Cost of tuberculosis treatment in low- and middle-income countries: systematic review and meta-regression.

BACKGROUND: Despite a scarcity of tuberculosis (TB) cost data, a substantial body of evidence has been accumulating for drug-susceptible TB (DS-TB) treatment. In this study, we review unit costs for DS-TB treatment from a provider´s perspective. We also examine factors driving cost variations and extrapolate unit costs across low- and middle-income countries (LMICs).METHODS: We searched published and grey literature for any empirically collected TB cost estimates. We selected a subgroup of estimates looking at DS-TB treatment. We extracted information on activities and inputs included. We standardised costs into an average per person-month, fitted a multi-level regression model and cross-validated country-level predictions. We then extrapolated estimates for facility-based, directly observed DS-TB treatment across countries.RESULTS: We included 95 cost estimates from 28 studies across 17 countries. Costs predictions were sensitive to characteristics such as delivery mode, whether hospitalisation was included, and inputs accounted for, as well as gross domestic product per capita. Extrapolation results are presented with uncertainty intervals (UIs) for LMICs. Predicted median costs per 6 months of treatment were US$315.30 (95$222.60-US$417.20) for low-income, US$527.10 (95% CI US$395.70-US$743.70) for lower middle-income and US$896.40 (95$654.00-US$1214.40) for upper middle-income countries.CONCLUSIONS: Our study provides country-level DS-TB treatment cost estimates suitable for priority setting. These estimates, while not standing as a substitute for local high-quality primary data, can inform global, regional and national exercises

The cold gas content of bulgeless dwarf galaxies

We present an analysis of the neutral hydrogen (H i) properties of a fully cosmological hydrodynamical dwarf galaxy, run with varying simulation parameters. As reported by Governato et al., the high-resolution, high star formation density threshold version of this galaxy is the first simulation to result in the successful reproduction of a (dwarf) spiral galaxy without any associated stellar bulge. We have set out to compare in detail the H i distribution and kinematics of this simulated bulgeless disc with what is observed in a sample of nearby dwarfs. To do so, we extracted the radial gas density profiles, velocity dispersion (e.g. velocity ellipsoid and turbulence) and the power spectrum of structure within the cold interstellar medium (ISM) from the simulations. The highest resolution dwarf, when using a high-density star formation threshold comparable to densities of giant molecular clouds, possesses bulk characteristics consistent with those observed in nature, though the cold gas is not as radially extended as that observed in nearby dwarfs, resulting in somewhat excessive surface densities. The lines-of-sight velocity dispersion radial profiles have values that are in good agreement with the observed dwarf galaxies, but due to the fact that only the streaming velocities of particles are tracked, a correction to include the thermal velocities can lead to profiles that are quite flat. The ISM power spectra of the simulations appear to possess more power on smaller spatial scales than that of the Small Magellanic Cloud. We conclude that unavoidable limitations remain due to the unresolved physics of star formation and feedback within parsec-scale molecular cloud

Costs of TB services in India (No 1).

BACKGROUND: There is a dearth of economic analysis required to support increased investment in TB in India. This study estimates the costs of TB services from a health systems´ perspective to facilitate the efficient allocation of resources by India´s National Tuberculosis Elimination Programme.METHODS: Data were collected from a multi-stage, stratified random sample of 20 facilities delivering TB services in two purposively selected states in India as per Global Health Cost Consortium standards and using Value TB Data Collection Tool. Unit costs were estimated using the top-down (TD) and bottom-up (BU) methodology and are reported in 2018 US dollars.RESULTS: Cost of delivering 50 types of TB services and four interventions varied according to costing method. Key services included sputum smear microscopy, Xpert® MTB/RIF and X-ray with an average BU costs of respectively US$2.45, US$17.36 and US$2.85. Average BU cost for bacille Calmette-Guérin vaccination, passive case-finding, TB prevention in children under 5 years using isoniazid and first-line drug treatment in new pulmonary and extrapulmonary TB cases was respectively US$0.76, US$1.62, US$2.41, US$103 and US$98.CONCLUSION: The unit cost of TB services and outputs are now available to support investment decisions, as diagnosis algorithms are reviewed and prevention or treatment for TB are expanded or updated in India

Cost of TB services in the public and private sectors in Georgia (No 2)

BACKGROUND: Patient-centred care along with optimal financing of inpatient and outpatient services are the main priorities of the Georgia National TB Programme (NTP). This paper presents TB diagnostics and treatment unit cost, their comparison with NTP tariffs and how the study findings informed TB financing policy.METHODS: Top-down (TD) and bottom-up (BU) mean unit costs for TB interventions by episode of care were calculated. TD costs were compared with NTP tariffs, and variations in these and the unit costs cost composition between public and private facilities was assessed.RESULTS: Outpatient interventions costs exceeded NTP tariffs. Unit costs in private facilities were higher compared with public providers. There was very little difference between per-day costs for drug-susceptible treatment and NTP tariffs in case of inpatient services. Treatment day financing exceeded actual costs in the capital (public facility) for drug-resistant TB, and this was lower in the regions.CONCLUSION: Use of reliable unit costs for TB services at policy discussions led to a shift from per-day payment to a diagnosis-related group model in TB inpatient financing in 2020. A next step will be informing policy decisions on outpatient TB care financing to reduce the existing gap between funding and costs

Efficiency of TB service provision in the public and private health sectors in Ethiopia.

BACKGROUND: The Ethiopian Government has identified efficiency of TB services as a key priority in planning and budgeting. Understanding the magnitude and sources of inefficiencies is key to ensuring value for money and improved service provision, and a requirement from donors to justify resource needs. This study identifies the cost of providing a wide range of TB services in public and private facilities in Ethiopia.METHODS: Financial and economic unit costs were estimated from a health provider´s perspective, and collected retrospectively in 26 health facilities using both top-down (TD) and bottom-up (BU) costing approaches for each TB service output. Capacity inefficiency was assessed by investigating the variation between TD and BU unit costs where the factor was 2.0 or more.RESULTS: Overall, TD unit costs were two times higher than BU unit costs. There was some variation across facility ownership and level of care. Unit costs in urban facilities were on average 3.8 times higher than in rural facilities.CONCLUSION: We identified some substantial inefficiencies in staff, consumable and capital inputs. Addressing these inefficiencies and rearranging the TB service delivery modality would be important in ensuring the achievement of the country´s End TB strategy

Cost of TB prevention and treatment in the Philippines in 2017.

BACKGROUND: The Philippines aims to accelerate TB reduction through the provision of universally accessible and affordable services. The objectives of this paper are to estimate the costs of TB services and interventions using a health systems´ perspective, and to explore cost differences in service delivery via primary care facilities or hospitals.METHODS: Data were collected from a multi-stage stratified random sampling of 28 facilities in accordance with Global Health Cost Consortium costing standards and analysis tools. Unit costs (in US$) estimated using top-down (TD) and bottom-up (BU) approaches, are summarised following Value TB reporting standards and by broad facility type.RESULTS: Cost of delivering 32 TB services and eight interventions varied by costing method and delivery platform. Average BU costs ranged from US$0.38 for treatment support visits, US$2.5 for BCG vaccination, US$19.48 for the Xpert® MTB/RIF test to US$3,677 for MDR-TB treatment using the long regimen. Delivering TB care in hospitals was generally more costly than in primary care facilities, except for TB prevention in children and MDR-TB treatment using the long regimen.CONCLUSION: Comprehensive costing data for TB care in the Philippines are now available to aid in the design, planning, and prioritisation of delivery models to End TB

Cost of TB services in healthcare facilities in Kenya (No 3).

BACKGROUND: The reduction of Kenya´s TB burden requires improving resource allocation both to and within the National TB, Leprosy and Lung Disease Program (NTLD-P). We aimed to estimate the unit costs of TB services for budgeting by NTLD-P, and allocative efficiency analyses for future National Strategic Plan (NSP) costing.METHODS: We estimated costs of all TB interventions in a sample of 20 public and private health facilities from eight counties. We calculated national-level unit costs from a health provider´s perspective using bottom-up (BU) and top-down (TD) approaches for the financial year 2017-2018 using Microsoft Excel and STATA v16.RESULTS: The mean unit cost for passive case-finding (PCF) was respectively US$38 and US$60 using the BU and TD approaches. The unit BU and TD costs of a 6-month first-line treatment (FLT) course, including monitoring tests, was respectively US$135 and US$160, while those for adult drug-resistant TB (DR-TB) treatment was respectively US$3,230.28 and US$3,926.52 for the 9-month short regimen. Intervention costs highlighted variations between BU and TD approaches. Overall, TD costs were higher than BU, as these are able to capture more costs due to inefficiency (breaks/downtime/leave).CONCLUSION: The activity-based TB unit costs form a comprehensive cost database, and the costing process has built-in capacity within the NTLD-P and international TB research networks, which will inform future TB budgeting processes

LADUMA: looking at the distant universe with the MeerKAT array

The cosmic evolution of galaxies’ neutral atomic gas content is a major science driver for the Square Kilometre Array (SKA), as well as for its South African (MeerKAT) and Australian (ASKAP) precursors. Among the H I large survey programs (LSPs) planned for ASKAP and MeerKAT, the deepest and narrowest tier of the “wedding cake” will be defined by the combined L-band+UHF-band Looking At the Distant Universe with the MeerKAT Array (LADUMA) survey, which will probe H I in emission within a single “cosmic vuvuzela” that extends to z = 1.4, when the universe was only a third of its present age. Through a combination of individual and stacked detections (the latter relying on extensive multi-wavelength studies of the survey’s target field), LADUMA will study the redshift evolution of the baryonic Tully–Fisher relation and the cosmic H I density, the variation of the H I mass function with redshift and environment, and the connection between H I content and galaxies’ stellar properties (mass, age, etc.). The survey will also build a sample of OH megamaser detections that can be used to trace the cosmic merger history. This proceedings contribution provides a brief introduction to the survey, its scientific aims, and its technical implementation, deferring a more complete discussion for a future article after the implications of a recent review of MeerKAT LSP project plans are fully worked out

Patients' costs associated with seeking and accessing treatment for drug-resistant tuberculosis in South Africa

SETTING: South Africa is one of the world's 22 high tuberculosis (TB) burden countries, with the second highest number of notified rifampicin-resistant TB (RR-TB) and multidrug-resistant TB (MDR-TB) cases. OBJECTIVE: To estimate patient costs associated with the diagnosis and treatment of RR-TB/MDR-TB in South Africa. DESIGN: Patients diagnosed with RR-TB/MDR-TB and accessing care at government health care facilities were surveyed using a structured questionnaire. Direct and indirect costs associated with accessing RR-TB/MDR-TB care were estimated at different treatment durations for each patient. RESULTS: A total of 134 patients were surveyed: 84 in the intensive phase and 50 in the continuation phase of treatment, 82 in-patients and 52 out-patients. The mean monthly patient costs associated with the diagnosis and treatment of RR-TB/MDR-TB were higher during the intensive phase than the continuation phase (US$235 vs. US$188) and among in-patients than among out-patients (US$269 vs. US$122). Patients in the continuation phase and those accessing care as out-patients reported higher out-of-pocket costs than other patients. Most patients did not access social protection for costs associated with RR-TB/MDR-TB illness. CONCLUSION: Despite free health care, patients bear high costs when accessing diagnosis and treatment services for RR-TB/MDR-TB; appropriate social protection mechanisms should be provided to assist them in coping with these costs