Denny John

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.

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 per centof 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.

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