Tuberculosis treatment in high TB / HIV settings : evaluating public-private partnerships in South Africa

The aim of this thesis is to evaluate the perfonnance of different models of publicprivate partnerships in the provision of tuberculosis treatment, and explore incentive mechanisms for private sector participation. It makes recommendations to policymakers in South Africa and elsewhere on the best way to approach a policy on the enhanced role of private sector providers in tuberculosis treatment in light of the HIV/AIDS epidemic. A common framework is used to analyse the nature of the models, their perfonnance in tenns of cost, effectiveness and quality of care, and incentives for private participation. Multiple research methods are employed in order to fully investigate complex situations and to validate the findings. Both quantitative and qualitative methods are used. The study found that the quality of care is superior in both models of public-private partnerships when compared to the purely public sector model of delivery, and shows that increased collaboration with private providers through partnerships could potentially improve the quality of care and increase access to care. The results of the cost-effectiveness show that, in comparison with the purely public provision, the public-private partnership models could significantly reduce costs to both the public health sector and patient, and increase cost-effectiveness of tuberculosis treatment. Private providers in the existing and potential partnerships have both financial and non-financial motivations and incentives for participation in partnership. Overall, these pUblic-private partnerships show that there is a strong economic case for expanding the private sector involvement in tuberculosis treatment in South Africa. Expansion may require increased investment in the public-private partnerships, but they seem to be capable of delivering important improvements in the affordability and efficiency of tuberculosis treatment, and improving the South African health system's capacity to cope with the impact of the HIV/AIDS epidemic

Financing and cost-effectiveness analysis of public-private partnerships: provision of tuberculosis treatment in South Africa

BACKGROUND: Public-private partnerships (PPP) could be effective in scaling up services. We estimated cost and cost-effectiveness of different PPP arrangements in the provision of tuberculosis (TB) treatment, and the financing required for the different models from the perspective of the provincial TB programme, provider, and the patient. METHODS: Two different models of TB provider partnerships are evaluated, relative to sole public provision: public-private workplace (PWP) and public-private non-government (PNP). Cost and effectiveness data were collected at six sites providing directly observed treatment (DOT). Effectiveness for a 12-month cohort of new sputum positive patients was measured using cure and treatment success rates. Provider and patient costs were estimated, and analysed according to sources of financing. Cost-effectiveness is estimated from the perspective of the provider, patient and society in terms of the cost per TB case cured and cost per case successfully treated. RESULTS: Cost per case cured was significantly lower in PNP (US $354–446), and comparable between PWP (US$788–979) and public sites (US $700–1000). PPP models could significantly reduce costs to the patient by 64–100$609–690 to $130–139 in PNP and$36–46 in PWP. CONCLUSION: There is a strong economic case for expanding PPP in TB treatment and potentially for other types of health services. Where PPPs are tailored to target groups and supported by the public sector, scaling up of effective services could occur at much lower cost than solely relying on public sector models

Tuberculosis treatment in high TB/HIV settings : evaluating public-private partnerships in South Africa

The aim of this thesis is to evaluate the perfonnance of different models of publicprivate partnerships in the provision of tuberculosis treatment, and explore incentive mechanisms for private sector participation. It makes recommendations to policymakers in South Africa and elsewhere on the best way to approach a policy on the enhanced role of private sector providers in tuberculosis treatment in light of the HIV/AIDS epidemic. A common framework is used to analyse the nature of the models, their perfonnance in tenns of cost, effectiveness and quality of care, and incentives for private participation. Multiple research methods are employed in order to fully investigate complex situations and to validate the findings. Both quantitative and qualitative methods are used. The study found that the quality of care is superior in both models of public-private partnerships when compared to the purely public sector model of delivery, and shows that increased collaboration with private providers through partnerships could potentially improve the quality of care and increase access to care. The results of the cost-effectiveness show that, in comparison with the purely public provision, the public-private partnership models could significantly reduce costs to both the public health sector and patient, and increase cost-effectiveness of tuberculosis treatment. Private providers in the existing and potential partnerships have both financial and non-financial motivations and incentives for participation in partnership. Overall, these pUblic-private partnerships show that there is a strong economic case for expanding the private sector involvement in tuberculosis treatment in South Africa. Expansion may require increased investment in the public-private partnerships, but they seem to be capable of delivering important improvements in the affordability and efficiency of tuberculosis treatment, and improving the South African health system's capacity to cope with the impact of the HIV/AIDS epidemic.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Modelling the cost-effectiveness of a new infant vaccine to prevent tuberculosis disease in children in South Africa

Abstract Background Tuberculosis remains the leading cause of death in South Africa. A number of potential new TB vaccine candidates have been identified and are currently in clinical trials. One such candidate is MVA85A. This study aimed to estimate the cost-effectiveness of adding the MVA85A vaccine as a booster to the BCG vaccine in children from the perspective of the South African government. Methods The cost-effectiveness was assessed by employing Decision Analytic Modelling, through the use of a Markov model. The model compared the existing strategy of BCG vaccination to a new strategy in which infants receive BCG and a booster vaccine, MVA85A, at 4 months of age. The costs and outcomes of the two strategies are estimated through modelling the vaccination of a hypothetical cohort of newborns and following them from birth through to 10 years of age, employing 6-monthly cycles. Results The results of the cost-effectiveness analysis indicate that the MVA85A strategy is both more costly and more effective – there are fewer TB cases and deaths from TB than BCG alone. The South African government would need to spend an additional USD 1,105 for every additional TB case averted and USD 284,017 for every additional TB death averted. The threshold analysis shows that, if the efficacy of the MVA85A vaccine was 41.3% (instead of the current efficacy of 17.3%), the two strategies would have the same cost but more cases of TB and more deaths from TB would be prevented by adding the MVA85A vaccine to the BCG vaccine. In this case, the government chould consider the MVA85A strategy. Conclusions At the current level of efficacy, the MVA85A vaccine is neither effective nor cost-effective and, therefore, not a good use of limited resources. Nevertheless, this study contributes to developing a standardized Markov model, which could be used, in the future, to estimate the potential cost-effectiveness of new TB vaccines compared to the BCG vaccine, in children between the ages of 0–10 years. It also provides an indicative threshold of vaccine efficacy, which could guide future development

Health-related quality of life and its association with medication adherence in active pulmonary tuberculosis– a systematic review of global literature with focus on South Africa

IntroductionTuberculosis (TB) is a leading cause of morbidity and mortality in South Africa. Clinical parameters are important objective outcomes in TB; however they often are not directly correlated with subjective well-being of the patient, but can be assessed using patient-reported outcome (PRO) measures. Health-related quality of life (HRQOL) is a specific PRO generally multi-dimensional in nature and includes physical, mental and social health domains. The inclusion of HRQOL PROs in trials and clinical practice can provide additional information beyondclinical and microbiological parameters. Furthermore, HRQOL may be associated with medication adherence. This review focuses on patient-reported HRQOL and its association with medication adherence in TB patients in South Africa.MethodsA comprehensive search strategy was developed focusing on the impact of TB on patient-reported HRQOL,the existence of a conceptual framework of TB-specific HRQOL, determinants of medication adherence and the association of HRQOL with medication adherence. Data were extracted from all identified articles and additionaldata extraction was performed by two independent reviewers with special focus on longitudinal studies in order to understand changes of HRQOL and adherence over time. Research gaps were identified with regard to patient-reported HRQOL and medication adherence.ResultsA total of 66 articles met the eligibility criteria. Ten HRQOL studies and one adherence study used a longitudinal design, none of these in South Africa. A variety of different generic and disease-specific HRQOL measures were identified in the articles. In South Africa four HRQOL and five adherence studies (non-longitudinal) were published. Similar factors (socio-demographic, socio-economic, disease-related, therapy-related and psycho-social aspects) affect HRQOL and adherence. Although standard TB treatment improved all health domains, psychological well-being and social functioning remained impaired in microbiologically cured patients after treatment.ConclusionWhile evidence of TB impact on HRQOL and medication adherence and their association exists, it is verylimited for the South African situation. No valid and reliable TB-specific HRQOL measures were identified in this systematicreview. An assessment of HRQOL in TB patients in South Africa is required as this may assist with improving current disease management programmes, medication adherence and national treatment guidelines.Electronic supplementary materialThe online version of this article (doi:10.1186/s12955-016-0442-6) contains supplementary material, which is available to authorized users

Comparing the Application of CEA and BCA to Tuberculosis Control Interventions in South Africa

Achieving ambitious targets to address the global tuberculosis (TB) epidemic requires consideration of the impact of competing interventions for improved identification of patients with TB. Cost-effectiveness analysis (CEA) and benefit-cost analysis (BCA) are two approaches to economic evaluation that assess the costs and effects of competing alternatives. However, the differing theoretical basis and methodological approach to CEA and BCA is likely to result in alternative analytical outputs and potentially different policy interpretations. A BCA was conducted by converting an existing CEA on various combinations of TB control interventions in South Africa using a benefits transfer approach to estimate the value of statistical life (VSL) and value of statistical life year (VSLY). All combinations of interventions reduced untreated active disease compared to current TB control, reducing deaths by between 5,000 and 75,000 and resulting in net benefits of Int$3.2–Int$137 billion (ZAR18.1 billion to ZAR764 billion) over a 20-year period. This analysis contributes to development and application of BCA methods for health interventions and demonstrates that further investment in TB control in South Africa is expected to yield significant benefits. Further work is required to guide the appropriate analytical approach, interpretation and policy recommendations in the South African policy perspective and context.</jats:p

Citogenotoksični efekat vode iz jezera Vidara

The aim of this study is to determine the degree of cytotoxic and genotoxic effects of the water from Vidara lake. Water samples were taken at five different sites. The highest mean length of roots was in the sample of water from the North side of the lake and it is 22,53 mm. The same water sample also had the highest median value of the mitotic index i 27.5%. The biggest difference in the value of the mitotic index was observed between the values obtained at the West side and the control sample, but this difference was not statistically significant at the level p <0,05 (T = 1,45589; p = 0,141351). The results suggest that water from the lake Vidara has no significant genocitotoxic effect.Cilj ovog rada je utvrđivanje stepena citotoksičnog i genotoksičnog efekta vode iz jezera Vidara (Bosna i Hercegovina). Uzorci vode uzeti su na pet različitih lokaliteta. Najveća srednja vrijednost dužine korjenčića luka (Allium cepa) je utvrđena pri tretmanu uzorkom vode sa sjeverne strane jezera i iznosila je 22,53 mm. Na istom uzorku vode zabilježena je i najveća srednja vrijednosti mitotičkog indeksa (27,5%). Najveća razlika u vrijednosti mitotičkog indeksa uočena je između vrijednosti dobivene na lokalitetu zapad i kontrolnog uzorka, ali ta razlika nije statistički značajna na nivou p < 0,05 (T = 1,45589; p = 0,141351). Rezultati upućuju na zaključak da voda iz jezera Vidara nema značajan genocitotoksični efekat

Cost-effectiveness of Xpert MTB/RIF for tuberculosis diagnosis in South Africa: a real-world cost analysis and economic evaluation

Background In 2010 a new diagnostic test for tuberculosis, Xpert MTB/RIF, received a conditional programmatic recommendation from WHO. Several model-based economic evaluations predicted that Xpert would be cost-effective across sub-Saharan Africa. We investigated the cost-effectiveness of Xpert in the real world during national roll-out in South Africa. Methods For this real-world cost analysis and economic evaluation, we applied extensive primary cost and patient event data from the XTEND study, a pragmatic trial examining Xpert introduction for people investigated for tuberculosis in 40 primary health facilities (20 clusters) in South Africa enrolled between June 8, and Nov 16, 2012, to estimate the costs and cost per disability-adjusted life-year averted of introducing Xpert as the initial diagnostic test for tuberculosis, compared with sputum smear microscopy (the standard of care). Findings The mean total cost per study participant for tuberculosis investigation and treatment was US$312·58 (95$298·58 (246·35–350·82) in the microscopy group. The mean health service (provider) cost per study participant was $168·79 (149·16–188·42) for the Xpert group and$160·46 (143·24–177·68) for the microscopy group of the study. Considering uncertainty in both cost and effect using a wide range of willingness to pay thresholds, we found less than 3% probability that Xpert introduction improved the costeffectiveness of tuberculosis diagnostics. Interpretation After analysing extensive primary data collection during roll-out, we found that Xpert introduction in South Africa was cost-neutral, but found no evidence that Xpert improved the cost-effectiveness of tuberculosis diagnosis. Our study highlights the importance of considering implementation constraints, when predicting and evaluating the cost-effectiveness of new tuberculosis diagnostics in South Africa

Severe adverse events during second-line tuberculosis treatment in the context of high HIV Co-infection in South Africa: a retrospective cohort study

Background: According to the World Health Organization, South Africa ranks as one of the highest burden of TB, TB/HIV co-infection, and drug-resistant TB (DR-TB) countries. DR-TB treatment is complicated to administer and relies on the use of multiple toxic drugs, with potential for severe adverse drug reactions. We report the occurrence of adverse events (AEs) during a standardised DR-TB treatment regimen at two outpatient, decentralized, public-sector sites in Johannesburg, South Africa. Methods: We reviewed medical records of the six-month intensive treatment phase for rifampicin-resistant (RR) TB patients registered May 2012 - December 2014. Patients contributed follow-up time until death, loss from treatment, censoring (6 months) or data extraction. A standardized regimen of kanamycin, moxifloxacin, ethionamide, terizidone, and pyrazinamide was used according to national guidelines. AEs were graded using the AIDS Clinical Trial Group scale. We present subhazard ratios from competing risk analysis for time to severe AE, accounting for mortality and loss from treatment. Results: Across the two sites, 578 eligible patient files were reviewed. 36.7 % were categorized as low weight (≤50 kg) at DR-TB initiation. 76.0 % had no history of TB treatment prior to the current episode of RR TB. 26.8 % were diagnosed with RR TB while hospitalized, indicating poor clinical condition. 82.5 % of patients were also HIV positive, of whom 43. 8 % were on ART prior to RR TB treatment and 32.1 % initiated ART with or after RR TB treatment. Median CD4 count was 114.5 (IQR: 45-246.5). Overall, 578 reports of AEs were captured for 204 patients (35.3 %) and 110 patients (19.0 %) had at least one severe AE reported. Patients with at least one AE experienced a median of 3 (IQR: 2-4) AEs per patient. HIV-positive patients with CD4 counts ≤100 cells/mm3 and those newly initiating ART were more likely to experience a severe AE (sHR: 2.76, 95 % CI: 1.30–5.84 and sHR: 3.07, 95 % CI: 1.46–6.46, respectively). Conclusion: Severe AE are common during the first 6 months of RR TB treatment and HIV-positive patients newly initiating ART have the highest subdistribution hazard ratio for severe AE, accounting for the competing risks of death and loss from treatment