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Kohler S, Sitali N, Achar J, Paul N. Costs and import costs of past, present, and future TB drug regimens: a case study for Karakalpakstan, Uzbekistan. J Public Health (Oxf) 2022:6842872. [DOI: 10.1093/pubmed/fdac124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 06/23/2022] [Accepted: 09/26/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background
Tuberculosis (TB) drugs and their import are costly. We assessed how shorter TB drug regimens, which were non-inferior or superior in recent TB trials, can affect the costs for purchasing and importing TB drugs.
Methods
We estimated the drug costs and import costs of 39 longer and shorter TB drug regimens using TB drug prices from the Global Drug Facility and import cost estimates for a TB program in Karakalpakstan, Uzbekistan. Drug regimens from recent TB trials were compared with TB drug regimens following present or past World Health Organization recommendations.
Results
We estimated an import cost of $4.19 and a drug cost of $43 per standard 6-month drug-sensitive (DS)-TB regimen. A new 17-week DS-TB regimen from the TBTC Study 31 currently requires more tablets and is more expensive to import ($6.08) and purchase ($233). The TB program can substantially decrease import costs ($2.26–14) and drug costs ($391–2308) per multidrug-resistant (MDR)-TB regimen when using new 6-month or shorter drug regimens from the Nix-TB, NExT, TB PRACTECAL, ZeNix, or BEAT TB trials instead of 9–20-month regimens with import costs of $9.96–507 and drug costs of $354–15 028. For a commonly used 20-month all-oral, bedaquiline-containing MDR-TB regimen, we estimated costs of $41 for drug import and $1773 for drug purchase.
Conclusions
The implementation of a new and shorter DS-TB regimen may increase the costs for drug purchase and import. The implementation of new and shorter MDR-TB regimens may decrease the costs for drug purchase and/or drug import.
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Affiliation(s)
- Stefan Kohler
- Heidelberg Institute of Global Health , Faculty of Medicine and University Hospital, , Im Neuenheimer Feld 130.3, 69120 Heidelberg , Germany
- Heidelberg University , Faculty of Medicine and University Hospital, , Im Neuenheimer Feld 130.3, 69120 Heidelberg , Germany
- Institute of Social Medicine , Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Norman Sitali
- Médecins Sans Frontières , Schwedenstraße 9, 13359 Berlin , Germany
| | - Jay Achar
- Department of Global Public Health, Karolinska Institutet , Tomtebodavägen 18, 171 65 Solna , Sweden
| | - Nicolas Paul
- Heidelberg Institute of Global Health , Faculty of Medicine and University Hospital, , Im Neuenheimer Feld 130.3, 69120 Heidelberg , Germany
- Heidelberg University , Faculty of Medicine and University Hospital, , Im Neuenheimer Feld 130.3, 69120 Heidelberg , Germany
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Kohler S, Sitali N, Achar J, Paul N. The contribution of drug import to the cost of tuberculosis treatment: A cost analysis of longer, shorter, and short drug regimens for Karakalpakstan, Uzbekistan. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000567. [PMID: 36962528 PMCID: PMC10021759 DOI: 10.1371/journal.pgph.0000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 05/11/2022] [Indexed: 11/19/2022]
Abstract
Tuberculosis (TB) programs depend on a continuous supply of large amounts of high-quality TB drugs. When TB programs procure TB drugs from international suppliers, such as the Global Drug Facility, they can incur import costs for international transport, customs clearance, and national transport. We assessed the drug costs and import costs of 18 longer (≥18 months), 10 shorter (9-12 months), and 8 short (≤6 months) drug regimens for drug-sensitive (DS) and multidrug-resistant (MDR)-TB treatment. Costs per regimen were estimated by multiplying recommended drug amounts with 2021 Global Drug Facility prices and drug import costs of a TB program in Karakalpakstan, Uzbekistan. The standard short-course treatment of DS-TB requires taking 730 fixed-dose combination tablets, which weigh 0.79 kg and cause an import cost of $4.19 (9.8% of the regimen's drug cost of $43). A new 4-month DS-TB regimen requires taking 1358 tablets, which weigh 1.1 kg and cause an import cost of $6.07 (2.6% of the regimen's drug cost of $233). MDR-TB regimens that last between 24 weeks and 20 months involve 546-9368 tablets and injections. The drugs for these MDR-TB regimens were estimated to weigh 0.42-96 kg and cause an import cost of $2.26-507 per drug regimen (0.29-11% of a regimen's drug cost of $360-15,028). In a multivariable regression analysis, an additional treatment month increased the import cost of a drug regimen by $5.45 (95% CI: 1.65 to 9.26). Use of an injectable antibiotic in a regimen increased the import cost by $133 (95% CI: 47 to 219). The variable and potentially sizable import costs of TB regimens can affect the financial needs of TB programs. Drug regimens that are shorter and all-oral tend to reduce import costs compared to longer regimens and regimens including an injectable drug.
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Affiliation(s)
- Stefan Kohler
- Institute of Social Medicine, Epidemiology and Health Economics, Charité –Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | | | - Jay Achar
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Nicolas Paul
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
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Kohler S, Sitali N, Achar J, Paul N. Program costs of longer and shorter tuberculosis drug regimens and drug import: A modelling study for Karakalpakstan, Uzbekistan. ERJ Open Res 2022; 8:00622-2021. [PMID: 35350276 PMCID: PMC8943289 DOI: 10.1183/23120541.00622-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/28/2021] [Indexed: 11/07/2022] Open
Abstract
Background The introduction of new and often shorter tuberculosis (TB) drug regimens affects the cost of TB programmes. Methods We modelled drug purchase and import costs for 20-month, 9-month and 4- to 6-month TB drug regimens based on 2016–2020 treatment numbers from a TB programme in Karakalpakstan, Uzbekistan, and 2021 Global Drug Facility prices. Results On average, 2225±374 (±sd) people per year started TB treatment, 30±2.1% of whom were diagnosed with drug-resistant forms of TB. Transitioning from a 6-month to a 4-month drug-susceptible (DS)-TB drug regimen increased the TB programme's annual DS-TB drug cost from USD 65±10 K to USD 357±56 K (p<0.001) and its drug import cost from USD 6.4±1.0 K to USD 9.3±1.4 K (p=0.008). Transitioning from a 20-month all-oral multidrug-resistant (MDR)-TB drug regimen to a 9-month MDR-TB drug regimen with an injectable antibiotic decreased the TB programme's annual MDR-TB drug cost from USD 1336±265 K to USD 266±53 K (p<0.001) and had no significant effect on the drug import cost (USD 28±5.5 K versus USD 27±5.4 K; p=0.88). Purchasing (USD 577±114 K) and importing (USD 3.0±0.59 K) the 6-month all-oral MDR-TB drug regimen cost more than procuring the 9-month MDR-TB drug regimen but less than the 20-month all-oral MDR-TB drug regimen (both p<0.01). Conclusion Introducing new and shorter TB drug regimens could increase the cost of TB programmes with low drug resistance rates and decrease the cost of TB programmes with high drug resistance rates. Introduction of new TB drug regimens can increase or decrease programme expenses for drug purchase and import. Modelling programme costs of different drug regimens can inform financial planning and help prepare TB programmes for changes in treatment.https://bit.ly/3r8coRj
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Kohler S, Sitali N, Paul N. A Framework for Assessing Import Costs of Medical Supplies and Results for a Tuberculosis Program in Karakalpakstan, Uzbekistan. HEALTH DATA SCIENCE 2021; 2021:9813732. [PMID: 38487507 PMCID: PMC10904066 DOI: 10.34133/2021/9813732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/04/2021] [Indexed: 03/17/2024]
Abstract
Background. Import of medical supplies is common, but limited knowledge about import costs and their structure introduces uncertainty to budget planning, cost management, and cost-effectiveness analysis of health programs. We aimed to estimate the import costs of a tuberculosis (TB) program in Uzbekistan, including the import costs of specific imported items.Methods. We developed a framework that applies costing and cost accounting to import costs. First, transport costs, customs-related costs, cargo weight, unit weights, and quantities ordered were gathered for a major shipment of medical supplies from the Médecins Sans Frontières (MSF) Procurement Unit in Amsterdam, the Netherlands, to a TB program in Karakalpakstan, Uzbekistan, in 2016. Second, air freight, land freight, and customs clearance cost totals were estimated. Third, total import costs were allocated to different cargos (standard, cool, and frozen), items (e.g., TB drugs), and units (e.g., one tablet) based on imported weight and quantity. Data sources were order invoices, waybills, the local MSF logistics department, and an MSF standard product list.Results. The shipment contained 1.8 million units of 85 medical items of standard, cool, and frozen cargo. The average import cost for the TB program was 9.0% of the shipment value. Import cost varied substantially between cargos (8.9-28% of the cargo value) and items (interquartile range 4.5-35% of the item value). The largest portion of the total import cost was caused by transport (82-99% of the cargo import cost) and allocated based on imported weight. Ten (14%) of the 69 items imported as standard cargo were associated with 85% of the standard cargo import cost. Standard cargo items could be grouped based on contributing to import costs predominantly through unit weight (e.g., fluids), imported quantity (e.g., tablets), or the combination of unit weight and imported quantity (e.g., items in powder form).Conclusion. The cost of importing medical supplies to a TB program in Karakalpakstan, Uzbekistan, was sizable, variable, and driven by a subset of imported items. The framework used to measure and account import costs can be adapted to other health programs.
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Affiliation(s)
- Stefan Kohler
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Médecins Sans Frontières, Berlin, Germany
- Institute of Social Medicine, Epidemiology and Health Economics, Charité–Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | | | - Nicolas Paul
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Médecins Sans Frontières, Berlin, Germany
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Darisheva M, Tracy M, Terlikbayeva A, Zhussupov B, Schluger N, McCrimmon T. Knowledge and attitudes towards ambulatory treatment of tuberculоsis in Kazakhstan. BMC Health Serv Res 2020; 20:563. [PMID: 32571356 PMCID: PMC7310255 DOI: 10.1186/s12913-020-05413-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 06/09/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Ambulatory based treatment of tuberculosis has been recently introduced in Kazakhstan. We sought to assess the attitudes of the general population, TB patients and their household members towards ambulatory TB treatment and identify how knowledge of TB is associated with these attitudes. METHODS New pulmonary TB cases and their household and community controls were recruited from three regions of Kazakhstan in 2012-2014. 1083 participants completed audio computer-assisted self interviews to assess their knowledge of TB and attitudes towards ambulatory care. Mixed effects logistic regression models were used to identify factors associated with attitudes toward ambulatory TB treatment. RESULTS The proportion of people who considered ambulatory TB treatment as appropriate was very low (24.9%). Positive attitudes towards ambulatory TB treatment were significantly associated with region of residence, higher level of education, family support and experience with TB. The association between sufficient tuberculosis knowledge and favorable attitude toward ambulatory treatment was stronger among community controls compared to TB patients and their family members. CONCLUSIONS This study provides insight into attitudes toward ambulatory TB treatment among different groups and the specific influence of TB knowledge on these attitudes. Our findings can inform the process of integration of new TB treatment strategies and the development of appropriate education and advocacy programs in the general population.
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Affiliation(s)
- Meruyert Darisheva
- Columbia University Global Health Research Center of Central Asia, Almaty, Kazakhstan.
| | - Melissa Tracy
- School of Public Health, Department of Epidemiology and Biostatistics, University at Albany, Albany, NY, USA
| | - Assel Terlikbayeva
- Columbia University Global Health Research Center of Central Asia, Almaty, Kazakhstan
| | | | - Neil Schluger
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
| | - Tara McCrimmon
- Columbia University School of Social Work, 1255 Amsterdam Avenue, New York, NY, USA
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Kohler S, Asadov DA, Bründer A, Healy S, Khamraev AK, Sergeeva N, Tinnemann P. Health system support and health system strengthening: two key facilitators to the implementation of ambulatory tuberculosis treatment in Uzbekistan. HEALTH ECONOMICS REVIEW 2016; 6:28. [PMID: 27406392 PMCID: PMC4942444 DOI: 10.1186/s13561-016-0100-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 05/28/2016] [Indexed: 06/06/2023]
Abstract
Uzbekistan inherited a hospital-based health system from the Soviet Union. We explore the health system-related challenges faced during the scale-up of ambulatory (outpatient) treatment for drug-susceptible and drug-resistant tuberculosis (TB) in Karakalpakstan in Uzbekistan. Semi-structured interviews were conducted with key informants of the TB services, the ministries of health and finance, and their TB control partners. Structural challenges and resource needs were both discussed as obstacles to the expansion of ambulatory TB treatment. Respondents stated need for revising the financing mechanisms of the TB services to incentivize referral to ambulatory TB treatment. An increased workload and need for transportation in ambulatory TB care were also pointed out by respondents, given the quickly rising outpatient numbers but per capita financing of outpatient care. Policy makers showed strong interest in good practice examples for financing ambulatory-based management of TB in comparable contexts and in guidance for revising the financing of the TB services in a way that strengthens ambulatory TB treatment. To facilitate changing the model of care, TB control strategies emphasizing ambulatory care in hospital-oriented health systems should anticipate health system support and strengthening needs, and provide a plan of action to resolve both. Addressing both types of needs may require not only involving TB control and health financing actors, but also increasing knowledge about viable and tested financing mechanisms that incentivize the adoption of new models of care for TB.
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Affiliation(s)
- Stefan Kohler
- Institute of Public Health, Heidelberg University, Heidelberg, Germany.
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Médecins Sans Frontières, Nukus and Tashkent, Uzbekistan.
| | - Damin Abdurakhimovich Asadov
- Department of Health Management, Evidence-based Medicine Centre, Tashkent Institute of Postgraduate Medical Education, Tashkent, Uzbekistan
| | | | - Sean Healy
- Médecins Sans Frontières, Nukus and Tashkent, Uzbekistan
| | | | | | - Peter Tinnemann
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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