Cost analysis of integrating depression treatment into chronic care in Malawi: evidence from a cluster randomised controlled trial.

OBJECTIVE

To quantify the costs associated with a stepped model of depression care-Integrated Chronic Care Clinics-Depression Module (IC3D)-in rural Malawi.

DESIGN

Cross-sectional cost analysis.

SETTING

Integrated chronic care clinics (n=14) throughout Neno District, Malawi.

INTERVENTIONS: The stepped model of depression care provided behavioural therapy (Problem Management Plus (PM+)) to adults (aged 18+) with moderate depression and joint PM+ and antidepressant therapy (ADT) to those with moderate-to-severe and severe depression. The model incorporated two cost-saving features: treatment was integrated into existing chronic care services within the health system, and PM+ was group-based rather than one-on-one.

PRIMARY AND SECONDARY OUTCOME MEASURES: We conducted time-driven activity-based costing to quantify the marginal economic cost of implementing PM+ and ADT, inclusive of training and supervision. We measured all costs in 2025 US dollars and quantified costs from a societal perspective-including human resources, infrastructure, equipment, consumables, indirect costs and opportunity costs.

RESULTS

The marginal cost of PM+ was $90 per patient treated for five sessions over 2 months, while ADT was $138 for eight sessions over 8 months. In both instances, human resources (45% from PM+, 52% for ADT) and consumables (30% for PM+, 31% for ADT) represented primary health system cost drivers. In the first year of implementation, 15 002 depression screenings were conducted, 724 adults were evaluated with a diagnostic tool and 398 adults subsequently received care: 263 received PM+ alone, 31 received ADT alone and 104 received both PM+ and ADT. The total cost of introducing operations throughout Neno District was $62 806.

CONCLUSIONS

These findings indicate that integrating depression care services into the Malawian health system is financially feasible and successfully reached many individuals with major depressive disorder.

TRIAL REGISTRATION NUMBER: NCT04777006.