Cost-effectiveness of the polymerase chain reaction versus smear examination for the diagnosis of tuberculosis in Kenya: a theoretical model.

SETTING: A major out-patient tuberculosis clinic in Nairobi, Kenya. OBJECTIVE: To ascertain the cost-effectiveness of the polymerase chain reaction (PCR) for the diagnosis of tuberculosis in an urban setting in a developing country. DESIGN: A cost-effectiveness analysis of PCR and direct smear microscopy examination based on theoretical modelling. The cost-effectiveness was expressed in costs per correctly diagnosed tuberculosis patient for each of the two diagnostic techniques. Data were obtained from the literature, from the staff and the register at the health facility and from structured interviews with patients. Assumptions were made when no data were available. RESULTS: The PCR is expected to be more specific and sensitive than the routine procedure for diagnosis, but it is also more costly. The routine procedure based on direct smear microscopy turned out to be 1.8 times as cost-effective as PCR. CONCLUSION: It is concluded that the PCR method can potentially be a cost-effective screening procedure for tuberculosis, provided that the largest contributing cost component, the costs of the PCR-kit, can be reduced substantially.

Use of facility-based assessment in the evaluation of a comprehensive leprosy training program in Nepal.

A facility-based assessment (FBA) was done to evaluate a comprehensive leprosy training program in Nepal. The training course was developed to prepare the Basic Health Services staff for integrated leprosy work. FBA is a coordinated set of data collection activities designed to determine the extent to which patients are properly diagnosed, treated, and cared for in the treatment facility. During the present evaluation, the data collection activities included: observation of health worker performance, exit interviews with leprosy patients, interviews with health workers, inventory of essential equipment and supplies, and collection of routine statistical data. The objectives of the training course were used as guidelines for the evaluation. Surveys and observation visits were done repeatedly and compared with a (untrained) control group. Different actors involved in leprosy care were used as informants, and different data collection methods were used which enabled cross-checking of the information. Part of the data collection activities was already routinely carried out. FBA proved to be a very useful and effective tool for the evaluation of a leprosy training program. Those parts of the training which need extra attention during the course itself as well as during refresher training and supervision visits became obvious.

Integration of leprosy control into basic health services; an example from Nepal.

The need for integration of vertical projects into the Basic Health Services (BHS) has been felt in Nepal since 1968. In 1987 it was decided to provide integrated BHS all over the country. The Nepal Leprosy Control Project (NLCP) was one of the vertical projects which had to be integrated from that year. In order to prepare the BHS staff for this new task the NLCP developed a Comprehensive Leprosy Training course. Besides adequate training, three other prerequisites for successful integration are: a) adequate supply of drugs and equipment; b) regular supervision and specialist referral facilities; and c) a well functioning BHS system in which to integrate. This article tries to assess to what extent these prerequisites have been met for leprosy control in Nepal. To do this, some results of an evaluation of the training are used as well as existing literature on the functioning of the BHS system. The first three prerequisites are not fully met, but problems and obstacles related to these are mainly due to problems in the last prerequisite: a not so well functioning BHS system. It was, therefore, recommended to continue a (semi)vertical support system of leprosy control in those districts where the BHS is not so well developed.