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Scaling up different public-private partnership models of tuberculosis intervention in South Africa

Edina Sinanovic and Lilani Kumaranayake, Health Economics Unit, University of Cape Town,  and Department of Public Health and Policy, London School of Hygiene and Tropical Medicine

Background:


Tuberculosis (TB) is the most common opportunistic illness related to HIV/AIDS and the most common cause of death among HIV-infected people in the developing world. Given the scale of the HIV/AIDS epidemic and its impact on TB caseloads, the existing levels of resources needed are likely to increase in future, and additional funds will be required for new kinds of interventions. The type of interventions that are required to raise detection and cure rates may include strengthened public-private partnerships (PPPs) in the provision of TB treatment. Although the public health sector is predominant in the provision of TB treatment in South Africa, the private sector is an important component of the health care system, employing an increasing proportion of health care providers.

The study aims to estimate future resource requirements for a scaled-up response of TB treatment in South Africa, assessing the role of private and public sectors in alternative financing strategies in light of the dual HIV/TB epidemic. Two different models of TB provider partnerships are considered relative to sole public provision: public-private workplace (PPW), and public-private non-government (PPN). Treatment of tuberculosis is defined according to the WHO framework for tuberculosis control – DOTS (Directly Observed Treatment-Short Course). Costs of TB prevention amongst HIV-infected persons are also included in the model.

Methods:


A model to estimate likely resource implications for scaling-up different PPP models was developed. Estimates of the financial resources required for tuberculosis control in light of the TB/HIV epidemic in South Africa for the next 10 years was made using three types of data, namely demographic data, epidemiological data on TB and HIV incidence, and cost data. Epidemiological data were drawn from existing epidemiological modelling undertaken in Southern Africa. The expenditure modelling of the estimates adopted a three-fold approach. First, available demographic and epidemiological data were used to determine the population in need. Second, the quantity of services provided in each year was calculated as the product of the size of the population in need and existing (2005) and increased (2014) levels of coverage. Finally, cost estimates were generated by linking information on unit (average) costs to the quantity of additional services provided in 2013 (linear projection). Unit costs were drawn from previous studies on PPPs in South Africa, and present full cost associated with the implementation of services up to the district level. Unit costs reflect the provision of TB treatment as an ambulatory and hospital-based intervention. Impact of scaled-up TB treatment for different models of TB treatment provision is measured through effectiveness data: cure rate and successful treatment completion rate.

Results


PPP models could significantly reduce costs to the patient by 64%-100%. Relative to pure public sector provision and financing, expansion of PPPs could reduce government financing required per TB patient treated from $609-690 to $130-139 in PPN and $36-46 in PPW. There is a strong economic case for expanding PPP in TB treatment and potentially for other types of health services.   Where PPPs are tailored to target groups and supported by the public sector, scaling up of effective services could occur at much lower cost than just relying on public sector models. The study also finds that whilst there are associated financial costs with PPPs, the private sector can play a critical role in scaling-up activities quickly, maximising the use of existing infrastructure to increase coverage.

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