Cost and cost-effectiveness of community-based care for tuberculosis in Cape Town, South Africa.

SETTING Guguletu and Nyanga areas of Cape Town, South Africa. OBJECTIVE To evaluate the affordability and cost-effectiveness of community involvement in tuberculosis (TB) care. DESIGN A cost-effectiveness analysis comparing treatment for new smear-positive pulmonary and retreatment TB patients in two similar townships, one providing clinic-based-care with community-based observation options available for its TB patients (Guguletu) and one providing clinic-based care only, with no community-based observation of treatment (Nyanga). Costs were assessed from a societal perspective in 1997 US$, and cost-effectiveness was calculated as the cost per patient successfully treated. RESULTS TB treatment in Guguletu was more cost-effective than TB treatment in Nyanga for both new and retreatment patients ($726 vs. $1201 and $1419 vs. $2058, respectively). This reflected both lower costs ($495 vs. $769 per patient treated for new cases; $823 vs. $1070 per patient treated for retreatment cases) and better treatment outcomes (successful treatment rate 68% vs. 64% and 58% vs. 52% for new and retreatment patients, respectively). Within Guguletu, community-based care was more than twice as cost-effective as clinic-based care ($392 vs. $1302 per patient successfully treated for new patients, and $766 vs. $2008 for retreatment patients), for similar reasons (e.g., for new cases, $314 vs. $703 per patient treated, successful treatment rate 80% vs. 54%). CONCLUSION Community involvement in TB care can improve the affordability and cost-effectiveness of TB treatment in urban South Africa. Expansion in the Western Cape and in similar areas of the country is worthy of serious consideration by planners and policy-makers.