Cost Effectiveness and Resource

Allocation BioMed Central

Research Open Access

Cost analysis of an integrated disease surveillance and response
system: case of Burkina Faso, Eritrea, and Mali
Zana C Somda*1, Martin I Meltzer1, Helen N Perry1, Nancy E Messonnier1,
Usman Abdulmumini2, Goitom Mebrahtu3, Massambou Sacko4,
Kandioura Touré5, Salimata Ouédraogo Ki6, Tuoyo Okorosobo7,
Wondimagegnehu Alemu7 and Idrissa Sow7

Address: 1Centers for Disease Control and Prevention, Atlanta, Georgia, USA, 2WHO Country Office, Asmara, Eritrea, 3Disease Prevention and
Control, Ministry of Health, Eritrea, 4WHO Country Office, Bamako, Mali, 5Service Surveillance des Maladies, Ministère de la Santé, Mali,
6Direction des Etudes et de la Planification, Ministère de la Santé, Ouagadougou, Burkina Faso and 7WHO African Regional Office, Harare,

Zimbabwe
Email: Zana C Somda* - ZSomda@cdc.gov; Martin I Meltzer - MMeltzer@cdc.gov; Helen N Perry - HPerry@cdc.gov;
Nancy E Messonnier - NMessonnier@cdc.gov; Usman Abdulmumini - abdulmuminiu@er.afro.who.int;
Goitom Mebrahtu - goitomm2004@yahoo.com; Massambou Sacko - sackom@ml.afro.who.int; Kandioura Touré - ktoure@dnsmali.org;
Salimata Ouédraogo Ki - ouedraosali@yahoo.fr; Tuoyo Okorosobo - okorosobot@na.afro.who.int;
Wondimagegnehu Alemu - alemuw@afro.who.int; Idrissa Sow - sowi@zw.afro.who.int
* Corresponding author

Published: 8 January 2009 Received: 16 June 2008

Accepted: 8 January 2009
Cost Effectiveness and Resource Allocation 2009, 7:1 doi:10.1186/1478-7547-7-1
This article is available from: http://www.resource-allocation.com/content/7/1/1
© 2009 Somda et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Communicable diseases are the leading causes of illness, deaths, and disability in sub-Saharan
Africa. To address these threats, countries within the World Health Organization (WHO) African region adopted
a regional strategy called Integrated Disease Surveillance and Response (IDSR). This strategy calls for streamlining
resources, tools, and approaches to better detect and respond to the region's priority communicable disease. The
purpose of this study was to analyze the incremental costs of establishing and subsequently operating activities
for detection and response to the priority diseases under the IDSR.
Methods: We collected cost data for IDSR activities at central, regional, district, and primary health care center
levels from Burkina Faso, Eritrea, and Mali, countries where IDSR is being fully implemented. These cost data
included personnel, transportation items, office consumable goods, media campaigns, laboratory and response
materials and supplies, and annual depreciation of buildings, equipment, and vehicles.
Results: Over the period studied (2002–2005), the average cost to implement the IDSR program in Eritrea was
$0.16 per capita, $0.04 in Burkina Faso and $0.02 in Mali. In each country, the mean annual cost of IDSR was
dependent on the health structure level, ranging from $35,899 to $69,920 at the region level, $10,790 to $13,941
at the district level, and $1,181 to $1,240 at the primary health care center level. The proportions spent on each
IDSR activity varied due to demand for special items (e.g., equipment, supplies, drugs and vaccines), service
availability, distance, and the epidemiological profile of the country.
Conclusion: This study demonstrates that the IDSR strategy can be considered a low cost public health system
although the benefits have yet to be quantified. These data can also be used in future studies of the cost-
effectiveness of IDSR.

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Background action; 41 countries had already adapted the technical

Communicable diseases remain the most common causes guidelines to meet their own public health priorities and
of death, illness and disability in African countries. Lopez situations and then launched IDSR activities at their dis-
et al. (2006) reported that one-third of the deaths in low- trict levels; and 33 countries had trained staff on IDSR in
and-middle income countries in 2001 were from commu- at least 60% of their districts (Table 1).
nicable and parasitic diseases and maternal and nutri-
tional conditions [1,2]. In addition, the economic cost in In order to better understand the investment and imple-
terms of prevention, treatment, and loss of productivity is mentation costs of this IDSR strategy, the IDSR multi-part-
enormous [3-5]. Although a number of studies on eco- ner task force that guides the implementation of this
nomic evaluation of interventions against communicable regional strategy recommended that the partners under-
diseases have been reported in the literature [6,7], most of take cost analyses and cost-effectiveness studies. There-
these studies in sub-Saharan Africa have focused on indi- fore, the purpose of this study was to analyze the
vidual disease-specific intervention programs, such as pre- incremental costs of establishing and subsequently oper-
vention or treatment of malaria, measles, meningitis, ating activities for detection and response to the priority
tuberculosis and HIV/AIDS [5,8-15]. Relatively few stud- diseases under the IDSR.
ies have looked at the economics of integrating resources
for disease surveillance and public health response activi- Methods
ties [16]. Study countries
The study was conducted in Burkina Faso, Eritrea, and
Surveillance is an important component of disease pre- Mali, countries where infectious diseases such as cholera,
vention and control programs. It is useful in early detec- malaria, meningococcal meningitis and yellow fever are
tion of unusual events for effective and timely action, either epidemic or endemic (Table 2). Burkina Faso, with
monitoring and evaluation of interventions and guiding a population of 13.2 million, is divided into 13 health
selection of appropriate corrective measures [17]. In 1998, regions, 55 districts and has more than 1,232 primary
the Regional Committee of the World Health Organiza- health care centers. Mali, with about 13.5 million inhab-
tion Africa region (WHO-AFRO) adopted a strategy called itants, has nine regions, 57 districts and over 709 fully
Integrated Disease Surveillance and Response (IDSR) operational primary health care centers. Eritrea, with an
[18]. Under the IDSR strategy, countries address improve- estimated population of 4.4 million, is divided into six
ments in infrastructure capacities and support activities regions, 57 districts and has 664 primary health care cent-
and select a number of priority diseases and health risk ers. These three countries were selected for this study
conditions from a list of the 19 communicable diseases because each had fully established IDSR leadership and
that affect African communities (Figure 1) [19-21]. By structures at the national level by 2002, with implementa-
December 2007, considerable progress had been tion at regional and district levels in 2003 and 2004,
achieved, with 43 of the 46 countries having assessed their respectively.
national surveillance system and developed plans of
Table 1: Progress with IDSR implementation in the WHO AFRO African Region†: 2001 – 2007

IDSR Activities Number of countries (% of total 46 countries)

2001 2002 2003 2004 2005 2006 2007

Sensitization of Ministry of Health officials and stakeholders on IDSR 22 35 36 43 44 44 44

(48%) (76%) (78%) (96%) (96%) (96%) (96%)
Assessment of national surveillance and response, including laboratory 22 35 36 43 43 43 43
(48%) (76%) (78%) (93%) (93%) (93%) (93%)
Development of IDSR plans of action 13 31 32 43 43 43 43
(28%) (67%) (70%) (93%) (93%) (93%) (93%)
Adaptation of generic IDSR technical guidelines* 1 26 35 39 41 41 41
(2%) (57%) (76%) (85%) (89%) (89%) (89%)
Adaptation of generic IDSR training materials* 1 20 35 39 39 39
(2%) (43%) (76%) (85%) (85%) (85%)
Training staff on IDSR in at least 60% of the districts 33
(72%)
Publishing feedback bulletins 32
(70%)

†Source: Progress with IDSR implementation http://www.cdc.gov/idsr/implementation.htm#progress.

*Materials were developed by WHO AFRO and the US Centers for Disease Control and Prevention (CDC)

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Figure 1
Recommended IDSR priority diseases, core functions and activities in the WHO African region
Recommended IDSR priority diseases, core functions and activities in the WHO African region.

Study design ducted in three regions (Kayes, Mopti, and Sikasso), and
We conducted retrospective surveys of costs for integrating included one district per region and one primary health
surveillance and response to the priority diseases adopted care center per district. We consulted, in each country,
by each country (see Additional file 1, Appendix 1) at with public health and disease surveillance officers to
national, regional, and district surveillance offices as well select sites that they considered representative of the
as public health clinics, laboratories and pharmacies. We national IDSR system.
conducted one field test in Eritrea followed by full field
studies in Burkina Faso and Mali. In Eritrea, the survey We took the perspective of the government-funded health
sites included the central Ministry of Health, the Anseba care system (i.e., we only recorded costs incurred by the
provincial office, and offices in the Haquaz district. In governments and external partners). All cost data were
Burkina Faso, most IDSR activities were focused on the recorded in local currency values and then converted into
epidemic-prone diseases, with particular emphasis on US dollar using the appropriate mean annual exchange
detection and response to meningococcal meningitis. The rate. We used the general consumer price index from each
data were obtained from four health regions (Bobo Diou- country and a discount rate of 3% to adjust all costs into
lasso, Gaoua, Kaya, and Ouahigouya), 14 districts, and 20 2002 US dollars equivalent [22]. We also examined the
primary health care centers. In Mali, the survey was con- effect on cost per capita estimate of using purchasing

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Table 2: Summary of country health status*

Burkina Faso Eritrea Mali WHO African Region†

Total population (× 1,000) 13,228 4,401 13,518 738,083

Total expenditure on health (as % of GDP) 5.6 4.4 4.8
Adult mortality rate (per 1000 population) 441 313 452 492
Under-5 mortality rate (per 1000 live births) 192 82 219 167
Year of life lost by communicable diseases (%) 87 81 86 59
Causes of death among children under 5 years of age (%)
Neonatal causes 18.3 27.4 25.9 26.2
Diarrhoeal diseases 18.8 15.6 18.3 16.6
Malaria 20.3 13.6 16.9 17.5
Pneumonia 23.3 18.6 23.9 21.1
Measles 3.4 2.5 6.1 4.3
HIV/AIDS 4.0 6.2 1.6 6.8
Other 11.9 16 7.3 7.5

* Source: World Health Statistics 2006 http://www.who.int/whosis/en/

†WHO African region comprises 46 countries in sub-Saharan Africa including Algeria and Mauritania (African countries outside WHO/AFRO
region are Western Sahara, Morocco, Tunisia, Libya, Egypt, Sudan, and Somalia).

power parities (PPP) to convert national currencies into or equipment per year, and resources provided through
international dollars (PPP removes currency conversion other activities and organizations.
problems due to fixed conversion rates that may not
reflect actual relative costs) [22]. IDSR specific cost estimation
For each health structure level, all resources were grouped
Cost data into the following major categories: personnel; transpor-
We collected data associated with all "health-related sur- tation; office consumable goods; public awareness cam-
veillance" (HRS) activities (i.e., all communicable and paigns; drugs or treatment; laboratory supplies; and
non-communicable diseases and risk factors, including capital items (Additional file 1, Appendix 2). For each cat-
the surveillance and response activities of the IDSR tar- egory, we identified the proportion of those cost data
geted diseases) from Burkina Faso and Eritrea for the years (such as staff workload or actual use of resources, if esti-
2002 to 2005 and from Mali for the years 2000 to 2005. mates or records were available) attributable to IDSR.
For each country, region/province and district, we
obtained annual population data from the disease surveil- Personnel costs
lance units. Program cost data were obtained from disease When time keeping records were absent, we interviewed
surveillance budget and program records, and from inter- each staff member to estimate the breakdown of their
views with IDSR program coordinators and key public time on all HRS, IDSR priority diseases, each IDSR activity
health staff. Whenever we found a difference between (i.e., detection, notification, analysis, investigation,
budget and reported expenditure, we used the reported response, feedback, and support), and other ministry of
expenditure. Aggregated pharmacy, clinical and medical health activities. We recorded the number of workers,
records were collected using a structured questionnaire. their annual income, and the number of full time equiva-
The survey instrument (available from http:// lents needed for administration or delivering of each HRS
www.cdc.gov/idsr/survcost.htm) guided collection of and IDSR activity. We then apportioned total personnel
data on all the resources used, including capital (one-time costs to each IDSR activity based on the ratio of personnel
investment) and recurrent (on-going) items. The capital time allocated to that activity relative to all IDSR activities.
items included building infrastructure, vehicle, equip- We included fees of individual consultants hired for spe-
ment (e.g., refrigerators, computers, etc.), and furniture cialized services such as short-term training.
(e.g., tables, chairs, etc.). The recurrent items included per-
sonnel (salaries and benefits of surveillance officers, data Transportation costs
managers, physicians, nurses, etc.), rent (rent, utilities, We considered vehicles purchased for IDSR activities as
operation, and maintenance), office and laboratory sup- capital items (see below). IDSR-related running costs for
plies, transportation, public awareness campaigns and transporting personnel and patients, drugs, specimens,
short-term training. The questionnaire also collected vaccines and other items, as a percentage of the total fuel
information on other variables related to disease surveil- and maintenance costs, were estimated based on the vehi-
lance activities, such as length of use of buildings, vehicles cle use-time per IDSR activity. When there were no data to

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apportion transport costs, we proportioned costs using the scrap value of the capital items at the end of the useful
the ratio of personnel time for IDSR to total personnel life to be zero.
time for all HRS activities. We included rental vehicle and
public transportation fees for IDSR-specific activities. For equipment and vehicles, we apportioned out capital
costs using the equipment and vehicle use-time (see
Office consumable costs above). For buildings, we proportioned capital costs using
These included office supplies and materials, facilities and the ratio of IDSR personnel time to all HRS personnel
equipment maintenance, and utilities costs. Office con- time.
sumable costs for IDSR, as a proportion of all HRS costs,
were calculated using either the ratio of IDSR personnel Data analysis
time to all HRS personnel time, or actual amount of We entered and analyzed the data in a spreadsheet (Micro-
resources used for IDSR-activities (if the latter were avail- soft Excel 5.0, Microsoft Corp., Seattle), calculating aver-
able). ages and standard deviations per resource category and
per IDSR activity. We aggregated costs of all HRS and IDSR
Public awareness campaign costs activities across all resource categories by health structure
We measured advertising, broadcasting and media costs level. Using the estimated total costs for each province
for public campaigns and targeted social mobilization. and district included in the study, and population esti-
IDSR costs were estimated as a proportion of total media mates for each included province and district, we calcu-
health education costs using the ratio of IDSR personnel lated average annual cost per capita per year for all HRS
time to all HRS personnel time. and IDSR activities. We then used these per capita costs
and the annual population estimates to calculate the total
Treatment costs annual national IDSR program cost in each country. We
These included all drugs and vaccines as well as other pro- also compared the per capita surveillance costs to the per
grammatic measures (e.g., treated bed nets) used in the capita national health expenditures [23].
line of controlling and preventing diseases included in the
IDSR program. Total annual costs were calculated based Missing data
on the procurement cost and the quantity of each specific We encountered two types of missing data. The first cate-
product required for the treatment of diseases. We esti- gory of missing data involved cost data for some building
mated IDSR costs using either the actual amount of structures and equipment. For example, cost data were
resource or the ratio of IDSR personnel time to all HRS missing for approximately half of buildings in each coun-
personnel time at the health facility (if the former were try. The second category of missing data involved cost data
available). for the laboratory testing and treatments from Burkina
Faso. To fill in for the structure and equipment cost data,
Laboratory consumable costs we used average cost data for similar structures and equip-
We estimated the costs of laboratory consumable materi- ment at other sites (in the same country) as a proxy for the
als and supplies (e.g., reagents, slides, gloves, test tubes, missing data. For example, when the information neces-
cotton wool swabs, blood culture bottles, aluminum foil, sary to estimate the cost of a specific building was not
syringes, rapid diagnostic kits, etc) required for the pur- available, we used the data for similar ministry buildings
pose of various diagnostic tests for diseases included in in the same locality or nearby health structures. For the
the IDSR strategy. missing cost data from Burkina Faso, we conducted two
analyses: one by cost category (personnel, transport,
Capital equipment costs office, etc.) excluding any cost categories for which we had
The costs of buildings, laboratory and office equipment no data and the other by extrapolating the relevant cost
and vehicles were depreciated at 3% annually over a 50-, data from the other countries.
10-, and 5-year useful-life time horizon, respectively. We
calculated the annualized cost using the following general Results
equation: Table 3 summarizes the mean annual costs by resource
categories at the region, district, and primary health care
⎡ r(1+ r )t ⎤ center level in the three countries. Detailed costs are
Annualized cost = K ⎢ ⎥ shown in Additional file 1, Appendix 3. As expected,
⎢⎣ (1+ r )t −1 ⎥⎦ because of larger populations and types of IDSR activities,
regional-level costs were greater in all categories than at
where K is the purchase price of the item, r represents the the level of district and primary health care center. How-
depreciation rate, and t is the useful-life-year. We assumed ever, the cost of running IDSR at each site varied substan-
tially by resource-type. Since disease surveillance requires

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Table 3: Mean annual costs (in 2002 US $) of all health-related surveillance and IDSR per category of resources in Burkina Faso, Mali,
and Eritrea

Health structure level Cost category Burkina Faso§ Mali Eritrea

All health-related IDSR All health-related IDSR All health-related IDSR

surveillance surveillance surveillance

Region Personnel 15,275 3,568 25,951 11,353 82,589 32,622

Transport 13,015 4,771 18,226 7,292 4,137 3,309
Office 13,102 5,471 31,362 10,889 67,032 27,643
Media 1,664 238 4,515 1,481 0 0
Treatment 55,964§ 12,391 14,007 3,594 30,789 3,506
§

Laboratory 27,275§ 5,032§ 9,156 2,301 12,759 1,726

Capital 11,271 4,429 8,368 2,663 8,026 1,114

District Personnel 7,735 1,686 18,484 7,341 7,488 3,541

Transport 10,712 2,159 16,519 2,233 5,490 1,098
Office 7,855 1,807 5,642 1,718 7,141 5,358
Media 527 116 677 169 0 0
Treatment 13,571§ 2,986§ 3,409 369 2,029 350
Laboratory 6,577§ 1,209§ 322 79 513 100
Capital 4,318 826 6,301 2,032 5,561 1,540

Primary¶ health Personnel 1,839 478 2,752 728 1,974,579 191,58

4
care center Transport 627 166 274 53 42,804 42,043
Office 993 186 270 49 359,817 42,988
Media 233 42 14 3 36,292 35,738
Treatment 591§ 131§ 1632 182 756,914 123,54
7
Laboratory 288§ 53§ 0 0 345,554 56,878
Capital 624 184 909 167 119,475 16,204

§ In Burkina Faso, laboratory and treatment costs were calculated using the average annual per capita costs of laboratory and treatment for Eritrea
and Mali
¶ In Eritrea, data were for the central Ministry level (primary health care center was not included in the study).

trained staff, mean annual personnel costs were among $91,362) of IDSR program per region occurred in 2003,
the largest components of the region (10% to 47%) and and the highest costs ($13,297 and $15,781) per district
district (16% to 44%) total IDSR costs in all three coun- in 2004 (Fig. 2). These were possibly associated with start-
tries. Based on the results from Eritrea and Mali, we esti- up costs of IDSR implementation at regional and district
mated that the laboratory and treatment costs ranged levels. By the end 2003, for example, Eritrea had com-
from 4% to 35% of the total IDSR cost in Burkina Faso. pleted training on IDSR in all the provinces; Burkina Faso
The proportion of the total IDSR cost due to treatment had trained 18 national core trainers, 135 province super-
varied considerably (2% to 13%) by health structure in visors, 110 laboratory technicians, and 1233 district and
Eritrea and Mali. In general, the annualized capital costs primary health care personnel; and Mali had trained only
constituted 2% to 13% of the total annual cost of IDSR in 406 health personnel from 28 districts of the four regions
Eritrea, 6% to 12% in Mali, and 8% to 15% in Burkina including Bamako.
Faso.
Costs disaggregated into IDSR activities are shown in
The mean annual costs by health structure levels from the Table 5. Detailed costs by year per IDSR activity are pre-
three countries surveyed are presented in Table 4. Eritrea sented in Additional file 1, Appendix 4. As expected, the
had the highest total IDSR-related costs, and Burkina Faso surveillance activities (e.g., detection, report, and analy-
had the lowest costs. The mean cost of IDSR, expressed as sis) that are carried out on a routine basis absorbed more
percentage of all HRS cost, also varied by health structure resources than the support activities (e.g., evaluation and
level (Table 4). In all three countries, the mean annual monitoring). Outbreak investigation and treatment of
IDSR costs were 20% to 43% of the all HRS costs. In confirmed cases also constituted a substantial component
Burkina Faso and Eritrea, the highest costs ($39,419 and (23% to 67%) of the total IDSR cost. When evaluating

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Table 4: Mean annual costs* of IDSR strategy in comparison to all disease surveillance† systems in Burkina Faso, Mali, and Eritrea

Country Health structure level All health-related surveillance IDSR IDSR as % of all health-related surveillance

Burkina Faso¶
Region 137,566 35,899 26.1
(18,231) (4,746) (5.51)
District 51,296 10,790 21.0
(4,388) (1,714) (2.40)
Primary 5,196 1,240 23.9
(965) (161) (2.92)
Mali
Region 111,584 39,573 35.5
(23,116) (8,977) (2.62)
District 51,354 13,941 27.1
(27,864) (5,892) (2.91)
Primary health care center 5,851 1,181 20.2
(1,699) (780) (7.90)
Eritrea
Province 205,333 69,920 34.1
(29,914) (24,386) (9.4)
District 28,220 11,985 42.5
(4 411) (2547) (2.8)

*All costs were converted to 2002 US dollar equivalent. Values in parenthesis are standard deviation from the means (2002 – 2005) of 4 health
regions, 14 districts and 20 primary health care centers in Burkina Faso, 3 regions, 3 districts and 3 primary health care centers in Mali, and 1
province and 1 district in Eritrea.
† All health-related surveillance involves all communicable and non-communicable diseases and health risk factors, including the IDSR targeted
diseases and conditions listed in Additional file 1, appendix 1.
¶In Burkina Faso, total costs included costs extrapolated from the average per capita costs of laboratory and treatment costs for Eritrea and Mali
(see Table 2). Without the laboratory and treatment costs, the mean annual all disease surveillance and IDSR program costs were 54,327 and
18,476, 31,147 and 6,594, and 4,316 and 1,056 per region, district, and primary health care center level, respectively.

costs allocation at district level, detection of cases cost to 40% of the total HRS costs in all three countries. The
21% to 40% of total IDSR costs, while outbreak investiga- per capita costs spent on all IDSR activities represented
tion and verification accounted for only 2% to 18% of 3.2% (in the case of Eritrea) or less (in the case of Burkina
total IDSR cost. However, primary health care centers Faso and Mali) of the total per capita government health
spent 8% to 67% of the total IDSR resources on detection budget.
and treatment of disease cases.
Discussion
The mean cost in Eritrea for an integrated surveillance sys- IDSR attempts to integrate multiple, competing vertical
tem per capita was $0.16, which was 4 and 8 times larger systems in order to use surveillance and response-related
than the $0.04 and $0.02 per capita recorded in Burkina resources more efficiently and reduce duplication of
Faso and Mali, respectively (Table 6). When we estimated effort, especially at district and primary health care center
costs using PPP, the mean cost per capita of IDSR for Erit- levels [20,21]. In this study, we measured the incremental
rea was $0.87 and $0.06 for Mali (14 times larger). Erit- costs of setting-up and implementing an integrated sur-
rea's higher costs were possibly tied to post-war rebuilding veillance and response strategy in Burkina Faso, Eritrea
of the national infrastructure, including the health system and Mali. In each country, the cost of IDSR was dependent
(see Additional file 1, appendix 5 for detailed IDSR on the health structure level. The district and primary
budget in Eritrea). In Burkina Faso, we did not collect lab- health care center levels had much lower costs, as they
oratory and treatment data. Instead, we extrapolated the usually had only lower cadre health workers and disease
costs from average annual cost of laboratory supplies and surveillance officers to provide services. A full understand-
treatment for Eritrea and Mali. Without the laboratory ing of the between-country differences in per capita costs
and treatment costs, the mean annual per capita cost of of IDSR will require further study. As shown when we
IDSR in Burkina Faso and Mali was $0.02 compared to used PPP to convert local costs into US dollars, difference
$0.13 in Eritrea. Using annual population estimates exchange rates may alter the degree of differences between
(Table 2) and the average per capita costs (Table 6), we countries.
estimated that the total annual national integrated surveil-
lance program cost $476,208 in Burkina Faso, $690,957 The study's main limitation is the potential inaccuracy
in Eritrea and $270,360 in Mali. These accounted for 24% when we apportioned total cumulative surveillance activ-

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Total
Figure 2 cost per region and district in Burkina Faso†, Mali and Eritrea
IDSR
Total IDSR cost per region and district in Burkina Faso†, Mali and Eritrea. †In Burkina Faso, total annual IDSR costs
included costs extrapolated from the average per capita costs of laboratory and treatment for Eritrea and Mali.

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Table 5: Mean annual costs (standard deviation) by IDSR activity* per health structure levels in Burkina Faso, Eritrea and Mali: 2002 –
2005

Country Health structure Surveillance activities Response activities Support activities

Detection Report Analysis Feedback Investigation§ Treatment Evaluation Others†

Burkina Faso¶ Region 3,257 5,158 2,611 2,410 7,647 12,391 2,161 265
(648) (1,567) (791) (784) (1,216) (1,331) (420) (85)
District 2,248 1,485 821 601 1,971 2,924 721 143
(917) (417) (271) (142) (351) (309) (46) (60)
Primary health care center 305 238 146 130 164 129 57 69
(47) (12) (64) (16) (14) (14) (37) (71)

Eritrea Central 120,260 52,510 17,536 14,539 54,804 178,760 29,998 40,844
(33,084) (26,766) (8,013) (4,660) (6,442) (50,404) (11,216) (17,325)
Province 15,323 17,081 5,953 2,901 7,427 10,137 2,402 8,697
(8,064) (6,739) (2,596) (1,035) (3,507) (2,670) (629) (2,842)
District 3,702 2,495 1,225 542 1,059 1,660 40 1,263
(721) (671) (171) (52) (206) (269) (4) (742)

Mali Region 441 3,989 1,557 2,736 3,877 12,430 515 16,348
(180) (2,183) (216) (815) (216) (2,961) (520) (4,791)
District 5,629 1,268 723 395 334 4,002 212 1,378
(1,940) (456) (861) (171) (70) (2,077) (160) (648)
Primary health care center 98 57 1 0 7 794 0 224
77 (58) (1) (0) (14) (573) (0) (109)

* Costs per IDSR activity were converted to 2002 US dollar equivalent. To calculate the cost of each resource per IDSR activity, we multiplied the
estimated total IDSR cost of that resource by the proportion of personnel time (or actual amount of resource) allocated to that activity relative to
all IDSR activities.
§ Investigation, verification and laboratory confirmation of suspected cases.
† Other support activities include training, supervision, communication and coordination.
¶Laboratory and treatment costs in Burkina Faso were extrapolated from the average annual per capita costs of laboratory and treatment for
Eritrea and Mali and the average population per health structure level in Burkina Faso (see Table 2)

ities cost (e.g., personnel time and building, equipment mate of IDSR cost based on 4-year data may be higher
and vehicle use-time) to IDSR-specific activities. Log than when a longer term perspective is taken due to non-
books of time and expenses did not provide the level of recurring start up costs. Absolute difference in cost per
details needed to accurately divide out costs between capita will depend upon the exchange rates used.
IDSR and other surveillance and public health activities.
As explained, we used the proportion of personnel time This study focused only the cost of resources accrued to
given to IDSR to proportion other costs. Furthermore, our IDSR activities and not the impact on the indicators used
retrospective survey may not have fully captured all costs by the countries to monitor and evaluate their progress
due to the limitations of data records (e.g., no personnel with their IDSR activities. In Eritrea, for example, the com-
time keeping records and the usual recall bias) in these pleteness of reporting case-based data from the health
countries. It is also possible that our data collection meth- care center to the next high level increased from 50% in
ods missed some surveillance-related expenditures. This is 2000 to 93% by the end of 2003. In Burkina Faso, the
because, in Africa, donors often support specific public timeliness of surveillance reporting, especially data on
health projects (such as surveillance for a specific disease) epidemic-prone diseases, increased from 71% in 2000 to
that run parallel to the national public health system. 99% by the end of 2004. Although Mali had also achieved
Such projects often have a distinct identity (i.e., names the 80% target for these progress indicators, the transmis-
and logos), and may even have staff paid directly by sion of complete data on time (83%) in 2005 was lower
donor funds. Public health staff may not consider such than that in Burkina Faso and Eritrea.
projects part of the general public health system when
enumerating costs associated with surveillance and IDSR. There are few studies on the costs of disease surveillance,
Another limitation of this study is the reliance on expend- and those are often not directly comparable to our study
iture data, which may be weakened by over- and under- [16,24]. For example, John et al. (1998) measured the cost
estimation and incomplete recording and do not reflect of emerging childhood vaccine-preventable diseases in
the whole economic cost. Further, indirect costs and pro- India [16]. They found surveillance cost $0.01 per capita
ductivity losses were not incorporated. Moreover, our esti- (1998 US $), which is approximately equal to the costs we

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Table 6: Mean annual per capita disease surveillance* and total health care costs (standard deviation): Burkina Faso, Eritrea, and Mali

Country IDSR strategy All health-related National expenditure on health‡

surveillance

Surveillance Response Support Total IDSR† Total Government

activities# activities¶ activities§ expenditure only

Per capita cost (2002 US $)

Burkina Faso 0.014 0.020 0.002 0.036 0.136 15.86 6.86
(0.004) (0.001) (0.0004) (0.005) (0.023) (3.93) (2.27)

Eritrea 0.086 0.049 0.021 0.157 0.66 8.14 4.86

(0.034) (0.023) (0.008) (0.041) (0.44) (0.69) (0.90)

Mali 0.005 0.008 0.007 0.020 0.05 13.60 7.00

(0.001) (0.0003) (0.004) (0.008) (0.01) (3.21) (2.34)

* Cost per capita was calculated using the annual population size and all health-related (i.e., all communicable and non-communicable diseases and
risk conditions) surveillance and IDSR costs for each health region/province and district included in the study in each country from 2000 to 2005.
Total number of regions and districts surveyed each year in Burkina Faso, Mali and Eritrea was 18, 6 and 2, respectively.
# Surveillance activities include detection, report, analysis and feedback
¶Response activities include field investigation and laboratory confirmation of suspected cases and treatment of confirmed cases. In Burkina Faso,
laboratory and treatment costs were calculated using the average annual per capita costs of laboratory and treatment for Eritrea and Mali and the
population size of the health structure in Burkina Faso (see Table 2). Without laboratory and treatment costs, the annual costs (std. dev) per capita
of IDSR and total national disease surveillance were $0.019 (0.005) and $0.055 (0.013), respectively.
§Support activities include training, supervision, evaluation, communication and coordination.
† Costs shown were converted using official exchange rate. When costs were converted using the purchasing parity power (PPP), the mean cost
for Eritrea was $0.87 (0.34) and for Mali $0.06 (0.03).
‡ Source: National Health Accounts http://www.who.int/nha/en/

measured in Burkina Faso and Mali (Table 6). However, Additional material
the program in India only included childhood vaccine-
preventable diseases, while the IDSR system includes not
only childhood and adult vaccine-preventable diseases
Additional file 1
Appendix _ Cost Analysis of IDSR. Appendix 1. List of IDSR priority dis-
but also epidemic-prone diseases and endemic epidemics eases and diseases of public health importance weekly or monthly reported
such as HIV/AIDS, malaria, TB, childhood diarrhea and in Burkina, Eritrea, and Mali during the study period. Appendix 2. The
acute respiratory infections. We can, therefore, consider following table includes the IDSR functions (Identify, Report, Analyze,
IDSR a low cost public health system although the bene- Investigate, Respond, Feedback, Evaluate, etc.) and the general categories
fits, such as cases prevented, due to the IDSR program of implementation inputs (Personnel, Transport, Office Supplies, Public
awareness Campaign, laboratory and treatment supplies, and Capital
have yet to be quantified.
items). The table provides a few examples of specific costs related to the
function and inputs. Many cells are left blank to illustrate that each coun-
Competing interests try and health structure level (Central, Province/Region, district, and pri-
The authors declare that they have no competing interests. mary health center) will have different demands for costs. Appendix 3.
Total annual cost (2002 US dollar equivalent) by year of each category of
Authors' contributions resources allocated for all disease surveillance † and IDSR-only activities
in Burkina Faso, Eritrea, and Mali. Appendix 4. Mean annual costs (in
ZCS, MIM, HNP conceived, carried out the study, ana-
2002 US $) by year per IDSR-only activities in Burkina Faso, Eritrea, and
lyzed the data, and drafted the manuscript. UA, MS, KT, Mali. Appendix 5. Budget allocated for IDSR implementation by year and
and SOK each participated in the organization and coor- estimated annual cost of national IDSR activities in Eritrea.
dination of the field data collection. NRM, TO, WA and IS Click here for file
participated in the design and coordination of the study. [http://www.biomedcentral.com/content/supplementary/1478-
All authors read and approved the final manuscript. 7547-7-1-S1.xls]

Acknowledgements
This research was supported by the Centers for Disease Control and Pre-
vention with funding from USAID Global Surveillance and Africa Bureaus.
The findings and conclusions in this report are those of the authors and do
not necessarily represent the views of the Centers for Disease Control and

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Cost Effectiveness and Resource Allocation 2009, 7:1 http://www.resource-allocation.com/content/7/1/1

Prevention (CDC), the World Health Organization Africa region (WHO- 16. John TJ, Samuel , Balraj V, John R: Disease surveillance at district
AFRO), and the Ministry of Health of Burkina Faso, Eritrea and Mali. level: a model for developing countries. Lancet 1998,
352:58-61.
17. Thacker SB: Surveillance. In Field Epidemiology 2nd edition. Edited
We wish to thank our colleagues on the integrated disease surveillance and by: Gregg MB. New York: Oxford University Press; 2002:26-50.
response teams at the WHO Regional Office for Africa, the WHO head- 18. World Health Organization, Regional Office for Africa: Integrated
quarters, and the Centers for Disease Control and Prevention for their Disease Surveillance and Response: A Regional Strategy for
review and comments during the development and implementation of the Communicable Diseases 1999 – 2003 (AFR/RC/48.8). Harare
1999 [http://www.afro.who.int/csr/ids/publications/ids.pdf].
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20. World Health Organization, Regional Office for Africa: Technical
tionally, we thank the WHO country representatives and the Disease Sur- Guidelines for Integrated Disease Surveillance and Response
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cooperation in providing information as well as for their effort and dedica- 21. Perry NH, McDonnell MS, Alemu W, Nsubuga P, Chungong S, Otten
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