Academic journal article Bulletin of the World Health Organization

Cost and Cost-Effectiveness of PPM-DOTS for Tuberculosis Control: Evidence from India/Cout et Rapport Cout/ Efficacite De la Strategie PPM-DOTS Dans la Lutte Contre la Tuberculose: Resultats Obtenus En Inde/Costo Y Costoeficacia De la DOTS-PP Contra la Tuberculosis: Datos De la India

Academic journal article Bulletin of the World Health Organization

Cost and Cost-Effectiveness of PPM-DOTS for Tuberculosis Control: Evidence from India/Cout et Rapport Cout/ Efficacite De la Strategie PPM-DOTS Dans la Lutte Contre la Tuberculose: Resultats Obtenus En Inde/Costo Y Costoeficacia De la DOTS-PP Contra la Tuberculosis: Datos De la India

Article excerpt

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Introduction

Globally, there are almost nine million new cases of tuberculosis (TB) each year, two million of which result in death. More than one-third of these cases and deaths are in India and China. (1,2)

The global targets for TB control established by the World Health Assembly (WHA) are to detect 70% of new smear-positive cases and to successfully treat 85% of all detected cases; the target year was initially 2000, and was later reset to 2005. (3,4) More recently, targets to decrease TB prevalence and deaths by 50% by 2015 (compared with 1990) have been set by the Stop TB partnership, within the framework of the Millennium Development Goals. (1)

From the mid-1990s until 2005, the internationally-recommended strategy for achievement of these TB control targets was DOTS. The DOTS strategy has five components: (i) government commitment to tuberculosis control; (ii) diagnosis by sputum smear microscopy; (iii) standardized short-course chemotherapy using first-line drugs, provided under proper case management conditions including directly observed treatment (DOT); (iv) a regular supply of free drugs; and (v) a recording and reporting system with assessment of treatment outcomes. (5) In March 2000, 20 of the 22 high-burden countries that collectively account for 80% of global cases committed to achieving the WHA targets through implementation of the DOTS strategy, (6) and DOTS remains the foundation of the new Stop TB Strategy developed by WHO to guide TB control efforts during the period 2006-15. (7) However, while 82% of new smear-positive cases enrolled in DOTS programmes in 2002 were successfully treated, only 45% of estimated new smear-positive cases were detected by DOTS programmes in 2003. (1) Implementing new strategies that can help to meet the case detection target has become an important global TB control priority.

Health expenditure in the private sector is substantial in high-burden countries. (8) Many TB cases are detected and treated in this sector, but are not notified to public authorities and therefore not recorded in official statistics. (9) Treatment outcomes are also generally poor in this sector. (10-13) To increase case detection rates, improve successful treatment rates and reduce out-of-pocket expenditures by patients, it is necessary to involve the private sector in DOTS implementation.

From the late 1990s, WHO has developed a strategy called "Public-Private Mix DOTS" (PPM-DOTS), which is based on field projects in diverse settings. (9,14) It consists of DOTS implementation in the private sector, with free drugs and financial support provided by the government and strengthened collaboration between public and private providers through improved referral and information systems.

By 2003, pilot projects had shown that PPM-DOTS could improve case detection and treatment outcomes. (15-20) However, the cost and cost-effectiveness of PPM-DOTS remained unclear. This was an important gap. Cost data are required to facilitate budgeting for PPM-DOTS within national TB control plans. Cost-effectiveness data are needed to allow assessment of whether PPM-DOTS provides value for money, and if results are favourable to assist resource mobilization.

We assessed the cost and cost-effectiveness of two of the first PPM-DOTS projects to be established. Both projects are in India, which accounts for about 20% of TB cases globally. India has a successful public sector DOTS programme implemented by the Revised National Tuberculosis Control Programme (RNTCP) (1) and a large private sector.

Methods

Description of pilot projects

The two PPM-DOTS projects we evaluated were located in Hyderabad and Delhi, cities with populations of 5 and 18 million, respectively. Both projects covered one TB unit (TU), the standard planning unit of the RNTCP that is expected to serve 500 000 people.

The project in Hyderabad was started in October 1998, following the signature of a Memorandum of Understanding (MoU) between the RNTCP and Mahavir Charitable Hospital (MCH). …

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