Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness Analysis of Tuberculosis Control Policies in Ivanovo Oblast, Russian Federation

Academic journal article Bulletin of the World Health Organization

Cost-Effectiveness Analysis of Tuberculosis Control Policies in Ivanovo Oblast, Russian Federation

Article excerpt

Introduction

In 1995 the Russian Federation reported over 85 000 new tuberculosis (TB) cases (57.4 cases per 100 000 population), a 69% increase over a minimum-ever incidence of 34 cases per 100 000 in 1991. With a mortality rate of 14.7 cases per 100 000 in 1994, the Russian Federation has the highest TB mortality rate in Europe and 40% of these deaths occur among patients [is less than] 39 years of age (1-4). The present situation has been attributed to a combination of delayed diagnosis and ineffective treatment (3), largely arising from difficulties in the transition period towards a market economy. Many of the TB programmes currently in place in the former Soviet Union are based on costly strategies (mass screening procedures and extensive hospitalization), are underfunded, and use unnecessarily long treatment regimens (2, 3). WHO advocates a strategy of TB control based on rapid case detection, largely through case-finding among symptomatic patients who self-report to health services, and the supervised administration of standardized short-course chemotherapy. Government committment to the implementation of a national TB programme, the regular supply of drugs, and a monitoring system for programme supervision and evaluation are essential elements of the WHO policy (5).

In the present article the results are reported of an economic analysis of a pilot TB control project based on the WHO strategy currently being implemented in Ivanovo Oblast. The cost-effectiveness of two alternative approaches was compared: the new WHO strategy (three different scenarios) based on case-finding among symptomatic patients self-reporting to health services and shorter regimens; and the old strategy based on active screening among asymptomatic persons and use of longer regimens. Both the costs and consequences of health programmes or treatments are examined (6). The four scenarios of two programmes were compared in terms of the following end-points: cost per TB case cured; and cost per TB case detected (6).

Methods

Setting

A pilot project of TB control based on the WHO strategy was implemented in 1995 in the Ivanovo Oblast (population: 1.27 million; economy: industrial (mainly textile) and agricultural), located 300 km NE of Moscow. In 1994 the TB notification rate was 44.4 per 100 000 and the TB mortality rate, 12.2 per 100 000. All patients have free access to all care facilities for diagnosis and treatment of TB and other diseases.

General principles

A separate analysis was carried out for each scenario to determine the end-points. Only direct costs were included in the model. The future consequences of a wider application of outpatient care (reduced need for buildings and personnel time) were not evaluated in monetary terms. An exchange rate of US$ 1 = 5000 rubles was applied (7). All costs were adjusted for inflation as of 30 June 1996; the inflation rates applied were derived from the consumer price, based on the chained Laspeyres index, calculated using weights from the previous year and including 288 representative items in metropolitan areas and towns (7). All data used, TB case definitions, and regimen abbreviations were obtained from WHO (8). The role and cost of BCG vaccination and chemoprophylaxis in preventing TB were not included in the analysis.

Cost per case cured

The regimen categories applied in the model (see Tables 1 and 2) were as follows: category I: new cases of smear-positive pulmonary TB and other newly diagnosed seriously ill patients with severe forms of TB; category II: relapse and failure smear-positive TB patients; category III: new cases of smear-negative pulmonary TB and other newly diagnosed patients with TB not included in category I (7). Four scenarios were used (three for the new strategy and one for the old). In scenario 1, 10% of patients were admitted for the intensive phase and WHO-recommended regimens were used. …

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