title: Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models.
abstract: The post-2015 End TB Strategy sets global targets of reducing tuberculosis incidence by 50% and mortality by 75% by 2025. We aimed to assess resource requirements and cost-effectiveness of strategies to achieve these targets in China, India, and South Africa.
  
  
  
  We examined intervention scenarios developed in consultation with country stakeholders, which scaled up existing interventions to high but feasible coverage by 2025. Nine independent modelling groups collaborated to estimate policy outcomes, and we estimated the cost of each scenario by synthesising service use estimates, empirical cost data, and expert opinion on implementation strategies. We estimated health effects (ie, disability-adjusted life-years averted) and resource implications for 2016-35, including patient-incurred costs. To assess resource requirements and cost-effectiveness, we compared scenarios with a base case representing continued current practice.
  
  
  
  Incremental tuberculosis service costs differed by scenario and country, and in some cases they more than doubled existing funding needs. In general, expansion of tuberculosis services substantially reduced patient-incurred costs and, in India and China, produced net cost savings for most interventions under a societal perspective. In all three countries, expansion of access to care produced substantial health gains. Compared with current practice and conventional cost-effectiveness thresholds, most intervention approaches seemed highly cost-effective.
  
  
  
  Expansion of tuberculosis services seems cost-effective for high-burden countries and could generate substantial health and economic benefits for patients, although substantial new funding would be required. Further work to determine the optimal intervention mix for each country is necessary.
  
  
  
  Bill & Melinda Gates Foundation.
authors.affiliation: Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA. Electronic address: nmenzies@hsph.harvard.edu.
authors.forename: Nicolas A
authors.initials: NA
authors.lastname: Menzies
authors.affiliation: Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands; Department of Global Health, Academic Medical Center, University of Amsterdam, Netherlands; Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Gabriela B
authors.initials: GB
authors.lastname: Gomez
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Fiammetta
authors.initials: F
authors.lastname: Bozzani
authors.affiliation: Public Health Foundation of India, Delhi NCR, India.
authors.forename: Susmita
authors.initials: S
authors.lastname: Chatterjee
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Nicola
authors.initials: N
authors.lastname: Foster
authors.affiliation: Monitoring and Evaluation Unit, Geneva, Switzerland.
authors.forename: Ines Garcia
authors.initials: IG
authors.lastname: Baena
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Yoko V
authors.initials: YV
authors.lastname: Laurence
authors.affiliation: School of Health Care Management and Key Laboratory of Health Economics and Policy Research of Ministry of Health, Shandong University, Jinan, China.
authors.forename: Sun
authors.initials: S
authors.lastname: Qiang
authors.affiliation: Global TB Programme, Geneva, Switzerland.
authors.forename: Andrew
authors.initials: A
authors.lastname: Siroka
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Sedona
authors.initials: S
authors.lastname: Sweeney
authors.affiliation: Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Verguet
authors.affiliation: Public Health Foundation of India, Delhi NCR, India; Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
authors.forename: Nimalan
authors.initials: N
authors.lastname: Arinaminpathy
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Andrew S
authors.initials: AS
authors.lastname: Azman
authors.affiliation: Department of Medicine, Stanford University, Stanford, CA, USA.
authors.forename: Eran
authors.initials: E
authors.lastname: Bendavid
authors.affiliation: Institute for Disease Modeling, Seattle, WA, USA.
authors.forename: Stewart T
authors.initials: ST
authors.lastname: Chang
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
authors.forename: Ted
authors.initials: T
authors.lastname: Cohen
authors.affiliation: Victorian Tuberculosis Program at the Peter Doherty Institute, Melbourne, VIC, Australia; Department of Microbiology and Immunology, University of Melbourne, Melbourne, VIC, Australia.
authors.forename: Justin T
authors.initials: JT
authors.lastname: Denholm
authors.affiliation: Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: David W
authors.initials: DW
authors.lastname: Dowdy
authors.affiliation: Institute for Disease Modeling, Seattle, WA, USA.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Eckhoff
authors.affiliation: Stanford Health Policy, Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA.
authors.forename: Jeremy D
authors.initials: JD
authors.lastname: Goldhaber-Fiebert
authors.affiliation: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.
authors.forename: Andreas
authors.initials: A
authors.lastname: Handel
authors.affiliation: Institute for Disease Modeling, Seattle, WA, USA; Synthetic Neurobiology Group, Media Lab, Massachusetts Institute of Technology, Cambridge, MA, USA.
authors.forename: Grace H
authors.initials: GH
authors.lastname: Huynh
authors.affiliation: TB Modelling Group, TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Marek
authors.initials: M
authors.lastname: Lalli
authors.affiliation: Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Hsien-Ho
authors.initials: HH
authors.lastname: Lin
authors.affiliation: Public Health Foundation of India, Delhi NCR, India.
authors.forename: Sandip
authors.initials: S
authors.lastname: Mandal
authors.affiliation: Victorian Tuberculosis Program at the Peter Doherty Institute, Melbourne, VIC, Australia; Department of Microbiology and Immunology, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia.
authors.forename: Emma S
authors.initials: ES
authors.lastname: McBryde
authors.affiliation: Public Health Foundation of India, Delhi NCR, India.
authors.forename: Surabhi
authors.initials: S
authors.lastname: Pandey
authors.affiliation: Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Center for Health Decision Science, Harvard T H Chan School of Public Health, Boston, MA, USA.
authors.forename: Joshua A
authors.initials: JA
authors.lastname: Salomon
authors.affiliation: Department of Management Science and Engineering, Stanford University, Stanford, CA, USA.
authors.forename: Sze-Chuan
authors.initials: SC
authors.lastname: Suen
authors.affiliation: TB Modelling Group, TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Tom
authors.initials: T
authors.lastname: Sumner
authors.affiliation: Victorian Tuberculosis Program at the Peter Doherty Institute, Melbourne, VIC, Australia; Department of Microbiology and Immunology, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia.
authors.forename: James M
authors.initials: JM
authors.lastname: Trauer
authors.affiliation: Institute for Disease Modeling, Seattle, WA, USA.
authors.forename: Bradley G
authors.initials: BG
authors.lastname: Wagner
authors.affiliation: Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.
authors.forename: Christopher C
authors.initials: CC
authors.lastname: Whalen
authors.affiliation: Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan.
authors.forename: Chieh-Yin
authors.initials: CY
authors.lastname: Wu
authors.affiliation: Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Delia
authors.initials: D
authors.lastname: Boccia
authors.affiliation: Epidemiology and Research Division, National Tuberculosis Institute, Bangalore, India.
authors.forename: Vineet K
authors.initials: VK
authors.lastname: Chadha
authors.affiliation: Aurum Institute, Johannesburg, South Africa.
authors.forename: Salome
authors.initials: S
authors.lastname: Charalambous
authors.affiliation: Bill & Melinda Gates Foundation, Seattle, WA, USA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Chin
authors.affiliation: Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; Aurum Institute, Johannesburg, South Africa; School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Gavin
authors.initials: G
authors.lastname: Churchyard
authors.affiliation: Stop TB Partnership, Geneva, Switzerland.
authors.forename: Colleen
authors.initials: C
authors.lastname: Daniels
authors.affiliation: Bill & Melinda Gates Foundation, New Delhi, India.
authors.forename: Puneet
authors.initials: P
authors.lastname: Dewan
authors.affiliation: Stop TB Partnership, Geneva, Switzerland.
authors.forename: Lucica
authors.initials: L
authors.lastname: Ditiu
authors.affiliation: Department of Infectious Disease Epidemiology, Imperial College London, London, UK.
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Eaton
authors.affiliation: Department of Clinical Research, London School of Hygiene & Tropical Medicine, London, UK; School of Public Health, University of Witwatersrand, Johannesburg, South Africa; Africa Centre for Population Health, School of Nursing & Public Health, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: Alison D
authors.initials: AD
authors.lastname: Grant
authors.affiliation: Aurum Institute, Johannesburg, South Africa.
authors.forename: Piotr
authors.initials: P
authors.lastname: Hippner
authors.affiliation: Strategic Information Department, The Global Fund, Geneva, Switzerland.
authors.forename: Mehran
authors.initials: M
authors.lastname: Hosseini
authors.affiliation: National Department of Health, Pretoria, South Africa.
authors.forename: David
authors.initials: D
authors.lastname: Mametja
authors.affiliation: Avenir Health, Glastonbury, CT, USA.
authors.forename: Carel
authors.initials: C
authors.lastname: Pretorius
authors.affiliation: National Department of Health, Pretoria, South Africa.
authors.forename: Yogan
authors.initials: Y
authors.lastname: Pillay
authors.affiliation: World Health Organization Country Office for India, New Delhi, India.
authors.forename: Kiran
authors.initials: K
authors.lastname: Rade
authors.affiliation: Stop TB Partnership, Geneva, Switzerland.
authors.forename: Suvanand
authors.initials: S
authors.lastname: Sahu
authors.affiliation: National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China.
authors.forename: Lixia
authors.initials: L
authors.lastname: Wang
authors.affiliation: TB Modelling Group, TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Rein M G J
authors.initials: RMGJ
authors.lastname: Houben
authors.affiliation: KNCV Tuberculosis Foundation, The Hague, Netherlands.
authors.forename: Michael E
authors.initials: ME
authors.lastname: Kimerling
authors.affiliation: TB Modelling Group, TB Centre, London School of Hygiene & Tropical Medicine, London, UK; Faculty of Epidemiology and Public Health, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Richard G
authors.initials: RG
authors.lastname: White
authors.affiliation: Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
mesh_terms: D002681:China; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care / Q000191:economics; D005544:Forecasting; D006040:Goals; D017048:Health Care Costs; D005102:Health Expenditures; D006291:Health Policy; D006295:Health Resources; D006297:Health Services Accessibility; D006301:Health Services Needs and Demand; D006801:Humans; D007194:India; D008962:Models, Theoretical; D010342:Patient Acceptance of Health Care; D019057:Quality-Adjusted Life Years; D013019:South Africa; D014376:Tuberculosis / Q000191:economics / Q000401:mortality / Q000517:prevention & control*