The Costs and Cost-effectiveness of Tuberculosis Control (UvA Proefschriften)

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Today Social Democratic parties were Democracy grounded? Reasonably think sell, dozens students carrying signs reading End Hate Now. The costs and cost-effectiveness of tuberculosis control Academisch Proefschrift ter verkrijging van de graad van doctor aan de Universiteit van Amsterdam op gezag van de Rector Magnificus prof. Van der Gaag Co-promotor: Prof. Borgdorff Overige leden: Prof. Rutten Prof. Rinke de Wit Prof. Kager Prof. Pradhan Prof.


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My special thanks are extended to all my colleagues and friends who supported me during this thesis. My special thanks goes to my family, in particular my husband Jan-Paul Wagenaar. This strategy has been proven to be highly effective and cost-effective in low income settings 1. Finally, TB control faces a significant challenge in trying to reach the poorest of the poor, a group that is highly susceptible to TB.


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Although these challenges are consid- erable, there are opportunities ahead. Developments in health systems and new diagnostic tools, drugs and vaccines all have an important contribution to make to the effectiveness of TB control in the future. Improving the evidence base on the economic and financial aspects of TB con- trol can contribute towards TB control in the following ways: Firstly, economic analysis can be used to justify domestic and international investment in TB control.

If TB control is to meet the challenges it faces it will require both innovative approaches and increased resources. Economic analysis provides policy-makers and planners with a clear framework to justify invest- ment in TB control compared to investment in other areas. In particular, it can be used to justify the use of public finances for TB control by assessing market failure and identifying efficiency gains.

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It is particularly useful in low income countries where the burden of TB is the high- est, but resource constraints most severe. Through the assessment of the potential markets and cost-effectiveness of new prevention, diagnostic and treatment technologies, economic analysis can support investment in the devel- opment of new technologies to control TB. Thirdly, financial and economic analyses have a role to play in supporting TB policy makers, planners and managers identify, plan and channel financial resources to and within TB control programmes.

Economic analysis provides a framework to examine the resource gaps which exist, estimate the resource requirements of filling them and to develop the most efficient ways to finance them. The development and use of improved tools for the estimating resource requirements and the financial planning of TB control are essential to support the successful implementation of TB control programmes.

This thesis aims to contribute towards this effort by improving the evidence base on the costs and cost-effectiveness of a variety of TB control interventions. This summary contains a detailed examination of the evidence establishing the cost-effectiveness of different elements of DOTS compared to their alternatives. It first examines the cost-effectiveness of different methods of case detection and evidence of the relative cost-effectiveness of passive approaches.

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It moves on to look at the cost-effectiveness of different ways of diagnosing TB and in particular the evidence that established the cost-effectiveness of smear micro- scopy. Finally, evidence of the cost-effectiveness of short course standardised therapy and improving treatment compliance are examined. The main source of data for the estimates used in the WDR is a study of the cost-effectiveness of TB control conducted in Malawi, Tanzania and Mozambique in 3.

This study clearly demonstrates that in all three countries TB control is a cost-effective intervention. One of the main reasons for this finding is that, although TB treatment is often thought to be a curative intervention, its main benefit is preventative and therefore compares favorably against most other interventions, despite the relative expense and long course of treatment.

There are several studies that focus on measuring the gains in cost-effectiveness made from moving from existing systems of TB control to DOTS. This type of study often supports the re-orientation of substantial TB infrastructure away from hospitalisation towards integrated ambulatory care. A study from South Africa 4 finds that cure rates rose substantially when TB treatment was pro- vided through twice weekly ambulatory care with a week initial stay in hos- pital, compared to hospitalisation for the whole course of treatment, making it substantially more cost-effective.

Furthermore a study from Uganda, also shows that the cost-effectiveness of TB control is likely to increase as patients are moved from hospitalised care to ambulatory DOT 5. In recent years, this issue has become increasing relevant in middle income set- tings, where a TB control infrastructure is well established, but TB remains a threat.

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Cost-effectiveness studies can demonstrate the economic gains of adopt- ing DOTS to policy makers who may be reluctant to apply evidence solely from low-income settings. For example, studies from Russia show that moving from a TB control strategy based on active case detection and individual hospi- talised treatment to one based on passive case finding and ambulatory short course therapy significantly improves cost-effectiveness 6,7. Nevertheless more examples are still required to demonstrate that DOTS is cost-effective in middle-income countries. Elements of DOTS Whilst the DOTS strategy overall is seen as being cost-effective, different ele- ments of the strategy have also been subjected to economic evaluation, in order to inform its design.

The alternative, active case detection, involves screening populations using chest X-ray, or by survey- ing respiratory symptoms. There are no recent cost-effectiveness studies in low-income countries. However, one of the studies from Russia, which has a history of using active case detection, shows that it is less cost-effective 7. The cost of a case detected through active methods is estimated to be up to five or six times the cost of a passively detected case.

In addition the conclu- sion that passive finding is more cost-effective than active case finding is intui- tive, given the widespread experience that improvements in diagnostic services lead to substantial increases in the notification of TB cases, but have a consid- erably lower cost than providing screening detection. Sputum—positive TB is highly symptomatic and surveys show that high proportions of patients seek care relatively quickly if high quality and low cost diagnostic and treatment ser- vices are available. In addition, clinical TB develops quicker than the shortest possible screening intervals, and therefore screening does not always detect cases before they become infectious.

The finding that passive case detection is more cost-effective than active screening does not mean that active screening should not be provided. It only implies that passive screening should be established first. In some circum- stances active screening for TB may still be cost-effective compared to other health interventions. At the current time, case detection methods are coming under renewed scrutiny as, despite the fact that some countries have good laboratory services, high DOTS coverage and cure rates, many of them still have low case detection rates.

In these circumstances, where capacity has been developed to provide effective passive case detection, it may be cost-effective to pursue active case detection 8. The evidence supporting this is currently based on modeling and is controversial given the high costs of screening and the fact that there are no studies that demonstrate either the cost or effective- ness of active case detection in a field setting in low-income countries. However, these models suggest that active screening may be cost-effective as an extension to DOTS for population groups where TB incidence is suspected to be high.

As an intermediate approach to boost case detection, information, education and communication IEC is considered as an integral part of DOTS. In coun- tries, which have low case detection rates together with high cure rates, signifi- cant investment in IEC may also be highly cost-effective. IEC can take many forms, from a doctor providing a patient with appropriate information on how TB is transmitted, to mass media campaigns.

However, there are no studies either on the overall cost effectiveness of IEC for TB or the cost-effectiveness of General Introduction 13 different methods. Unfortunately, it is also difficult to make estimates of cost- effectiveness based on IEC from other areas of health, as there is little evidence on the cost-effectiveness of IEC generally.

This is because the effects of IEC have proven difficult to measure and attribute.