Drug prescribing practices for tuberculosis in Uzbekistan

SETTING

Uzbekistan has had 100% DOTS coverage since 2005; however, the treatment success rate has remained at around 80% for the last 4 years. Surveys from the capital city of Tashkent and from western Uzbekistan have shown high levels of primary multidrug resistance.

OBJECTIVE

To assess treatment regimens prescribed for new cases of tuberculosis (TB), including the prescription of additional non-TB drugs, and the cost implications for the patient.

DESIGN

We randomly sampled 30 clusters of seven new TB patients. Enrolled patients were interviewed and their medical records were reviewed.

RESULTS

In general, the treatment regimens prescribed were correct; doses were high rather than low. Second-line anti-tuberculosis drugs were rarely prescribed. In addition to anti-tuberculosis drugs, patients were prescribed on average seven to eight non-TB drugs. The rationale for prescribing the non-TB drugs was, however, questionable. Patients incurred substantial costs for these drugs, some of which were not without risk.

CONCLUSION

Prescriptions of anti-tuberculosis drugs for new TB patients are adequate; however, the practice of prescribing additional non-TB drugs needs to be reconsidered.

Global tuberculosis trends: a reflection of changes in tuberculosis control or in population health?

BACKGROUND

Many international organizations are advocating for new funds for tuberculosis (TB) specific interventions. Although this approach should help reduce TB incidence, improvements in population health may also be important. We have analyzed the association between changes in population health and health service indicators, and concomitant changes in TB incidence between 1990 and 2005.

METHODS

Country level data on population health and health services, economic and epidemiologic indicators were obtained for 165 countries. Regression methods were used to estimate the association of changes in potential predictors with changes in TB incidence.

RESULTS

Improvements in population health and health services are associated with improvements in TB outcomes. In adjusted analyses, each 1 year increase in life expectancy was associated with a 7.8/100,000 decline in TB incidence. A 1/1000 decrease in mortality rate in children aged <5 years and a 1% increase in measles vaccination coverage (serving as a general health services indicator) was associated with approximately a 1/100,000 decrease in TB incidence. In countries with a lower prevalence of human immunodeficiency virus (HIV) infection, a 1% increase in TB treatment success rate was also associated with a 1/100,000 decrease in incidence.

CONCLUSION

Investment in improving population health and health services may be as important as targeted strategies for controlling TB.

Perceptions of tuberculosis patients about private providers before and after implementation of Revised National Tuberculosis Control Programme

BACKGROUND

Most of the persons with chest symptoms in India approach private providers (PPs) for health care. It has been observed that patients who start treatment with PPs for tuberculosis (TB) frequently switch over subsequently to the public sector. The reasons for this discontinuation and their perceptions of the TB care provided by the PPs are unknown.

OBJECTIVE

To document the perceptions about PPs India's Revised National TB Control Programme (RNTCP) and the reasons for discontinuation of treatment with PPs and subsequent attendance at a public provider.

METHODS

This was a cross sectional study on patients registered under TB programme during 1997 and 2005 in rural and urban areas. During this period patients who were initially diagnosed and treated for TB in a private clinic and subsequently shifted to public health facility were considered for the study. A semi-structured interview schedule was used to collect the factors related to patient's perceptions on PPs, the factors responsible for initiating treatment with PPs, reasons for discontinuing treatment with PPs, and their willingness to continue treatment from government health facilities were collected. This data was compared with data collected in 1997 before implementation of the RNTCP.

RESULTS

A total of 1000 and 1311 TB patients were registered during 1997 and 2005 respectively. Among them, 203 (20%) and 104 (8%) patients were identified as having been initially diagnosed and started on TB treatment by PPs and subsequently shifted to government health facilities. There were significant changes in reasons for selecting PPs between the two periods: being convenient (47% vs 10%; p < 0.001), quality care (41% vs 19%; p < 0.001), motivated by others (49% vs 19%; p < 0.001), confidentiality (19% vs 9%; p < 0.05) and known doctor (6% vs 28%; p < 0.001) respectively. Financial problems were the most common reason for discontinuation of treatment in both periods. The use of sputum test for diagnosing TB by PPs was significantly increased after RNTCP implementation.

CONCLUSION

This study suggests that slowly perceptions of patients have changed towards PPs, and RNTCP has begun to gain acceptance amongst patients in terms of convenience, confidentiality and personal care.

Saving the lives of South Africa's mothers, babies, and children: can the health system deliver?

South Africa is one of only 12 countries in which mortality rates for children have increased since the baseline for the Millennium Development Goals (MDGs) in 1990. Continuing poverty and the HIV/AIDS epidemic are important factors. Additionally, suboptimum implementation of high-impact interventions limits programme effectiveness; between a quarter and half of maternal, neonatal, and child deaths in national audits have an avoidable health-system factor contributing to the death. Using the LiST model, we estimate that 11,500 infants' lives could be saved by effective implementation of basic neonatal care at 95% coverage. Similar coverage of dual-therapy prevention of mother-to-child transmission with appropriate feeding choices could save 37,200 children's lives in South Africa per year in 2015 compared with 2008. These interventions would also avert many maternal deaths and stillbirths. The total cost of such a target package is US$1.5 billion per year, 24% of the public-sector health expenditure; the incremental cost is $220 million per year. Such progress would put South Africa squarely on track to meet MDG 4 and probably also MDG 5. The costs are affordable and the key gap is leadership and effective implementation at every level of the health system, including national and local accountability for service provision.

The value of tuberculosis elimination and of progress in tuberculosis control in twentieth-century England and Wales

OBJECTIVE

To calculate the monetary value of tuberculosis (TB) elimination and of progress in TB control in twentieth-century England and Wales.

METHODS

An original methodology that utilises original data is used, which facilitates the calculation of the number of life years that have been saved as a result of the decline in the TB mortality rate, prevalence rate and quality of life burden.

RESULTS

The magnitude of the decline in the mortality and morbidity burden of TB is estimated at 104,425 life years, which is valued to be worth in excess of US$127 billion. The value of improvements in morbidity contributes nearly as much as the more obvious gains for mortality.

CONCLUSION

Such significant results indicating the value of improvements in TB control have important implications for our understanding of these achievements and justify increased spending in developing countries that continue to be plagued by high rates of TB prevalence.

Can paying for results help to achieve the Millennium Development Goals? A critical review of selected evaluations of results-based financing

BACKGROUND

Results-based financing (RBF) refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. RBF is being promoted for helping to achieve the Millennium Development Goals (MDGs).

METHODS

We undertook a critical appraisal of selected evaluations of RBF schemes in the health sector in low and middle-income countries (LMIC). In addition, key informants were interviewed to identify literature relevant to the use of RBF in the health sector in LMIC, key examples, evaluations, and other key informants.

RESULTS

The use of RBF in LMIC has commonly been a part of a package that may include increased funding, technical support, training, changes in management, and new information systems. It is not possible to disentangle the effects of financial incentives as one element of RBF schemes, and there is very limited evidence of RBF per se having an effect. RBF schemes can have unintended effects.

CONCLUSION

When RBF schemes are used, they should be designed carefully, including the level at which they are targeted, the choice of targets and indicators, the type and magnitude of incentives, the proportion of financing that is paid based on results, and the ancillary components of the scheme. For RBF to be effective, it must be part of an appropriate package of interventions, and technical capacity or support must be available. RBF schemes should be monitored for possible unintended effects and evaluated using rigorous study designs.

Targeted screening and treatment for latent tuberculosis infection using QuantiFERON-TB Gold is cost-effective in Mexico

OBJECTIVE

To assess the cost-effectiveness of screening for latent tuberculosis infection (LTBI) using a commercially available detection test and treating individuals at high risk for human immunodeficiency virus (HIV) infection in a middle-income country.

DESIGN

We developed a Markov model to evaluate the cost per LTBI case detected, TB case averted and quality-adjusted life year (QALY) gained for a cohort of 1000 individuals at high risk for HIV infection over 20 years. Baseline model inputs for LTBI prevalence were obtained from published literature and cross-sectional data from tuberculosis (TB) screening using QuantiFERON-TB Gold In-Tube (QFT-GIT) testing among sex workers and illicit drug users at high risk for HIV recruited through street outreach in Tijuana, Mexico. Costs are reported in 2007 US dollars. Future costs and QALYs were discounted at 3% per year. Sensitivity analyses were performed to evaluate model robustness.

RESULTS

Over 20 years, we estimate the program would prevent 78 cases of active TB and 55 TB-related deaths. The incremental cost per case of LTBI detected was US$730, cost per active TB averted was US$529 and cost per QALY gained was US$108.

CONCLUSIONS

In settings of endemic TB and escalating HIV incidence, targeting LTBI screening and treatment among high-risk groups may be highly cost-effective.

Economic evaluation of public-private mix for tuberculosis care and control, India. Part II. Cost and cost-effectiveness

SETTING

Bangalore City, India.

OBJECTIVES

To assess the cost and cost-effectiveness of public-private mix (PPM) for tuberculosis (TB) care and control when implemented on a large scale.

DESIGN

DOTS implementation under the Revised National TB Control Programme (RNTCP) began in 1999, PPM was introduced in mid-2001 and a second phase of intensified PPM began in 2003. Data on the costs and effects of TB treatment from 1999 to 2005 were collected and used to compare the two distinct phases of PPM with a scenario of no PPM. Costs were assessed in 2005 $US for public and private providers, patients and patient attendants. Sources of data included expenditure records, medical records, interviews with staff and patient surveys. Effectiveness was measured as the number of cases successfully treated.

RESULTS

When PPM was implemented, total provider costs increased in proportion to the number of successfully treated TB cases. The average cost per patient treated from the provider perspective when PPM was implemented was stable, at US$69, in the intensified phase compared with US$71 pre-PPM. PPM resulted in the shift of an estimated 7200 patients from non-DOTS to DOTS treatment over 5 years. PPM implementation substantially reduced costs to patients, such that the average societal cost per patient successfully treated fell from US$154 to US$132 in the 4 years following the initiation of PPM.

CONCLUSION

Implementation of PPM on a large scale in an urban setting can be cost-effective, and considerably reduces the financial burden of TB for patients.

The cost of intensified case finding and isoniazid preventive therapy for HIV-infected patients in Battambang, Cambodia

SETTING

The current study evaluates one of four pilot sites initiated in Cambodia to establish feasible and effective ways to manage patients with human immunodeficiency virus (HIV) infection and tuberculosis (TB).

OBJECTIVE

To measure the costs of intensified case finding (ICF) and isoniazid preventive therapy (IPT) services for HIV-infected patients in Battambang Province, Cambodia.

DESIGN

We analyzed cost data retrospectively from September 2003 to February 2006 using a microcosting or ingredients-based approach and interviewed clinic personnel to determine the cost of ICF and IPT per person.

RESULTS

Adherence to IPT at Battambang IPT clinic was high (86%) relative to other reported studies of IPT among HIV patients in developing countries. The estimated cost per TB case averted through ICF was US$363, while the estimated cost per TB case averted through IPT was US$955.

CONCLUSION

Economic evaluations of TB-HIV integrated services are necessary as countries move to establish or scale-up these services. Based upon the estimated effectiveness of ICF and IPT used by other studies examining the provision of integrated HIV-TB services, the cost per TB case prevented by ICF and IPT in Battambang, Cambodia, is less than the reported cost of treating a new smear-positive TB case.

Economic evaluation of public-private mix for tuberculosis care and control, India. Part I. Socio-economic profile and costs among tuberculosis patients

SETTING

Bangalore City, India.

OBJECTIVES

To assess the socio-economic profile, health-seeking behaviour and costs related to tuberculosis (TB) diagnosis and treatment among patients treated under the Revised National TB Control Programme (RNTCP).

DESIGN

All 1106 new TB patients registered for treatment under the RNTCP in the second quarter of 2005 participated. Interviews at the beginning and at the end of treatment were conducted. A convenience sample of 32 patients treated outside the RNTCP also participated.

RESULTS

Among the TB patients, respectively 50% and 39% were from low and middle standard of living (SL) households, and 77% were from households with a per capita income of less than US$1 per day. The first health contact was with a private practitioner in the case of >70% of patients. Mean patient delay was low, at 21 days, but the mean health system delay was 52 days. The average cost incurred by patients before treatment in the RNTCP was US$145, and during treatment it was US$21. Costs as a proportion of annual household income per capita were 53% for people from low SL households and 41% for those from other households. Costs during treatment faced by patients treated outside the RNTCP averaged US$127.

CONCLUSION

Patients treated under the RNTCP through a public-private mix approach were predominantly poor. Many of them experienced considerable health expenditures before starting treatment. Additional efforts are required to reduce the delays and the number of health care providers consulted, and to ensure that patients are shifted to subsidised treatment within the RNTCP.

[Social anthropological approach to tuberculosis in Mopti (Mali): popular representations and use of treatment]

In Mali, there were 4508 new cases of tuberculosis in 2003, and 5222 in 2006. Tuberculosis (TB) is thus an important public health problem, decreasing the physical, financial and social capital of individuals, their families and society. Because responses to TB have not yet applied a sufficiently integrated approach that can improve patients' access to quality care, this FORESA project advocates a patient-centered approach. Before any intervention, FORESA thus sought to analyse the situation of TB in Mali and responses to it. The study aims to analyse the discourse about and popular representations of TB (its forms, its signs), the situations in which people are exposed to it or transmit it, and popular practices related to its prevention and the experience of having it. This qualitative, descriptive and analytical study includes a literature review, in-depth interviews with opinion leaders, community health workers and TB patients, focus groups, and the observations of practices. The interviews were recorded, transcribed, and analysed. Subjects provided informed consent to participation. This study showed that: * the terms for TB in local languages (Bambara, Dogon and Fulfuldé) include white cough, big cough, and long cough; * These communities differentiate between 2 main forms of cough (simple and wet); * TB is perceived as a transmissible disease, a disease of contact with a contaminated body or objects; * TB is seen as a serious, contagious, hereditary, shameful disease that may result from the transgression of social norms; * The prevention of TB consists of avoiding people who have the disease or transmitting factors; * Therapeutic remedies, in order, are self-medication, the use of traditional healers, and finally visits to health centres; * The population wants more information about TB and be involved in the fight against it. This study shows the many points of convergence about TB nosology, etiology and therapy between the Mopti population and other groups in Mali (including the Mande, Senoufo and Soso), between the population of Mali and some ethnic groups in Burkina Faso (such as the Dioula, Bobo, Tiéfo Vigué), and between the population of Mali and, Burkina Faso and others in Africa (Gambia, Nigeria, South Africa, etc.). There is also a difference between popular knowledge about TB and biomedical knowledge. The population does not know that TB is transmitted mainly, even exclusively, by nasal droplets or that patients are no longer contagious after two weeks of treatment. The widespread dissemination of this information may have a positive effect, reducing stigmatization and improving access to treatment. Mali must strengthen the skills of all participants in the fight against tuberculosis, to strengthen their framework and to monitor and evaluate their activities.

[Marketing as an effective tool to overcome systems problems in the organization of antituberculous care to the pediatric population]

The paper analyzes the efficiency of vaccination and tuberculin diagnosis in the megapolis on the basis of official reporting forms Nos. 8 and 33 approved by the 11 November, 2005 Resolution of the Russian Statistics Agency and the Moscow tuberculosis monitoring system. It is concluded that refusals to undergo vaccination and tuberculin diagnosis may result in the system crisis of antituberculous care to the pediatric population. For the optimum solution of reducing the rate of refusals to take the drugs prescribed by a physician, the authors propose to use in pediatric antituberculous care the marketing methods that level off the responsibility of the parties in taking a decision whether a medical service is expedient. Under the marketing conditions of medical services, combating the foci of tuberculous infection should be a main line to reduce the prevalence of tuberculosis. Prevention of tuberculosis is most effective with the active interaction of medical services (pediatric phthisiological and primary pediatric care services) and society and with the needs being molded in it (as a market medical service) in the population.

[Some topics of TB research using epidemetric models]

Recent challenges to research in tuberculosis (TB) epidemiology were overviewed, with special emphasis on studies using mathematical models. They include; the effectiveness of DOTS strategy on TB epidemiology, impact of HIV epidemics and multi-drug resistant TB, simulation of selected TB control measures (BCG vaccination, case-finding, the use of interferon-gamma release assay for sub-clinical infections). The perspectives on molecular epidemiology and the host susceptibility are discussed, and these topics are considered as important research agendas in TB epidemiology. Also, discussions were made on the relevant ways of organizing epidemiological studies in TB, now and in the near future.

Why financial incentives did not reach the poor tuberculosis patients? A qualitative study of a Fidelis funded project in Shanxi, China

BACKGROUND

A project implemented in 50 counties of Shanxi province provided incentives to poor TB patients for their first trip to tuberculosis (TB) dispensaries. Incentives were also given to doctors for referring and supervising TB patients. A previous quantitative evaluation identified no improvement on TB case detection and management. This qualitative study was then conducted to explore reasons for project failure.

OBJECTIVE

To understand how the incentives were distributed to and viewed by their recipients and the implications for TB and health systems.

METHODS

Qualitative in-depth interviews were conducted with 32 TB patients, 13 village doctors, 12 village leaders, 8 TB doctors and 8 TB programme managers.

RESULTS

The study revealed a lack of operational tools on how to evaluate patients' economic status and how to publicise the incentives. As a result, patients did not know the level of incentives in advance and regarded the amount as inadequate. Patients faced a huge financial burden and a long delay in treating TB, dwarfing the benefits of travel incentives. The referral and case supervision incentives were not implemented. Doctors did not receive any referral and supervision incentives in addition to those already existing.

CONCLUSIONS

Strategies to address health system and TB programme issues should be implemented before or alongside financial incentives. Operational details and tools for any intervention should be developed, field-tested and revised prior to wide-scale use.

Public-private mix for control of tuberculosis and TB-HIV in Nairobi, Kenya: outcomes, opportunities and obstacles

SETTING

Nairobi, the capital of Kenya.

OBJECTIVE

To promote standardised tuberculosis (TB) care by private health providers and links with the public sector.

DESIGN AND METHODS

A description of the results of interventions aimed at engaging private health providers in TB care and control in Nairobi. Participating providers are supported to provide TB care that conforms to national guidelines. The standard surveillance tools are used for programme monitoring and evaluation.

RESULTS

By the end of 2006, 26 of 46 (57%) private hospitals and nursing homes were engaged. TB cases reported by private providers increased from 469 in 2002 to 1740 in 2006. The treatment success rate for smear-positive pulmonary TB treated by private providers ranged from 76% to 85% between 2002 and 2005. Of the 1740 TB patients notified by the private sector in 2006, 732 (42%) were tested for human immunodeficiency virus (HIV), of whom 372 (51%) were positive. Of the 372 HIV-positive TB patients, 227 (61%) were provided with cotrimoxazole preventive treatment (CPT) and 136 (37%) with antiretroviral treatment (ART).

CONCLUSION

Private providers can be engaged to provide TB-HIV care conforming to national norms. The challenges include providing diagnostics, CPT and ART and the capacity to train and supervise these providers.

Cost-effectiveness of novel diagnostic tools for the diagnosis of tuberculosis

SETTING

The potential cost-effectiveness of improved diagnostic tests for tuberculosis (TB) in resource-limited settings is unknown.

OBJECTIVE

To estimate the incremental cost-effectiveness of a hypothetical new point-of-care TB diagnostic test in South Africa, Brazil and Kenya.

DESIGN

Decision-analysis model, adding four diagnostic interventions (sputum smear microscopy, new test, smear plus new test and smear plus TB culture) to a baseline of existing infrastructure without smear.

RESULTS

Adding sputum smear was estimated to be more cost-effective (incremental cost per disability-adjusted life year [DALY] of $86 [South Africa], $131 [Brazil], $38 (Kenya]) than a new TB diagnostic with 70% sensitivity, 95% specificity and price of $20 per test ($198 [South Africa], $275 [Brazil], $84 [Kenya]). However, compared to sputum smear, smear plus new test averted 46-49% more DALYs per 1000 TB suspects (321 vs. 215 [South Africa], 243 vs. 166 [Brazil], 790 vs. 531 [Kenya]), at an incremental cost of $170 (Kenya) to $625 (Brazil) per DALY averted. Cost-effectiveness was most sensitive to the specificity and price of the new test, the baseline TB case detection rate and the discount rate.

CONCLUSION

Novel diagnostic tests for TB are potentially highly cost-effective. Cost-effectiveness is maximized by high-specificity, low-cost tests deployed to regions with poor infrastructure.

[What is needed to prevent defaulting from tuberculosis treatment?]

PURPOSE

To investigate the factors relating to defaulting from tuberculosis treatment in Japan, and clarify what is needed to prevent defaulting.

OBJECT

Tuberculosis patients who were registered at public health centers (PHCs), and interrupted treatment for more than 2 months without the doctors' direction at the end of December 2005.

METHOD

Investigation by questionaire sent by post-mail to all public health centers (608 PHCs) in Japan.

RESULT

The valid answers was obtained from 89.0% (541/ 608) of PHCs. Tuberculosis patients who had interrupted treatment, but could be contacted by PHCs' staff were 137, and for those patients the factors relating to defaulting from treatment were analyzed. The factors were classified into 7 categories (there may be more than one factors in one patients); factors related to disbelief and/or prejudice for diagnosis and/or treatment (except factors related to drug adverse effects) were observed in 51.8%, factors related to economical problem in 24.1%, factors related to job or studies in 23.4%, factors related to drug adverse effects in 22.6%, factors related to visiting out-patients departments in 6.6%, psychiatric disease and/or drug abuse in 4.4%, others in 9.5%.

CONCLUSION

It is needed to prevent defaulting, first, to improve the quality of tuberculosis medical care and services including good and sufficient explanations on TB and how to cure it to patients, and proper managements for drug adverse effects, and then to expand public economical support for the costs of medicine and travel expenses to medical facilities and to make accessible time and place of the tuberculosis outpatient clinic more convenient and flexible for patients.

Cost of tuberculosis diagnosis and treatment from the patient perspective in Lusaka, Zambia

SETTING

Urban primary health centres in Lusaka, Zambia.

OBJECTIVES

1) To estimate patient costs for tuberculosis (TB) diagnosis and treatment and 2) to identify determinants of patient costs.

METHODS

A cross-sectional survey of 103 adult TB patients who had been on treatment for 1-3 months was conducted using a standardised questionnaire. Direct and indirect costs were estimated, converted into US$ and categorised into two time periods: 'pre-diagnosis/care-seeking' and 'post-diagnosis/treatment'. Determinants of patient costs were analysed using multiple linear regression.

RESULTS

The median total patient costs for diagnosis and 2 months of treatment was $24.78 (interquartile range 13.56-40.30) per patient--equivalent to 47.8% of patients' median monthly income. Sex, patient delays in seeking care and method of treatment supervision were significant predictors of total patient costs. The total direct costs as a proportion of income were higher for women than men (P < 0.001). Treatment costs incurred by patients on the clinic-based directly observed treatment strategy were more than three times greater than those incurred by patients on the self-administered treatment strategy (P < 0.001).

CONCLUSION

Clinic-based treatment supervision posed a significant economic burden on patients. The creation or strengthening of community-based treatment supervision programmes would have the greatest potential impact on reducing patients' TB-related costs.

Cultural epidemiology of TB with reference to gender in Bangladesh, India and Malawi

SETTING

TB control programmes in Bangladesh, India and Malawi.

OBJECTIVE

To identify and compare socio-cultural features of tuberculosis (TB) and the distribution of TB-related experiences, meanings and behaviours with reference to gender across cultures in three high-endemic low-income countries.

DESIGN

Approximately 100 patients at three sites were interviewed with in-depth semi-structured Explanatory Model Interview Catalogue (EMIC) interviews inquiring about patterns of distress, perceived causes and help-seeking behaviours in the context of illness narratives.

RESULTS

Female patients reported more diverse symptoms and men more frequently focused on financial concerns. Most patients reported psychological and emotional distress. Men emphasised smoking and drinking alcohol as causes of TB, and women in Malawi reported sexual causes associated with HIV/AIDS. In Bangladesh, exaggerated concerns about the risk of spread despite treatment contributed to social isolation of women. Public health services were preferred in Malawi, and private doctors in India and Bangladesh.

CONCLUSION

Cross-site analysis of these studies has identified features of TB that influence the burden of disease and are likely to affect timely help seeking and adherence to treatment. Health systems benefit from sex-disaggregated epidemiological data complemented by cultural epidemiological study, which together clarify the role of gender and contribute to the knowledge base for TB control at various levels.

Financial resources required for tuberculosis control to achieve global targets set for 2015

OBJECTIVE

To estimate the financial resources required to achieve the 2015 targets for global tuberculosis (TB) control, which have been set within the framework of the Millennium Development Goals (MDGs).

METHODS

The Global Plan to Stop TB, 2006-2015 was developed by the Stop TB Partnership. It sets out what needs to be done to achieve the 2015 targets for global TB control, based on WHO's Stop TB Strategy. Plan costs were estimated using spreadsheet models that included epidemiological, demographic, planning and unit cost data.

FINDINGS

A total of US$ 56 billion is required during the period 2006-2015 (93% for TB-endemic countries, 7% for international technical agencies), increasing from US$ 3.5 billion in 2006 to US$ 6.7 billion in 2015. The single biggest cost (US$ 3 billion per year) is for the treatment of drug-susceptible cases in DOTS programmes. Other major costs are treatment of patients with multi- and extensively drug-resistant TB (MDR-TB and XDR-TB), collaborative TB/HIV activities, and advocacy, communication and social mobilization. Low-income countries account for 41% of total funding needs and 65% of funding needs for TB/HIV. Middle-income countries account for 72% of the funding needed for treatment of MDR-TB and XDR-TB. African countries require the largest increases in funding.

CONCLUSION

Achieving the 2015 global targets set for TB control requires a major increase in funding. To support resource mobilization, comprehensive and costed national plans that are in line with the Global Plan to Stop TB are needed, backed up by robust assessments of the funding that can be raised in each country from domestic sources and the balance that is needed from donors.

[Dona Amélia Queen Reformatory: a sanatorium for weak children]

This article intends to examine the conditions of the city of Rio de Janeiro, regarding the city's health safety of the living and housing condition of its workers, which helped bringing about the spread of tuberculosis in the end of the 19th century and beginning of the 20th century. Evidencing the high incidence of tuberculosis at this time, it intends to verify the reasons for creating the Brazilian League Against Tuberculosis and its purpose, analyzing its project of assistance to children's health and its intervention to discipline, which resulted in the creation of the Dona Amélia Queen Reformatory.

[Discourses and practices in the sanatoriums for tuberculosis sufferers in the province of Cordoba. 1910-1947]

Tuberculosis was a stigmatized disease, with a strong social meaning developed by medicine itself. In this paper, we make an analysis of the medical conceptions about the disease, and their repercussions on patients in a special place such as tuberculosis sanatoriums. In the first place, we enumerate the sanatoriums in the province of Cordoba, after that, we study the medical views about the sanatoriums and the infection, as a central element for hospitalized patients with tuberculosis. Later, we analyze the myths generated around the disease, and finally, we try to understand how these myths made possible to create a particular social group within those sanatoriums.

Determining the cost of tuberculosis case management in a low-incidence state

OBJECTIVE

To establish the average cost per patient of nurse case management for tuberculosis (TB) in Oregon State and so facilitate estimates of the overall cost of TB treatment. TB treatment is currently funded by a combination of local, state and federal public health dollars.

DESIGN

A longitudinal survey was used to assess the amount of case management time patients required per week. Additional patient information was collected from public health records. Mixed effects modeling techniques were used to identify important factors associated with case management time and to make predictions.

RESULTS

The following variables were significantly associated with case management time: non-adherence to treatment, the use of incentives, the phase of treatment and the presence of complicating factors, including human immunodeficiency virus infection, antibiotic resistance, homelessness and adverse reaction to drugs. The mean case management cost was $4831 per patient for a standard 28-week treatment course, and ranged from $3386 for a simple case to $7542 for a case with multiple complications.

CONCLUSIONS

These estimates are substantially higher than the current state funding for case management. Using these data, health officials can make better informed budget decisions and provide more appropriate support for TB control.

Global Fund-supported programmes contribution to international targets and the Millennium Development Goals: an initial analysis

OBJECTIVE

The Global Fund to Fight AIDS, Tuberculosis and Malaria is one of the largest funders to fight these diseases. This paper discusses the programmatic contribution of Global Fund-supported programmes towards achieving international targets and Millennium Development Goals, using data from Global Fund grants.

METHODOLOGY

Results until June 2006 of 333 grants supported by the Global Fund in 127 countries were aggregated and compared against international targets for HIV/AIDS, tuberculosis and malaria. Progress reports to the Global Fund secretariat were used as a basis to calculate results. Service delivery indicators for antiretrovirals (ARV) for HIV/AIDS, case detection under the DOTS strategy for tuberculosis (DOTS) and insecticide-treated nets (ITNs) for malaria prevention were selected to estimate programmatic contributions to international targets for the three diseases. Targets of Global Fund-supported programmes were projected based on proposals for Rounds 1 to 4 and compared to international targets for 2009.

FINDINGS

Results for Global Fund-supported programmes total 544,000 people on ARV, 1.4 million on DOTS and 11.3 million for ITNs by June 2006. Global Fund-supported programmes contributed 18% of international ARV targets, 29% of DOTS targets and 9% of ITNs in sub-Saharan Africa by mid-2006. Existing Global Fund-supported programmes have agreed targets that are projected to account for 19% of the international target for ARV delivery expected for 2009, 28% of the international target for DOTS and 84% of ITN targets in sub-Saharan Africa.

CONCLUSION

Global Fund-supported programmes have already contributed substantially to international targets by mid-2006, but there is a still significant gap. Considerably greater financial support is needed, particularly for HIV, in order to achieve international targets for 2009.

The prevalence of tuberculosis in different economic strata: a community survey from South India

A cross-sectional socio-economic survey to assess the standard of living index (SLI) of a rural population in South India was undertaken along with a tuberculosis (TB) prevalence survey during 2004-2006. Of 32,780 households, the SLI was low, medium and high in 22%, 36% and 42%, and TB prevalence was 343, 169 and 92 per 100,000 population, respectively, a significant decrease in trend (P < 0.001); 57% of the TB patients had a low SLI and the prevalence of TB was higher amongst the landless (P < 0.001), those living below the poverty line (P < 0.01) and in katcha houses (P < 0.001), suggesting that TB disproportionately affects those with a low SLI.

[Costs estimation of tuberculosis cases detection. La Habana Vieja Municipality, Cuba. 2002]

BACKGROUND

The Cuban Tuberculosis Control Program has been able to significantly reduce the tuberculosis cases incidence in all its forms. La Habana Vieja municipality has maintained the highest incidence in Havana City province during 5 years and one of the highest in the country.

OBJECTIVE

To estimate the cost of Tuberculosis cases detection in Habana Vieja municipality, in the year 2002.

METHODS

A descriptive retrospective study to estimate the costs with social perspective was carried out. The costs of cases detection and their departures in health facilities were considered. For patients with cough/expectoration > or =14 days (RS+14) the pocket expense and monetary losses for labour absences were considered. Costs were expressed in equivalent Cuban pesos to American dollars (1 CUC = 1 USD). Information from official records in health institutions and from interviews to workers and RS+14 was obtained.

RESULTS

Social cost of tuberculosis cases detection for an RS+14 was in average 24,11 CUC, and institutional cost was 12,55; for clinical investigation 0.37; for sputum smear microscopy 2,25; for culture 7,05; for thorax X-ray 1,67; for notification 3,07; and for registering 0,36.

CONCLUSIONS

The biggest costs were observed in sputum smear microscopies and cultures performance; salaries and reagents were the issues contributing more in that cost. The results obtained in this study could be extrapolated to other municipalities in the country with social and economic conditions similar to La Habana Vieja.

Review series: the politics of TB: the politics, economics and impact of directly observed treatment (DOT) in India

India harbors approximately one-third of the world's tuberculosis cases. The disease being multi-factorial; various political, social and economic factors play pivotal roles in causation and control. The country's policy-makers, via the Revised National Tuberculosis Programme (RNTCP), have embraced DOTS, i.e. Directly Observed Treatment; short course, as a means of combating the disease. Today, a decade after being launched, the DOTS programme in India is the largest in the world. The achievements of the programme have been significant in reaching out to the millions and having impressive cure rates, but the disease is far from eradicated. Social taboos, economic obstacles, and deficient infrastructure are impediments that hamper the success of the programme. With multidrug-resistant TB and HIV co-infection complicating the management of TB; the task has become more daunting. In a country as heterogeneous as India, novel holistic strategies that address individual needs will have to be developed to successfully curb the spread of the disease in the future.

Cost-effectiveness of alternative strategies for tuberculosis screening before kindergarten entry

OBJECTIVE

We undertook a decision analysis to evaluate the economic and health effects and incremental cost-effectiveness of using targeted tuberculin skin testing, compared with universal screening or no screening, before kindergarten.

METHODS

We constructed a decision tree to determine the costs and clinical outcomes of using targeted testing compared with universal screening or no screening. Baseline estimates for input parameters were taken from the medical literature and from California health jurisdiction data. Sensitivity analyses were performed to determine plausible ranges of associated outcomes and costs. We surveyed California health jurisdictions to determine the prevalence of mandatory universal tuberculin skin testing.

RESULTS

In our base-case scenario, the cost to prevent an additional case of tuberculosis by using targeted testing, compared with no screening, was $524,897. The cost to prevent an additional case by using universal screening, compared with targeted testing, was $671,398. The incremental cost of preventing a case through screening remained above $100,000 unless the prevalence of tuberculin skin testing positivity increased to >10%. More than 51% of children entering kindergarten in California live where tuberculin skin testing is mandatory.

CONCLUSIONS

The cost to prevent a case of tuberculosis by using either universal screening or targeted testing of kindergarteners is high. If targeted testing replaced universal tuberculin skin testing in California, then $1.27 million savings per year would be generated for more cost-effective strategies to prevent tuberculosis. Improving the positive predictive value of the risk factor tool or applying it to groups with higher prevalence of latent tuberculosis would make its use more cost-effective. Universal tuberculin skin testing should be discontinued, and targeted testing should be considered only when the prevalence of risk factor positivity and the prevalence of tuberculin skin testing positivity among risk factor-positive individuals are high enough to meet acceptable thresholds for cost-effectiveness.

The economic burden to families of HIV and HIV/tuberculosis coinfection in a subsidized HIV treatment program

INTRODUCTION

The high cost of antiretroviral (ARV) drugs has led to the initiation of subsidized HIV treatment programs in developing countries. The care of tuberculosis (TB), a common opportunistic infection, is not built into the subsidized program. The current study was done to evaluate the cost burden of HIV/AIDS, TB, and TB and HIV/AIDS coinfections to the family.

SUBJECTS AND METHODS

The study was carried out in the consultant outpatient department of the University of Benin Teaching Hospital in Nigeria. Consecutive families with 21 family member managed for HIV and or TB were recruited into three cohorts of HIV only, TB only and HIV/TB cohorts. The average monthly costs of treatment, transportation family income and percentage of income spent on care were computed for each family. The average monthly man-hours per family spent on clinic visitation were determined.

RESULTS

A total of 61 families consisting of 128 family members met the study criteria. The mean cost of treatment per month was significantly higher in families in the HIV/TB cohort than in other cohorts, P = 0.0001. The mean percentage of income spent on treatment was significantly higher in the HIV/TB cohort compared to other cohorts, P = 0.0001.

CONCLUSION

The cost of managing TB/HIV coinfection significantly increased the costs to the families in the subsidized HIV treatment program. It is recommended that a comprehensive package of subsidized HIV care that is inclusive of TB treatment and care for other comorbidities be initiated in developing countries.

Global Fund grant programmes: an analysis of evaluation scores

BACKGROUND

The Global Fund to Fight AIDS, Tuberculosis and Malaria evaluates programme performance after 2 years to help decide whether to continue funding. We aimed to identify the correlation between programme evaluation scores and characteristics of the programme, the health sector, and the recipient country.

METHODS

We obtained data on the first 140 Global Fund grants evaluated in 2006, and analysed 134 of these. We used an ordered probit multivariate analysis to link evaluation scores to different characteristics, allowing us to record the association between changes in those characteristics and the probability of a programme receiving a particular evaluation score.

FINDINGS

Programmes that had government agencies as principal recipients, had a large amount of funding, were focused on malaria, had weak initial proposals, or were evaluated by the accounting firm KPMG, scored lowest. Countries with a high number of doctors per head, high measles immunisation rates, few health-sector donors, and high disease-prevalence rates had higher evaluation scores. Poor countries, those with small government budget deficits, and those that have or have had socialist governments also received higher scores.

INTERPRETATION

Our results show associations, not causality, and they focus on evaluation scores rather than actual performance of the programmes. Yet they provide some early indications of characteristics that can help the Global Fund identify and monitor programmes that might be at risk. The results should not be used to influence the distribution of funding, but rather to allocate resources for oversight and risk management.

Financial tuberculosis control: the role of a global financial monitoring system

Control of tuberculosis (TB), like health care in general, costs money. To sustain TB control at current levels, and to make further progress so that global targets can be achieved, information about funding needs, sources of funding, funding gaps and expenditures is important at global, regional, national and sub-national levels. Such data can be used for resource mobilization efforts; to document how funding requirements and gaps are changing over time; to assess whether increases in funding can be translated into increased expenditures and whether increases in expenditure are producing improvements in programme performance; and to identify which countries or regions have the greatest needs and funding gaps. In this paper, we discuss a global system for financial monitoring of TB control that was established in WHO in 2002. By early 2007, this system had accounted for actual or planned expenditures of more than US$ 7 billion and was systematically reporting financial data for countries that carry more than 90% of the global burden of TB. We illustrate the value of this system by presenting major findings that have been produced for the period 2002-2007, including results that are relevant to the achievement of global targets for TB control set for 2005 and 2015. We also analyse the strengths and limitations of the system and its relevance to other health-care programmes.

[New diagnosis tools for tuberculosis laboratory network in Latin America]

Feasibility of rapid and sustainable diagnostic methods that provide useful and timely results to guide the clinical control of tuberculosis patients was analyzed. However, policies guiding the insertion of new diagnostics in the laboratory services that support the tuberculosis control are lacking in developing countries. The introduction of these methods in developing countries laboratories requires rational policies guiding the application of these technologies. In the last few years, some automated systems for culture and molecular testing in laboratory services for tuberculosis diagnosis, which offered accuracy and speed, have been reported. However, their implementation is restricted because of costly resources, logistics and infrastructure. Recently, various economically feasible tests have demonstrated to be applicable in poor-resource labs. The detection of adenosine desaminase (ADA) in pleural fluid is a valuable low-cost approach to the diagnosis of tuberculosis. On the other hand, the microscopic detection of Mycobacterium tuberculosis using thin layer agar is a moderate cost alternative method. Drug susceptibility testing to antituberculous drugs can be expedited by the nitrate reduction assay in tuberculosis laboratories using routine procedures for tuberculosis diagnosis.

Costs of investigating and managing non-residents with possible tuberculosis: New Zealand experience of an international problem

BACKGROUND AND OBJECTIVE

This study's aims were to identify the diagnoses, the public hospital costs and payments for non-New Zealand (non-NZ) patients referred because of possible tuberculosis (TB). There have been no previous financial studies in this area. Funding arrangements for these patients were also reviewed.

METHODS

A systematic, retrospective review was performed to identify the costs of investigating and managing non-NZ patients referred to the adult TB unit of a large, teaching hospital in Auckland, NZ. Patients were enrolled between 1 July 2002 and 30 June 2003.

RESULTS

Forty-five non-NZ patients were studied. The mean age was 33.8 (+/-13.4) years. Thirty-four (75.5%) were managed under compulsion through Section 9 of the NZ TB Act. Thirty-two (71%) patients received TB treatment: 11 (24%) had infectious pulmonary TB and four had active extra-pulmonary TB. There were no multi-drug-resistant isolates. Three TB cases accounted for 250 (39%) inpatient days. One patient with rifampicin-resistant TB was responsible for 117 (29%) day-patient ward visits. Four (13%) infectious TB cases were managed as inpatients for more than 6 weeks. The total cost of services (US dollars) for the 45 patients was 350,236 dollars. The cost range was 544-43,513 dollars per patient. Four patients incurred costs over 25,000 dollars.

CONCLUSIONS

TB in non-residents is a costly problem in NZ. Current policy applying to this area and the ability to determine its cost-effectiveness are in need of review.

Why are clinicians reluctant to treat smear-negative tuberculosis? An inquiry about treatment thresholds in Rwanda

PURPOSE

The diagnosis of tuberculosis remains controversial between clinicians and public health officers. Public health officials fear to treat too many patients; clinicians fear that truly diseased will be denied treatment. We wondered whether an analysis of the treatment threshold could help making the often intuitive decision to treat smear-negative cases more evidence based.

METHODS

Eighteen clinicians and 10 public health specialists were asked for an intuitive estimate of their treatment threshold for tuberculosis and of key determinant factors for this threshold: the magnitude and subjective weight of mortality and morbidity due to both the disease and the treatment and risk and cost of the latter. With these factors, the authors calculated treatment thresholds and compared them to the intuitive thresholds of the interviewees. A prescriptive threshold was calculated based on literature data, omitting cost and subjective factors.

RESULTS

The median overall intuitive treatment threshold was 52.5%, the calculated 11.9%, and the prescriptive 2.7%. For 2 factors, public health officers provided significantly lower values than clinicians: cost of treatment (median = 20 dollars v. 300 dollars; U = 2.5; P = 0.0002); cost of life (median = 500 dollars v. 5000 dollars; U = 17.5; P = 0.009).

CONCLUSION

These results suggest that clinicians and public health officers estimate wrongly the threshold even when using their own subjective estimate of influencing factors. Omitting treatment cost and subjective weight of provoked harm can result in a very low threshold. Sound training in threshold principles and providing tools to correctly assess data might help in making better decisions in tuberculosis in developing countries.