Cost and cost-effectiveness of a public-private mix project in Kannur District, Kerala, India, 2001-2002.

BACKGROUND: Little is known yet about the cost-effectiveness of public-private mix (PPM) collaborations for the delivery of tuberculosis (TB) diagnostic and treatment services. DESIGN: We evaluated the cost and cost-effectiveness of a PPM project targeting private laboratories in Kannur district, India, from the perspective of the Revised National TB Control Programme (RNTCP). We estimated the cost per provider recruited and retained, the cost per additional patient notified under various effectiveness scenarios and the cost per additional patient successfully treated. Intervention cost data were abstracted from RNTCP records. Treatment costs were estimated based on RNTCP case management protocols. RESULTS: The annual total estimated cost of the project was US$8712-$11611. The cost per private provider recruited varied between US$22 and US$54. The cost per additional pulmonary TB patient privately diagnosed was US$14-$18. In the most conservative scenario, the cost per additional patient notified was US$29-$36. The cost per new acid-fast bacilli-positive patient successfully treated was US$47-$51. Higher notification rates would improve cost-effectiveness. CONCLUSIONS: Comparisons with public sector diagnostic costs are required to determine if this intervention remains economically attractive to the public health care system at different activity levels and to determine the supplemental resources needed if scale-up is pursued.

Improved tuberculosis case detection through public-private partnership and laboratory-based surveillance, Kannur District, Kerala, India, 2001-2002.

BACKGROUND: Efforts to intensify global tuberculosis (TB) control are limited by difficulties in coordinating with private doctors. More than half of Indian TB patients may initially consult a private provider, but many are neither diagnosed accurately nor treated effectively. We established and evaluated a public-private partnership based on surveillance of TB detected in private laboratories and use of standardised directly observed treatment regimens. METHODS: In one district, the governmental TB control programme offered training in microscopy to all large private sector laboratories, and educated private physicians on the importance of microscopy for TB diagnosis. We reviewed records from participating private laboratories and all publicly diagnosed patients. RESULTS: Of 2328 pulmonary TB patients registered from July 2001 to December 2002, 404 (17%) were detected in the private sector. The annual new AFB-positive case notification rate increased by 21%, from 27.8/100,000 in 2000 to 33.5/100,000 in 2002. Surveillance at private laboratories found an additional 260 nonregistered AFB-positive patients. CONCLUSIONS: This public-private partnership substantially increased TB case detection and established a sustainable framework for private sector involvement in TB control. In the setting of a strong public sector programme, the combination of active surveillance of private laboratories along with physician sensitisation is a promising approach to improve TB case detection.