INT J TUBERC LUNG DIS 18(8):939–945 Q 2014 The Union http://dx.doi.org/10.5588/ijtld.13.0131
Cost-effectiveness of the Health X Project for tuberculosis control in China W-B. Wang,* H. Zhang,† M. Petzold,‡ Q. Zhao,* B. Xu,* G-M. Zhao* *Department of Epidemiology, and Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, †Chinese Center for Disease Control and Prevention, Beijing, China; ‡Centre for Applied Biostatistics, Occupational and Environmental Medicine, University of Gothenburg, Sweden SUMMARY BACKGROUND:
Between 2002 and 2008, China’s National Tuberculosis Control Programme created the Health X Project, financed in part by a World Bank loan, with additional funding from the UK Department for International Development. O B J E C T I V E S : To assess the cost-effectiveness of the Project and its impact from a financial point of view on tuberculosis (TB) control in China. M E T H O D S : A decision-analytic model was used to evaluate the cost-effectiveness of the Project. Sensitivity analysis was used to assess the impact of different scenarios and assumptions on results. The primary outcome of the study was cost per disability-adjusted life-year (DALY) saved and incremental DALYs saved. R E S U LT S : In comparison with alternative scenario 1,
the Project detected 1.6 million additional cases, 44 000 deaths were prevented and a total of 18.4 million DALYs saved. The Project strategies cost approximately Chinese yuan (CNY) 953 per DALY saved (vs. CNY1140 in the control areas), and saved an estimated CNY17.5 billion in comparison with the unchanged alternative scenario (scenario 1) or CNY10.8 billion with the control scenario (scenario 2). C O N C L U S I O N : The Project strategies were affordable and of comparable cost-effectiveness to those of other developing countries. The results also provide strong support for the existing policy of scaling up DOTS in China. K E Y W O R D S : World Bank loan; tuberculosis; China; cost-effectiveness; Health X Project
TUBERCULOSIS (TB) is one of China’s principal public health problems. China’s national surveys found a prevalence rate of bacteriologically confirmed pulmonary TB of respectively 177 (all ages in 1990), 160 (all ages in 2000) and 119 per 100 000 population (age 715 years in 2010). The proportion of TB deaths (excluding those in patients co-infected with the human immunodeficiency virus [HIV]) to TB notifications fell from 24% in 2000 to 6% in 2010.1 Despite this, China still has the second highest TB disease burden in the world, with about 1.8 million new cases and 150 000 deaths reported annually,1,2 and has become one of the hot spots of multidrugresistant TB (MDR-TB), with a prevalence of 10% of all TB cases.3–5 Between 1992 and 2001, the Chinese government implemented a major TB control project, funded in part by a World Bank loan of US$58 million. The project covered half of China’s population and implemented the DOTS strategy in 13 provinces.6 The project led to several important achievements,
including the diagnosis and cure of nearly 1.5 million smear-positive TB cases.7 In early 2002, the government signed a new US$242 million loan with the World Bank, which was added to funding from the UK Department for International Development (DFID) to create the ‘Health X Project’. The Project was integrated into China’s National Tuberculosis Control Programme (NTP), covering 1450 counties (districts) in 16 relatively poor provinces with a total target population of 668 million. The Project was jointly designed by the Chinese government, the World Bank, DFID and other funders, and has implemented and scaled up DOTS coverage with human resources, fiscal and other support from the government at different levels. In addition, the Project established a system for steady drug supply, increased the quality and affordability of anti-tuberculosis drugs, and established a system for case registration and reporting. Implemented between March 2002 and December 2009, this is the largest TB control project in the world to apply the DOTS strategy. This
Correspondence to: Genming Zhao, School of Public Health, Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China. e-mail: [email protected] Biao Xu, School of Public Health, Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China. e-mail: bxu@ shmu.edu.cn Article submitted 14 February 2014. Final version accepted 13 April 2014.
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7-year experience has important implications for China as it seeks to sustain and further expand the different aspects of the DOTS strategy. The purpose of the present study is to assess the cost-effectiveness of the Health X Project and its impact from a financial point of view on China’s TB control strategy.
METHODS Materials and sources of data Between May and August 2009, data were collected from the following four sources to obtain TB information during the implementation period of the Health X Project: 1) the database of the National Tuberculosis Information System (data for 2009 were not shown as the Project had not completed data collection);8 2) collection of data on institutional costs through a survey using a standardised form administered in six counties (three project counties and three control counties) chosen based on their geographic location and TB prevalence; 3) collection of mortality and case fatality estimates from the Global Health Observatory Data Repository of the World Health Organization (WHO); and 4) compiling of the family cost estimates of TB patients from published literature. Costs Per case cost estimates comprised three components, including expenditures related to TB diagnosis and treatment incurred by TB health sectors, and patients/ families as well as productivity losses.9 National level expenditures refer to funds from the NTP at the national level during 2002–2008. County-level institutional costs of the project were based on the survey. A total of six counties were purposively sampled to report their expenditures on DOTS-related activities, including 1) variable costs, covering utilities for water, electricity, materials, consumables and pharmaceutical costs, and 2) fixed costs, mainly rent, depreciation of important equipment, salaries, fuel and some wages. Overheads were distributed proportionally to TB activities based on the use of shared buildings. Direct and indirect family costs were obtained from studies.10–12 The direct family costs of MDR-TB patients and non-MDR-TB patients were estimated separately. All costs were inflated to the year 2008 by 3% annually. Health outcomes The primary outcome of this study was cost per disability-adjusted life-year (DALY) saved and incremental DALYs saved.13 Secondary outcomes included the number of cases who were successfully treated and potential cases prevented from secondary TB transmission. We discounted all effects (DALYs and
secondary TB transmission) into 2008 for comparability by 3% per year. DALYs per case during lifetime were compiled from the published literature and calculated on the basis of the sum of years of lives lost and years lived with disabilities.10,14,15 In DOTS areas, it was reported that one TB patient can result in a cumulative number of 1.5 cases, which is proportional to the percentage of the population with latent tuberculous infection developing active TB.16 Incremental analysis The incremental number of intervention cases detected was estimated by calculating the difference between the number of cases actually identified and the estimated number computed by following the longitudinal trends in case detection in non-Health X Project areas and the national average. For example, the number of incremental cases was calculated on the basis of the national average according to the following formula: Incremental TB case detected ¼
2X 008
ðndi npi Þ
i¼2002
where ndi refers to the number of cases detected in i year in the project areas, assuming that this followed notification trends in the national average; and npi is the number of cases notified in Project areas in i year. The decrease in the incremental number of deaths due to the implementation of the Project was computed as the number of incremental cases detected plus incremental cured cases from the improved case fatality rate. Alternative scenario 1 assumed that the performance of TB control activities was the same as that observed in 2002, while alternative scenario 2 allowed a comparison of the current performance with the national average. The incremental number of DALYs was therefore estimated as the total of the improved cure rate (compared with the two alternative scenarios) and cured patients from the incremental number of cases detected: Incremental DALYs 2008 X ðindi 3 CRpi þ npi 3 CRpi CRcs Þ ¼ i¼2002
where indi refers to the incremental number of cases detected by the Project; CRpi, the cure rate in the Project areas in I year; npi, the number of cases notified in the Project areas; and CRcs, the cure rate in the Project areas minus the cure rate in the alternative scenarios. Cost-effectiveness analysis The economic feasibility of the incremental costeffectiveness ratio (ICER) was assessed in relation to
Cost-effectiveness of the Health X Project
per capita gross domestic product (GDP). ICER models were established using TreeAge (TreeAge Software Inc, Williamstown, MA, USA). The analysis was based on a lifetime period from commencement of symptoms to the different treatment outcomes (death, cured, etc.). For the Project arm, it was assumed that patients had a 65% detection rate, and that 61.6% of these patients had access to anti-tuberculosis treatment; the cure rate among the patients with access to treatment was 71.9%. Input parameters from the alternative scenarios were used for comparison. Sensitivity analysis We used TreeAge to test the sensitivities of a proposed decision to change the values of the cure rate of new and retreatment cases in different years during 2002– 2008, the case fatality rate of active cases and the treatment costs for MDR-TB cases. Ethics approval statement Ethics approval was not required for the study, as all information was anonymised.
RESULTS Financing of China’s NTP for Health X Project areas The total funding available for TB control in areas covered by the Health X Project increased annually from 2002, reaching CNY100 million in 2008 (Figure 1). Most of this funding has been used to support diagnosis and treatment with first-line drugs in Project areas. During the same period, the total amount of domestic government funding for TB control at all levels in the project areas reached CNY1.47 billion. This was CNY440 million more than the budget planned by the Chinese government. At the same
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time, a noticeably larger share of funds came from the government in the budget allocated for the Project each year (Figure 1). Nonetheless, domestic funding has been increasing since 2004, and was estimated at US$362 million in 2012. Per case cost analysis The NTP contributed a total of CNY1511 per case at the national level (Table 1). For each active TB case, county-level health sectors put in an additional CNY1804 and CNY2345 in Project and control areas, respectively. The total estimates per case varied between CNY13 729 and 26 689 for new non-MDRTB cases, retreatment non-MDR-TB cases and MDRTB cases in Project and control areas. Effectiveness of the Health X Project Using the parameters presented in Table 2, Figure 2 shows that the Health X Project enabled additional TB patients to be detected. From 1 January 2002 to 31 December 2008, the project detected 1.6 million additional cases in comparison with alternative scenario 1, while 44 000 deaths were averted by the Project (Table 3). During the Project period, a total of 18.4 million DALYs were saved by Health X Project strategies, compared with 7.1 million DALYs reduced in alternative scenario 1. If we assume that one TB patient infects 1.5 cases in DOTS areas, the estimated effectiveness would increase by at least 2.6 times, to around 49 million DALYs. Cost-effectiveness analysis The cost per DALY saved and other cost-effectiveness ratios were estimated in the decision tree using TreeAge. Table 3 shows that Project strategies would cost approximately CNY953/DALY prevented, compared to CNY1140 in the control areas (i.e., CNY187
Figure 1 Financing of tuberculosis control in Health X Project provinces, 2002–2008. CNY ¼ Chinese yuan.
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Figure 2
Estimated additional case numbers detected by the Health X Project.
more than in the Project areas). The cost per DALY saved in Project areas is also ,US$223 (converted to year 2008 $US prices), which was suggested as the threshold for defining an ‘attractive’ investment in low-income countries; the cost of control areas was similar to the threshold (Table 3). The Project has saved an estimated CNY17.5 billion in comparison with alternative scenario 1, and obtained an incremental benefit of CNY10.8 billion over alternative scenario 2. An estimated CNY46.7 and CNY28.8 billion, respectively, were saved if the benefits of preventing TB transmission are included compared to the two alternative scenarios.
Table 1
One-way sensitivity analysis The model was sensitive to variations in the following parameters: 1) the cure rate among new and retreatment cases in different years during 2002–2008 (Table 2), which changed the number of cured cases to between 2.6 and 2.7 million and DALYs saved to between 18.0 and 18.6 million, excluding the benefits from transmission prevention (Table 3);20 2) the case fatality rate among active cases ranged between 1.0 and 1.9 (Table 2), which resulted in the reduction of 16 000–31 000 deaths (Table 3); and 3) the cost per DALY saved would be changed to CNY3217 if the costs for treatment of MDR-TB cases were doubled.
Cost analysis per case detected and treated Per case estimates, CNY* Source
Project cost NTP costs
1 511
NTP
Institutional costs† Institutional costs of project areas Institutional costs of non-project areas
1 804 2 345
Survey Survey
Family cost Direct cost of a MDR-TB case Indirect cost for a MDR-TB case Direct cost of a new non-MDR-TB case Indirect cost for a new non-MDR-TB case Direct cost of a retreatment non-MDR-TB case Indirect cost of a retreatment non-MDR-TB case Costs for patients lost to treatment Costs of patients failed to be diagnosed with TB
10 674 11 494 5 300 4 811 8 600 4 811 1 941 795
10
13 426 13 967 16 725 17 266 25 483 26 024
Estimate Estimate Estimate Estimate Estimate Estimate
10 10 10 10 10 11 12
‡
Total cost per case Total cost per new non-MDR-TB case in project areas Total cost per new non-MDR-TB case in non-project areas Total cost per retreated non-MDR-TB case in project areas Total cost per retreated non-MDR-TB case in non-project areas Total cost per MDR-TB case in project areas Total cost per MDR-TB case in non-project areas
* Mean cost. † The institutional cost was extrapolated using a standardised form from six sample counties. ‡ The number of patients is based on 2007 data. CNY ¼ Chinese yuan; NTP ¼ National Tuberculosis Programme; MDR-TB ¼ multidrug-resistant tuberculosis.
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Table 2 Model parameter input Alternative scenario 1 % (range)
Project areas %
Indicators
Alternative scenario 2 % (range)
Case detection rate, % (range) 77 (23–80) 74 (35–88)* 64 (28–79) Proportions with access to anti-tuberculosis treatment 96.5 89.8 Proportions of new cases 81.5 78.0 84.5 Proportions of MDR-TB, % (range) 11.8 (6.4–16.1) 11.8 (6.4–16.1) 11.8 (6.4–16.1) § Infection rate in contacts with active case, % (range) 14 (10–15) 14 (10–15) 14 (10–15) Progress to active TB 7.5 7.5 7.5 Cure rate, new cases 92.5 95.3 95.3 Cure rate, retreatment cases 83.8 84.7 84.7 Cure rate, MDR-TB cases 79.0 79.0 79.0 Case fatality rate, active cases, % (range) 1.5 (1.0–1.9) 4.2 1.5 (1.3–1.7) DALY saved for treating a new case 7.0 6.4 4.9 DALY saved for treating a retreat case 6.5 5.8 4.4 DALY saved for treating a new case, including transmission benefits 18.5 17.9 12.6 DALY saved for treating a retreat case, including transmission benefits 18.0 17.2 12.5
Source NTP,† WHO‡ NTP† NTP† 4,5 17,18
WHO‡ NTP† NTP† 19
WHO,‡ NTP† 10 NTP† 10 NTP† 10 NTP† 14 NTP†
* National average. † Source of data: statistics from the National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention. ‡ According to WHO estimates. § WHO estimates for the years 2002–2008. NTP ¼ National Tuberculosis Programme; WHO ¼ World Health Organization; TB ¼ tuberculosis; MDR-TB ¼ multidrug-resistant TB; DALY ¼ disability-adjusted lifeyear.
DISCUSSION Globally, the Health X Project (covering a population of 668 million) is the first project to have been evaluated from an economic perspective. Results and lessons learnt may also be of interest to other countries as they scale up DOTS implementation. Our results show that 1.6 million additional active TB cases were detected by the Project areas, of which most were cured or completed treatment. Globally, the DOTS/Stop TB Strategy has saved 4.6–6.3 million lives,21 while this Project alone has prevented 25 000– 41 000 deaths and saved 18.4 million DALYs (vs. 11.3 in scenario 2) in the regions covered by the Project. If the benefits of prevented future transmission are included, 49.0 million DALYs have been Table 3
saved by the Project, vs. a 30.2 million incremental effect in scenario 1. Costs per DALY vary substantially in different countries, and between industrialised and developing settings.22,23 Since the early 1990s, short-course regimens for new smear-positive TB cases have been promoted as one of the most cost-effective health care interventions available, based on studies in lowincome African countries that have reported a cost per DALY saved of between US$1 and US$3.23–25 In countries with similar income levels to China, such as Peru and Brazil, the mean cost per DALY saved was respectively US$211 and US$86.25,26 Compared to the control areas, the cost per DALY saved in the intervention areas was lower than the threshold for defining an ‘attractive’ investment in
Cost-effectiveness of the Health X Project ICER analysis* (Alternative scenario 1)
Cost-effectiveness analysis Effectiveness Number of active cases detected, million Number of cases cured, million Deaths reduced, thousand DALYs saved, million DALYs saved, including transmission benefits, million Cost per DALY reduced, CNY Costs saved from DALYs saved, CNY, billion# Costs saved from DALYs saved, including transmission benefits, CNY, billion#
3.1 2.7 — — — 953
Sensitivity range
Threshold
ICER analysis* (Alternative scenario 2)
Incremental Sensitivity Incremental Sensitivity effectiveness range effectiveness range
— 2.6–2.7† — — — 953–1135¶ USD 223 (WHO)
1.6 1.6‡ 25‡ 18.4
— 1.6–1.7† 16–31† 18.0–18.6
1.0 1.6 41 11.3§
— 1.6–1.7† 16–31† 11.0–11.4
49.0 187
48.1–49.5 —
30.2§ 187
29.3–30.5 —
—
—
17.5
17.2–17.7
10.8
10.5–10.9
—
—
46.7
45.8–47.2
28.8
27.9–29.0
* Compared to alternative scenarios. † Sensitive to the cure rate in different years. ‡ Benefits from improved case detection rate and improved cure rate. § Benefits from case detection and cure rates. ¶ Sensitive to the costs of treatment of MDR-TB (double). # Assume annual discount rate at 3%. ICER ¼ incremental cost-effectiveness ratio; DALY ¼ disability-adjusted life-year; CNY ¼ Chinese yuan.
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low-income countries. Given that the per capita GDP for China was US$3315 in 2008,26 TB control in both the Project and the control areas were very costeffective (below the threshold of GDP per capita) according to the WHO cost-effectiveness thresholds.27 The Project is more cost-effective than the control areas, and was much more effective than in 2002. The Project had substantially lower health system costs than those of non-project areas. While increased costs following DOTS implementation have been reported — for example, the DOTS strategy doubled patient costs and quadrupled health system costs per completed treatment in Brazil,28 our study did not show significant changes in health system costs. Due to the modest increase in the treatment completion rate due to DOTS during the Project period, the ICER was higher than the previous figure.14 ICER for patients would remain high, as showed by the sensitivity analyses in various scenarios. The cost per DALY saved for treating a new case had the highest impact on ICER for the total economic burden of TB. However, if the average case detection rates of both scenarios are assumed to be the same (i.e., the non-project areas also improved their case finding), the incremental effects would decrease by about one third. Recent studies have reported an association between increased case detection rates and a reduction in TB incidence and mortality.29 Improved case detection and treatment success rates help reduce TB mortality, and success rates were significantly associated with a downward trend in the TB burden. In Project areas, the growing detection rate may affect TB incidence by reducing community transmission, and consequently infection rates, especially in the long term. Given the high prevalence of MDR-TB in China,4,5 the observed high cost-effectiveness ratio is even more remarkable. With the high cure rates achieved in China, the recent expansion of DOTS should help limit the development of the MDR-TB epidemic. However, the concurrent high rates of relapse cases and inadequate treatment in both the public health system and the hospital system indicate that DOTS alone may not be enough to tackle MDR-TB-related problems in China,5 although sound cost-effectiveness has been observed. The data also suggest that the incremental effectiveness from current DOTS strategies in the future may be limited, especially without implementing a high-quality system such as DOTSplus strategies to treat MDR-TB cases.30 As with all estimates of this kind, several limitations need to be acknowledged. First, we may have underestimated the effectiveness of the DOTS/Stop TB strategy. Given the impossibility of obtaining accurate data for some parameters, the national average has been used in the models as control input
(e.g., for MDR-TB proportions), which may have underestimated the effects of the Project. Finally, regarding the estimates of some other parameters, the effectiveness of the Project may have been overestimated. The provinces covered by the Project were relatively poor areas; it may thus not be appropriate to use non-Project areas as controls. Under such circumstances, we used data from when the Project was launched.29
CONCLUSIONS Our results show that Health X Project-based DOTS strategies were affordable and their cost-effectiveness was comparable with those of other developing countries. The results also provide strong support for the existing policy of scaling up DOTS and its contents (e.g., MDR-TB treatment) in China. Acknowledgements This study was granted by the Independent Evaluation Programme on WB/DFID TB Control Project of China, and the National Natural Science Foundation of China, Beijing, China (No. 30800937). Conflict of interest: None declared.
References 1 World Health Organization. WHO report, 2010. Global tuberculosis control. WHO/HTM/TB/2010.7. Geneva, Switzerland: WHO, 2010. 2 Ministry of Health, China. Report on nationwide random survey for the epidemiology of tuberculosis in 2000. Beijing, China: MoH, 2002. 3 Kremer K, Glynn J R, Lillebaek T, et al. Definition of the Beijing/W lineage of Mycobacterium tuberculosis on the basis of genetic markers. J Clin Microbiol 2004; 42: 4040–4049. 4 He G X, Zhao Y L, Jiang G L, et al. Prevalence of tuberculosis drug resistance in 10 provinces of China. BMC Infect Dis 2008; 8: 166. 5 Zhao Y, Xu S, Wang L, et al. National survey of drug-resistant tuberculosis in China. N Engl J Med 2012; 366: 2161–2170. 6 Wang L, Liu J, Chin D P. Progress in tuberculosis control and the evolving public-health system in China. Lancet 2007; 369: 691–696. 7 Xianyi C, Fengzeng Z, Hongjin D, et al. The DOTS strategy in China: results and lessons after 10 years. Bull World Health Organ 2002; 80: 430–436. 8 Ma J, Yang G, Shi X. Information technology platform in China’s disease surveillance system. Dis Surveill 2006; 21: 1–3. 9 Drummond M F. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford, UK; New York, NY, USA: Oxford University Press, 2005. 10 Wang X, Wu G, Gong Y, et al. Study on the disease economic burden of TB patients with drug resistance in areas of TB control program. Chinese Health Econ 2005; 24: 3. 11 National Center for Disease Control and Prevention C. Report of the 5th National Tuberculosis Epidemiological Sampling Survey. Beijing, China: National Center for Disease Control and Prevention, 2012. 12 Xu B, Dong H J, Zhao Q, et al. DOTS in China — removing barriers or moving barriers? Health Policy Plann 2006; 21: 365–372. 13 World Health Organization. Making choices in health WHO
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14
15 16
17
18
19
20
21
guide to cost-effectiveness analysis. Geneva, Switzerland: WHO, 2003. Wu G, Gong Y, Li Y, et al. A study of the effect of TB control programs on disease burden. Chinese J Hospital Administration 2001; 17: 4. Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plann 2006; 21: 402–408. Liao C M, Cheng Y H, Lin Y J, et al. A probabilistic transmission and population dynamic model to assess tuberculosis infection risk. Risk analysis: an official publication of the Society for Risk Analysis 2012; 32: 1420–1432. Vynnycky E, Fine P E. The natural history of tuberculosis: the implications of age-dependent risks of disease and the role of reinfection. Epidemiol Infect 1997; 119: 183–201. World Health Organization. Tuberculosis Fact Sheet. Geneva, Switzerland: WHO, 2012. http://www.who.int/mediacentre/ factsheets/en/. Accessed May 2014. Wang S, Wang X, Zhao X, et al. Research on treatment efficacy of the patients with drug resistance in the project for drug resistance surveillance in Guangdong and Zhejiang provinces. The Journal of the Chinese Antituberculosis Association 2005; 27: 4. World Health Organization. Investing in health research and development: report of the ad hoc committee on health research relating to future intervention options. Geneva, Switzerland: WHO, 1996. Glaziou P, Floyd K, Korenromp E L, et al. Lives saved by tuberculosis control and prospects for achieving the 2015 global target for reducing tuberculosis mortality. Bull World Health Organ 2011; 89: 573–582.
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22 Currie C S, Floyd K, Williams B G, et al. Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence. BMC Public Health 2005; 5: 130. 23 Baltussen R, Floyd K, Dye C. Cost-effectiveness analysis of strategies for tuberculosis control in developing countries. BMJ 2005; 331: 1364. 24 Murray C J, DeJonghe E, Chum H J, et al. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991; 338: 1305–1308. 25 Wilton P, Smith R D, Coast J, et al. Directly observed treatment for multidrug-resistant tuberculosis: an economic evaluation in the United States of America and South Africa. Int J Tuberc Lung Dis 2001; 5: 1137–1142. 26 China economy yearbook. Chinese Academy of Social Sciences yearbooks. Vol 1: Economy. Leiden, The Netherlands: Brill Press, 2008. 27 World Health Organization. Cost-effectiveness thresholds. Geneva, Switzerland: WHO, 2014. http://www.who.int/ choice/costs/CER_thresholds/en/. Accessed May 2014. 28 Steffen R, Menzies D, Oxlade O, et al. Patients’ costs and costeffectiveness of tuberculosis treatment in DOTS and non-DOTS facilities in Rio de Janeiro, Brazil. PLOS ONE 2010; 5: e14014. 29 Akachi Y, Zumla A, Atun R. Investing in improved performance of national tuberculosis programs reduces the tuberculosis burden: analysis of 22 high-burden countries, 2002–2009. J Infect Dis 2012; 205 (Suppl 2): S284–S292. 30 Singla R, Sarin R, Khalid U K, et al. Seven-year DOTS-Plus pilot experience in India: results, constraints and issues. Int J Tuberc Lung Dis 2009; 13: 976–981.
Cost-effectiveness of the Health X Project
i
RESUME
Le Projet Health X e´ tait un prˆet de la Banque Mondiale au Programme National de Lutte contre la Tuberculose de la Chine entre 2002 et 2008, avec un financement suppl´ementaire du Department for International Development du Royaume Uni. O B J E C T I F S : Evaluer le rapport cout-efficacit´ ˆ e du projet et son impact financier sur la lutte contre la tuberculose (TB) en Chine. M E´ T H O D E S : Un mod`ele d’analyse de d´ecision a permis d’estimer le rapport cout-efficacit´ ˆ e du projet. L’analyse de sensibilit´e a permis d’´evaluer l’impact de diff´erents scenarios et hypoth`eses sur les r´esultats. Le principal r´esultat de cette e´ tude a e´ t´e le cout ˆ par ann´ees de vie corrig´ees de l’incapacit´e (DALY) r´eduite et par DALY diff´erentielle r´eduite. CONTEXTE :
Le Projet a d´etect´e 1,6 millions de cas supple´ mentaires par comparaison avec le sc´enario hypoth´etique 1, et 44 000 d´ec`es ont e´ t´e e´ vit´es (soit une r´eduction totale de 18,4 millions de DALY). Cette strat´egie a cout´ ˆ e environ 953 yuan chinois (CNY) par DALY e´vit´ee (contre 1140 CNY dans les zones t´emoins) et a sauv´e environ 17,5 milliards de CNY en comparaison avec le sc´enario hypoth´etique inchang´e (scenario 1) ou 10,8 milliards de CNY du sc´enario t´emoin (sc´enario 2). C O N C L U S I O N : Cette strat´egie a e´ t´e abordable et son rapport cout-efficacit´ ˆ e a e´ t´e comparable a` celui d’autres pays en d´eveloppement. Les r´esultats sont fortement en faveur de la politique existante d’expansion des DOTS et de son contenu en Chine. R E´ S U LT A T S :
RESUMEN
El proyecto Health X fue una iniciativa del Programa Nacional de Control de la Tuberculosis en China, ejecutada entre el 2002 y el 2008, financiado por un pr´estamo del Banco Mundial y fondos complementarios del Department for International Development del Reino Unido. O B J E T I V O S: Evaluar la eficacia del proyecto y sus repercusiones econ omicas ´ en el control de la tuberculosis (TB) en la China. M E´ T O D O S: Se aplico ´ un modelo decisional anal´ıtico con el fin de evaluar la rentabilidad del proyecto. Mediante un ana´lisis de sensibilidad se examino´ el efecto de diferentes hipotesis ´ y supuestos en los resultados. El criterio primario de evaluacion ´ del estudio fue el costo por la disminucion ´ de cada ano ˜ de vida ajustado en funcion ´ de la discapacidad (DALY) y la disminucion ´ diferencial de DALY. M A R C O D E R E F E R E N C I A:
En el Proyecto se detectaron 1,6 millones de casos adicionales, en comparacion ´ con la hipotesis ´ de contraste 1, y se evitaron 44 000 muertes (una disminucion ´ total de 18,4 millones de DALY). Las estrategias del proyecto habr´ıan costado cerca de 953 yuanes chinos (CNY) por cada DALY evitado (contra CNY 1140 en las zonas testigo) y ahorrado cerca de CNY 17,5 miles de millones, al compararlo con la hipotesis ´ de contraste sin ningun ´ cambio (hipotesis ´ 1, situacion ´ en el 2002) o CNY 10,8 miles de millones en comparacion ´ con las regiones testigo (hipotesis ´ 2). ´ N: Las estrategias fueron asequibles y CONCLUSIO ofrecieron una rentabilidad equivalente a la rentabilidad observada en otros pa´ıses en desarrollo. Adema´ s, los resultados respaldan firmemente las pol´ıticas vigentes en la China de ampliacion ´ de escala de la estrategia de DOTS y sus componentes. R E S U LT A D O S:
Cost-effectiveness of the Health X Project for tuberculosis control in China W-B. Wang,* H. Zhang,† M. Petzold,‡ Q. Zhao,* B. Xu,* G-M. Zhao* *Department of Epidemiology, and Key Laboratory of Public Health Safety, Ministry of Education, Fudan University, Shanghai, †Chinese Center for Disease Control and Prevention, Beijing, China; ‡Centre for Applied Biostatistics, Occupational and Environmental Medicine, University of Gothenburg, Sweden SUMMARY BACKGROUND:
Between 2002 and 2008, China’s National Tuberculosis Control Programme created the Health X Project, financed in part by a World Bank loan, with additional funding from the UK Department for International Development. O B J E C T I V E S : To assess the cost-effectiveness of the Project and its impact from a financial point of view on tuberculosis (TB) control in China. M E T H O D S : A decision-analytic model was used to evaluate the cost-effectiveness of the Project. Sensitivity analysis was used to assess the impact of different scenarios and assumptions on results. The primary outcome of the study was cost per disability-adjusted life-year (DALY) saved and incremental DALYs saved. R E S U LT S : In comparison with alternative scenario 1,
the Project detected 1.6 million additional cases, 44 000 deaths were prevented and a total of 18.4 million DALYs saved. The Project strategies cost approximately Chinese yuan (CNY) 953 per DALY saved (vs. CNY1140 in the control areas), and saved an estimated CNY17.5 billion in comparison with the unchanged alternative scenario (scenario 1) or CNY10.8 billion with the control scenario (scenario 2). C O N C L U S I O N : The Project strategies were affordable and of comparable cost-effectiveness to those of other developing countries. The results also provide strong support for the existing policy of scaling up DOTS in China. K E Y W O R D S : World Bank loan; tuberculosis; China; cost-effectiveness; Health X Project
TUBERCULOSIS (TB) is one of China’s principal public health problems. China’s national surveys found a prevalence rate of bacteriologically confirmed pulmonary TB of respectively 177 (all ages in 1990), 160 (all ages in 2000) and 119 per 100 000 population (age 715 years in 2010). The proportion of TB deaths (excluding those in patients co-infected with the human immunodeficiency virus [HIV]) to TB notifications fell from 24% in 2000 to 6% in 2010.1 Despite this, China still has the second highest TB disease burden in the world, with about 1.8 million new cases and 150 000 deaths reported annually,1,2 and has become one of the hot spots of multidrugresistant TB (MDR-TB), with a prevalence of 10% of all TB cases.3–5 Between 1992 and 2001, the Chinese government implemented a major TB control project, funded in part by a World Bank loan of US$58 million. The project covered half of China’s population and implemented the DOTS strategy in 13 provinces.6 The project led to several important achievements,
including the diagnosis and cure of nearly 1.5 million smear-positive TB cases.7 In early 2002, the government signed a new US$242 million loan with the World Bank, which was added to funding from the UK Department for International Development (DFID) to create the ‘Health X Project’. The Project was integrated into China’s National Tuberculosis Control Programme (NTP), covering 1450 counties (districts) in 16 relatively poor provinces with a total target population of 668 million. The Project was jointly designed by the Chinese government, the World Bank, DFID and other funders, and has implemented and scaled up DOTS coverage with human resources, fiscal and other support from the government at different levels. In addition, the Project established a system for steady drug supply, increased the quality and affordability of anti-tuberculosis drugs, and established a system for case registration and reporting. Implemented between March 2002 and December 2009, this is the largest TB control project in the world to apply the DOTS strategy. This
Correspondence to: Genming Zhao, School of Public Health, Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China. e-mail: [email protected] Biao Xu, School of Public Health, Fudan University, 138 Yi Xue Yuan Road, Shanghai 200032, China. e-mail: bxu@ shmu.edu.cn Article submitted 14 February 2014. Final version accepted 13 April 2014.
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7-year experience has important implications for China as it seeks to sustain and further expand the different aspects of the DOTS strategy. The purpose of the present study is to assess the cost-effectiveness of the Health X Project and its impact from a financial point of view on China’s TB control strategy.
METHODS Materials and sources of data Between May and August 2009, data were collected from the following four sources to obtain TB information during the implementation period of the Health X Project: 1) the database of the National Tuberculosis Information System (data for 2009 were not shown as the Project had not completed data collection);8 2) collection of data on institutional costs through a survey using a standardised form administered in six counties (three project counties and three control counties) chosen based on their geographic location and TB prevalence; 3) collection of mortality and case fatality estimates from the Global Health Observatory Data Repository of the World Health Organization (WHO); and 4) compiling of the family cost estimates of TB patients from published literature. Costs Per case cost estimates comprised three components, including expenditures related to TB diagnosis and treatment incurred by TB health sectors, and patients/ families as well as productivity losses.9 National level expenditures refer to funds from the NTP at the national level during 2002–2008. County-level institutional costs of the project were based on the survey. A total of six counties were purposively sampled to report their expenditures on DOTS-related activities, including 1) variable costs, covering utilities for water, electricity, materials, consumables and pharmaceutical costs, and 2) fixed costs, mainly rent, depreciation of important equipment, salaries, fuel and some wages. Overheads were distributed proportionally to TB activities based on the use of shared buildings. Direct and indirect family costs were obtained from studies.10–12 The direct family costs of MDR-TB patients and non-MDR-TB patients were estimated separately. All costs were inflated to the year 2008 by 3% annually. Health outcomes The primary outcome of this study was cost per disability-adjusted life-year (DALY) saved and incremental DALYs saved.13 Secondary outcomes included the number of cases who were successfully treated and potential cases prevented from secondary TB transmission. We discounted all effects (DALYs and
secondary TB transmission) into 2008 for comparability by 3% per year. DALYs per case during lifetime were compiled from the published literature and calculated on the basis of the sum of years of lives lost and years lived with disabilities.10,14,15 In DOTS areas, it was reported that one TB patient can result in a cumulative number of 1.5 cases, which is proportional to the percentage of the population with latent tuberculous infection developing active TB.16 Incremental analysis The incremental number of intervention cases detected was estimated by calculating the difference between the number of cases actually identified and the estimated number computed by following the longitudinal trends in case detection in non-Health X Project areas and the national average. For example, the number of incremental cases was calculated on the basis of the national average according to the following formula: Incremental TB case detected ¼
2X 008
ðndi npi Þ
i¼2002
where ndi refers to the number of cases detected in i year in the project areas, assuming that this followed notification trends in the national average; and npi is the number of cases notified in Project areas in i year. The decrease in the incremental number of deaths due to the implementation of the Project was computed as the number of incremental cases detected plus incremental cured cases from the improved case fatality rate. Alternative scenario 1 assumed that the performance of TB control activities was the same as that observed in 2002, while alternative scenario 2 allowed a comparison of the current performance with the national average. The incremental number of DALYs was therefore estimated as the total of the improved cure rate (compared with the two alternative scenarios) and cured patients from the incremental number of cases detected: Incremental DALYs 2008 X ðindi 3 CRpi þ npi 3 CRpi CRcs Þ ¼ i¼2002
where indi refers to the incremental number of cases detected by the Project; CRpi, the cure rate in the Project areas in I year; npi, the number of cases notified in the Project areas; and CRcs, the cure rate in the Project areas minus the cure rate in the alternative scenarios. Cost-effectiveness analysis The economic feasibility of the incremental costeffectiveness ratio (ICER) was assessed in relation to
Cost-effectiveness of the Health X Project
per capita gross domestic product (GDP). ICER models were established using TreeAge (TreeAge Software Inc, Williamstown, MA, USA). The analysis was based on a lifetime period from commencement of symptoms to the different treatment outcomes (death, cured, etc.). For the Project arm, it was assumed that patients had a 65% detection rate, and that 61.6% of these patients had access to anti-tuberculosis treatment; the cure rate among the patients with access to treatment was 71.9%. Input parameters from the alternative scenarios were used for comparison. Sensitivity analysis We used TreeAge to test the sensitivities of a proposed decision to change the values of the cure rate of new and retreatment cases in different years during 2002– 2008, the case fatality rate of active cases and the treatment costs for MDR-TB cases. Ethics approval statement Ethics approval was not required for the study, as all information was anonymised.
RESULTS Financing of China’s NTP for Health X Project areas The total funding available for TB control in areas covered by the Health X Project increased annually from 2002, reaching CNY100 million in 2008 (Figure 1). Most of this funding has been used to support diagnosis and treatment with first-line drugs in Project areas. During the same period, the total amount of domestic government funding for TB control at all levels in the project areas reached CNY1.47 billion. This was CNY440 million more than the budget planned by the Chinese government. At the same
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time, a noticeably larger share of funds came from the government in the budget allocated for the Project each year (Figure 1). Nonetheless, domestic funding has been increasing since 2004, and was estimated at US$362 million in 2012. Per case cost analysis The NTP contributed a total of CNY1511 per case at the national level (Table 1). For each active TB case, county-level health sectors put in an additional CNY1804 and CNY2345 in Project and control areas, respectively. The total estimates per case varied between CNY13 729 and 26 689 for new non-MDRTB cases, retreatment non-MDR-TB cases and MDRTB cases in Project and control areas. Effectiveness of the Health X Project Using the parameters presented in Table 2, Figure 2 shows that the Health X Project enabled additional TB patients to be detected. From 1 January 2002 to 31 December 2008, the project detected 1.6 million additional cases in comparison with alternative scenario 1, while 44 000 deaths were averted by the Project (Table 3). During the Project period, a total of 18.4 million DALYs were saved by Health X Project strategies, compared with 7.1 million DALYs reduced in alternative scenario 1. If we assume that one TB patient infects 1.5 cases in DOTS areas, the estimated effectiveness would increase by at least 2.6 times, to around 49 million DALYs. Cost-effectiveness analysis The cost per DALY saved and other cost-effectiveness ratios were estimated in the decision tree using TreeAge. Table 3 shows that Project strategies would cost approximately CNY953/DALY prevented, compared to CNY1140 in the control areas (i.e., CNY187
Figure 1 Financing of tuberculosis control in Health X Project provinces, 2002–2008. CNY ¼ Chinese yuan.
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Figure 2
Estimated additional case numbers detected by the Health X Project.
more than in the Project areas). The cost per DALY saved in Project areas is also ,US$223 (converted to year 2008 $US prices), which was suggested as the threshold for defining an ‘attractive’ investment in low-income countries; the cost of control areas was similar to the threshold (Table 3). The Project has saved an estimated CNY17.5 billion in comparison with alternative scenario 1, and obtained an incremental benefit of CNY10.8 billion over alternative scenario 2. An estimated CNY46.7 and CNY28.8 billion, respectively, were saved if the benefits of preventing TB transmission are included compared to the two alternative scenarios.
Table 1
One-way sensitivity analysis The model was sensitive to variations in the following parameters: 1) the cure rate among new and retreatment cases in different years during 2002–2008 (Table 2), which changed the number of cured cases to between 2.6 and 2.7 million and DALYs saved to between 18.0 and 18.6 million, excluding the benefits from transmission prevention (Table 3);20 2) the case fatality rate among active cases ranged between 1.0 and 1.9 (Table 2), which resulted in the reduction of 16 000–31 000 deaths (Table 3); and 3) the cost per DALY saved would be changed to CNY3217 if the costs for treatment of MDR-TB cases were doubled.
Cost analysis per case detected and treated Per case estimates, CNY* Source
Project cost NTP costs
1 511
NTP
Institutional costs† Institutional costs of project areas Institutional costs of non-project areas
1 804 2 345
Survey Survey
Family cost Direct cost of a MDR-TB case Indirect cost for a MDR-TB case Direct cost of a new non-MDR-TB case Indirect cost for a new non-MDR-TB case Direct cost of a retreatment non-MDR-TB case Indirect cost of a retreatment non-MDR-TB case Costs for patients lost to treatment Costs of patients failed to be diagnosed with TB
10 674 11 494 5 300 4 811 8 600 4 811 1 941 795
10
13 426 13 967 16 725 17 266 25 483 26 024
Estimate Estimate Estimate Estimate Estimate Estimate
10 10 10 10 10 11 12
‡
Total cost per case Total cost per new non-MDR-TB case in project areas Total cost per new non-MDR-TB case in non-project areas Total cost per retreated non-MDR-TB case in project areas Total cost per retreated non-MDR-TB case in non-project areas Total cost per MDR-TB case in project areas Total cost per MDR-TB case in non-project areas
* Mean cost. † The institutional cost was extrapolated using a standardised form from six sample counties. ‡ The number of patients is based on 2007 data. CNY ¼ Chinese yuan; NTP ¼ National Tuberculosis Programme; MDR-TB ¼ multidrug-resistant tuberculosis.
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Table 2 Model parameter input Alternative scenario 1 % (range)
Project areas %
Indicators
Alternative scenario 2 % (range)
Case detection rate, % (range) 77 (23–80) 74 (35–88)* 64 (28–79) Proportions with access to anti-tuberculosis treatment 96.5 89.8 Proportions of new cases 81.5 78.0 84.5 Proportions of MDR-TB, % (range) 11.8 (6.4–16.1) 11.8 (6.4–16.1) 11.8 (6.4–16.1) § Infection rate in contacts with active case, % (range) 14 (10–15) 14 (10–15) 14 (10–15) Progress to active TB 7.5 7.5 7.5 Cure rate, new cases 92.5 95.3 95.3 Cure rate, retreatment cases 83.8 84.7 84.7 Cure rate, MDR-TB cases 79.0 79.0 79.0 Case fatality rate, active cases, % (range) 1.5 (1.0–1.9) 4.2 1.5 (1.3–1.7) DALY saved for treating a new case 7.0 6.4 4.9 DALY saved for treating a retreat case 6.5 5.8 4.4 DALY saved for treating a new case, including transmission benefits 18.5 17.9 12.6 DALY saved for treating a retreat case, including transmission benefits 18.0 17.2 12.5
Source NTP,† WHO‡ NTP† NTP† 4,5 17,18
WHO‡ NTP† NTP† 19
WHO,‡ NTP† 10 NTP† 10 NTP† 10 NTP† 14 NTP†
* National average. † Source of data: statistics from the National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention. ‡ According to WHO estimates. § WHO estimates for the years 2002–2008. NTP ¼ National Tuberculosis Programme; WHO ¼ World Health Organization; TB ¼ tuberculosis; MDR-TB ¼ multidrug-resistant TB; DALY ¼ disability-adjusted lifeyear.
DISCUSSION Globally, the Health X Project (covering a population of 668 million) is the first project to have been evaluated from an economic perspective. Results and lessons learnt may also be of interest to other countries as they scale up DOTS implementation. Our results show that 1.6 million additional active TB cases were detected by the Project areas, of which most were cured or completed treatment. Globally, the DOTS/Stop TB Strategy has saved 4.6–6.3 million lives,21 while this Project alone has prevented 25 000– 41 000 deaths and saved 18.4 million DALYs (vs. 11.3 in scenario 2) in the regions covered by the Project. If the benefits of prevented future transmission are included, 49.0 million DALYs have been Table 3
saved by the Project, vs. a 30.2 million incremental effect in scenario 1. Costs per DALY vary substantially in different countries, and between industrialised and developing settings.22,23 Since the early 1990s, short-course regimens for new smear-positive TB cases have been promoted as one of the most cost-effective health care interventions available, based on studies in lowincome African countries that have reported a cost per DALY saved of between US$1 and US$3.23–25 In countries with similar income levels to China, such as Peru and Brazil, the mean cost per DALY saved was respectively US$211 and US$86.25,26 Compared to the control areas, the cost per DALY saved in the intervention areas was lower than the threshold for defining an ‘attractive’ investment in
Cost-effectiveness of the Health X Project ICER analysis* (Alternative scenario 1)
Cost-effectiveness analysis Effectiveness Number of active cases detected, million Number of cases cured, million Deaths reduced, thousand DALYs saved, million DALYs saved, including transmission benefits, million Cost per DALY reduced, CNY Costs saved from DALYs saved, CNY, billion# Costs saved from DALYs saved, including transmission benefits, CNY, billion#
3.1 2.7 — — — 953
Sensitivity range
Threshold
ICER analysis* (Alternative scenario 2)
Incremental Sensitivity Incremental Sensitivity effectiveness range effectiveness range
— 2.6–2.7† — — — 953–1135¶ USD 223 (WHO)
1.6 1.6‡ 25‡ 18.4
— 1.6–1.7† 16–31† 18.0–18.6
1.0 1.6 41 11.3§
— 1.6–1.7† 16–31† 11.0–11.4
49.0 187
48.1–49.5 —
30.2§ 187
29.3–30.5 —
—
—
17.5
17.2–17.7
10.8
10.5–10.9
—
—
46.7
45.8–47.2
28.8
27.9–29.0
* Compared to alternative scenarios. † Sensitive to the cure rate in different years. ‡ Benefits from improved case detection rate and improved cure rate. § Benefits from case detection and cure rates. ¶ Sensitive to the costs of treatment of MDR-TB (double). # Assume annual discount rate at 3%. ICER ¼ incremental cost-effectiveness ratio; DALY ¼ disability-adjusted life-year; CNY ¼ Chinese yuan.
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low-income countries. Given that the per capita GDP for China was US$3315 in 2008,26 TB control in both the Project and the control areas were very costeffective (below the threshold of GDP per capita) according to the WHO cost-effectiveness thresholds.27 The Project is more cost-effective than the control areas, and was much more effective than in 2002. The Project had substantially lower health system costs than those of non-project areas. While increased costs following DOTS implementation have been reported — for example, the DOTS strategy doubled patient costs and quadrupled health system costs per completed treatment in Brazil,28 our study did not show significant changes in health system costs. Due to the modest increase in the treatment completion rate due to DOTS during the Project period, the ICER was higher than the previous figure.14 ICER for patients would remain high, as showed by the sensitivity analyses in various scenarios. The cost per DALY saved for treating a new case had the highest impact on ICER for the total economic burden of TB. However, if the average case detection rates of both scenarios are assumed to be the same (i.e., the non-project areas also improved their case finding), the incremental effects would decrease by about one third. Recent studies have reported an association between increased case detection rates and a reduction in TB incidence and mortality.29 Improved case detection and treatment success rates help reduce TB mortality, and success rates were significantly associated with a downward trend in the TB burden. In Project areas, the growing detection rate may affect TB incidence by reducing community transmission, and consequently infection rates, especially in the long term. Given the high prevalence of MDR-TB in China,4,5 the observed high cost-effectiveness ratio is even more remarkable. With the high cure rates achieved in China, the recent expansion of DOTS should help limit the development of the MDR-TB epidemic. However, the concurrent high rates of relapse cases and inadequate treatment in both the public health system and the hospital system indicate that DOTS alone may not be enough to tackle MDR-TB-related problems in China,5 although sound cost-effectiveness has been observed. The data also suggest that the incremental effectiveness from current DOTS strategies in the future may be limited, especially without implementing a high-quality system such as DOTSplus strategies to treat MDR-TB cases.30 As with all estimates of this kind, several limitations need to be acknowledged. First, we may have underestimated the effectiveness of the DOTS/Stop TB strategy. Given the impossibility of obtaining accurate data for some parameters, the national average has been used in the models as control input
(e.g., for MDR-TB proportions), which may have underestimated the effects of the Project. Finally, regarding the estimates of some other parameters, the effectiveness of the Project may have been overestimated. The provinces covered by the Project were relatively poor areas; it may thus not be appropriate to use non-Project areas as controls. Under such circumstances, we used data from when the Project was launched.29
CONCLUSIONS Our results show that Health X Project-based DOTS strategies were affordable and their cost-effectiveness was comparable with those of other developing countries. The results also provide strong support for the existing policy of scaling up DOTS and its contents (e.g., MDR-TB treatment) in China. Acknowledgements This study was granted by the Independent Evaluation Programme on WB/DFID TB Control Project of China, and the National Natural Science Foundation of China, Beijing, China (No. 30800937). Conflict of interest: None declared.
References 1 World Health Organization. WHO report, 2010. Global tuberculosis control. WHO/HTM/TB/2010.7. Geneva, Switzerland: WHO, 2010. 2 Ministry of Health, China. Report on nationwide random survey for the epidemiology of tuberculosis in 2000. Beijing, China: MoH, 2002. 3 Kremer K, Glynn J R, Lillebaek T, et al. Definition of the Beijing/W lineage of Mycobacterium tuberculosis on the basis of genetic markers. J Clin Microbiol 2004; 42: 4040–4049. 4 He G X, Zhao Y L, Jiang G L, et al. Prevalence of tuberculosis drug resistance in 10 provinces of China. BMC Infect Dis 2008; 8: 166. 5 Zhao Y, Xu S, Wang L, et al. National survey of drug-resistant tuberculosis in China. N Engl J Med 2012; 366: 2161–2170. 6 Wang L, Liu J, Chin D P. Progress in tuberculosis control and the evolving public-health system in China. Lancet 2007; 369: 691–696. 7 Xianyi C, Fengzeng Z, Hongjin D, et al. The DOTS strategy in China: results and lessons after 10 years. Bull World Health Organ 2002; 80: 430–436. 8 Ma J, Yang G, Shi X. Information technology platform in China’s disease surveillance system. Dis Surveill 2006; 21: 1–3. 9 Drummond M F. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford, UK; New York, NY, USA: Oxford University Press, 2005. 10 Wang X, Wu G, Gong Y, et al. Study on the disease economic burden of TB patients with drug resistance in areas of TB control program. Chinese Health Econ 2005; 24: 3. 11 National Center for Disease Control and Prevention C. Report of the 5th National Tuberculosis Epidemiological Sampling Survey. Beijing, China: National Center for Disease Control and Prevention, 2012. 12 Xu B, Dong H J, Zhao Q, et al. DOTS in China — removing barriers or moving barriers? Health Policy Plann 2006; 21: 365–372. 13 World Health Organization. Making choices in health WHO
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14
15 16
17
18
19
20
21
guide to cost-effectiveness analysis. Geneva, Switzerland: WHO, 2003. Wu G, Gong Y, Li Y, et al. A study of the effect of TB control programs on disease burden. Chinese J Hospital Administration 2001; 17: 4. Sassi F. Calculating QALYs, comparing QALY and DALY calculations. Health Policy Plann 2006; 21: 402–408. Liao C M, Cheng Y H, Lin Y J, et al. A probabilistic transmission and population dynamic model to assess tuberculosis infection risk. Risk analysis: an official publication of the Society for Risk Analysis 2012; 32: 1420–1432. Vynnycky E, Fine P E. The natural history of tuberculosis: the implications of age-dependent risks of disease and the role of reinfection. Epidemiol Infect 1997; 119: 183–201. World Health Organization. Tuberculosis Fact Sheet. Geneva, Switzerland: WHO, 2012. http://www.who.int/mediacentre/ factsheets/en/. Accessed May 2014. Wang S, Wang X, Zhao X, et al. Research on treatment efficacy of the patients with drug resistance in the project for drug resistance surveillance in Guangdong and Zhejiang provinces. The Journal of the Chinese Antituberculosis Association 2005; 27: 4. World Health Organization. Investing in health research and development: report of the ad hoc committee on health research relating to future intervention options. Geneva, Switzerland: WHO, 1996. Glaziou P, Floyd K, Korenromp E L, et al. Lives saved by tuberculosis control and prospects for achieving the 2015 global target for reducing tuberculosis mortality. Bull World Health Organ 2011; 89: 573–582.
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22 Currie C S, Floyd K, Williams B G, et al. Cost, affordability and cost-effectiveness of strategies to control tuberculosis in countries with high HIV prevalence. BMC Public Health 2005; 5: 130. 23 Baltussen R, Floyd K, Dye C. Cost-effectiveness analysis of strategies for tuberculosis control in developing countries. BMJ 2005; 331: 1364. 24 Murray C J, DeJonghe E, Chum H J, et al. Cost effectiveness of chemotherapy for pulmonary tuberculosis in three sub-Saharan African countries. Lancet 1991; 338: 1305–1308. 25 Wilton P, Smith R D, Coast J, et al. Directly observed treatment for multidrug-resistant tuberculosis: an economic evaluation in the United States of America and South Africa. Int J Tuberc Lung Dis 2001; 5: 1137–1142. 26 China economy yearbook. Chinese Academy of Social Sciences yearbooks. Vol 1: Economy. Leiden, The Netherlands: Brill Press, 2008. 27 World Health Organization. Cost-effectiveness thresholds. Geneva, Switzerland: WHO, 2014. http://www.who.int/ choice/costs/CER_thresholds/en/. Accessed May 2014. 28 Steffen R, Menzies D, Oxlade O, et al. Patients’ costs and costeffectiveness of tuberculosis treatment in DOTS and non-DOTS facilities in Rio de Janeiro, Brazil. PLOS ONE 2010; 5: e14014. 29 Akachi Y, Zumla A, Atun R. Investing in improved performance of national tuberculosis programs reduces the tuberculosis burden: analysis of 22 high-burden countries, 2002–2009. J Infect Dis 2012; 205 (Suppl 2): S284–S292. 30 Singla R, Sarin R, Khalid U K, et al. Seven-year DOTS-Plus pilot experience in India: results, constraints and issues. Int J Tuberc Lung Dis 2009; 13: 976–981.
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i
RESUME
Le Projet Health X e´ tait un prˆet de la Banque Mondiale au Programme National de Lutte contre la Tuberculose de la Chine entre 2002 et 2008, avec un financement suppl´ementaire du Department for International Development du Royaume Uni. O B J E C T I F S : Evaluer le rapport cout-efficacit´ ˆ e du projet et son impact financier sur la lutte contre la tuberculose (TB) en Chine. M E´ T H O D E S : Un mod`ele d’analyse de d´ecision a permis d’estimer le rapport cout-efficacit´ ˆ e du projet. L’analyse de sensibilit´e a permis d’´evaluer l’impact de diff´erents scenarios et hypoth`eses sur les r´esultats. Le principal r´esultat de cette e´ tude a e´ t´e le cout ˆ par ann´ees de vie corrig´ees de l’incapacit´e (DALY) r´eduite et par DALY diff´erentielle r´eduite. CONTEXTE :
Le Projet a d´etect´e 1,6 millions de cas supple´ mentaires par comparaison avec le sc´enario hypoth´etique 1, et 44 000 d´ec`es ont e´ t´e e´ vit´es (soit une r´eduction totale de 18,4 millions de DALY). Cette strat´egie a cout´ ˆ e environ 953 yuan chinois (CNY) par DALY e´vit´ee (contre 1140 CNY dans les zones t´emoins) et a sauv´e environ 17,5 milliards de CNY en comparaison avec le sc´enario hypoth´etique inchang´e (scenario 1) ou 10,8 milliards de CNY du sc´enario t´emoin (sc´enario 2). C O N C L U S I O N : Cette strat´egie a e´ t´e abordable et son rapport cout-efficacit´ ˆ e a e´ t´e comparable a` celui d’autres pays en d´eveloppement. Les r´esultats sont fortement en faveur de la politique existante d’expansion des DOTS et de son contenu en Chine. R E´ S U LT A T S :
RESUMEN
El proyecto Health X fue una iniciativa del Programa Nacional de Control de la Tuberculosis en China, ejecutada entre el 2002 y el 2008, financiado por un pr´estamo del Banco Mundial y fondos complementarios del Department for International Development del Reino Unido. O B J E T I V O S: Evaluar la eficacia del proyecto y sus repercusiones econ omicas ´ en el control de la tuberculosis (TB) en la China. M E´ T O D O S: Se aplico ´ un modelo decisional anal´ıtico con el fin de evaluar la rentabilidad del proyecto. Mediante un ana´lisis de sensibilidad se examino´ el efecto de diferentes hipotesis ´ y supuestos en los resultados. El criterio primario de evaluacion ´ del estudio fue el costo por la disminucion ´ de cada ano ˜ de vida ajustado en funcion ´ de la discapacidad (DALY) y la disminucion ´ diferencial de DALY. M A R C O D E R E F E R E N C I A:
En el Proyecto se detectaron 1,6 millones de casos adicionales, en comparacion ´ con la hipotesis ´ de contraste 1, y se evitaron 44 000 muertes (una disminucion ´ total de 18,4 millones de DALY). Las estrategias del proyecto habr´ıan costado cerca de 953 yuanes chinos (CNY) por cada DALY evitado (contra CNY 1140 en las zonas testigo) y ahorrado cerca de CNY 17,5 miles de millones, al compararlo con la hipotesis ´ de contraste sin ningun ´ cambio (hipotesis ´ 1, situacion ´ en el 2002) o CNY 10,8 miles de millones en comparacion ´ con las regiones testigo (hipotesis ´ 2). ´ N: Las estrategias fueron asequibles y CONCLUSIO ofrecieron una rentabilidad equivalente a la rentabilidad observada en otros pa´ıses en desarrollo. Adema´ s, los resultados respaldan firmemente las pol´ıticas vigentes en la China de ampliacion ´ de escala de la estrategia de DOTS y sus componentes. R E S U LT A D O S:
