomiasis and torandomly select households within these communities. Eachhousehold head was requested to provide written consent, andall children aged 5 to 16 years were asked to give verbal consentbefore providing stool and urine samples for examination of schistosome and STH infection; adults were only sampled for LFtesting using immunochromatographic tests (ICT, BinaxNOWFilariasis, Inverness Medical).For LF, up to three communities and 250 individuals per payamwere sampled. Sites selected for LF were also sampled forschistosomiasis and STH, as well as loiasis, a disease whosepresence complicates LF elimination [25]. In each payam,between three to four additional communities were sampled forSTH and schistosomiasis, with the actual number depending onpayam size and estimated population. A total of 43 communitieswere sampled for LF infections and 73 communities forschistosomiasis and STH infections. Communities were selectedfrom each of the five counties of Northern Bahr-e-Ghazal State,with only one out of 22 payams not surveyed. Due to delays in thesupply of ICTs for LF, the survey had to be conducted in twophases, lasting 22 and 31 days respectively, with a gap of threeweeks in-between. Because of this delay, a total of 13 sites had tobe revisited for LF data collection. As this delay was not part of standard operating procedures, we excluded the cost associatedwith re-visiting these communities, though the test-specific costswere included.The composition of survey teams varied depending on thenumber of NTDs to be surveyed in each location. Where all fourNTDs were surveyed, teams included two drivers, one supervisor,one interviewer/translator, and up to four technicians, travelling in two vehicles. One or two technicians undertook blood sampling and LF testing while the other two to three prepared and readstool and urine samples. For those sites where schistosomiasis andSTH infection or just LF were surveyed, the team consisted out of one driver, one supervisor, one interviewer/translator, and at leasttwo laboratory technicians, travelling in one vehicle. Due to severehuman resource constraints affecting Southern Sudan, only twonational laboratory technicians per team could be recruited, withadditional technicians recruited as short-term consultants from theVector Control Division, MoH, Uganda. Village guides wererecruited locally.Owing to the poor infrastructure in Northern Bahr-el-GhazalState and fluctuating security, teams established camps in locationsthat were centrally located between study communities. In manycases, space to pitch tents was provided by non-governmental orfaith-based organizations in their compounds, but a charge waslevied. Otherwise teams stayed in local guesthouses. For camping,sleeping and cooking equipment, food, fuel and small generatorswere procured. Three Toyota Land Cruisers were used during thesurveys.To prepare for the surveys, ten days were needed to arrangesupplies and develop the database, a total of four days wererequired to move vehicles from Juba to Northern Bahr-el-GhazalState and back, and two days were required to train surveyors onthe study protocol. At the end of the survey, one day was allocatedto take stock and clean and store supplies and equipment. Aftercompletion of all survey activities, five days were needed to cleanthe data and undertake preliminary analysis. Collection of Cost Data Both financial and economic costs were estimated from theperspective of the provider [26], in this case Malaria Consortiumand the MoH-GoSS. Financial costs were the cash expendituresmade to enable implementation of the survey. For capital items,these were estimated for the total number of survey days by meansof straight-line depreciation followed by calculation of an averagefinancial daily cost. Economic costs captured the value of allresources consumed by the survey, including opportunity costs of  volunteers and equipment that were used in the survey but notpaid for, as well as appropriate treatment of costs of capital itemswith a value of   . USD 100 and an expected useful life of morethan one year [27]. Costs of MoH staff were based on the GoSSpay scale for 2009 while the time of international volunteers was valued using equivalent Malaria Consortium salaries for thissetting. Capital items were discounted over their estimated usefullife using the recommended discount rate of 3% [28,29]. Dailyeconomic costs were calculated for all capital items and multipliedby the appropriate number of days in use during the survey. Basedon our experience of working in the harsh climatic environment of Southern Sudan we estimated the useful life to be four years for vehicles and high frequency radios (fitted to vehicles) and two yearsfor all other items, including laptop computers and laboratory fieldequipment. All resources used for research activities, such as thiscosting study, were excluded from the analysis as were the costsassociated with the development of the survey protocol.Cost data were collated from financial expenditure records of Malaria Consortium during the survey and shortly afterwards. Toaccommodate considerable fluctuations in currency conversionrates, two time periods were used. For payments for surveysupplies, which started in October 2008 and continued throughMay 2009, we used average exchange rates of 1 United StatesDollars (USD)=0.67 British Pounds (GBP) or 1 USD=2024Ugandan Shillings (UGX). For costs associated with the actualsurvey activities between February and May 2009 we used a rateof 1 USD=2.3 Sudanese Pounds (SDG) (http://www.oanda.com/convert/fxhistory). We assumed that these exchange ratesand the wages paid reflected competitive foreign exchangemarkets, and therefore did not use shadow prices to adjust forpossible distortions [30].Costs were identified using an ingredients approach, wherebythe total value of each of the services and goods employed inimplementing the survey was estimated by identifying the numberof units consumed and multiplying these by their unit price[26,31]. Following the structure of the survey, cost and services Cost of Integrated NTD Surveys, Southern Sudanwww.plosntds.org 3 July 2010 | Volume 4 | Issue 7 | e745  were organized into capital and recurrent costs, both of whichwere divided into cost categories [Box 1, Dataset S1].It is common practice to include overheads in cost analyses[32]. To capture the indirect costs of project managementand administration we applied an overhead of 25% to thefinancial cost estimate for all budget lines. This rate is higherthan those applicable to operations in more stable settings of eastern Africa [e.g. [33], but in our experience provides anaccurate reflection of the cost involved in implementing programmes in a land-locked country undergoing post-conflictreconstruction. Outcomes The overall purpose of the integrated survey was to generatedata by which IUs could be classified according to interventionthresholds recommended by the WHO [3]. The present analysisconsidered both the county and the payam as IUs, because a two-tier system may be needed to account for inherent differences inthe geographical distribution of the targeted NTDs. While for LFelimination the county is likely to be an appropriate IU, control of onchocerciasis is already more geographically focused and the firstround of integrated NTD surveys indicated that a similarapproach is also more appropriate for schistosomiasis [19]. Theoutcomes used for our costing study were thus the county and thepayam surveyed, to allow their classification for interventionaccording to WHO recommended thresholds. Sensitivity Analysis Calculation of costs and outcomes involves a number of assumptions; the ones underlying the present study have beenoutlined above and in table 1. One-way sensitivity analysis wasconducted to explore the effects of key assumptions on the results.We varied the discount rate (reduced to 0% or increased to 10%)and increased the assumed lifespan of vehicles to 7.5 years. Inaddition we investigated the effect of modifying the standardoperating procedures. Instead of using Hemastix reagent strips validated by urine filtration for diagnosis of urinary schistosomi-asis, as used in the first survey round [34], we assumed thaturinary schistosomiasis could be adequately diagnosed using reagent strips only and excluded the cost of urine filtration, amethod that is relatively costly because it requires isoporemembrane filters at a price of nearly USD 2 per filter. Therationale for cutting out urine filtration was that the use of reagent strips alone is a reliable diagnostic procedure in some Box 1. Cost Categories Used and Ingredients Included Type/Category IngredientsCapital costs Vehicles  N  Vehicles, including freight charges N  Vehicle parts with a unit cost of USD 100 or more N  Any vehicle equipment expected to last for more than one year (e.g. first aid kits)Communications & IT Equipment  N  High Frequency (HF) and Very High Frequency (VHF) radios N  Phones (fixed, mobile, satellite) N  Global Positioning System (GPS) devices, Geographic Information Systems (GIS) software and manuals N  ComputersAccommodation equipment  N  Camping equipment estimated to last  . 1 year N  GeneratorSurvey equipment  N  Microscopes N  Laboratory glassware and storage containers N  Furniture (i.e. plastic tables and chairs) N  All durable equipment for Kato-Katz test and urine filtration Recurrent costs Travel  N  Airfares & short-term vehicle hire (e.g. during preparatory activities) N  Per-diems N  Visas and other in-country registration fees N  Accommodation during travel to survey area N  Travel insurance and pre-travel medical expenses N  Fuel costs associated with moving vehicles to survey areaFuel/Maintenance  N  Fuel for vehicles during field work & all costs associated with obtaining the fuel, such asloading/unloading of fuel barrels N  Any maintenance costs, including parts with a unit cost below USD 100 N  Vehicle insuranceAccommodation & sustenance  N  Rental of guesthouse N  Hotel bills N  All costs associated with purchasing and preparing food N  Cook and guesthouse guards N  Camping equipment estimated to last  , 1 yearSurvey consumables  N  Laboratory consumables, including rapid diagnostic tests and drugs to treat survey participants N  Freight charges for import of consumables N  Stationary items N  T-shirts and other types of identification worn by members of survey teamCommunication  N  Mobile and satellite phone creditPersonnel  N  Salaries paid to drivers, supervisors, laboratory staff, village guides and consultants N  Field allowances N  Staff time for cross-checking of slides N  Technical support time for data entry and analysis Cost of Integrated NTD Surveys, Southern Sudanwww.plosntds.org 4 July 2010 | Volume 4 | Issue 7 | e745   African countries [35] and may, after validation, be applicable inhigh schistosomiasis transmission settings in Southern Sudan. Wealso explored the effect on cost of classifying counties, rather thanpayams, for LF elimination. Instead of sampling 250 individualsfrom up to three sites per payam, the analysis investigated thecost implications of applying exactly the same procedure but atcounty level. This procedure would have yielded the sameclassification of IUs for LF elimination in Northern Bahr-el-Ghazal State [19] and is likely to be appropriate throughoutSouthern Sudan. Ethical Considerations The present study involved collection of data on cost and non-financial inputs through analysis of Malaria Consortium expen-ditures and activities during an epidemiological survey. Datacollection was conducted from the ‘provider perspective’, ratherthan the all encompassing ‘societal perspective’ [26], sinceparticipation in the survey incurred minimal time commitmentfrom the study communities. The epidemiological survey itself received ethical approval from the Directorate of Research,Planning and Health System Development, MoH-GoSS, and fromthe Ethics Committee of the London School of Hygiene andTropical Medicine, UK. Collection of the data presented here didnot involve human subjects and therefore did not require ethicalapproval. Results The total financial costs for the survey amounted to USD182,067, the majority of which was spent on recurrent items. Theprincipal cost drivers were personnel (34.4%) followed by surveyconsumables (30.4%) (Table 2). Economic costs amounted to atotal of USD 201,030 and were arrived at by including theimputed value of the time provided by MoH employees and othernon-cash inputs, as well as the opportunity cost of capital itemsused in the survey. Because all assets above USD 100 in value andwith a lifespan . 1 year were annualised and only their time in useduring the survey was included, capital cost amounted to only4.3% of the total survey costs and were largely comprised of  vehicle costs. As for the financial costs, most economic costs weretaken up by survey consumables and personnel, accounting for27% and 38% of the total, respectively (Table 2).The outcome from this investment was that 21 payams in thefive counties of Northern Bahr-el-Ghazal State, an area the size of Belgium, were surveyed for LF, schistosomiasis, STH infectionand loiasis. These five counties and 21 payams were, for the firsttime ever, categorised as requiring MDA delivery or not,according to WHO recommended thresholds [3]. The averageeconomic cost per IU classified was USD 40,206 per county orUSD 9,573 per payam. These estimates changed very little whenthe two key assumptions, the discount rate or lifespan of vehicles,were varied (Table 3). Table 1.  Reference case scenario. Parameter Suggested Reference Scenario Explanation Perspective Provider Use provider perspective unless considerable survey contributions weremade by other parties and resources are available to measure all of theseinputs, including the opportunity cost of survey participants. In this casepresent results from both the provider and societal viewpoints.Output Implementation unit surveyed Implementation unit (e.g. district) surveyed to allow classification forintervention according to WHO recommended thresholds [3]. Provideindication of the geographic and population size of the implementation unit.Cost data Include:All survey costs (e.g. wages, transport)Time cost of survey staff, includingvolunteersTransportation and other non-medicalservicesDonated itemsOverhead costsUse ingredient approach with cost categories as suggested in box 1.Quantities and prices need to be presented separatelyExclude research costs.Include relevant overheads of collaborating organizations (e.g. NGOcontributions to procurement, management, etc), if relevant.Treat any equipment as a capital item if it is expected to last for more thanone year and is purchased at a value of USD 100 or more.Calculate a daily financial cost for capital items by using straight linedepreciation, and include the cost of each capital item for the number of survey days that it was used.Currency US $  Costs should be presented in US $ , indicating the year of conversion.Lifespan of capital items Vehicles: 4 yearsOther equipment: 2 yearsEstablish average lifespan of capital items under local conditions and providedetails on these in the narrative. Explore the impact of these assumptions inthe sensitivity analysis.Adjustment of financial costs to calculated economic costsAnnualisation Lifespan of capital items asspecified aboveTo obtain an equivalent annual cost for each capital outlay, an annualisationprocedure needs to be followed. This requires an estimate of the lifespan of each capital item and a decision on the discount rate to be used (see below).A proportion of the annualised costs should be included as economic costs.We recommend that time (i.e. days of use of the equipment) is used for thiscalculation.Discount rate 3% Base-case calculations should use 3%, to be consistent with World Bank recommendations [32]. This should be varied in the sensitivity analysis, e.g.from 0 – 10%.Reporting of resultsCost estimate Cost per implementation unit surveyed Provide costs in US $ Specify year in which costs were calculated or adjusted todoi:10.1371/journal.pntd.0000745.t001 Cost of Integrated NTD Surveys, Southern Sudanwww.plosntds.org 5 July 2010 | Volume 4 | Issue 7 | e745
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