Cost-effectiveness analysis of an alternative tuberculosis management strategy for permanent farm dwellers in South Africa amidst health service contraction

Abstract

Aim: To establish the cost-effectiveness of lay health workers (LHWs) in conjunction with the current, local tuberculosis (TB) control programme, amidst health service contraction. Method: A cost-effectiveness analysis, comparing direct time costs of the current TB management strategy among permanent farm dwellers, with an intervention, whereby LHWs are involved in TB control activities on farms. Measure of effectiveness was case finding and cure rates of adult new smearpositive (NSP) TB cases, alongside a randomized control trial (RCT): Results: The observed cost reduction to the Boland Health District was 74% per case detected and cured on the intervention farms relative to the control farms. Intervention farms reached 83% successful treatment completion rate, control farms 65%. Although the successful treatment adherence was significantly different (18% letter). The improved case detection and cure rates were not statistically significant (chisquared test). Direct LHW costs are borne by farmers. Farmers were motivated to bear costs by reduced job absenteeism and other positive side-effects. Even without outcome improvements costs per case cured were 59% lower on the intervention farms. Conclusion: TB control has suffered from budget reductions in South Africa. It is critically important to develop cost-effective strategies to reduce the TB burden. Costs to public budgets can be substantially reduced while maintaining or improving case detection and treatment outcomes, by using farm-based LHWs.