Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi.
METHODS
Lilongwe District, Malawi.


OBJECTIVE
To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997.


METHODS
For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or outpatient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US dollars, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases).


RESULTS
For new smear-positive patients, the cost per patient treated was dollars 456 with the conventional hospital-based strategy, and dollars 106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was dollars 787 for the conventional hospital-based strategy, and dollars 296 for decentralised treatment. For smear-negative patients, the cost per patient treated was dollars 67 with the conventional unsupervised strategy, and dollars 101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around dollars 200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs.


CONCLUSIONS
There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.
Floyd
K
K
Stop TB Department, World Health Organization, Geneva, Switzerland. floydk@who.int
Skeva
J
J
Nyirenda
T
T
Gausi
F
F
Salaniponi
F
F
D003153:Community Health Services / Q000191:economics* / Q000706:statistics & numerical data; D003362:Cost-Benefit Analysis; D003365:Costs and Cost Analysis; D017048:Health Care Costs / Q000706:statistics & numerical data*; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008295:Malawi; D011320:Primary Health Care / Q000191:economics* / Q000706:statistics & numerical data; D014397:Tuberculosis, Pulmonary / Q000188:drug therapy* / Q000191:economics*