Cost and cost-effectiveness of increased community and primary care facility involvement in tuberculosis care in Lilongwe District, Malawi.

SETTING Lilongwe District, Malawi. OBJECTIVE To assess the cost and cost-effectiveness of new treatment strategies for new pulmonary tuberculosis patients, introduced in 1997. METHODS For new smear-positive pulmonary patients, two strategies were compared: 1) the strategy used until the end of October 1997, involving 2 months of hospitalisation at the beginning of treatment, and 2) a new decentralised strategy introduced in November 1997, in which patients were given the choice of in- or out-patient care during the first 2 months of treatment. For new smear-negative pulmonary patients, the two strategies compared were 1) the strategy used until the end of October 1997, which did not require any direct observation of treatment (DOT) and 2) a new community-based strategy introduced in November 1997, which required DOT by a community member 'guardian' or a health worker for the first 2 months of treatment. Costs were analysed from the perspective of health services, patients, and the community in 1998 US$, using standard methods. Cost-effectiveness was calculated as the cost per patient cured (smear-positive cases) and as the cost per patient completing treatment (new smear-negative cases). FINDINGS For new smear-positive patients, the cost per patient treated was $456 with the conventional hospital-based strategy, and $106 with the new decentralised strategy. Costs fell by 54% for health services and 58% for patients. The cost per patient cured was $787 for the conventional hospital-based strategy, and $296 for decentralised treatment. For smear-negative patients, the cost per patient treated was $67 with the conventional unsupervised strategy, and $101 with the community-based DOT strategy. Costs increased for health services, patients and guardians. Cost-effectiveness was similar with both strategies, at around $200 per patient completing treatment. When new smear-positive and new smear-negative patients were considered together, the new strategies were associated with a 50% reduction in total annual costs. CONCLUSION There is a strong economic case for expansion of decentralisation and community-based DOT in Malawi. Further investment in training and programme supervision may help to increase effectiveness.