A frontline health worker visits a family to build awareness about tuberculosis (TB). Decentralised care for multidrug-resistant TB could potentially cure an additional 1,058 patients, help patients gain additional 3,824 Quality Adjusted Life Years, and avert 2,165 deaths, as compared to centralised care, a new study has found.

Decentralised care--provided in the local community where the patient lives--is cost-effective in comparison with centralised care--provided at specialised tuberculosis (TB) care centres--for managing multidrug-resistant TB (MDR-TB) in India, according to a new study.

This could provide an alternative to hospitalisation for anti-tuberculosis therapy as recommended by the Government of India’s Revised National Tuberculosis Control Programme (RNTCP).

MDR-TB is a more potent form of TB that does not respond to at least two of the most powerful anti-TB drugs, isoniazid and rifampicin, and is more expensive to cure.

In 2017, over 48,000 patients started treatment for MDR-TB under the RNTCP, and decentralised care could potentially save the country save $80 million (Rs 523 crore) based on savings of $1,666.50 (Rs 108,878) per case when compared to centralised care, according to the study, published in September 2017 in the Indian Journal of Tuberculosis.

The cost of staying in the hospital, which was significantly more intensive and thus more expensive, was one of the most important drivers of this difference.

Decentralised care could potentially cure an additional 1,058 patients, help patients gain additional 3,824 Quality Adjusted Life Years (QALYs), and avert 2,165 deaths, as compared to centralised care, the health economic modelling study found.

The cost difference between decentralised and centralised care could be between 23% and 94%, based on the proportion of the population under each kind of care.

Cost Of Care For Multidrug-Resistant Tuberculosis
Cost HeadCentralised careDecentralised careCost DifferenceDifference (In %)
Total programme cost
(Rs crore)
Cost per patient cured (Rs)262,934.2885,609.38177,324.9067.44
Cost per death averted (Rs)68,913.1833,577.3335,335.8551.28

Scenario Analysis: Centralised Vs Decentralised Care For Multidrug-Resistant Tuberculosis
Coverage rate scenarioCentralised care
(Rs crore)
Decentralised care
(Rs crore)
Cost Difference
(Rs crore)
Difference (In %)
70%:30 %741.00161.49579.5178.21
50%: 50%529.29269.15260.1449.15

Source: Author's calculations, cited in this study

Decentralised care is provided in the local community where the patient lives, by non-specialised or peripheral health centres, by community health workers or nurses, non-specialised doctors, community volunteers or treatment supporters. The care could occur at the patient’s home, workplace or local venues such as a community centre.

The treatment and care could include Direct Observed Therapy (DOT), which includes drugs, patient support and injections, and in some cases a brief phase of hospitalisation of less than one month during the initial phase of treatment or because of any treatment complications.

In comparison, centralised care is inpatient treatment and care provided solely by specialised drug-resistant TB centres or teams during intensive treatment phase or until there is a response to anti-tuberculosis treatment. The patient could later receive decentralised care.

India constitutes the highest burden of TB in the world, with 15% of its 2.8 million cases MDR, a number which is expected to persist in the near future if current practices of managing MDR-TB in the country continue. One of the ways of scaling up MDR-TB therapy to all who need it could be the strategy of switching a proportion of MDR-TB patients (depending on severity) over to the decentralised care model in India.

WHO recommends decentralised care in resource-poor settings

As use of Xpert® MTB/RIF--which are tests for drug-resistant TB--expand across countries, more patients will be diagnosed and enrolled for MDR-TB treatment. In resource poor settings, the World Health Organization guidelines recommend conditional implementation of decentralised care. “Having treatment and care provided in decentralised health-care facilities is a practical approach to scale up treatment and care for patients who are eligible for MDR-TB treatment,” according to the guidelines.

These guidelines are based on recent evidence which showed that treatment success and loss to follow-up improved with decentralised care in comparison with centralised care. In addition, the risk due to mortality and treatment failure was similar for both kinds of care.

For instance, in Ethiopia’s ambulatory service delivery model, MDR-TB patients are treated at the outpatient level at treatment follow-up centres from day one. These centres might recommend temporary admission based on clinical or social criteria, with medications to be given under direct observation and strict follow up by health workers. This approach showed treatment success rates of over 75%, higher than the global average of 52%, and increased the number of MDR-TB patients treated in the programme.

Similarly, after a national MDR-TB decentralisation policy issued by the Department of Health of South Africa in 2011, majority of MDR-TB patients in South Africa are on treatment at their local clinic, with the doctor initiating MDR-TB treatment at the Primary Health Centre, with follow-ups by trained nurses.

(John is a public health professional and works as Evidence Synthesis Specialist with the Campbell Collaboration, a nonprofit based in New Delhi.)

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