PurposeEstimating the incremental costs of scaling‐up novel technologies in low‐income and middle‐income countries is a methodologically challenging and substantial empirical undertaking, in the absence of routine cost data collection. We demonstrate a best practice pragmatic approach to estimate the incremental costs of new technologies in low‐income and middle‐income countries, using the example of costing the scale‐up of Xpert Mycobacterium tuberculosis (MTB)/resistance to riframpicin (RIF) in South Africa.Materials and methodsWe estimate costs, by applying two distinct approaches of bottom‐up and top‐down costing, together with an assessment of processes and capacity.ResultsThe unit costs measured using the different methods of bottom‐up and top‐down costing, respectively, are $US16.9 and $US33.5 for Xpert MTB/RIF, and $US6.3 and $US8.5 for microscopy. The incremental cost of Xpert MTB/RIF is estimated to be between $US14.7 and $US17.7. While the average cost of Xpert MTB/RIF was higher than previous studies using standard methods, the incremental cost of Xpert MTB/RIF was found to be lower.ConclusionCosts estimates are highly dependent on the method used, so an approach, which clearly identifies resource‐use data collected from a bottom‐up or top‐down perspective, together with capacity measurement, is recommended as a pragmatic approach to capture true incremental cost where routine cost data are scarce.

SummaryBackgroundIn 2010 a new diagnostic test for tuberculosis, Xpert MTB/RIF, received a conditional programmatic recommendation from WHO. Several model-based economic evaluations predicted that Xpert would be cost-effective across sub-Saharan Africa. We investigated the cost-effectiveness of Xpert in the real world during national roll-out in South Africa.MethodsFor this real-world cost analysis and economic evaluation, we applied extensive primary cost and patient event data from the XTEND study, a pragmatic trial examining Xpert introduction for people investigated for tuberculosis in 40 primary health facilities (20 clusters) in South Africa enrolled between June 8, and Nov 16, 2012, to estimate the costs and cost per disability-adjusted life-year averted of introducing Xpert as the initial diagnostic test for tuberculosis, compared with sputum smear microscopy (the standard of care).FindingsThe mean total cost per study participant for tuberculosis investigation and treatment was US$312·58 (95% CI 252·46–372·70) in the Xpert group and $298·58 (246·35–350·82) in the microscopy group. The mean health service (provider) cost per study participant was $168·79 (149·16–188·42) for the Xpert group and $160·46 (143·24–177·68) for the microscopy group of the study. Considering uncertainty in both cost and effect using a wide range of willingness to pay thresholds, we found less than 3% probability that Xpert introduction improved the cost-effectiveness of tuberculosis diagnostics.InterpretationAfter analysing extensive primary data collection during roll-out, we found that Xpert introduction in South Africa was cost-neutral, but found no evidence that Xpert improved the cost-effectiveness of tuberculosis diagnosis. Our study highlights the importance of considering implementation constraints, when predicting and evaluating the cost-effectiveness of new tuberculosis diagnostics in South Africa.FundingBill & Melinda Gates Foundation.

Summary Setting South Africa is one of the world’s 22 high tuberculosis (TB) burden countries, with the second highest number of notified rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB) cases. Objective To estimate patient costs associated with the diagnosis and treatment of RR-TB/MDR-TB in South Africa. Design Patients diagnosed with RR-TB/MDR-TB and accessing care at government health care facilities were surveyed using a structured questionnaire. Direct and indirect costs associated with accessing RR-TB/MDR-TB care were estimated at different treatment durations for each patient. Results A total of 134 patients were surveyed: 84 in the intensive phase and 50 in the continuation phase of treatment, 82 in-patients and 52 out-patients. The mean monthly patient costs associated with the diagnosis and treatment of RR-TB/MDR-TB were higher during the intensive phase than the continuation phase (US$235 vs. US$188) and among in-patients than among out-patients (US$269 vs. US$122). Patients in the continuation phase and those accessing care as out-patients reported higher out-of-pocket costs than other patients. Most patients did not access social protection for costs associated with RR-TB/MDR-TB illness. Conclusion Despite free health care, patients bear high costs when accessing diagnosis and treatment services for RR-TB/MDR-TB; appropriate social protection mechanisms should be provided to assist them in coping with these costs.

SUMMARYSETTING-The cost of multidrug-resistant tuberculosis (MDR-TB) treatment is a major barrier to treatment scale-up in South Africa.OBJECTIVE-To estimate and compare the cost of treatment for rifampicin-resistant tuberculosis (RR-TB) in South Africa in different models of care in different settings. DESIGN-We estimated the costs of different models of care with varying levels of hospitalisation. These costs were used to calculate the total cost of treating all diagnosed cases of RR-TB in South Africa, and to estimate the budget impact of adopting a fully or partially decentralised model vs. a fully hospitalised model. RESULTS-The fully hospitalised model was 42% more costly than the fully decentralised model (US$13 432 vs. US$7753 per patient). A much shorter hospital stay in the decentralised models of care (44-57 days), compared to 128 days of hospitalisation in the fully hospitalised model, was the key contributor to the reduced cost of treatment. The annual total cost of treating all diagnosed cases ranged from US$110 million in the fully decentralised model to US$190 million in the fully hospitalised model. The World Health Organization recommends ambulatory models of care for drug-resistant anti-tuberculosis treatment over hospital-based models. 4 Before 2010, MDR-TB treatment was primarily centralised in specialist TB hospitals with mandatory in-patient admission. In 2011, faced with long waiting lists for admission and treatment initiation, the National Department of Health revised their policy to support the decentralisation of MDR-TB treatment. 5 The revised policy removes the requirement to initiate treatment in hospital, but still suggests that sputum smear-positive patients be hospitalised. While the extent to which this policy has been implemented across South Africa's provinces varies, the treatment gap for MDR-TB remains and may be increasing as case detection improves with Xpert. 6 Previous studies in South Africa have estimated the cost of a centralised MDR-TB model of care. 2,7 However, there is limited evidence on the impact of introducing a decentralised model of care on both the episode costs and the overall budget. Decentralisation of MDR-TB treatment is likely to be less costly than a fully hospitalised model, and can therefore potentially improve the capacity to scale up treatment for all diagnosed cases. We aimed to estimate the costs of treatment for RR-TB in South Africa across a range of models of care, based on the cost of treatment from a decentralised programme in Cape Town. 8 We also estimated the likely budget impact of introducing decentralised MDR-TB treatment across South Africa. Province. This model of care permits initiation of treatment for RR-TB at primary health care clinics, provided the patient is sufficiently clinically stable to initiate MDR-TB treatment. 9 The programme is associated with improved case detection and treatment initiation and results in treatment outcomes comparable to those seen in centralised specialist centres. 8 Europe PMC Funders Group ME...

Basic education in South Africa faces a crisis as learners fail to achieve the necessary outcomes in the related areas of language and literacy. The aims of this paper are twofold. Firstly, we aim to describe and discuss the education crisis by outlining the educational landscape, relevant policy imperatives and implementation challenges in post-apartheid education. The systemic factors contributing to the literacy crisis are emphasised. Secondly, we argue that speech language therapists and audiologists (SLTAs) have a role to play in supporting basic education in South Africa through developing language and literacy. It is suggested that the professions of speech-language pathology and audiology must be socially responsive and population-focused in order to make meaningful contributions to development in South Africa. The potential roles of SLTAs are discussed with suggestions for further actions required by the professions to enable a contextually relevant practice in a resource-constrained environment.

BackgroundThere has been some debate in the past as to who should determine values for different health states for economic evaluation. The aim of this study was to compare the Health Related Quality of Life (HRQoL) in children attending open schools (OS) and children with disabilities attending a special school (SS) and their parents in Cape Town South Africa.MethodsThe EQ-5D-Y and a proxy version were administered to the children and their parents were requested to fill in the EQ-5D-Y proxy version without consultation with their children on the same day.ResultsA response rate of over 20% resulted in 567 sets of child/adult responses from OS children and 61 responses from SS children. Children with special needs reported more problems in the "Mobility" and "Looking after myself" domains but their scores with regard to "Doing usual activities", "Pain or discomfort" and "Worried, sad or unhappy" were similar to their typically developing counterparts. The mean Visual Analogue Scale (VAS) score of SS children was (88.4, SD18.3, range 40-100) which was not different to the mean score of the OS respondents (87.9, SD16.5, range 5-100).The association between adult and child scores was fair to moderate in the domains. The correlations in VAS scores between Open Schools children and female care-givers' scores significant but low (r = .33, p < .001) and insignificant between Special School children and adult (r = .16, p = .24).DiscussionIt would appear that children with disabilities do not perceive their HRQoL to be worse than their able bodied counterparts, although they do recognise their limitations in the domains of "Mobility" and "Doing usual activities".ConclusionsThis finding lends weight to the argument that valuation of health states by children affected by these health states should not be included for the purpose of economic analysis as the child's resilience might result in better values for health states and possibly a correspondingly smaller resource allocation. Conversely, if HRQoL is to be used as a clinical outcome, then it is preferable to include the children's values as proxy report does not appear to be highly correlated with the child's own perceptions.

Background and aims: Very young children have a relatively high prevalence of morbidity and mortality. Health care and supportive technology has improved but may require difficult choices and decisions regarding the allocation of these resources in this age group. Cost-effective analysis (CEA) can inform these decisions and thus measurement of Health-Related Quality of Life (HRQoL) is becoming increasingly important. However, the components of HRQoL are likely to be specific to infants and young children. This study aimed to develop a bank of items to inform the possible development of a new proxy report instrument. Methods: A review of the literature was done to define the concepts, generate items and identify measures that might be an appropriate starting point of reference. The items generated from the cognitive interviews and systematic review were subsequently pruned by experts in the field of HRQoL and paediatrics over two rounds of a Delphi study. Results: Based on the input from the different sources, the greatest need for a new HRQoL measure was in the 0-3year age group. The item pool identified from the literature consisted of 36 items which was increased to 53 items after the cognitive interviews. The ranking of items from the first round of the Delphi study pruned this pool to 28 items for consideration. The experts further reduced this pool to 15 items for consideration in the second round. The experts also recommended that items could be merged due to their similar nature or construct. This process allowed for further reduction of items to 11 items which showed content validity and no redundancy. Conclusion: The need for an instrument to measure appropriate aspects of HRQoL in infants and young children became apparent as items included in existing measures did not cover the required spectrum. The identification of the final items was based on a sound conceptual model, acceptability to stakeholders and consideration of the observability of the item selected. The pruned item bank of 11 items needs to be subject to further testing with the target population to ensure validity and reliability before a new measure can be developed.

SummaryObjectivesThe high cost of rifampicin‐resistant tuberculosis (RR‐TB) treatment hinders treatment access. South Africa has a high RR‐TB burden, and national policy outlines decentralisation to improve access and reduce costs. We analysed health system costs associated with RR‐TB treatment by drug resistance profile and treatment outcome in a decentralised programme.MethodsRetrospective, routinely collected patient‐level data were combined with unit cost data to determine costs for each patient in a cohort treated between January 2009 and December 2011. Drug costs were based on recommended regimens according to drug resistance and treatment duration. Hospitalisation costs were estimated based on admission/discharge dates, while clinic visit and diagnostic/monitoring costs were estimated according to recommendations and treatment duration. Missing data were imputed.ResultsAmong 467 patients (72% HIV infected), 49% were successfully treated. Treatment was initiated in primary care for 62%, with the remainder as inpatients. The mean cost per patient treated was $7916 (range 260–87 140), ranging from $5369 among patients who did not complete treatment to $23 006 for treatment failure. Mean cost for successful treatment was $8359 (2585–32 506). Second‐line drug resistance was associated with a mean cost of $15 567 vs. $6852 for only first‐line resistance, with the major cost difference due to hospitalisation. Costs are reported in 2013 USD.Conclusions RR‐TB treatment cost was high and varied according to treatment outcome. Despite decentralisation, hospitalisation remained a significant cost, particularly among those with more extensive resistance and those with treatment failure. These cost estimates can be used to model the impact of new interventions to improve patient outcomes.