Scaling Up TB Screening and TB Preventive Treatment Globally: Key Actions and Healthcare Service Costs

The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.

National tuberculosis spending efficiency and its associated factors in 121 low-income and middle-income countries, 2010–19: a data envelopment and stochastic frontier analysis

Background

Maximising the efficiency of national tuberculosis programmes is key to improving service coverage, outcomes, and progress towards End TB targets. We aimed to determine the overall efficiency of tuberculosis spending and investigate associated factors in 121 low-income and middle-income countries between 2010 and 2019.

Methods

In this data envelopment and stochastic frontier analysis, we used data from the WHO Global TB report series on tuberculosis spending as the input and treatment coverage as the output to estimate tuberculosis spending efficiency. We investigated associations between 25 independent variables and overall efficiency.

Findings

We estimated global tuberculosis spending efficiency to be between 73·8% (95% CI 71·2–76·3) and 87·7% (84·9–90·6) in 2019, depending on the analytical method used. This estimate suggests that existing global tuberculosis treatment coverage could be increased by between 12·3% (95% CI 9·4–15·1) and 26·2% (23·7–28·8) for the same amount of spending. Efficiency has improved over the study period, mainly since 2015, but a substantial difference of 70·7–72·1 percentage points between the most and least efficient countries still exists. We found a consistent significant association between efficiency and current health expenditure as a share of gross domestic product, out-of-pocket spending on health, and some Sustainable Development Goal (SDG) indicators such as universal health coverage.

Interpretation

To improve efficiency, treatment coverage will need to be increased, particularly in the least efficient contexts where this might require additional spending. However, progress towards global End TB targets is slow even in the most efficient countries. Variables associated with TB spending efficiency suggest efficiency is complimented by commitments to improving health-care access that is free at the point of use and wider progress towards the SDGs. These findings support calls for additional investment in tuberculosis care.

Funding

None.

Households experiencing catastrophic costs due to tuberculosis in Uganda: magnitude and cost drivers

BACKGROUND

Tuberculosis (TB) patients in Uganda incur large costs related to the illness, and while seeking and receiving health care. Such costs create access and adherence barriers which affect health outcomes and increase transmission of disease. The study ascertained the proportion of Ugandan TB affected households incurring catastrophic costs and the main cost drivers.

METHODS

A cross-sectional survey with retrospective data collection and projections was conducted in 2017. A total of 1178 drug resistant (DR) TB (44) and drug sensitive (DS) TB patients (1134), 2 weeks into intensive or continuation phase of treatment were consecutively enrolled across 67 randomly selected TB treatment facilities.

RESULTS

Of the 1178 respondents, 62.7% were male, 44.7% were aged 15-34 years and 55.5% were HIV positive. For each TB episode, patients on average incurred costs of USD 396 for a DS-TB episode and USD 3722 for a Multi drug resistant tuberculosis (MDR TB) episode. Up to 48.5% of households borrowed, used savings or sold assets to defray these costs. More than half (53.1%) of TB affected households experienced TB-related costs above 20% of their annual household expenditure, with the main cost drivers being non-medical expenditure such as travel, nutritional supplements and food.

CONCLUSION

Despite free health care in public health facilities, over half of Ugandan TB affected households experience catastrophic costs. Roll out of social protection interventions like TB assistance programs, insurance schemes, and enforcement of legislation related to social protection through multi-sectoral action plans with central NTP involvement would palliate these costs.

Tracking total spending on tuberculosis by source and function in 135 low-income and middle-income countries, 2000-17: a financial modelling study

BACKGROUND

Estimates of government spending and development assistance for tuberculosis exist, but less is known about out-of-pocket and prepaid private spending. We aimed to provide comprehensive estimates of total spending on tuberculosis in low-income and middle-income countries for 2000-17.

METHODS

We extracted data on tuberculosis spending, unit costs, and health-care use from the WHO global tuberculosis database, Global Fund proposals and reports, National Health Accounts, the WHO-Choosing Interventions that are Cost-Effective project database, and the Institute for Health Metrics and Evaluation Development Assistance for Health Database. We extracted data from at least one of these sources for all 135 low-income and middle-income countries using the World Bank 2019 definitions. We estimated tuberculosis spending by source and function for notified (officially reported) and non-notified tuberculosis cases separately and combined, using spatiotemporal Gaussian process regression to fill in for missing data and estimate uncertainty. We aggregated estimates of government, out-of-pocket, prepaid private, and development assistance spending on tuberculosis to estimate total spending in 2019 US$.

FINDINGS

Total spending on tuberculosis in 135 low-income and middle-income countries increased annually by 3·9% (95% CI 3·0 to 4·6), from $5·7 billion (5·2 to 6·5) in 2000 to $10·9 billion (10·3 to 11·8) in 2017. Government spending increased annually by 5·1% (4·4 to 5·7) between 2000 and 2017, and reached $6·9 billion (6·5 to 7·5) or 63·5% (59·2 to 66·8) of all tuberculosis spending in 2017. Of government spending, $5·8 billion (5·6 to 6·1) was spent on notified cases. Out-of-pocket spending decreased annually by 0·8% (-2·9 to 1·3), from $2·4 billion (1·9 to 3·1) in 2000 to $2·1 billion (1·6 to 2·7) in 2017. Development assistance for country-specific spending on tuberculosis increased from $54·6 million in 2000 to $1·1 billion in 2017. Administrative costs and development assistance for global projects related to tuberculosis care increased from $85·3 million in 2000 to $576·2 million in 2017. 30 high tuberculosis burden countries of low and middle income accounted for 73·7% (71·8-75·8) of tuberculosis spending in 2017.

INTERPRETATION

Despite substantial increases since 2000, funding for tuberculosis is still far short of global financing targets and out-of-pocket spending remains high in resource-constrained countries, posing a barrier to patient's access to care and treatment adherence. Of the 30 countries with a high-burden of tuberculosis, just over half were primarily funded by government, while others, especially lower-middle-income and low-income countries, were still primarily dependent on development assistance for tuberculosis or out-of-pocket health spending.

FUNDING

Bill & Melinda Gates Foundation.

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models

BACKGROUND

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.

METHODS

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.

FINDINGS

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.

INTERPRETATION

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.

FUNDING

Bill & Melinda Gates Foundation.