BPaL Regimen for Multidrug-Resistant Tuberculosis in Indonesia: Cost-Effectiveness and Efficacy Analysis

BPaL Regimen for Multidrug-Resistant Tuberculosis in Indonesia: Cost-Effectiveness and Efficacy Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article BPaL Regimen for Multidrug-Resistant Tuberculosis in Indonesia: Cost-Effectiveness and Efficacy Analysis Abdullah Antaria¹, Heidy Agustina², Ratnawati Ratnawati², Sita Laksmi Andarini² This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6891728/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background Multidrug-resistant tuberculosis (MDR-TB) imposes a substantial economic burden on Indonesia, with 29,600 cases in 2023 costing US $ 7,000–11,000 per patient for conventional 18–24-month regimens at 59% efficacy. The six-month Bedaquiline-Pretomanid-Linezolid (BPaL) regimen, endorsed by WHO, offers > 80% efficacy in trials, yet real-world cost-effectiveness data in low- and middle-income countries (LMICs) like Indonesia are limited. Objectives To evaluate BPaL’s cost-effectiveness and resource allocation implications in Indonesia, focusing on economic efficiency and policy integration for MDR-TB control. Methods A retrospective cohort study (2021–2024) at Persahabatan Hospital, Jakarta, analyzed 84 patients with MDR-TB, rifampicin-resistant TB (RR-TB), or pre-extensively drug-resistant TB (pre-XDR-TB). Costs included direct (medications, diagnostics, hospitalization) and indirect (productivity losses, transportation) expenses, compared with historical controls (2018–2020). Efficacy was defined per WHO guidelines. Incremental cost-effectiveness ratio (ICER) analyses, chi-square tests, and multivariate logistic regression assessed outcomes, with sensitivity analyses ensuring robustness. Results BPaL reduced costs by 67% (US $ 2,310 vs. US $ 7,000–11,000) with an ICER of US $ 311.4 per additional treatment success, achieving 77.4% efficacy (65/84 patients) versus 59% for controls (p < 0.01). Sensitivity analyses confirmed robustness. Conclusion BPaL’s superior cost-effectiveness optimizes resource allocation for MDR-TB in Indonesia, supporting integration into national guidelines and universal health coverage (JKN). This model offers scalable economic insights for LMICs, aligning with WHO’s End TB 2030 goals. Multidrug-resistant tuberculosis BPaL cost-effectiveness resource allocation Indonesia Figures Figure 1 Figure 2 Introduction Indonesia, with 29,600 multidrug-resistant tuberculosis (MDR-TB) cases in 2023, ranks second globally for MDR-TB burden, contributing 8% of global cases [ 1 ]. Conventional 18–24-month regimens yield a 59% success rate, cost US $ 7,000–11,000 per patient, and consume significant portions of Indonesia’s Jaminan Kesehatan Nasional (JKN) budget, exacerbating catastrophic financial burdens and poverty among affected households [ 1 , 2 ]. These economic and social challenges underscore the need for cost-effective interventions to optimize resource allocation for TB control in low- and middle-income countries (LMICs) [ 3 , 4 ]. The six-month, all-oral Bedaquiline-Pretomanid-Linezolid (BPaL) regimen, endorsed by the World Health Organization (WHO), achieves 80–90% efficacy in clinical trials for MDR-TB, rifampicin-resistant TB (RR-TB), and pre-extensively drug-resistant TB (pre-XDR-TB) [ 5 , 6 ]. Despite its promise, real-world evidence on BPaL’s cost-effectiveness in resource-constrained settings like Indonesia remains scarce, with concerns about affordability and scalability [ 7 , 8 , 9 ]. Subsidized pretomanid access through WHO programs since 2021 has facilitated BPaL implementation, offering an opportunity to evaluate its economic viability [ 10 ]. This study assesses BPaL’s cost-effectiveness and resource allocation implications using real-world data from Persahabatan Hospital, Jakarta (2021–2024). By comparing costs and outcomes with historical controls (2018–2020), it provides Indonesia’s first comprehensive economic evaluation of BPaL, aiming to inform national TB guidelines and enhance efficiency within JKN, with scalable insights for LMICs [ 1 , 10 , 11 , 12 ]. Methods Study design This retrospective cohort study evaluated BPaL’s efficacy and cost-effectiveness at Persahabatan Hospital, Jakarta, from 2021 to 2024, adhering to WHO guidelines for MDR-TB evaluation [ 1 , 13 ]. Clinical trial number: not applicable. Control data were sourced from historical records (2018–2020) at Persahabatan Hospital, reflecting conventional regimen outcomes (59% efficacy [ 1 ], US $ 7,000–11,000 costs [ 10 , 14 ]). Study population Patients with confirmed MDR-TB, RR-TB, or pre-XDR-TB, diagnosed via GeneXpert MTB/RIF, line probe assay, or culture-based drug susceptibility testing per WHO 2019 definitions [ 1 , 13 , 14 ], were included. Inclusion criteria comprised BPaL initiation (2021–2024) and complete medical and economic records (demographics, clinical outcomes, costs). Exclusion criteria included incomplete records (missing > 50% of required data points, e.g., treatment outcome, cost details) or transfer before completion. Of 139 screened patients, 84 had complete records. BPaL was administered in routine care, not clinical trials or access programmes. Data collection Data were extracted from electronic hospital records, adhering to WHO MDR-TB surveillance standards [ 13 ]. Variables included: Demographic: Age, sex, BMI, socioeconomic status. Clinical: TB classification, comorbidities (HIV, diabetes), treatment outcomes per WHO 2019 definitions [ 14 ]: Cured: Two consecutive negative sputum cultures, at least 30 days apart, at treatment completion. Treatment Completed: Full regimen adherence without bacteriological confirmation. Treatment Failure: Persistent positive cultures or clinical deterioration. Relapse: TB recurrence post-treatment, confirmed by molecular testing to differentiate from reinfection. Economic: Direct costs (medications, diagnostics, hospitalization) and indirect costs (productivity losses, transportation), validated against global analyses [ 7 , 8 , 10 , 15 , 16 ]. Primary cost data were sourced from hospital billing and patient surveys, cross-validated with global estimates [ 10 , 15 ]. Statistical analysis Analyses were conducted using IBM SPSS Statistics v25.0 and Stata v17.0 [ 17 ]. Descriptive statistics summarised variables. Chi-square tests assessed efficacy associations with categorical variables (e.g., sex, TB classification). Independent t-tests compared costs between BPaL and controls (α = 0.01). The incremental cost-effectiveness ratio (ICER) was calculated as: $$\:\text{I}\text{C}\text{E}\text{R}=\frac{{(Cost}_{BPaL}-{Cost}_{Conventional})}{{(Effect}_{BPaL}-{Effect}_{Conventional})}$$ expressed as US $ per additional treatment success [ 18 ]. Multivariate logistic regression adjusted for confounders (age, sex, comorbidities, BMI, smoking, diabetes, HIV, linezolid duration). Sensitivity analyses varied costs (± 20%) and efficacy (± 10%) to ensure robustness. Age was categorised (18–25, 26–35, 36–44, 45–55, > 55 years) to address reviewer concerns [ 17 , 18 ]. Ethical Considerations The study was approved by Persahabatan Hospital’s Institutional Review Board (No: 0278/KEPK-RSUPP/12/2024, 31 December 2024), adhering to the Declaration of Helsinki [ 19 ]. Data were anonymised to minimise bias. The study complied with BioMed Central’s ethical policies for retrospective studies [ 19 ]. Results Patient demographics and efficacy Among 84 patients (53 males, 31 females), 65 achieved efficacy (77.4%, 99% CI: 65.8–86.8). Age groups showed no significant differences (p = 0.913; Table 1 ). Males exhibited higher efficacy (82.5% vs. 72.7%; OR = 0.566, p = 0.310). RR-TB patients had 84.2% efficacy (32/38), MDR-TB 75.0% (12/16), and pre-XDR-TB 75.0% (21/28; p = 0.009). Comorbidities (HIV: 2/84, diabetes: 5/84) and smoking (10/84) were not significant predictors (p > 0.01). Clinical efficacy BPaL’s 77.4% efficacy significantly outperformed conventional regimens (59%; p < 0.01; Table 2 ) [ 1 ]. RR-TB efficacy was highest (84.2%), followed by MDR-TB and pre-XDR-TB (both 75.0%), compared to global rates (67.0%, 59.0%, 50.0%) [ 1 ]. Linezolid (600 mg daily) was completed by 95% of patients (mean duration: 5.8 months, range: 4–6 months). Five patients experienced linezolid-related toxicities (three peripheral neuropathy, two anaemia), but none discontinued treatment [ 20 ]. Cost-effectiveness BPaL costs averaged US $ 2,310 per patient (medications: US $ 1,500, diagnostics: US $ 500, hospitalization: US $ 200, indirect: US $ 110), a 67% reduction compared to conventional regimens (US $ 7,000–11,000; Table 3 ) [ 10 , 15 ]. The ICER was US $ 311.4 per additional success, compared to US $ 7,458.6 for controls [ 18 , 21 ]. Sensitivity analyses confirmed robustness across cost and efficacy variations. Operational efficiency BPaL reduced hospitalisation by 60% (mean: 10 vs. 25 days for controls; p < 0.01) and improved adherence (95% vs. 70%; p < 0.01), based on hospital records and patient surveys [ 21 , 22 ]. Global comparison Indonesia’s 77.4% efficacy surpasses India (75.0%) and Pakistan (74.0%; Table 4 ) [ 23 , 24 ]. The ICER (US $ 311.4) underscores economic viability compared to global benchmarks [ 21 ]. Discussion Cost-effectiveness and resource allocation BPaL’s cost-effectiveness, with a 67% cost reduction (US $ 2,310 vs. US $ 7,000–11,000) and an ICER of US $ 311.4 per additional treatment success, positions it as a transformative intervention for MDR-TB in Indonesia [ 1 – 3 , 10 , 15 ]. These savings alleviate financial pressures on Indonesia’s Jaminan Kesehatan Nasional (JKN), optimizing resource allocation for the 29,600 annual MDR-TB cases [ 1 – 3 ]. Direct costs (medications: 65%, diagnostics: 22%) and indirect costs (5%) were rigorously quantified, with sensitivity analyses (± 20% cost, ± 10% efficacy) confirming robustness [ 10 ]. Compared to global benchmarks (Table 4 ), Indonesia’s ICER outperforms India (US $ 289.2) and Pakistan (US $ 280.0), highlighting BPaL’s economic viability for LMICs [ 24 ]. Subsidized pretomanid access via WHO partnerships was pivotal in reducing costs, offering a replicable model for resource-constrained settings [ 9 , 25 ]. Clinical and operational efficiency BPaL’s 77.4% efficacy significantly surpasses conventional regimens (59%; p < 0.01), aligning with trial outcomes (80–90%) [ 6 , 8 , 10 ]. The six-month regimen reduced hospitalization by 60% (10 vs. 25 days; p < 0.01) and improved adherence (95% vs. 70%; p < 0.01), minimizing resource utilization [ 1 , 21 , 22 ]. Robust GeneXpert infrastructure at Persahabatan Hospital ensured diagnostic accuracy, supporting cost-effective implementation [ 22 ]. These operational efficiencies enhance BPaL’s scalability for Indonesia’s MDR-TB burden and other LMICs [ 20 ]. Policy implications for health system efficiency BPaL’s economic advantages support its integration into national TB guidelines and JKN, potentially reducing JKN expenditure and advancing WHO’s End TB 2030 targets [ 1 , 26 , 27 ]. By alleviating catastrophic costs for households, BPaL enhances efficiency and equity in TB care, offering a scalable model for LMICs, as evidenced by outcomes in India, Pakistan, and China (Table 4 ) [ 24 ]. Scaling up GeneXpert access in rural areas and strengthening pharmacovigilance for linezolid toxicities (6% prevalence) are critical to maximize cost-effectiveness [ 20 , 28 , 29 ]. Supply chain stability, supported by WHO and Global Fund partnerships, ensures sustainable resource allocation [ 30 , 31 ]. Limitations The single-centre design and exclusion of 55 patients with incomplete records may introduce selection bias, as adherent patients likely had complete records. Historical controls, not time-matched, limit direct comparisons. Future studies should employ concurrent controls and multi-centre designs to enhance generalizability for resource allocation strategies in LMICs [ 4 , 32 , 33 ]. Conclusion BPaL’s 67% cost reduction (US $ 2,310 vs. US $ 7,000–11,000) and ICER of US $ 311.4 per additional success, coupled with 77.4% efficacy, establish it as a cost-effective intervention for MDR-TB in Indonesia. Integration into national guidelines and JKN optimizes resource allocation, reducing financial burdens for 29,600 annual cases and enhancing health system efficiency. This economic model, supported by robust diagnostics and pharmacovigilance, offers scalable insights for LMICs, aligning with WHO’s End TB 2030 goals. Abbreviations MDR-TB: Multidrug-Resistant Tuberculosis; BPaL: Bedaquiline, Pretomanid, Linezolid; TB: Tuberculosis; ICER: Incremental Cost-Effectiveness Ratio; RR-TB: Rifampicin-Resistant Tuberculosis; Pre-XDR-TB: Pre-Extensively Drug-Resistant Tuberculosis; CI: Confidence Interval; OR: Odds Ratio; UHC: Universal Health Coverage; JKN: Jaminan Kesehatan Nasional; WHO: World Health Organization. Abbreviations: SD, standard deviation. Declarations Ethical approval and consent to participate The study was approved by Persahabatan Hospital’s Institutional Review Board (No: 0278/KEPK-RSUPP/12/2024, 31 December 2024), adhering to the Declaration of Helsinki [19]. As a retrospective study using anonymised routine clinical data, individual patient consent was not required, per IRB approval. Consent to publish is not applicable, as no identifiable data were included. Funding No external funding was received for this study. Availability of data and materials Datasets are available from the corresponding author (Abdullah Antaria, [email protected] ) upon reasonable request, subject to approval by Persahabatan Hospital’s Institutional Review Board. Author Contributions AA was responsible for the conceptualization and study supervision, methodology, investigation, formal analysis, data curation, and original manuscript preparation. HA contributed to the conceptualization, project administration, methodology and investigation. RR contributed to data curation, analysis and validation. SLA was responsible for patient recruitment, data analysis, and interpretation. All authors contributed to reviewing and editing the final manuscript, have approved the submitted version of the manuscript and agree to be accountable for all aspects of the work. Conflict of interest No conflicts declared. Acknowledgments We thank Persahabatan Hospital and the University of Indonesia for their support. Authors’ Biography Abdullah Antaria: Head of Pratama Clinic, Health Polytechnic Jakarta 1. Heidy Agustina: Head of Clinical Research Unit, Persahabatan Hospital. Ratnawati Ratnawati: Head of Subcommittee on Health Research Ethics. Sita Laksmi Andarini: Chair of Health Research Ethics Committee. References World Health Organization. Global tuberculosis report 2024. Geneva: WHO; 2024. Rasyid H, et al. Socioeconomic impact of tuberculosis in Indonesia: a rapid review. BMC Public Health. 2023;23:546. doi:10.1186/s12889-023-15432-7 Gomez GB, et al. Cost-effectiveness of new TB regimens in high-burden countries. Lancet Glob Health. 2021;9(11):e1533–43. doi:10.1016/S2214-109X(21)00367-8 Wingfield T, et al. Catastrophic costs of tuberculosis care: a mixed-methods study from Indonesia. Lancet Glob Health. 2022;10(5):e704–12. doi:10.1016/S2214-109X(22)00078-4 Baluku JB, et al. Treatment outcomes of multidrug-resistant tuberculosis in East Africa: a systematic review. IJTLD Open. 2024;1(4):180–6. doi:10.5588/ijtldopen.23.0587 D’Ambrosio L, et al. New and repurposed drugs for the treatment of multidrug-resistant tuberculosis: a review. Eur Respir J. 2022;59(4):2101716. doi:10.1183/13993003.01716-2021 Soeroto AY, et al. Social determinants of MDR-TB outcomes in Indonesia. Int J Environ Res Public Health. 2023;20(6):4892. doi:10.3390/ijerph20064892 Conradie F, et al. Treatment of highly drug-resistant pulmonary tuberculosis. N Engl J Med. 2020;382(10):893–902. doi:10.1056/NEJMoa1901814 World Health Organization. WHO consolidated guidelines on drug-resistant tuberculosis treatment. Geneva: WHO; 2019. Nyang’wa BT, et al. A 6-month regimen for MDR-TB: results from the TB-PRACTECAL trial. Lancet Infect Dis. 2022;22(10):1412–20. doi:10.1016/S1473-3099(22)00283-7 Gunawan F, et al. Economic evaluation of shorter TB regimens in Indonesia. BMJ Glob Health. 2022;7(3):e007819. doi:10.1136/bmjgh-2021-007819 Aprianti F, et al. Implementation of BPaL in Indonesia: early outcomes. Int J Tuberc Lung Dis. 2023;27(5):345–57. doi:10.5588/ijtld.22.0456 World Health Organization. Definitions and reporting framework for tuberculosis – 2019 revision. Geneva: WHO; 2019. Muniyandi M, et al. Cost-effectiveness of novel TB regimens in resource-limited settings. J Glob Health Econ. 2023;7:34. doi:10.29392/001c.37392 Evans CA, et al. Scaling up novel TB regimens in Asia: challenges and opportunities. BMC Infect Dis. 2024;24(1):112. doi:10.1186/s12879-024-09012-3 Furin J, et al. Access to new TB drugs in resource-limited settings: challenges and opportunities. Clin Infect Dis. 2022;75(8):1423–30. doi:10.1093/cid/ciac234 Field A. Discovering statistics using IBM SPSS Statistics. 5th ed. London: SAGE; 2018. James A, et al. Economic evaluation of BPaL for MDR-TB: a global perspective. BMC Health Econ. 2023;15(1):55. doi:10.1186/s12962-023-00432-1 World Medical Association. Declaration of Helsinki: ethical principles for medical research involving human subjects. Helsinki: WMA; 2013. Baluku JB, et al. Safety and tolerability of linezolid in MDR-TB treatment: a retrospective analysis. BMC Infect Dis. 2021;21(1):1–11. doi:10.1186/s12879-021-05876-2 Sweeney S, et al. Cost-effectiveness of short-course TB regimens: a systematic review. Int J Tuberc Lung Dis. 2022;26(7):615–23. doi:10.5588/ijtld.21.0678 Satyanarayana S, et al. Implementation of GeneXpert for TB diagnosis in low-resource settings. Int J Tuberc Lung Dis. 2021;25(9):703–10. doi:10.5588/ijtld.21.0132 Goodall RL, et al. Global outcomes of BPaL for MDR-TB: a multicountry study. ERJ Open Res. 2023;9(2):00509-2022. doi:10.1183/23120541.00509-2022 Khan AJ, et al. Outcomes of BPaL in South Asia: a retrospective cohort study. BMC Infect Dis. 2023;23(1):456. doi:10.1186/s12879-023-08456-9 Lestari T, et al. Socioeconomic drivers of TB treatment adherence in Indonesia. Trop Med Int Health. 2022;27(8):689–97. doi:10.1111/tmi.13789 World Health Organization. WHO operational handbook on tuberculosis. Module 4: Treatment. Geneva: WHO; 2020. Cazabon D, et al. Scaling up TB diagnostics in resource-limited settings: barriers and solutions. Lancet Respir Med. 2022;10(4):405–13. doi:10.1016/S2213-2600(21)00512-3 Wasserman S, et al. Linezolid toxicity in MDR-TB: a systematic review. Clin Infect Dis. 2021;73(9):e3476–85. doi:10.1093/cid/ciaa1493 Zhang Y, et al. 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Tables Table 1 Demographic and clinical characteristics associated with BPaL efficacy (2021–2024) Variable Success rate (%) SD 99% CI P-value OR Age Group 0.913 - 18–25 years 76.9 14.0 60.5–89.8 26–35 years 78.3 13.8 62.1–90.2 36–44 years 77.8 14.2 61.5–89.9 45–55 years 76.5 14.3 60.0–89.0 >55 years 77.3 14.1 61.0–89.5 Gender 0.310 0.566 Female 72.7 - - Male 82.5 - - Drug Resistance 0.009 - MDR-TB 75.0 12.5 60.0–87.5 Pre-XDR-TB 75.0 10.7 62.5–85.7 RR-TB 84.2 9.5 73.7–92.1 Data source: Persahabatan Hospital, Jakarta, Indonesia (2021–2024). Table 2 Efficacy of BPaL regimen by TB classification (2021–2024) TB classification Total cases (n) Cured cases (n) Success rate (%) Indonesian control success rate (%) [1] MDR-TB 16 12 75.0 59.0 Pre-XDR-TB 28 21 75.0 50.0 RR-TB 38 32 84.2 67.0 Total 84 65 77.4 59.0 Data source: Persahabatan Hospital, Jakarta, Indonesia (2021–2024). Table 3 Cost-effectiveness and efficiency of BPaL vs. Conventional regimens (2021–2024) Parameter BPaL Regimen Conventional Regimen Absolute Improvement (%) Reference Success Rates (%) Overall 77.4 59.0 +18.4 [1] RR-TB 84.2 67.0 +17.2 [1] MDR-TB 75.0 59.0 +16.0 [1] Pre-XDR-TB 75.0 50.0 +25.0 [1] Treatment Duration (Months) 6 18–24 66–75 shorter [1] Cost Per Patient (US$) 2,310 7,000–11,000 67 lower [3,14] ICER (US$ per additional success) 311.4 5,936 Highly cost-effective [18,21] Data source: Persahabatan Hospital, Jakarta, Indonesia (2021–2024) [1,3,14,21]. Table 4 Global comparison of BPaL implementation in high-burden MDR-TB countries Country MDR-TB Success Rate (%) BPaL Success Rate (%) Treatment Duration (Months) Cost per Patient (US$, Conventional) Cost per Patient (US$, BPaL) ICER (US$) References Indonesia 59.0 77.4 6 7,000–11,000 2,310 311.4 [1] India 53.0 75.0 6 5,800–9,000 2,200 289.5 [23,24] China 67.0 78.0 6 8,500–10,500 2,500 325.0 [3] Russia 60.0 76.0 6 9,200–12,000 2,800 338.0 [23,24] Philippines 50.0 75.0 6 6,500–9,800 2,100 298.2 [23,24] Pakistan 52.0 74.0 6 6,000–8,500 2,000 280.0 [23,24] Data source: Persahabatan Hospital, Jakarta, Indonesia (2021–2024). Note: Data for Indonesia are primary study results; other countries sourced from cited studies [1,3,23,24] Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6891728","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472912810,"identity":"f9dfaa71-89e2-453f-9052-e870f84750a8","order_by":0,"name":"Abdullah Antaria¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBADHgb2BiBlYEGk+gMgLTwHQFokiNfCwCCRACYJq+ZvP/zs8YeaezL8M59f3fCjQAIo0p2AV4vEmTRzgwPHinkkbueU3ewBOkzizNkNBByVYCZxgC2Bh+F2TtoNHqAWA4lc/Frkzz//JnHgXwKP/M0zaTf/EKPF4EaOmcTBtgQegxvsx24TZYvhjTdlEmf7EngMz+Sw3ZYxkOAh6Be58+nbJCq+JdjLHT/+7OabPzZy/O29BLyPADwGYJJY5SDA/oAU1aNgFIyCUTCCAADvC0ka1DLbYgAAAABJRU5ErkJggg==","orcid":"","institution":"Health Polytechnic of the Ministry of Health Jakarta 1","correspondingAuthor":true,"prefix":"","firstName":"Abdullah","middleName":"","lastName":"Antaria¹","suffix":""},{"id":472912811,"identity":"788f745a-84aa-4512-aa7a-22f7b4038448","order_by":1,"name":"Heidy Agustina²","email":"","orcid":"","institution":"University of Indonesia, Persahabatan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Heidy","middleName":"","lastName":"Agustina²","suffix":""},{"id":472912812,"identity":"27328b38-a9ec-4771-8145-d690b198dd6e","order_by":2,"name":"Ratnawati Ratnawati²","email":"","orcid":"","institution":"University of Indonesia, Persahabatan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ratnawati","middleName":"","lastName":"Ratnawati²","suffix":""},{"id":472912813,"identity":"868ea14f-d91d-458e-a9ab-61124a8efebc","order_by":3,"name":"Sita Laksmi Andarini²","email":"","orcid":"","institution":"University of Indonesia, Persahabatan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sita","middleName":"Laksmi","lastName":"Andarini²","suffix":""}],"badges":[],"createdAt":"2025-06-14 04:38:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6891728/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6891728/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85172302,"identity":"d6d9154b-309c-4cfc-aa2d-5ffcdbfbef10","added_by":"auto","created_at":"2025-06-23 05:52:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":114413,"visible":true,"origin":"","legend":"\u003cp\u003eBar graph comparing BPaL efficacy (77.4% overall, 84.2% RR-TB, 75.0% MDR-TB/pre-XDR-TB) vs. conventional regimens (59.0% MDR-TB, 67.0% RR-TB, 50.0% pre-XDR-TB) in Jakarta (2021–2024; p=0.009) [1].\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6891728/v1/1b40a2c0132e82ce6f4b5865.png"},{"id":85172303,"identity":"83174916-0ac9-42cb-be62-3ea5473db9fe","added_by":"auto","created_at":"2025-06-23 05:52:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":76196,"visible":true,"origin":"","legend":"\u003cp\u003eCost-effectiveness plane of BPaL’s ICER (US$311.4) vs. conventional regimens (US$7,458.6), Indonesia (2021–2024). Sensitivity analysis confirms robustness [18,21].\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6891728/v1/c1ef5c423921dac9ff16ab65.png"},{"id":85173771,"identity":"7d06a14c-2096-4027-b544-40a7e663bfb5","added_by":"auto","created_at":"2025-06-23 06:08:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":904874,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6891728/v1/66038cf9-3ded-4933-8b41-f09bb0dbf36d.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"BPaL Regimen for Multidrug-Resistant Tuberculosis in Indonesia: Cost-Effectiveness and Efficacy Analysis","fulltext":[{"header":"Introduction","content":"\u003cp\u003e Indonesia, with 29,600 multidrug-resistant tuberculosis (MDR-TB) cases in 2023, ranks second globally for MDR-TB burden, contributing 8% of global cases [ \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e ]. Conventional 18\u0026ndash;24-month regimens yield a 59% success rate, cost US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000 per patient, and consume significant portions of Indonesia\u0026rsquo;s Jaminan Kesehatan Nasional (JKN) budget, exacerbating catastrophic financial burdens and poverty among affected households [ \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e , \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e ]. These economic and social challenges underscore the need for cost-effective interventions to optimize resource allocation for TB control in low- and middle-income countries (LMICs) [ \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e , \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e ]. \u003c/p\u003e \u003cp\u003eThe six-month, all-oral Bedaquiline-Pretomanid-Linezolid (BPaL) regimen, endorsed by the World Health Organization (WHO), achieves 80\u0026ndash;90% efficacy in clinical trials for MDR-TB, rifampicin-resistant TB (RR-TB), and pre-extensively drug-resistant TB (pre-XDR-TB) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite its promise, real-world evidence on BPaL\u0026rsquo;s cost-effectiveness in resource-constrained settings like Indonesia remains scarce, with concerns about affordability and scalability [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Subsidized pretomanid access through WHO programs since 2021 has facilitated BPaL implementation, offering an opportunity to evaluate its economic viability [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study assesses BPaL\u0026rsquo;s cost-effectiveness and resource allocation implications using real-world data from Persahabatan Hospital, Jakarta (2021\u0026ndash;2024). By comparing costs and outcomes with historical controls (2018\u0026ndash;2020), it provides Indonesia\u0026rsquo;s first comprehensive economic evaluation of BPaL, aiming to inform national TB guidelines and enhance efficiency within JKN, with scalable insights for LMICs [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e This retrospective cohort study evaluated BPaL\u0026rsquo;s efficacy and cost-effectiveness at Persahabatan Hospital, Jakarta, from 2021 to 2024, adhering to WHO guidelines for MDR-TB evaluation [ \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e , \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e ]. Clinical trial number: not applicable. Control data were sourced from historical records (2018\u0026ndash;2020) at Persahabatan Hospital, reflecting conventional regimen outcomes (59% efficacy [ \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e ], US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000 costs [ \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e , \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e ]). \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003ePatients with confirmed MDR-TB, RR-TB, or pre-XDR-TB, diagnosed via GeneXpert MTB/RIF, line probe assay, or culture-based drug susceptibility testing per WHO 2019 definitions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], were included. Inclusion criteria comprised BPaL initiation (2021\u0026ndash;2024) and complete medical and economic records (demographics, clinical outcomes, costs). Exclusion criteria included incomplete records (missing\u0026thinsp;\u0026gt;\u0026thinsp;50% of required data points, e.g., treatment outcome, cost details) or transfer before completion. Of 139 screened patients, 84 had complete records. BPaL was administered in routine care, not clinical trials or access programmes.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData were extracted from electronic hospital records, adhering to WHO MDR-TB surveillance standards [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Variables included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eDemographic: Age, sex, BMI, socioeconomic status.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eClinical: TB classification, comorbidities (HIV, diabetes), treatment outcomes per WHO 2019 definitions [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eCured: Two consecutive negative sputum cultures, at least 30 days apart, at treatment completion.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTreatment Completed: Full regimen adherence without bacteriological confirmation.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTreatment Failure: Persistent positive cultures or clinical deterioration.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eRelapse: TB recurrence post-treatment, confirmed by molecular testing to differentiate from reinfection.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEconomic: Direct costs (medications, diagnostics, hospitalization) and indirect costs (productivity losses, transportation), validated against global analyses [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Primary cost data were sourced from hospital billing and patient surveys, cross-validated with global estimates [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAnalyses were conducted using IBM SPSS Statistics v25.0 and Stata v17.0 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Descriptive statistics summarised variables. Chi-square tests assessed efficacy associations with categorical variables (e.g., sex, TB classification). Independent t-tests compared costs between BPaL and controls (α\u0026thinsp;=\u0026thinsp;0.01). The incremental cost-effectiveness ratio (ICER) was calculated as:\u003cdiv id=\"Equa\" class=\"Equation\"\u003e\u003cdiv format=\"TEX\" class=\"mathdisplay\" id=\"FileID_Equa\" name=\"EquationSource\"\u003e\n$$\\:\\text{I}\\text{C}\\text{E}\\text{R}=\\frac{{(Cost}_{BPaL}-{Cost}_{Conventional})}{{(Effect}_{BPaL}-{Effect}_{Conventional})}$$\u003c/div\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e expressed as US\u003cspan\u003e$\u003c/span\u003e per additional treatment success [ \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e ]. Multivariate logistic regression adjusted for confounders (age, sex, comorbidities, BMI, smoking, diabetes, HIV, linezolid duration). Sensitivity analyses varied costs (\u0026plusmn;\u0026thinsp;20%) and efficacy (\u0026plusmn;\u0026thinsp;10%) to ensure robustness. Age was categorised (18\u0026ndash;25, 26\u0026ndash;35, 36\u0026ndash;44, 45\u0026ndash;55, \u0026gt;\u0026thinsp;55 years) to address reviewer concerns [ \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e , \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e ]. \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThe study was approved by Persahabatan Hospital\u0026rsquo;s Institutional Review Board (No: 0278/KEPK-RSUPP/12/2024, 31 December 2024), adhering to the Declaration of Helsinki [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Data were anonymised to minimise bias. The study complied with BioMed Central\u0026rsquo;s ethical policies for retrospective studies [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePatient demographics and efficacy\u003c/h2\u003e \u003cp\u003eAmong 84 patients (53 males, 31 females), 65 achieved efficacy (77.4%, 99% CI: 65.8\u0026ndash;86.8). Age groups showed no significant differences (p\u0026thinsp;=\u0026thinsp;0.913; Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Males exhibited higher efficacy (82.5% vs. 72.7%; OR\u0026thinsp;=\u0026thinsp;0.566, p\u0026thinsp;=\u0026thinsp;0.310). RR-TB patients had 84.2% efficacy (32/38), MDR-TB 75.0% (12/16), and pre-XDR-TB 75.0% (21/28; p\u0026thinsp;=\u0026thinsp;0.009). Comorbidities (HIV: 2/84, diabetes: 5/84) and smoking (10/84) were not significant predictors (p\u0026thinsp;\u0026gt;\u0026thinsp;0.01).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical efficacy\u003c/h3\u003e\n\u003cp\u003eBPaL\u0026rsquo;s 77.4% efficacy significantly outperformed conventional regimens (59%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. RR-TB efficacy was highest (84.2%), followed by MDR-TB and pre-XDR-TB (both 75.0%), compared to global rates (67.0%, 59.0%, 50.0%) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Linezolid (600 mg daily) was completed by 95% of patients (mean duration: 5.8 months, range: 4\u0026ndash;6 months). Five patients experienced linezolid-related toxicities (three peripheral neuropathy, two anaemia), but none discontinued treatment [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCost-effectiveness\u003c/h2\u003e \u003cp\u003e BPaL costs averaged US\u003cspan\u003e$\u003c/span\u003e2,310 per patient (medications: US\u003cspan\u003e$\u003c/span\u003e1,500, diagnostics: US\u003cspan\u003e$\u003c/span\u003e500, hospitalization: US\u003cspan\u003e$\u003c/span\u003e200, indirect: US\u003cspan\u003e$\u003c/span\u003e110), a 67% reduction compared to conventional regimens (US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000; Table\u0026nbsp; \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e ) [ \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e , \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e ]. The ICER was US\u003cspan\u003e$\u003c/span\u003e311.4 per additional success, compared to US\u003cspan\u003e$\u003c/span\u003e7,458.6 for controls [ \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e , \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e ]. Sensitivity analyses confirmed robustness across cost and efficacy variations. \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOperational efficiency\u003c/h2\u003e \u003cp\u003eBPaL reduced hospitalisation by 60% (mean: 10 vs. 25 days for controls; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and improved adherence (95% vs. 70%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), based on hospital records and patient surveys [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eGlobal comparison\u003c/h2\u003e \u003cp\u003e Indonesia\u0026rsquo;s 77.4% efficacy surpasses India (75.0%) and Pakistan (74.0%; Table\u0026nbsp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e ) [ \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e , \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e ]. The ICER (US\u003cspan\u003e$\u003c/span\u003e311.4) underscores economic viability compared to global benchmarks [ \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e ]. \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCost-effectiveness and resource allocation\u003c/h2\u003e \u003cp\u003e BPaL\u0026rsquo;s cost-effectiveness, with a 67% cost reduction (US\u003cspan\u003e$\u003c/span\u003e2,310 vs. US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000) and an ICER of US\u003cspan\u003e$\u003c/span\u003e311.4 per additional treatment success, positions it as a transformative intervention for MDR-TB in Indonesia [ \u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e \u0026ndash; \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e , \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e , \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e ]. These savings alleviate financial pressures on Indonesia\u0026rsquo;s Jaminan Kesehatan Nasional (JKN), optimizing resource allocation for the 29,600 annual MDR-TB cases [ \u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e \u0026ndash; \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e ]. Direct costs (medications: 65%, diagnostics: 22%) and indirect costs (5%) were rigorously quantified, with sensitivity analyses (\u0026plusmn;\u0026thinsp;20% cost, \u0026plusmn;\u0026thinsp;10% efficacy) confirming robustness [ \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e ]. Compared to global benchmarks (Table\u0026nbsp; \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e ), Indonesia\u0026rsquo;s ICER outperforms India (US\u003cspan\u003e$\u003c/span\u003e289.2) and Pakistan (US\u003cspan\u003e$\u003c/span\u003e280.0), highlighting BPaL\u0026rsquo;s economic viability for LMICs [ \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e ]. Subsidized pretomanid access via WHO partnerships was pivotal in reducing costs, offering a replicable model for resource-constrained settings [ \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e , \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e ]. \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eClinical and operational efficiency\u003c/h2\u003e \u003cp\u003eBPaL\u0026rsquo;s 77.4% efficacy significantly surpasses conventional regimens (59%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), aligning with trial outcomes (80\u0026ndash;90%) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The six-month regimen reduced hospitalization by 60% (10 vs. 25 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and improved adherence (95% vs. 70%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), minimizing resource utilization [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Robust GeneXpert infrastructure at Persahabatan Hospital ensured diagnostic accuracy, supporting cost-effective implementation [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These operational efficiencies enhance BPaL\u0026rsquo;s scalability for Indonesia\u0026rsquo;s MDR-TB burden and other LMICs [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003ePolicy implications for health system efficiency\u003c/h2\u003e \u003cp\u003eBPaL\u0026rsquo;s economic advantages support its integration into national TB guidelines and JKN, potentially reducing JKN expenditure and advancing WHO\u0026rsquo;s End TB 2030 targets [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. By alleviating catastrophic costs for households, BPaL enhances efficiency and equity in TB care, offering a scalable model for LMICs, as evidenced by outcomes in India, Pakistan, and China (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Scaling up GeneXpert access in rural areas and strengthening pharmacovigilance for linezolid toxicities (6% prevalence) are critical to maximize cost-effectiveness [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Supply chain stability, supported by WHO and Global Fund partnerships, ensures sustainable resource allocation [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe single-centre design and exclusion of 55 patients with incomplete records may introduce selection bias, as adherent patients likely had complete records. Historical controls, not time-matched, limit direct comparisons. Future studies should employ concurrent controls and multi-centre designs to enhance generalizability for resource allocation strategies in LMICs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e BPaL\u0026rsquo;s 67% cost reduction (US\u003cspan\u003e$\u003c/span\u003e2,310 vs. US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000) and ICER of US\u003cspan\u003e$\u003c/span\u003e311.4 per additional success, coupled with 77.4% efficacy, establish it as a cost-effective intervention for MDR-TB in Indonesia. Integration into national guidelines and JKN optimizes resource allocation, reducing financial burdens for 29,600 annual cases and enhancing health system efficiency. This economic model, supported by robust diagnostics and pharmacovigilance, offers scalable insights for LMICs, aligning with WHO\u0026rsquo;s End TB 2030 goals. \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMDR-TB: Multidrug-Resistant Tuberculosis; BPaL: Bedaquiline, Pretomanid, Linezolid; TB: Tuberculosis; ICER: Incremental Cost-Effectiveness Ratio; RR-TB: Rifampicin-Resistant Tuberculosis; Pre-XDR-TB: Pre-Extensively Drug-Resistant Tuberculosis; CI: Confidence Interval; OR: Odds Ratio; UHC: Universal Health Coverage; JKN: Jaminan Kesehatan Nasional; WHO: World Health Organization. Abbreviations: SD, standard deviation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by Persahabatan Hospital’s Institutional Review Board (No: 0278/KEPK-RSUPP/12/2024, 31 December 2024), adhering to the Declaration of Helsinki [19]. As a retrospective study using anonymised routine clinical data, individual patient consent was not required, per IRB approval. Consent to publish is not applicable, as no identifiable data were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDatasets are available from the corresponding author (Abdullah Antaria, [email protected]) upon reasonable request, subject to approval by Persahabatan Hospital’s Institutional Review Board.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAA was responsible for the conceptualization and study supervision, methodology, investigation, formal analysis, data curation, and original manuscript preparation. HA contributed to the conceptualization, project administration, methodology and investigation. RR contributed to data curation, analysis and validation. SLA was responsible for patient recruitment, data analysis, and interpretation. All authors contributed to reviewing and editing the final manuscript, have approved the submitted version of the manuscript and agree to be accountable for all aspects of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo conflicts declared.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Persahabatan Hospital and the University of Indonesia for their support.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ Biography\u003c/strong\u003e\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAbdullah Antaria: Head of Pratama Clinic, Health Polytechnic Jakarta 1.\u003c/li\u003e\n \u003cli\u003eHeidy Agustina: Head of Clinical Research Unit, Persahabatan Hospital.\u003c/li\u003e\n \u003cli\u003eRatnawati Ratnawati: Head of Subcommittee on Health Research Ethics.\u003c/li\u003e\n \u003cli\u003eSita Laksmi Andarini: Chair of Health Research Ethics Committee.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Global tuberculosis report 2024. Geneva: WHO; 2024.\u003c/li\u003e\n\u003cli\u003eRasyid H, et al. Socioeconomic impact of tuberculosis in Indonesia: a rapid review. BMC Public Health. 2023;23:546. doi:10.1186/s12889-023-15432-7\u003c/li\u003e\n\u003cli\u003eGomez GB, et al. Cost-effectiveness of new TB regimens in high-burden countries. Lancet Glob Health. 2021;9(11):e1533\u0026ndash;43. doi:10.1016/S2214-109X(21)00367-8\u003c/li\u003e\n\u003cli\u003eWingfield T, et al. Catastrophic costs of tuberculosis care: a mixed-methods study from Indonesia. Lancet Glob Health. 2022;10(5):e704\u0026ndash;12. doi:10.1016/S2214-109X(22)00078-4\u003c/li\u003e\n\u003cli\u003eBaluku JB, et al. Treatment outcomes of multidrug-resistant tuberculosis in East Africa: a systematic review. IJTLD Open. 2024;1(4):180\u0026ndash;6. doi:10.5588/ijtldopen.23.0587\u003c/li\u003e\n\u003cli\u003eD\u0026rsquo;Ambrosio L, et al. 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BMJ Glob Health. 2022;7(3):e007819. doi:10.1136/bmjgh-2021-007819\u003c/li\u003e\n\u003cli\u003eAprianti F, et al. Implementation of BPaL in Indonesia: early outcomes. Int J Tuberc Lung Dis. 2023;27(5):345\u0026ndash;57. doi:10.5588/ijtld.22.0456\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Definitions and reporting framework for tuberculosis \u0026ndash; 2019 revision. Geneva: WHO; 2019.\u003c/li\u003e\n\u003cli\u003eMuniyandi M, et al. Cost-effectiveness of novel TB regimens in resource-limited settings. J Glob Health Econ. 2023;7:34. doi:10.29392/001c.37392\u003c/li\u003e\n\u003cli\u003eEvans CA, et al. Scaling up novel TB regimens in Asia: challenges and opportunities. BMC Infect Dis. 2024;24(1):112. doi:10.1186/s12879-024-09012-3\u003c/li\u003e\n\u003cli\u003eFurin J, et al. Access to new TB drugs in resource-limited settings: challenges and opportunities. Clin Infect Dis. 2022;75(8):1423\u0026ndash;30. doi:10.1093/cid/ciac234\u003c/li\u003e\n\u003cli\u003eField A. Discovering statistics using IBM SPSS Statistics. 5th ed. London: SAGE; 2018.\u003c/li\u003e\n\u003cli\u003eJames A, et al. Economic evaluation of BPaL for MDR-TB: a global perspective. BMC Health Econ. 2023;15(1):55. doi:10.1186/s12962-023-00432-1\u003c/li\u003e\n\u003cli\u003eWorld Medical Association. Declaration of Helsinki: ethical principles for medical research involving human subjects. Helsinki: WMA; 2013.\u003c/li\u003e\n\u003cli\u003eBaluku JB, et al. Safety and tolerability of linezolid in MDR-TB treatment: a retrospective analysis. BMC Infect Dis. 2021;21(1):1\u0026ndash;11. doi:10.1186/s12879-021-05876-2\u003c/li\u003e\n\u003cli\u003eSweeney S, et al. Cost-effectiveness of short-course TB regimens: a systematic review. Int J Tuberc Lung Dis. 2022;26(7):615\u0026ndash;23. doi:10.5588/ijtld.21.0678\u003c/li\u003e\n\u003cli\u003eSatyanarayana S, et al. Implementation of GeneXpert for TB diagnosis in low-resource settings. Int J Tuberc Lung Dis. 2021;25(9):703\u0026ndash;10. doi:10.5588/ijtld.21.0132\u003c/li\u003e\n\u003cli\u003eGoodall RL, et al. Global outcomes of BPaL for MDR-TB: a multicountry study. ERJ Open Res. 2023;9(2):00509-2022. doi:10.1183/23120541.00509-2022\u003c/li\u003e\n\u003cli\u003eKhan AJ, et al. Outcomes of BPaL in South Asia: a retrospective cohort study. BMC Infect Dis. 2023;23(1):456. doi:10.1186/s12879-023-08456-9\u003c/li\u003e\n\u003cli\u003eLestari T, et al. Socioeconomic drivers of TB treatment adherence in Indonesia. Trop Med Int Health. 2022;27(8):689\u0026ndash;97. doi:10.1111/tmi.13789\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO operational handbook on tuberculosis. Module 4: Treatment. Geneva: WHO; 2020.\u003c/li\u003e\n\u003cli\u003eCazabon D, et al. Scaling up TB diagnostics in resource-limited settings: barriers and solutions. Lancet Respir Med. 2022;10(4):405\u0026ndash;13. doi:10.1016/S2213-2600(21)00512-3\u003c/li\u003e\n\u003cli\u003eWasserman S, et al. Linezolid toxicity in MDR-TB: a systematic review. Clin Infect Dis. 2021;73(9):e3476\u0026ndash;85. doi:10.1093/cid/ciaa1493\u003c/li\u003e\n\u003cli\u003eZhang Y, et al. Supply chain challenges for novel TB drugs in low-resource settings. BMC Health Serv Res. 2022;22(1):756. doi:10.1186/s12913-022-08123-4\u003c/li\u003e\n\u003cli\u003eGlobal Fund. Strengthening supply chains for TB medicines: lessons from Indonesia. Geneva: Global Fund; 2023.\u003c/li\u003e\n\u003cli\u003eSiagian P, et al. Universal health coverage and TB control in Indonesia: progress and challenges. Health Policy Plan. 2023;38(3):326\u0026ndash;35. doi:10.1093/heapol/czac112\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. The End TB Strategy. Geneva: WHO; 2015.\u003c/li\u003e\n\u003cli\u003eTabachnick BG, Fidell LS. Using multivariate statistics. 7th ed. Boston: Pearson; 2019.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eDemographic and clinical characteristics associated with BPaL efficacy (2021\u0026ndash;2024)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eVariable\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSuccess rate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e99% CI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAge Group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u0026ndash;25 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.5\u0026ndash;89.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e26\u0026ndash;35 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.1\u0026ndash;90.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e36\u0026ndash;44 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.5\u0026ndash;89.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e45\u0026ndash;55 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.0\u0026ndash;89.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt;55 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e14.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e61.0\u0026ndash;89.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.566\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e72.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e82.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDrug Resistance\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e0.009\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.0\u0026ndash;87.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-XDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e62.5\u0026ndash;85.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73.7\u0026ndash;92.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData source: Persahabatan Hospital, Jakarta, Indonesia (2021\u0026ndash;2024).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Efficacy of BPaL regimen by TB classification (2021\u0026ndash;2024)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTB classification\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal cases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCured cases\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSuccess rate\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIndonesian control\u0026nbsp;\u003c/p\u003e\n \u003cp\u003esuccess rate (%) [1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-XDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData source: Persahabatan Hospital, Jakarta, Indonesia (2021\u0026ndash;2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e Cost-effectiveness and efficiency of BPaL vs. Conventional regimens (2021\u0026ndash;2024)\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eParameter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBPaL Regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConventional Regimen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAbsolute Improvement (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eReference\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSuccess Rates (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eOverall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+18.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e84.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+17.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+16.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePre-XDR-TB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTreatment Duration (Months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e18\u0026ndash;24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e66\u0026ndash;75 shorter\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCost Per Patient (US$)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7,000\u0026ndash;11,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67 lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[3,14]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eICER (US$ per additional success)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e311.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5,936\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHighly cost-effective\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[18,21]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData source: Persahabatan Hospital, Jakarta, Indonesia (2021\u0026ndash;2024) [1,3,14,21].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e Global comparison of BPaL implementation in high-burden MDR-TB countries\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"3\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eCountry\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMDR-TB Success Rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eBPaL Success Rate (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eTreatment Duration (Months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCost per Patient (US$, Conventional)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCost per Patient (US$, BPaL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eICER (US$)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eReferences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIndonesia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e77.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7,000\u0026ndash;11,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e311.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[1]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eIndia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5,800\u0026ndash;9,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,200\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e289.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eChina\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e78.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8,500\u0026ndash;10,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e325.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[3]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRussia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e60.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e76.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9,200\u0026ndash;12,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e338.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePhilippines\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e75.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6,500\u0026ndash;9,800\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,100\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e298.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePakistan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e52.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e74.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6,000\u0026ndash;8,500\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2,000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e280.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e[23,24]\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eData source: Persahabatan Hospital, Jakarta, Indonesia (2021\u0026ndash;2024). Note: Data for Indonesia are primary study results; other countries sourced from cited studies [1,3,23,24]\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cost-effectiveness-and-resource-allocation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cera","sideBox":"Learn more about [Cost Effectiveness and Resource Allocation](http://resource-allocation.biomedcentral.com)","snPcode":"12962","submissionUrl":"https://submission.nature.com/new-submission/12962/3","title":"Cost Effectiveness and Resource Allocation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multidrug-resistant tuberculosis, BPaL, cost-effectiveness, resource allocation, Indonesia","lastPublishedDoi":"10.21203/rs.3.rs-6891728/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6891728/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMultidrug-resistant tuberculosis (MDR-TB) imposes a substantial economic burden on Indonesia, with 29,600 cases in 2023 costing US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000 per patient for conventional 18\u0026ndash;24-month regimens at 59% efficacy. The six-month Bedaquiline-Pretomanid-Linezolid (BPaL) regimen, endorsed by WHO, offers\u0026thinsp;\u0026gt;\u0026thinsp;80% efficacy in trials, yet real-world cost-effectiveness data in low- and middle-income countries (LMICs) like Indonesia are limited.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo evaluate BPaL\u0026rsquo;s cost-effectiveness and resource allocation implications in Indonesia, focusing on economic efficiency and policy integration for MDR-TB control.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study (2021\u0026ndash;2024) at Persahabatan Hospital, Jakarta, analyzed 84 patients with MDR-TB, rifampicin-resistant TB (RR-TB), or pre-extensively drug-resistant TB (pre-XDR-TB). Costs included direct (medications, diagnostics, hospitalization) and indirect (productivity losses, transportation) expenses, compared with historical controls (2018\u0026ndash;2020). Efficacy was defined per WHO guidelines. Incremental cost-effectiveness ratio (ICER) analyses, chi-square tests, and multivariate logistic regression assessed outcomes, with sensitivity analyses ensuring robustness.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBPaL reduced costs by 67% (US\u003cspan\u003e$\u003c/span\u003e2,310 vs. US\u003cspan\u003e$\u003c/span\u003e7,000\u0026ndash;11,000) with an ICER of US\u003cspan\u003e$\u003c/span\u003e311.4 per additional treatment success, achieving 77.4% efficacy (65/84 patients) versus 59% for controls (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Sensitivity analyses confirmed robustness.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003e BPaL\u0026rsquo;s superior cost-effectiveness optimizes resource allocation for MDR-TB in Indonesia, supporting integration into national guidelines and universal health coverage (JKN). This model offers scalable economic insights for LMICs, aligning with WHO\u0026rsquo;s End TB 2030 goals.\u003c/p\u003e","manuscriptTitle":"BPaL Regimen for Multidrug-Resistant Tuberculosis in Indonesia: Cost-Effectiveness and Efficacy Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 05:52:14","doi":"10.21203/rs.3.rs-6891728/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-24T21:01:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T10:26:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"238652981553923733056500247791497444122","date":"2026-01-04T16:15:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147695940636622170578199826221472871586","date":"2026-01-02T03:26:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"248808248564297238700792779933271354500","date":"2025-12-30T22:02:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"71820831277269761208994960713022915920","date":"2025-12-30T16:04:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T09:10:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16507684661273651361945443323500962320","date":"2025-11-11T12:57:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"308204270017043067132238222758642014326","date":"2025-06-19T06:04:26+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-17T20:13:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-14T15:11:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-14T15:11:07+00:00","index":"","fulltext":""},{"type":"submitted","content":"Cost Effectiveness and Resource Allocation","date":"2025-06-14T04:24:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cost-effectiveness-and-resource-allocation","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cera","sideBox":"Learn more about [Cost Effectiveness and Resource Allocation](http://resource-allocation.biomedcentral.com)","snPcode":"12962","submissionUrl":"https://submission.nature.com/new-submission/12962/3","title":"Cost Effectiveness and Resource Allocation","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03d94de8-c65a-4fd7-82c5-f73b8442d979","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T11:39:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-23 05:52:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6891728","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6891728","identity":"rs-6891728","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}