Objective: To conduct an economic evaluation of directly observed treatment (DOT) and conventionally delivered treatment for the management of new cases of tuberculosis in adults.
Design: Community based directly observed treatment, which has been implemented in the Hlabisa district of South Africa since 1991, was compared with a conventional approach to tuberculosis treatment widely used in Africa. Each was assessed in terms of cost, cost effectiveness, and feasibility of implementation within existing resource constraints.
Setting: Hlabisa Health District, South Africa.
Subjects: Adult patients with new cases of tuberculosis on smear testing; the number of cases increased from 20 per month to over 100 from 1991 to 1996.
Main outcome measures: Cost of case management in 1996, cost effectiveness in terms of the cost per case cured, and bed requirements in comparison with bed availability for the 1990, 1993, and 1996 caseload. Costs are expressed in US dollars at values for 1996.
Results: Directly observed treatment was 2.8 times cheaper overall than conventional treatment ($740.90 compared with $2047.70) to deliver. Directly observed treatment worked out 2.4-4.2 times more cost effective, costing $890.50 per patient cured compared with either $2095.60 (best case) or $3700.40 (worst case) for conventional treatment. The 1996 caseload of tuberculosis required 47 beds to be dedicated to tuberculosis to implement directly observed treatment, whereas conventionally delivered treatment would have required 160 beds; the current number of beds for tuberculosis treatment in Hlabisa is fixed at 56.
Conclusions: Because of the reduced stay in hospital, directly observed treatment is cheaper, more cost effective, and more feasible than conventional treatment in managing tuberculosis in Hlabisa, given the existing hospital bed capacity and the escalating caseload due to the HIV/AIDS epidemic. Such results may hold elsewhere, and wherever conventional tuberculosis management is practised a switch to directly observed treatment will increase hospital capacity to cope with a growing caseload.
PIP: The authors compared the cost, cost-effectiveness, and feasibility of directly observed treatment (DOT) for tuberculosis (TB) in adults to that of conventional care within existing resource constraints in Hlabisa district, South Africa. Community-based DOT has been implemented in the district since 1991. Results are based upon the comparative costs of treating adult patients with new cases of TB on smear testing. The number of cases increased from 20/month to more than 100/month from 1991 to 1996. DOT was found to be 2.8 times cheaper overall to deliver than was conventional treatment, costing $740.90 to deliver compared to $2047.70 for the latter approach. DOT was also 2.4-4.2 times more cost effective, costing $890.50 per patient cured compared to $2095.60 in the best case scenario and $3700.40 in the worst case scenario using conventional treatment. Hlabisa district currently has 56 beds dedicated to TB treatment. The 1996 TB caseload using DOT required 47 beds dedicated to TB compared to 160 beds where conventional treatment was used.