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.
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