Cost and cost-effectiveness of community based and health facility based directly observed treatment of tuberculosis in Dar es Salaam, Tanzania

Abstract

BackgroundIdentifying new approaches to tuberculosis treatment that are effective and put less demand to meagre health resources is important. One such approach is community based direct observed treatment (DOT). The purpose of the study was to determine the cost and cost effectiveness of health facility and community based directly observed treatment of tuberculosis in an urban setting in Tanzania.MethodsTwo alternative strategies were compared: health facility based directly observed treatment by health personnel and community based directly observed treatment by treatment supervisors. Costs were analysed from the perspective of health services, patients and community in the year 2002 in US $ using standard methods. Treatment outcomes were obtained from a randomised-controlled trial which was conducted alongside the cost study. Smear positive, smear negative and extra-pulmonary TB patients were included. Cost-effectiveness was calculated as the cost per patient successfully treated.ResultsThe total cost of treating a patient with conventional health facility based DOT and community based DOT were $ 145 and $ 94 respectively. Community based DOT reduced cost by 35%. Cost fell by 27% for health services and 72% for patients. When smear positive and smear negative patients were considered separately, community DOT was associated with 45% and 19% reduction of the costs respectively. Patients used about $ 43 to follow their medication to health facility which is equivalent to their monthly income. Indirect costs were as important as direct costs, contributing to about 49% of the total patient's cost. The main reason for reduced cost was fewer number of visits to the TB clinic. Community based DOT was more cost-effective at $ 128 per patient successfully treated compared to $ 203 for a patient successfully treated with health facility based DOT.ConclusionCommunity based DOT presents an economically attractive option to complement health facility based DOT. This is particularly important in settings where TB clinics are working beyond capacity under limited resources.

Resource utilization pattern and cost of tuberculosis treatment from the provider and patient perspectives in the state of Penang, Malaysia

“…These results are somewhat comparable to the findings of similar studies published elsewhere [10, 13]. However, a few studies from developing and developed countries showed that the cost of TB medicines ranged from 4.7–63.8% of the total cost of TB management [6, 9–11, 14, 32]. Differences in cost accounting methods, characteristics of study population and variability in the unit cost of TB medicines are some of the factors that could explain inconsistency in the findings of various studies.…”

“…In contrast, a Haitian study reported 75 DOT visits per patient [32]. Along the same lines, studies from Tanzania and Tajikistan mentioned fewer than 80 DOT visits per patient [11, 12]. Nonetheless, these differences in DOT visits might be associated with difference in treatment strategies (i.e., daily dose vs. twice-weekly dose, DOT at clinic vs. weekly packing of the daily dose) employed at these settings.…”

“…Cost and cost-effectiveness studies from Tanzania, Uganda and South Africa emphasized the importance of implementing community-based TB care [9–11]. A systematic review which compared self-administered therapy with DOT concluded that DOT did not improve the outcomes [35].…”

“…Recently, a study from Western Asia showed that the average cost of treating a PTB patient was USD 142.40, in which patient costs constituted 76.1% of the total cost [14]. In 2005, a Tanzania study reported that on an average USD 145.00 were required to treat an episode of TB, whereby the provider costs constituted 70.3% of the total cost [11]. Another study from Africa showed that an average of USD 703.00 was required to treat a PTB patient [10].…”

Cost and cost-effectiveness of tuberculosis treatment shortening: a model-based analysis

“…GuidelinesHealthcare provider costs First-line treatment, IP, 1mo (excl drugs)200 (152–230)333 (117–479)17 (12–21)65 (24–106)[16, 18, 19] First-line treatment, CP, 1mo (excl drugs)54 (41–62)333 (117–479)11 (7–15)16 (7–24)[16, 18, 19] Drugs, first-line, IP, 1mo167 (6–9)7 (6–8)6[16, 18–20] Drugs, first-line, CP, 1mo194 (3–6)3 (3–3)2[16, 18–20] Retreatment: alln/an/a213 (160–266)430 (310–549)[16, 18, 19] MDR treatment: all10,215 (8,619–24,580)5,223 (4,800–5,348)4,262 (3,836–4,688)2,507 (2,454–2,561)[16, 18, 19] ART cost in year 11,128 (1,117–1,139)5,875 (5,288–6,463) a 800 (720–880)315 (283–346)[21, 22, 49–52] ART cost per year (after year 1)639 (575–703)600 (540–660)277 (249–304)[21, 22, 49–52]Patient costs First-line treatment, IP, 1mo149 (87–164)40 (8–131)314 (283–346)186 (167–204)[3, 16, 17] First-line treatment, CP, 1mo117 (34–129)40 (8–131)31 (28–34)44 (40–48)[3, 16, 17] Retreatment: alln/an/a135 (121–148)354 (319–390)[3, 16, 17] MDR treatment: all3,319 (2,987–3,650)…”