Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis in six high tuberculosis incidence countries: a mathematical modelling study
Marc d’Elbée, Martin Harker, Nyashadzaishe Mafirakureva, Mastula Nanfuka, Minh Huyen Ton Nu Nguyet, Jean-Voisin Taguebue, Raoul Moh, Celso Khosa, Ayeshatu Mustapha, Juliet Mwanga-Amumpere, Laurence Borand, Sylvie Kwedi Nolna, Eric Komena, Saniata Cumbe, Jacob Ross Mugisha, Naome Natukunda, Tan Eang Mao, Jérôme Wittwer, Antoine Bénard, Tanguy Bernard, Hojoon Sohn, Maryline Bonnet, Eric Wobudeya, Olivier Marcy, Peter J. Dodd, Doris Arlt-Hilares, Éric Balestre, Marie-France Banga, Antoine Bénard, Tanguy Bernard, Maryline Bonnet, Laurence Borand, Guillaume Breton, Bunnet Dim, Paul-Damien Chateau, Saniata Cumbe, Marc d’Elbée, Agathe de Lauzanne, Peter J. Dodd, Martin Harker, Minh Huyen Ton Nu Nguyet, Sanary Kaing, Celso Khosa, Eric Komena, Monica Koroma, Sylvie Kwedi Nolna, Nyashadzaishe Mafirakureva, Tan Eang Mao, Olivier Marcy, Douglas Mbang Massom, Raoul Moh, Jacob Ross Mugisha, Ayeshatu Mustapha, Juliet Mwanga-Amumpere, Mastula Nanfuka, Naome Natukunda, Joanna Orne‐Gliemann, Éric Ouattara, Julien Poublan, Hojoon Sohn, Jean-Voisin Taguebue, Immaculate Tulinawe, Yara Voss De Lima, Jérôme Wittwer, Eric Wobudeya
Abstract
Background: The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods: In this mathematical modelling study, we assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC). The project was conducted in Cambodia, Cameroon, Côte d'Ivoire, Mozambique, Sierra Leone, and Uganda between August 1st, 2018 and September 30th, 2021. A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability-adjusted life years (DALYs) and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. The TB-Speed Decentralization study is registered with ClinicalTrials.gov, NCT04038632. Findings: For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d'Ivoire) per DALY averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d'Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $12.8 M (range 10.8-16.4) (Cambodia) and $50.4 M (36.5-74.4) (Mozambique), and between $13.9 M (12.6-15.6) (Sierra Leone) and $134.6 M (127.1-143.0) (Uganda) for the PHC-focused strategy. Interpretation: The DH-focused strategy may be cost-effective in some countries, depending on the cost-effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding: Unitaid.