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Informed decisions concerning emerging technologies against dengue require knowledge about the disease’s economic cost and each stakeholder’s potential benefits from better control. To generate such data for Indonesia, we reviewed recent literature, analyzed expenditure and utilization data from two hospitals and two primary care facilities in Yogyakarta city, and interviewed 67 dengue patients from hospital, ambulatory, and not medically attended settings. We derived the cost of a dengue episode by outcome, setting, and the breakdown by payer. We then calculated aggregate Yogyakarta and national costs and 95% uncertainty intervals (95% UIs). Dengue costs per nonfatal case in hospital, ambulatory, not medically attended, and overall average settings were US$316.24 (95% UI: $242.30–$390.18), US$22.45 (95% UI: $14.12–$30.77), US$7.48 (95% UI: $2.36–$12.60), and US$50.41 (95% UI: $35.75–$65.07), respectively. Costs of nonfatal episodes were borne by the patient’s household (37%), social contributors (relatives and friends, 20%), national health insurance (25%), and other sources (government, charity, and private insurance, 18%). After including fatal cases, the average cost per episode became $90.41 (95% UI: $72.79–$112.35). Indonesia had an estimated 7.535 (95% UI: 1.319–16.513) million dengue episodes in 2017, giving national aggregate costs of $681.26 (95% UI: $232.28–$2,371.56) million. Unlike most previous research that examined only the formal medical sector, this study included the estimated 63% of national dengue episodes that were not medically attended. Also, this study used actual costs, rather than charges, which generally understate dengue’s economic burden in public facilities. Overall, this study found that Indonesia’s aggregate cost of dengue was 73% higher than previously estimated, strengthening the need for effective control.

The provision of meals at schools is considered to have the potential to enhance human dignity and facilitate equitable access to students from low socio-economic backgrounds, low social status (including Caste) and poor households. Using students and teachers from public schools in Utter Pradesh also known to be India’s most populous and poorest state as it’s as its unit of analysis, the paper examines the impact on International Non-Governmental Organizations (INGOs) led Midday Meal (MDM) School Feeding program in India on educational access, performance, participation, and wellbeing. The study sought to evaluate the implementation of the midday meal (MDM) program led by an INGO in Lucknow, Utter Pradesh, and India to ascertain if the strategic program implementation protocols also ensure social inclusion and held address various forms of discrimination commonly reported in the literature. The study revealed that students were satisfied with most of the implementation of the program, serving and food satisfaction indicators. Nevertheless, we argue that the implantation process could benefit from a more integrated inter-agency coordination so as to address concerns regarding at-risk children and improve sanitation and health facilities that are not directly associated with the MDM program. The study concludes that INGOs led MDM programs could serve as a model for inclusive and non-discriminatory school feeding system where all children, irrespective of their social, economic, religious and family backgrounds will equally benefit with dignity. Such an approach, we argue, could also enhance social equity, youth development and the attainment of the SDG targets in India.

Background Release of virus-blocking Wolbachia-infected mosquitoes is an emerging disease control strategy that aims to control dengue and other arboviral infections. Early entomological data and modelling analyses have suggested promising outcomes, and wMel Wolbachia releases are now ongoing or planned in 12 countries. To help inform government, donor, or philanthropist decisions on scale-up beyond single city releases, we assessed this technology’s cost-effectiveness under alternative programmatic options. Methods Using costing data from existing Wolbachia releases, previous dynamic model-based estimates of Wolbachia effectiveness, and a spatially explicit model of release and surveillance requirements, we predicted the costs and effectiveness of the ongoing programme in Yogyakarta City and three new hypothetical programmes in Yogyakarta Special Autonomous Region, Jakarta, and Bali. Results We predicted Wolbachia to be a highly cost-effective intervention when deployed in high-density urban areas with gross cost-effectiveness below $1500 per DALY averted. When offsets from the health system and societal perspective were included, such programmes even became cost saving over 10-year time horizons with favourable benefit-cost ratios of 1.35 to 3.40. Sequencing Wolbachia releases over 10 years could reduce programme costs by approximately 38% compared to simultaneous releases everywhere, but also delays the benefits. Even if unexpected challenges occurred during deployment, such as emergence of resistance in the medium-term or low effective coverage, Wolbachia would remain a cost-saving intervention. Conclusions Wolbachia releases in high-density urban areas are expected to be highly cost-effective and could potentially be the first cost-saving intervention for dengue. Sites with strong public health infrastructure, fiscal capacity, and community support should be prioritised.

BackgroundRelease of virus-blocking Wolbachia infected mosquitoes is an emerging disease control strategy that aims to control dengue and other arboviral infections. Early entomological data and modelling analyses have suggested promising outcomes and wMel Wolbachia releases are now ongoing or planned in 12 countries. To help inform potential scale-up beyond single city releases, we assessed this technology’s cost-effectiveness under different programmatic options.MethodsUsing costing data from existing Wolbachia releases, previous estimates of Wolbachia effectiveness, and a spatially-explicit model of release and surveillance requirements, we predicted the costs and effectiveness of the on-going programme in Yogyakarta City and three new hypothetical programmes in Yogyakarta Special Autonomous Region, Jakarta and Bali.ResultsWe predicted Wolbachia to be a highly cost-effective intervention when deployed in high density urban areas with gross cost-effectiveness ratios below $1,500 per DALY averted. When offsets from the health system and societal perspective were included, such programmes even became cost saving over 10-year time horizons with favourable benefit-cost ratios of 1.35 to 3.40. Sequencing Wolbachia releases over ten years could reduce programme costs by approximately 38% compared to simultaneous releases everywhere, but also delays the benefits. Even if unexpected challenges occurred during deployment, such as emergence of resistance in the medium-term or low effective coverage, Wolbachia would remain a cost saving intervention.ConclusionsWolbachia releases in high density urban areas is expected to be highly cost-effective and could potentially be the first cost saving intervention for dengue. Sites with strong public health infrastructure, fiscal capacity, and community support should be prioritized.

Additional file 2. The ISPOR Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

Additional file 1. Additional information on the methods and results of the main manuscript. Includes further details on the timing of different phases in different scenarios (S1.1), cost of release data (S1.2), more detailed methods on the cost of release model and its fit (S1.3), the parameter values and rational for long-term cost reductions (S1.4), further background on specific challenges to the establishing Wolbachia and how they can be overcome (S1.5) and maps of cost effectiveness with more detailed Ordinance survey base maps (S1.6).

BackgroundWolbachia-infected mosquitoes reduce dengue virus transmission, and city-wide releases in Yogyakarta city, Indonesia, are showing promising entomological results. Accurate estimates of the burden of dengue, its spatial distribution and the potential impact ofWolbachiaare critical in guiding funder and government decisions on its future wider use.MethodsHere, we combine multiple modelling methods for burden estimation to predict national case burden disaggregated by severity and map the distribution of burden across the country using three separate data sources. An ensemble of transmission models then predicts the estimated reduction in dengue transmission following a nationwide roll-out of wMelWolbachia.ResultsWe estimate that 7.8 million (95% uncertainty interval [UI] 1.8–17.7 million) symptomatic dengue cases occurred in Indonesia in 2015 and were associated with 332,865 (UI 94,175–754,203) lost disability-adjusted life years (DALYs). The majority of dengue’s burden was due to non-severe cases that did not seek treatment or were challenging to diagnose in outpatient settings leading to substantial underreporting. Estimated burden was highly concentrated in a small number of large cities with 90% of dengue cases occurring in 15.3% of land area. Implementing a nationwideWolbachiapopulation replacement programme was estimated to avert 86.2% (UI 36.2–99.9%) of cases over a long-term average.ConclusionsThese results suggest interventions targeted to the highest burden cities can have a disproportionate impact on dengue burden. Area-wide interventions, such asWolbachia, that are deployed based on the area covered could protect people more efficiently than individual-based interventions, such as vaccines, in such dense environments.

All supplementary methods and results. (DOCX 1194 kb)

All supplementary methods and results. (DOCX 1194 kb)