Cost-effectiveness and budget impact of decentralising childhood tuberculosis diagnosis: a mathematical modelling study in six high tuberculosis incidence countries

Background The burden of childhood tuberculosis remains high globally, largely due to under-diagnosis. Decentralising childhood tuberculosis diagnosis services to lower health system levels could improve case detection, but there is little empirically based evidence on cost-effectiveness or budget impact. Methods We assessed the cost-effectiveness and budget impact of decentralising a comprehensive diagnosis package for childhood tuberculosis to district hospitals (DH-focused) or primary health centres (PHC-focused) compared to standard of care (SOC) in Cambodia, Cameroon, Côte d’Ivoire, Mozambique, Sierra Leone, and Uganda ( NCT04038632 ). A mathematical model was developed to assess the health and economic outcomes of the intervention from a health system perspective. Estimated outcomes were tuberculosis cases, deaths, disability- adjusted life years and incremental cost-effectiveness ratios (ICERs). We also calculated the budget impact of nationwide implementation. Findings For the DH-focused strategy versus SOC, ICERs ranged between $263 (Cambodia) and $342 (Côte d’Ivoire) per disability-adjusted life-year (DALY) averted. For the PHC-focused strategy versus SOC, ICERs ranged between $477 (Cambodia) and $599 (Côte d’Ivoire) per DALY averted. Results were sensitive to TB prevalence and the discount rate used. The additional costs of implementing the DH-focused strategy ranged between $13M (Cambodia) and $50M (Mozambique), and between $14M (Sierra Leone) and $135M (Uganda) for the PHC-focused strategy. Interpretation The DH-focused strategy may be cost-effective in some countries, depending on the cost- effectiveness threshold used for policy making. Either intervention would require substantial early investment. Funding Unitaid