Report on Estimated Costs of Services of the Bangladesh...

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Report on Estimated Costs of Services of the Bangladesh National TB Control Program using One Health Tool:

2016-2022

Ziaul Islam Sayem Ahmed

Md. Zahid Hasan Zeenat Islam

Wahid Ahmed Gazi Golam Mehdi

Farzana Akhter Dorin Tazeen Tahsina

September 2019

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Report on Estimated Costs of Services of the Bangladesh National TB Control Program using One Health Tool: 2016-2022

Disclaimer

This report was produced with the support of the United States Agency for International Development (USAID) under the terms of USAID’s Research for Decision Makers (RDM) Activity cooperative agreement no. AID-388-A-17-00006. Views expressed herein do not necessarily reflect the views of the U.S. Government or USAID. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing unrestricted/institutional support.

Key Words

Tuberculosis, One Health Tool, costing, Bangladesh NTP

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Contents Acronyms ...................................................................................................................................................... 5

Acknowledgements ...................................................................................................................................... 6

Executive summary...................................................................................................................................... 7

1. BACKGROUND ..................................................................................................................... 11

1.1 Study rational ...................................................................................................................................... 11

1.2 Estimating TB Costs: One Health Tool (OHT) and TB Impact Model & Estimates (TIME) ....................................................................................................................................................................12

How the cost of health services/interventions was estimated: .................................................... 12

How OHT estimates the cost of health system components: ..................................................... 13

1.4 STUDY OBJECTIVES .................................................................................................................... 13

General objective .......................................................................................................................... 13

Specific objectives ........................................................................................................................ 13

2. METHODOLOGY ................................................................................................................. 13

2.1 OHT customization and calibration of TIME model: .................................................................. 15

2.2 Study sites ............................................................................................................................................ 16

2.3 Data collection ................................................................................................................................... 16

2.4 Data entry and cost calculation by OHT........................................................................................ 17

2.5 Assumptions and estimates .............................................................................................................. 19

2.6 Study limitations ................................................................................................................................. 20

3. RESULTS ................................................................................................................................... 21

3.1 Unit cost of drugs and investigations.............................................................................................. 21

3.2 Cost per patient of first line treatment: Category-I (Total cost of drugs and investigations per patient 2016) ....................................................................................................................................... 22

3.3 Cost per patient of first line treatment: Category-II (Total cost of drugs and investigations per patient for 2016)................................................................................................................................. 23

3.4 New Levofloxacin-based treatment regimen from 2019 onwards .............................................. 24

3.5 Cost of second line treatment: Drug resistant (DR) TB ............................................................... 28

3.6 Cost per person for prevention of TB ............................................................................................ 41

3.7 Year 2019 onwards: 3HP Preventive Therapy- Cost per person ................................................. 41

3.8 Estimated number of TB services/interventions .......................................................................... 44

3.9 Total cost for TB services by base year and target years .............................................................. 47

3.10 Total cost of TB services including health systems costs ........................................................... 49

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3.11 Cost by service delivery channel .................................................................................................... 52

3.12 Funding gap: ..................................................................................................................................... 53 3.13 Cost of icddr, b TB Screening & Treatment Centre ................................................................... 55

4. REFERENCE ........................................................................................................................... 57

5. Annexure: ................................................................................................................................... 58

Annex- A: Technical Working Group for TB costing study ............................................................. 58

6. Annexure- B: Price list of drugs and supplies used in the treatment inputs ..................... 59

Annexure- B.1: Drugs and supplies used for investigations .............................................................. 59

Annexure- B.2: Unit price of drugs used for treatment inputs from 2016-2018 ............................ 62

Annexure- B.3: Unit price of drugs used for treatment inputs from 2019 ...................................... 63

Annexure- C: Treatment inputs and unit cost for TB intervention of the base year (2016) ......... 64

Annexure- C.1: Treatment inputs and unit cost for new TB intervention from 2019 ................... 84

Annexure-D: Unit cost of Z-N and LED microscopy....................................................................... 92

Annexure-E: NTP’s Circular on Lfx based regimen for retreatment............................................... 94

Annexure-F: Target population for TB interventions ........................................................................ 97

Annexure G: Population in need of TB intervention from 2016-2022 .......................................... 99

Annexure H: Coverage of TB interventions from 2016-22 .............................................................101

Annexure-i: Cost of equipment per TBSTC, icddr, b (2018) ..........................................................103

Annexure-i1: Cost of human resources per TBSTC, icddr,b (2018) ..............................................103

Annexure-i2: Logistic costs TBSTC, icddr,b (2018) .........................................................................104

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Acronyms

ASP AIDS & STD program

BDT Bangladesh Taka (currency)

CDH Chest Disease Hospital

CDC

CMH

Chest Disease Clinic

Combined Military Hospital

CRHC Comprehensive Reproductive Health Care Centre

Cs Cycloserine

COPD Chronic Obstructive Pulmonary Disease

DOTS Directly Observed Treatment Short course

DR Drug Resistance

E Ethambutal

EPTB Extra Pulmonary Tuberculosis

FDC Fixed Dose Combination

FM Fluorescence Microscopy

FNAC Fine Needle Aspiration Cytology

GDF Global Drug Facility

IPT/H Isoniazid Preventive Therapy/Isoniazid

Pto Prothionamide

RTRL Regional TB Reference Laboratory

LED Light Emitting Diode

LPA Line Probe Assay

Lfx Levofloxacin

MDR Multi Drug Resistant

MOHFW Ministry of Health and Family Welfare

Mfx Moxifloxacin

MT Mantoux Test

NHSDP NGO Health Service Delivery Program

NIDCH National Institute of Diseases of Chest & Hospital

NTRL National TB Reference Laboratory

NTP National TB Control Program

NSP National Strategic Plan

UHC Upazila Health Complex

UN HLM USAID

United Nation’s High-Level Meeting United States Agency for International Development

XDR Extremely Drug Resistant

Z-N Ziehl-Neelsen

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Acknowledgements The authors are indebted to Prof. (Dr.) Md. Shamiul Islam, Director Mycobacterial Disease Control (MBDC) and Line Director TB-Leprosy & AIDS & STD programme (ASP), Directorate General of Health Services (DGHS), Ministry of Health and Family Welfare (MOHFW) for his guidance and support in conducting this study. The authors are thankful to Dr. Md. Assaduzzaman, Deputy Programme Manager, National TB control Programme (NTP) as well as Dr. Salim Hamid, National Advisor to NTP and Dr. Rupali Shishir, National Consultant of NTP for their expert opinion and technical inputs.

The authors appreciate and acknowledge the collaboration of Health Economics Unit of MOHFW, BRAC, Damien Foundation Bangladesh, and Challenge TB.

The authors thankfully acknowledge the technical support provided by Dr. Md. Mojibur Rahman; former consultant of NTP, Mustafizur Rahman, Microbiologist of Bangladesh NTP, Dr. Mursaleena Islam and Dr, Shamima Akhter of Health Finance and Governance (HFG) project, Dr Pushpita Samina of the United States Agency for International Development (USAID) and icddr, b’s Dr. Sayera Banu (TB theme lead) and Dr. Shahriar Ahmed.

The authors would like to extend their special thanks to Ms. Nadia Carvalho, Carel Pretorious and Matt Hamilton for capacity building of the study team members and helping in customization of One Health Tool (OHT) and calibration of TB Impact & Estimate (TIME) module.

Finally, the authors would like to express their gratitude to the participants of all key informant interviews, local managers and staff members of the facilities visited for data collection of this study.

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Executive summary Background: Over the last few years; the Bangladesh National Tuberculosis Control Program (NTP) has introduced state-of-the-art diagnostic technologies e.g. Gene Xpert, digital X-ray machine, LED microscopes and revised the diagnostic algorithm, treatment regimen and planned to introduce broader preventive therapy to accelerate TB case detection, management and prevention effectively. These interventions are expected to continue across the period of current operational plan (2017-2022) and national strategic plan (2018- 2022) for TB control - which is now being updated for the period of 2020- 2025. Understandably; introduction, expansion and maintenance of these new technologies and algorithms have additional cost implications on the program.

Furthermore; in the context of Bangladesh’s graduation from a low-income country to lower-middle income country since 2017- there have been changes in donor’s funding policy – including Global Fund that largely supports our national TB control program. It is anticipated that donor’s funding support would gradually decrease in the coming years and the issue of domestic financing would emerge. To address this issue of domestic financing; policy makers need reliable cost information of TB services offered by the Bangladesh NTP for planning sustainability of the National TB control Program.

In view of the above-mentioned changes in the program, this supply-side cost analysis of TB services of Bangladesh NTP was conducted by icddr,b, supported by the United States Agency for International Development (USAID)’s Research for Decision Makers (RDM) activity during January to September 2018. Specifically, this analysis was aimed at estimating the unit cost of TB services (prevention, diagnosis, treatment and follow up), provider’s total cost per patient and total cost of TB services by delivery channels during the base year 2016 and target years 2017-2022.

Methodology: Ingredients-based costing approach was followed using One Health Tool (OHT). The OHT was linked with the TB Impact Module & Estimates (TIME) model to allow for more accurate TB program costs to be estimated since the costs are based on the country’s TB disease burden and response.

At the onset; the tool was customized in the context of Bangladesh NTP and the TIME model was calibrated considering country-specific parameters. A Technical Working Group (TWG) was formed that selected TB interventions and service delivery channels for costing by OHT and facilitated data collection. Series of consultative meetings with the members of TWG, key informant interviews with the officials/managers of partner organizations, review of documents and databases alongside field visit to purposively selected facilities were conducted to collect necessary data.

All inputs mobilized and used up for TB service delivery during the base year 2016 and expected to be used in the target years 2017-22 were identified, quantified and valued in Bangladesh Taka (BDT) using a checklist. Quantity and unit price of these inputs were organized into the related OHT modules (health services and health systems modules). Unit price of anti-TB drugs, supplies and diagnostic reagents were calculated based on online price information shown in the Global Drug Facility (GDF) product/medicine catalogue 2016 and 2019 and validated with the local TB program experts of NTP. Ministry of Health and Family Welfare (MOHFW)’s price list was used for other investigations (i.e. supplementary tests for multi-drug resistant (MDR), extensively drug-resistant (XDR), MDR with additional resistance or pre-XDR patients) to estimate cost per patient. Unit costs of culture and drug susceptibility testing (DST) were estimated based on consultation with NTP microbiologist. The base year (2016) and projected year’s (2017-22) number of service/coverage data of investigation and treatment were estimated by TIME module based on Bangladesh NTP’s diagnostic algorithm, information derived from NTP’s Annual Report 2017 (showing estimates of 2016) and United Nations High Level Meeting (UNHLM) targets set for 2018-22. Assumptions and estimates were considered as and where required. Estimates of the base year 2016 were adjusted for inflation in 2019 considering rates taken from Bangladesh Bank sources and for

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2020-22 the World Economic Outlook Database 2018 were used. The exchange rate of BDT to USD in 2016 and mid-2019 were taken from the Bangladesh Bank’s Annual Reports and for 2020-22, per year 1.5% BDT depreciation was considered.

In line with the new Levofloxacin-based treatment regimen, diagnostic algorithm and 3HP preventive therapy effective from 2019; the total cost of treatment (drugs, supplies and investigations) per patient have been re-estimated separately for July 2019 and onwards. Therefore, the unit costs of 2016 (except LPA and drug cost) have been adjusted for inflation of 2019.

The data were entered into locked projections and reviewed. The locked data files were loaded into a master projection. The master projection was reviewed by the study team, as well as by international OHT experts, for gaps, errors, duplications, and inconsistencies. After necessary validation; results were generated on treatment inputs (health services cost) showing unit cost and cost per patient by category of TB, and total cost (health services plus health system cost) of services of the Bangladesh NTP.

Key findings: Among all investigations for TB in 2016, unit cost per smear microscopy was lowest (BDT 23.44; USD 0.30) and unit cost per Gene Xpert test was highest (928 BDT or 12 USD). Based on the proportion of usage – the unit cost of culture stood at BDT 327 (USD 4.18). With similar proportions applied for DST solid and liquid- the unit cost of DST stood at BDT 630 (USD 8.05) in 2016 (inflation adjusted figures for 2019 are shown in G). The unit cost of Fine needle aspiration cytology (FNAC) and Mantoux test (MT) stood at BDT 150 (USD 1.91) and BDT 100 (USD 1.27) per test.

In 2016; the unit cost of first line TB treatment (drugs and investigations) for adult patient under Category-I was BDT 3,104.58 (USD 39.64) and BDT 8,064.42 (USD 102.98) for category II previously treated adult cases. Cost of drugs and investigations per MDR TB patient with long regimen was BDT 1,38,998.4 (USD 1775.2) combining the cost of directly observed treatments (DOTS) at hospital and domiciliary level per patient in the base year 2016. The unit cost of short regimen was BDT 97,338.59 or USD 1,243.14 (combining hospital and domiciliary DOTS) - which is less than long regimen by USD 532.06. Cost of drugs and investigations per case of XDR TB was the highest among all types of TB that took around BDT 5,81,175.54 (USD 7,422. 42) in 2016 (inflation adjusted figures for 2019 are shown in Table 3.1). However; the cost per drug resistant patient was higher when added up with the cost of ancillary drugs, supplementary tests, social support, provider’s incentive, and specimen transportation costs (Table-3.3a, 3.5a and 3.7a).

Cost per patient of adult retreatment cases (Pulmonary+ ve/EPTB -Lymph node, Skin, GI tract, kidney) treated with Levofloxacin and 4FDC for 6 months DOTS regimen stood at BDT 8,628 (USD 103, Table- 3.2d). Cost per patient of adult retreatment cases with TB meningitis, bone TB, and neurological TB (Table-3.2h) that treated with Levofloxacin + 4FDC for 12 months DOTS in 2019 onwards was estimated to BDT 13,129 (USD 156.3).

Cost per patient of child retreatment with Pulmonary+ ve/EPTB (lymph node, skin, GI tract, kidney), Levofloxacin + 3FDC + E100 for 6 months DOTS) in 2019 stood at BDT 10,059 (USD 120, Table- 3.2i). On the other hand, cost per patient of child retreatment with TB meningitis, bone TB and neurological TB (Levofloxacin + 3FDC + E100 for 12 months DOTS) in 2019 stood at BDT 15,822 (USD 188) (Table-3.2k)

Considering the new treatment regimen and diagnostic algorithm, the grand total cost per MDR patient under long regimen was estimated at BDT 3,50,166.50 (USD 4,168.6, Table-3.4a).

However, considering 2019’s new treatment regimen and diagnostic algorithm the grand total cost per patient under short regimen stood at BDT 1, 24,258.1 (USD 1,479.3, Table-3.6a) which is around BDT 29,179.8 (USD 347) less than 2016’s previous short treatment regimen for MDR TB. With the change in algorithms in 2019, the total cost of drugs and investigations per MDR with additional resistance/Pre-

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XDR patients stood at BDT 3,98,979.50 (USD 4,749.8)- which is BDT 182,196 less compared to drugs & investigation cost of XDR patients in 2016. The estimated total cost i.e. inclusive other costs per MDR with additional resistance/Pre-XDR patients in 2019 was BDT 4,72,979.5 (USD 5,630.7, Table-3.8a) – which shows substantial decrease by BDT 3,39,503.2 (USD 4041.7) in total cost compared to 2016’s previously used XDR regimen.

According to new preventive therapy (3HP) the total cost per adult and children aged 12 years and older (for 3 months weekly therapy of Isoniazid and Rifapentin) was estimated at BDT 4,203 (USD 50, Table- 3.10b)

The total cost of National TB control program for base year 2016 was estimated to BDT 3,853.89 million (USD 49.22 million) which would increase to BDT 12,906.11 million (USD 146.93 million) in 2022 given the availability of resources committed, attainment of service coverage and efficient use of fixed assets. The highest proportion of the total cost (41%) was from human resources followed by medicines, investigations/supplies including wastage (38%) while the infrastructure accounted for 12% of the total cost. The program cost that included freight, transport/vehicle, social support, provider’s incentive, advocacy campaign, monitoring-supervision, repair & maintenance comprised around 9% of the total cost. Among the five selected delivery channels, DOTs Centre accounted for highest proportion of the total cost (60.1%) followed by community (24%).

According to OHT estimate, the total cost of drugs, supplies and investigations in base year 2016 should be BDT 795.7 million - which is BDT 112 million more than the actual expenditure (BDT 683.8 million; Expenditure Report, 2015-16, Bangladesh NTP) incurred upon NTP for drugs, supplies and investigations in the fiscal year 2015-16.

To estimate funding gap we considered calendar year 2018-2022 for both NSP and Operational Plan (OP) budgets and compared with the One Health Tool (OHT) estimates for similar period. The funding gap between OHT estimate and NSP budget in 2018 was 8.85 million USD which would increase to 81 million USD in 2022 with a total funding gap of 235 million USD over the whole period (Table-3.17). The annual funding gap is notable since 2019 and onwards due to inclusion of new treatment regimen, diagnostics and preventive therapy.

Conclusions:

• Under the new treatment regimen of 2019; the cost per patient for shorter treatment regimen of MDR and Pre-XDR/MDR with additional resistance patients are substantially less than previous treatment regimens of 2016 (Table-3.3a – 3.8a).

The total cost for base year 2016 was estimated to 3,853.89 million BDT which would increase to 12,906.11 million BDT in 2022 given the availability of resources committed, attainment of service coverage and efficient use of fixed assets (Table-3.13).

• OHT cost estimates revealed a funding gap of 235 million USD when compared with NSP budget of 2018-22 (Table-3.17 and Figure-6)

• The highest proportion of the total cost (41%) was from human resources followed by medicine, supplies and investigations including wastage (38%) and program cost (9.1%) while the infrastructure accounted for 12.1% of the total cost. The program cost included freight, transport/vehicle, social support cost, providers incentive, advocacy campaign, monitoring supervision, utility, stationeries, repair & maintenance (Figure-1)

• Around 80% of the human resource costs represent salaries followed by benefits (15%) and in- service trainings (5%) from base year to projected years (Figure-4)

• Medicines and supplies cost show a sharp increase from 2018 through 2022- which is attributable to purchase of new drugs for implementing new treatment regimen and preventive therapy effective from 2019 onwards. As per procurement and expansion plan detailed in OP,

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OHT estimated that the cost of infrastructure (e.g. medical equipment, renovation, construction of new facilities) would increase from 2020 to 2022. However; the HR shows a linear increase of cost over the target years (Figure-2).

• The majority of the costs consumed at the facility level appeared as capital cost of the facility per year except for the base year 2016. Most of the capital investments were made in 2017 followed by 2021 and 2022 according to the resources committed in the OP (Figure-3).

• According to OHT estimate, the total cost of drugs, supplies and investigations in base year 2016 was BDT 796 million - which is BDT 112 million more than the actual expenditure (BDT 684 million; Expenditure Report, 2015-16, Bangladesh NTP) incurred upon NTP for drugs, supplies and investigations in the fiscal year 2015-16 (Table-3.15).

• Among the five selected delivery channels; DOTS Centre accounted for the highest proportion of the total cost for drugs, supplies and investigations (60%) followed by community (24%). This is linked to higher number of cases treated at DOTS and preventive therapy at the community compared to other delivery channels (Figure-5)

Recommendations:

• The OHT estimates related to unit costs of TB treatment inputs (drugs, supplies and investigations) and total cost per patient estimated for 2019 and onwards should be considered for costing of the next National Strategic Plan for TB control.

• The funding gap as revealed between OHT estimate and NSP budget 2018-22 (235 million USD)

indicates the amount of additional investment required for delivering TB services effectively. Therefore; policy planners should consider these estimates to advocate for increased funding for Bangladesh NTP to match with the costs.

• Given the relatively low cost of shorter treatment regimen of MDR and MDR with additional

resistance than previous treatment regimens of 2016, shorter treatment regimen for MDR/MDR with additional resistance should be scaled up.

• Based on the current estimates; further studies should look at the cost of providing TB services with future changes in diagnostic and treatment algorithm.

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1. BACKGROUND

1.1 Study rationale

Over the last few years; the Bangladesh National Tuberculosis Control Program (NTP) has introduced state-of-the-art diagnostic technologies e.g. Gene Xpert, digital x-ray machine, LED microscopes and revised the diagnostic algorithm, treatment regimen and planned to introduce broader preventive therapy to accelerate TB case detection, management and prevention effectively. These interventions are expected to continue across the period of current Operational Plan (2017-22) and National Strategic Plan (2018- 2022) for TB control- which is now being updated for the period 2020-2025. Understandably; introduction, expansion and maintenance of these new technologies and algorithms have additional cost implications on the program.

The above-mentioned activities have been initiated in accordance with the objectives of the Bangladesh National Strategic Plan (NSP 2018-22) for TB control and UNHLM targets set for 2018-2022. In the face of high burden of TB with an estimated incidence of 225 per 100,000 population, prevalence of 382 per 100,000 of population and mortality of 45 per 100,000 population (WHO’s Global TB report 2016)- the Bangladesh NSP for TB control outlined a number of key interventions and activities that are expected to enable it’s NTP to achieve End TB strategy’s milestones for 2025 (75% reduction of TB mortality and 50% reduction in TB incidence rate) and targets for 2035 (95% reduction in TB mortality and 90% reduction in TB incidence rate). Some of the planned interventions and activities mentioned in NSP 2018- 22 include expansion and maintenance of GeneXpert and LED microscopy in all upazila health complexes by 2022, digital x-ray machines in all Chest Disease Centers (CDCs) and Chest Disease Hospitals (CDHs), increase case detection at community level and high risk groups, increase detection of TB in children, improve multi-drug resistant (MDR) case detection and implement shorter regimen MDR-TB treatment, introduce new diagnostic algorithm and ensure supply of quality controlled latest drugs at all facilities, ensure fully functional Regional Tuberculosis Reference Laboratory (RTRLs), infection control/contact screening, in-service training, greater engagement of private providers etc.

In view of the planned and ongoing changes in the program - the planning wing of the Ministry of Health and Family Welfare (MoHFW) had requested the United Stated Agency for International Development (USAID)_ in late-2016 to conduct a comprehensive cost analysis of TB services for better program planning and budgeting purposes.

Furthermore; in the context of Bangladesh’s graduation from low-income country to lower-middle income country since 2017- there have been changes in donor’s funding policy – including Global Fund that largely supports our national TB control program. It is anticipated that donor’s funding support would gradually decrease in the coming years and the issue of domestic financing would emerge. The Global Fund has been engaged in this discussion with the MOHFW about increased counterpart financing for essential program components. This has prompted the Government to think and act accordingly to invest more domestic resources for TB program. A notable result of this discourse has already been reflected in the procurement of first line-TB drugs by the Bangladesh Government since 2018. However; there is dearth of cost information of TB services e.g. unit cost of services, cost per patient by category, total cost and the funding gap of the program during 2017- 2022. Such information is essential for planning domestic financing, advocacy for additional funding and developing upcoming costed national strategic plan (NSP). Keeping these issues in mind, this supply-side cost analysis of TB services in Bangladesh was conducted by icddr,b using One Health Tool (OHT) to inform the policymakers for ensuring adequate financing for the National TB control Program.

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Box-1: OHT Steps of calculation

• Target population = the sub-population receiving the intervention (based on TB prevalence, incidence, or preventive properties of TB interventions generated from TIME)

• Population in need = % of population that requires the TB intervention

• # of cases (for a given TB intervention) = Target population x population in need × % intervention coverage

• TB intervention cost = # of cases (of a given TB intervention) × unit of resources needed per case × price per unit

• Cost per service delivery channel = # of cases (of a given TB intervention) × % delivery channel availability

1.2 Estimating TB Costs: One Health Tool (OHT) and TB Impact Model & Estimates (TIME) The One Health Tool (OHT) is designed to support medium- to long-term (3 to 10 years) strategic planning in the health sector, and has been used to inform strategic planning processes in over 30 low and middle-income countries. It provides a unified framework to support the planning, costing, and budgeting of health sector priorities, including health system strengthening strategies. The OHT facilitates scenario generation and informs priority setting by illustrating the health system implications of scaling up, delivery of health interventions, showing the investment gap, projecting the achievable health impact, and comparing costs with available financial resources. The tool assesses the costs related to health program areas, and includes health system modules following the WHO’s six building blocks.

TB Impact Module & Estimates (TIME)

TB Impact Model and Estimates (TIME) is a suite of analytic tools used for epidemiological, impact, and cost-effectiveness analysis and other steps in strategic policy and planning for TB. In 2016 in coordination with the NTP, TIME was calibrated for Bangladesh’s response to TB disease burden and with recommendations for case detection, diagnostic tool improvement and treatment outcomes within the NSP. This involved customizing TIME to produce estimates of historical and current TB incidence, mortality, and notification rates, broken down by case type (new or retreatment) and MDR, and using TIME Impact to generate projections of TB incidence and notification. Since these models are linked to OHT, it allows for more accurate TB program costs to be estimated since the costs are based on the country’s disease burden and response.

How the cost of health services/interventions was estimated:

The OHT uses a provider-focused costing perspective. The cost of a health service/intervention is determined by the number of people receiving the intervention and the quantity of resources required to deliver the intervention per person. Excluded from this are opportunity costs and health system inputs (for which costs are estimated in the health systems module). In summary, costs for each TB intervention or service are calculated by:

# of cases x cost per case per year; where

# of cases = target population x population in need of intervention (%) x coverage (%).

The cost per-case per- year for specific TB interventions were determined using ingredients-based costing of medicines and supplies required to deliver the respective intervention and is shown in Box- 1

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How OHT estimates the cost of health system components:

The OHT’s health systems module includes six components covering critical service delivery inputs, as defined by the WHO health system building blocks. These are: infrastructure, logistics, human resources, health information systems, governance, and financing. The cost of each component is driven by the availability of functional inputs (e.g., trained human resources, or equipped facilities), as well as program management costs (e.g. monitoring, supervision, or advocacy).

1.4 STUDY OBJECTIVES

General objective

To estimate the supply-side costs of services of the Bangladesh National TB control Program (NTP) during the base year 2016 and target years 2017-22

Specific objectives

a. To estimate the unit cost of TB services (prevention, diagnosis, treatment and follow up) and cost

per patient in the base year 2016 and target years 2017-22.

b. To estimate the total cost of TB services by delivery channels for the base year and target years as per operational plan

2. METHODOLOGY Ingredients-based costing methodology was followed using One Health Tool (OHT). The OHT was linked with the TB Impact Module & Estimates (TIME) model to allow for more accurate TB program costs to be estimated since the costs are based on the country’s TB disease burden and response.

At the onset of the study the OHT was customized in the context of Bangladesh’s TB control program and the TIME model was calibrated for country-specific parameters (considering revised diagnostic algorithm, programmatic management of drug-resistant TB (PMDT), NTP’s annual report, UNHLM target indicators set for 2018-22.) This exercise was conducted by two external experts and trained members of the study team. Earlier, the study team members received a week-long hands-on training on OHT and TIME model in January 2018. These sessions were moderated by two external experts from Avenir Hea lth (Nadia Carvalho for OHT and Carel Pretorius for TIME model). A Technical Working Group (TWG) chaired by the NTP Line Director was formed at the initiation of the study that was comprised of representatives of NTP and its partner organizations (Annexure-A). The technical working group (TWG) members selected TB interventions and service delivery channels for which costs would be estimated (Box-2, Box-3 and Table-1) and facilitated data collection. Based on consultative meeting with the NTP officials and review of documents; the recent changes/revisions adopted in 2019 in treatment regimen, diagnostic algorithm and preventive therapy have been shown in Box-3. A letter of collaboration for data collection was obtained from the Line Director, TB-Leprosy and ASP prior to field work.

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Box 2.

TB interventions of Bangladesh NTP: During 2016 – mid 2019

Tests for TB diagnosis: Microscopy (Z–N & F-M method), Gene Xpert, X-ray, FNAC, Culture (solid, liquid) & DST (solid, liquid) in follow up, HIV testing for risk group

First line treatment:

Category-1: treatment for new adult patient Category-2: previously treated adult patient

Second line treatment: Long regimen for MDR TB

Short regimen for MDR TB 24-month regimen for XDR TB

Treatment for childhood TB

Prevention: IPT for children under 5 years of age

Box 3.

Revised TB interventions of Bangladesh NTP:

2019 and onwards Tests for TB diagnosis: All as before + LPA

First line treatment:

Category-1: Treatment for new adult TB patient: Lfx based retreatment for adult patient: Lfx+ 4FDC for 6 months for Pul+ ve /EPTB (Lymph node, Skin, GI tract, Kidney); for Pul –ve: 4FDC for 6 months; For TB meningitis, Bone TB, neurological TB patients: Lfx+ 4FDC for 12 months Treatment for childhood TB Lfx based retreatment for child patient (Do) Treatment for new childhood TB patient (6 months) Second line treatment:

New short regimen for MDR TB (9 months) New long regimen for MDR TB (20 months) MDR with additional resistance (20 months)

(Pre XDR TB) Follow up tests for adult and child TB patients Microscopy, X-ray, Genexpert, Culture, DST,

Supplementary tests for MDR TB patients:

CBC, X-ray, ECG, Audiometry, Blood glucose, Serum createnin, Serum electrolyte, Serum bilirubin, Liver function tests, Thyroid function tests.

Preventive therapy 3HP therapy (for >2 yrs of age for 3 months) IPT therapy (for <2 yrs of age for 6 months)

Follow up tests for adult and child TB patients Microscopy, X-ray, Genexpert, Culture, DST,

Supplementary tests for MDR TB patients:

CBC, X-ray, ECG, Audiometry, Blood glucose, Serum creatinine, Serum electrolyte, Serum bilirubin, Liver function tests, Thyroid function tests.

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Table -1: TB service delivery channels selected for costing

TB Service delivery channels Point of care/Facility* 1. Community: (Preventive therapy and awareness campaign)

DOT providers: TLCA, HA, HI, AHI, FWA, SACMO, CHCP, paramedics in urban settings, BRAC’s Shasthya Shebika, Damien field staff, village doctors

2. DOT centers/corners (hospital outpatient DOTS and domiciliary DOTS)

All Upazila health complexes (424), District/General hospitals (62), CDC (44), CDH (12), Govt. medical college hospitals (22), Specialized hospitals (18 ), private medical college hospitals (67), Urban PHC clinics (120 ), CRHC (32), Damien hospitals (3), workplace (EPZ-, BGMEA- 6), prisons (47), BRAC, Damien and NHSDP operated DOTS centers in metropolitan/urban areas ( 159), CMH (6)

3. Microscopy centers (sputum microscopy at health facility level)

All UHCs (424), District/General hospitals (62), CDCs (44), CDHs (12), BRAC, Damien and NHSDP operated microscopy centers in metropolitan areas (107), Work place (EPZ-5 , BGMEA- 6).

4. Hospitals (providing TB inpatient DOTS, X-ray, Culture, DST & LPA)

All District/General hospitals (62), CDHs (12), Govt. medical college hospitals (22), NIDCH (1), NITRL (1), RTRL (4), Damien Hospital (3) & Reference Laboratory (1), BRAC’s TB diagnostic Centers with digital X-ray (34)

5. Xpert centers (GeneXpert test at facility level)

All CDC (42), CDH (12), NTRL (1), RTRL (4). Govt. Medical college hospitals (22), BRAC’s TB diagnostic Centers with Xpert (28)

*Health Bulletin 2016, 2018, NTP’s Annual Report 2016, 2018

2.1 OHT customization and calibration of TIME model:

During the training sessions, the OHT was customized in the context of Bangladesh NTP to estimate the costs of TB services. This involved mapping of default interventions in the OHT to those key TB interventions identified by the TWG: interventions from 2016 to June 2019 (Box-2) and interventions to be implemented from July 2019 and onwards (Box-3). Service delivery channels were determined (Table-1) for OHT projection in consultation with TWG members. Based on the revised NTP diagnostic algorithm - the TIME module was calibrated for country-specific parameters e.g. TB notification rate by case type, TB incidence, and mortality rates. The parameters used and coverage data thus generated by TIME module was then validated through partner consultation (i.e. NTP, BRAC and Challenge TB officials) and compared with the NTP’s Annual Report 2017 (showing estimates of 2016). The UNHLM targets of Bangladesh NTP set for 2018-22 were also considered in the calibration of TIME module.

The key activities of the study were conducted from January to September 2018. However; unit costs were re-estimated in line with the changes adopted by the NTP in 2019 in diagnostic algorithm, new treatment regimen and preventive therapy. Necessary data were derived through:

• Consultative meetings • Key informant interview (KII) • Document and database review and • Physical inventory of purposively selected facilities

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2.2 Study sites

Based on accessibility and readiness to provide data; the following facilities were purposively selected in consultation with the NTP for physical inventory and key informant interviews to gather facility level information. These include:

• Rajshahi chest disease hospital • Rajshahi chest disease clinic • Tangail chest disease clinic • Rajshahi regional TB reference laboratory (RTRL) • National TB reference laboratory (NTRL) • National institute of diseases of chest and hospital (NIDCH) • Damien’s Mymensingh TB hospital • DOT corner at Kalihati, Ghatail and Modhupur upazila health complexes • BRAC’s TB diagnostic centre (TDC) at Dhaka and • icddr,b TB Screening and Treatment Centre in Dhaka.

2.3 Data collection All inputs mobilized and used up for TB service delivery during the base year 2016 and expected to be used in the target years 2017-22 were identified, quantified and valued in Bangladesh Taka (BDT) using a checklist. Quantity and unit price of these inputs were organized into the related OHT modules (health services and health systems modules). Unit price of anti-TB drugs and diagnostic reagents were calculated based on online information shown in the Global Drug Facility (GDF) product/medicine catalogue 2016 and 2019 and validated with the local TB program experts of NTP. As suggested by GDF medicine catalogue, the highest price was considered in case of anti-tubercular medicines that appeared with a range of prices. Air freight, VAT and tax for all foreign purchases were collected from OP 2016-22. MOHFW’s price list for other investigations (i.e. supplementary tests for MDR, XDR/pre- XDR/MDR with additional resistance patients) was used for estimating cost per patient. In case of non- availability of any price, market price was considered. Unit price of drugs and supplies (price list) used in calculating unit cost of services are shown in Annexure-B. Shared costs were allocated based on apportionment according to the percentage of time spent by staff, space and supplies used in TB specific interventions.

Series of consultative meetings were held with the working group members, followed by Key Informant Interview with the national advisor to NTP, DPMs, Program Managers/organizers of BRAC and Damien Foundation Bangladesh, Head NTRL, service providers (Physicians, Consultants, Microbiologist, Laboratory technicians, Field workers), and Accounts officers for cost information on TB prevention, diagnosis and treatment for the base year 2016 and planned for the target years 2017-22.

All necessary information was collected on revised diagnostic algorithm, new Levofloxacin based treatment regimen for retreatment cases, new long and short regimen for MDR cases, MDR with additional resistance patients (i.e. pre- XDR) and preventive therapy adopted in 2019. The HRM data base of DGHS was used to derive NTP’s public-sector HR information. Staff time spent in TB service delivery was gathered from consultative meetings, KII and facility inventory. Details of standard procedure followed in sputum culture and DST were collected through extensive consultation with an experienced microbiologist of NTP. Unit cost (reagents and supplies) of culture (solid, liquid) and DST was then estimated based on the procedure of these tests and estimated percentage of use of solid and

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liquid culture in the field.

A comprehensive review of documents and databases was conducted, particularly the Operational Plan of TB, Leprosy and AIDS-STD for 2011-16, and 2017-22, National Strategic Plan for TB Control 2018-22, National Guidelines and Operational Manual for TB management in adult and children, National Guidelines for Programmatic Management of Drug Resistant TB- 2013 (PMDT), review of NTP’s Annual Report 2017, Annual Report of Damien Foundation Bangladesh 2016, GDF database of Stop TB, HRM database of DGHS, Health Bulletin, study reports etc. The review retrieved coverage/service data for the base year and target years, UNHLM t argets for 2018 - 22, current clinical practice and case management, unit price of consumables, number of concerned health facilities, program cost, NTP’s expenditure data of 2016, and relevant epidemiological data required for cost analysis. 2.4 Data entry and cost calculation by OHT

The health services module of OHT: Quantity and price of drugs, supplies, and tests along with coverage, dosage and duration of treatment (i.e. treatment inputs) of the Bangladesh NTP were entered into the health services module of OHT to estimate unit cost of TB interventions/services by delivery channel and reference years. Program cost was entered using NTP’s expenditure data of 2016 and aggregated budget by line items as shown in TB operational plan for 2017-2022.

The built-in algorithm shown in Box-1 was followed to estimate the cost of TB interventions using OHT.

The health systems module of OHT consists of several sub-modules including infrastructure, human resources, logistics, information systems, financing, and governance. We used infrastructure, human resources, and logistics modules to estimate the total cost and unit cost of TB interventions by delivery channels.

Infrastructure sub-module: Data were gathered about the costs of building construction, vehicles (purchase, maintenance, and operational costs), equipment, furniture, and communications technologies (purchase and maintenance) in TB facilities. Baseline information was gathered about the number of institutions (from the 2016 Health Bulletin), cost of construction per square foot (from the Health Engineering Department), and average floor space and utility costs (from facility records). Targets for infrastructure development, vehicles, and communication technologies for 2017-22 were derived from the corresponding operational plans.

Human resource sub-module: The study team collected data on staff salaries and benefits, increment patterns, and in-service training for different staff categories. The baseline numbers by cadre and different levels of care were obtained from the Human Resource Management database of DGHS, DHIS-2. The human resource targets for 2017-22 were identified from the operational plan. Usually the OHT calculates the cost of medicines/supplies and human resources separately. Costs of TB service providers and other management and support staff were included in the human resource sub-module under the health system module.

Logistics sub-module: The costs incurred for logistics activities included: warehouses (construction, maintenance, and utilities), drugs and supplies with wastage, transport (vehicle purchase, maintenance, operational costs, and third party contracts), and warehouse workers (e.g., managers, store keepers, clerks, drivers, and manual labors). These were collected from national sources/personal communications.

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Table-2: Summary of data sources

Information Data Source OHT module

Human resources Human Resource Management (HRM) database of DGHS, consultation with BRAC & Damien program officials

Human resource sub- module of health system module

Logistics DHIS-2, Logistics sub-module of health system module

Infrastructure Physical inventory at study facilities visited and operational plan

Infrastructure sub- module of health system module

Treatment inputs National guidelines & operational manual for TB control, 5th edition 2013, National guidelines for programmatic management of drug resistant TB (PMDT), 2nd edition 2013, National guidelines for management of childhood TB, 2nd edition 2016, Treatment regimen for latent TB infection-CDC web site, NTP circulars on Lfx based retreatment regimen Consultative meetings with program officials/experts, KII with NTP’s national advisor/ consultant and service providers

Health service module

Drugs, reagents, media and other consumable supplies

(i.e. price and quantity)

Global Drug Facility website (medicine and reagent catalogue), Standard operating procedure (SOP) : Quality assurance of AFB microscopy (Z-N & F-M method), 2nd edition, October 2013, consultation with NTP microbiologist, service providers, and store keepers at study sites, operational plans, NTP’s revised diagnostic algorithm, & treatment regimen, Institute of Public Health, MOHFW’s price list of diagnostic tests and market prices.


Average staff time per service

Consultation with service providers and their supervisors during field visit


Number of services/ coverage data for base year

Annual Report 2017 of NTP, National guidelines on programatic management of DR TB (PMDT), 2nd edition, Nov. 2013, estimates from TIME module, and Health Bulletin 2017

Health service module TIME module

Number of service/ coverage data for target years

TB Operational Plan 2017-22, estimates from TIME module using revised diagnostic algorithm, PMDT, UNHLM targets for 2018-22, consultation with experts

Health service module TIME module

Program cost data Consultative meetings with BRAC, Damien, NTP expenditure data of 2016 and budget by line items in TB operational plan for 2017-22.

Program costing section under Health services module

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As per OHT steps of calculation (Box-1), the population in need of intervention was calculated using incidence, prevalence and preventive properties of TB interventions through TIME module.

The base year (2016) and projected year’s (2017-22) number of service/coverage data on investigation and treatment were estimated by TIME module based on NTP’s diagnostic algorithm, information derived from NTP’s Annual Report 2017 (showing estimates of 2016) and UNHLM targets set for 2018- 22.

Inflation rates for 2019 were taken from Bangladesh Bank sources and for 2020-22 the World Economic Outlook Database 2018 were used for necessary adjustment. The exchange rate of BDT to USD in 2016 and mid-2019 were taken from the Bangladesh Bank’s Annual Reports.

The data were entered into locked projections and reviewed. The locked data files were loaded into a master projection. The master projection was reviewed by the study team, as well as by international OHT experts, for gaps, errors, duplications, and inconsistencies

Unit cost per service/intervention was estimated by health service module of OHT based on percentage of case receiving the input, quantity of input, unit price, dosage and duration of inputs related to treatment, investigation and prevention of TB. Using unit cost data and TB management guidelines, the total cost per patient by category of TB was estimated separately. Estimated number of services/coverage data was derived from the TIME model; based on WHO’s historical data on TB epidemiology, diagnostic algorithm, NTP’s Annual Report 2017and UNHLM targets set for 2018-22.

Total cost of TB services was estimated in OHT by multiplying the number of service with the unit cost of corresponding service. Total cost of services by delivery channels, base year and target years were estimated based on the proportion of services/coverage delivered through corresponding delivery channels. In addition; program cost was calculated by health services module using NTP’s expenditure data of 2016 and aggregated budget by line items as shown in TB-Leprosy-AIDS-STD operational plan for 2017-22. The proportion of total OP budget dedicated to TB program was apportioned beforehand to represent TB-specific budget for the target years 2017-22.

In addition to OHT estimates, cost of ancillary drugs, specimen transportation cost, social support cost, provider’s incentives and supplementary tests for DR patients were included separately to estimate the total cost per DR patients.

In response to a specific request from NTP, the team conducted a separate calculation of operational cost of icddr,b’ s social enterprise model based TB diagnostic approach using excel spread sheet.

Programme cost: Please see Table- 3.14 for list of items included in programme cost.

2.5 Assumptions and estimates

1. We assumed that according to the national guidelines and operational manuals for TB control; all

required drugs, supplies and staff were available at the service delivery channels during the base year 2016 and all resources committed in the current TB operational plan for target years (2017-22) would be available.

2. We assumed that the changes made in 2019 in diagnostic algorithm, treatment regimen and preventive therapy were effectively implemented since July 2019 (inclusion of Tab. Levofloxacin, Tab.

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Bedaquiline, Tab. Delamanid, LPA, 3HP preventive therapy etc.) 3. For unit cost estimation, we assumed one laboratory technician could perform 10 Gene Xpert test per

day. 4. One laboratory technician could process three sputum specimens per day for culture or DST. 5. Number of medicines (3FDC, 4FD, 2FDC) required per patient was calculated assuming bodyweight

38-54 kg for adult and 12-15 kg for children. However; maximum dosage was considered for Cs, Pto, E-400 mg and Mfx- 400 mg as suggested by the NTP’s national advisor.

6. Assumed bodyweight of <5-year-old child is 10 - 15 kg and for <2 years old child 5-10 kg for IPT (IPHN growth chart was used to make assumptions of bodyweight for different age group of

children) 7. For 3HP; bodyweight assumptions are as following: 8-12 years= 20-25 kg, 2-8 years=10-20 kg (IPHN

growth chart was used to make assumptions of bodyweight for different age group of children) 8. Cost of ancillary drugs per drug-resistant (DR) cases (TK. 550/pt. or USD 7/pt.), and specimen

transportation cost is included here based on assumption as shown in “Expansion plan of programmatic management of drug resistant TB (PMDT), 2013-17” by Bangladesh NTP.

9. With an assumption of future replacement of Z-N microscopy by LED, we considered higher percentage of coverage of LED (82%) compared to Z-N microscopy (18%). Similarly; we assumed greater coverage of solid culture (80%) compared to liquid culture (20%) in estimating unit cost.

2.6 Study limitations

1. Unit price of anti-tubercular drugs as shown in Global Drug Facility’s medicine catalogue may vary depending on volume of order, requested delivery time, and country regulatory requirements.

2. Based on reported proportion (9-11%) of the total grant, the Global Fund supported HR cost at NTP headquarters were included in the total HR cost.

3. Due to difficulty in accessing Shaymoli TB warehouse for physical inventory, personal communication was made with reliable sources to make assumptions about the warehouse system related to input price, quantities and wastage.

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3. RESULTS

3.1 Unit cost of drugs and investigations

Table-3.1 depicts the unit cost of TB services based on coverage, drugs, investigations/reagents and supplies used up for each service during 2016- alongside inflation adjusted costs for 2019. Detail calculation of unit costs by OHT; (based on percentage of coverage, number of unit, times per day, days per case and units required per case) is presented in Annexure –C as treatment inputs.

Table-3.1 shows that among all investigations for TB, unit cost per smear microscopy was lowest (BDT 23.44 or USD 0.30 considering 18% of patients receiving Z-N microscopy and 82% receiving LED microscopy as it would gradually replace Z-N microscopy in target years) and unit cost per Gene Xpert test was highest (928 BDT or 12 USD) in the base year 2016. Calculation on separate unit costs of Z-N and LED microscopy are shown in the Annexure-D. Target population, population in need of TB services and coverage of services are shown in Annexure- F, G, and H respectively. Based on the proportion of usage (i.e. patients who need culture 80% of them undergo solid while rest 20% receive liquid culture) – the unit cost of culture stood at BDT 327 (USD 4.8). With similar proportions applied for DST solid and liquid- the unit cost of DST stood at BDT 630 (USD 8.05) in 2016.

The unit cost of first line TB treatment (drugs and investigations) for adult patient under Category-I was BDT 3104.58 (USD 39.64) and BDT 8064.42 (USD 102.98) for category II previously treated adult cases. Cost of drugs and investigations per MDR TB patient with long regimen was BDT 1, 38, 998.4 (USD1775.2) combining the cost of DOTS at hospital and DOTS at domiciliary level per patient. The unit cost of short regimen was BDT 97,338.59 or USD 1243.14 (combining hospital and domiciliary DOTS) - which is less than long regimen by USD 532.06. Cost of drugs and investigations per case of XDR TB was highest among all types of TB that took around BDT 5, 81, 175.54 (USD 7422. 42).

Table- 3.1 Unit cost of TB services (Investigation, treatment & prevention in 2016)

Services in 2016 Unit cost*

(Drugs, reagents & supplies in 2016)

Inflation adjusted unit cost for 2019

BDT USD* BDT USD* Investigations Diagnosis by microscopy (Z-N 18% & LED 82%) 23.44 0.30 28.4 0.33 Follow up microscopy (Z-N 18% & LED 82%) 23.44 0.30 28.4 0.33 Z-N microscopy (100%) 26.00 0.33 31.5 0.37 LED microscopy (100%) 23.00 0.29 27.8 0.33 Culture (solid 80%, liquid 20%) 327.00 4.18 395.7 4.71 Drugs susceptibility test (solid 80%, liquid 20%) 630.29 8.05 1491.2 17.75 Gene-Xpert test (100%) 927.78 11.85 1122.8 13.36 X-ray chest (100%) 350.00 4.47 423.6 5.04 FNAC 150.00 1.91 180.00 2.14 MT 100.00 1.27 121.00 1.44 Treatment (Anti-TB drugs plus baseline and follow- up tests)

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Category I (cost per adult patient): First-line TB treatment: Initial treatment for adult

3104.58 39.64 3757.1 44.7

23

Services in 2016 Unit cost*

(Drugs, reagents & supplies in 2016)

Inflation adjusted unit cost for 2019

Treatment for children (cost per child) 1663.09 21.24 2012.6 23.96 Category II: First-line TB treatment: Previously treated adult

8064.42 102.98 9759.4 116.2

Long regimen treatment for MDR TB (20 months)** 1,38,998.4 1775.2 1, 68,212.4 2002.5 Short regimen treatment for MDR-TB (9 months)** 97,338.59 1243.14 1,17,797.8 1402.35 XDR TB treatment regimen (24 months)** 5,81,175.54 7422.42 7,03,324.4 8,372.9 Prevention IPT for children under 5 years of age 2,370.74 30.27 3,472.0 41.30

Exchange rate of 2016: 1USD = BDT 78.3, 2019: 1 USD = 84 BDT * See Annexure- C, page 64

** Excluding cost of ancillary drugs, specimen transportation, social support and providers incentive but inclusive baseline and follow-up tests

3.2 Cost per patient of first line treatment: Category-I (Total cost of drugs and investigations per patient 2016)

Table-3.2a shows the total cost required for management of each of the new smear positive pulmonary TB patients (Category-I) was BDT 3104.58 (USD 39.64) inclusive of all investigations and drugs cost for six months. The cost of drugs and investigations per patient was around BDT 1709.60 (USD 22) and BDT 1394 (USD 18) respectively in 2016. With inflation adjusted for 2019- it stands at BDT 3,757 (USD44.7) per patient.

Table-3.2a: Cost per patient: New Smear + ve/ Xpert MTB/Rif +ve Pulmonary TB Patient (Category I TB patients), 2016

Investigation Unit

Cost 2016 (BDT)

Baseline investigation

Follow up investigation

Total Investigation

cost/pt.

Total Drug cost/pt.

Total cost/pt.

# of tests Cost (BDT)


Smear Microscopy

23.44 2 46.88 3 70.32

1394.98

1709.60**

3104.58

Xpert 927.78 1 927.78

CXR 350 1 350

Total cost: BDT 1324.7 70.32

* USD 17.81 21.83 39.64* Inflation adjusted total cost for 2019; BDT (USD)

3,757.1 (44.7)

*Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT; **See Annexure-C, page-64

Table-3.2b shows the total cost per patents with new smear negative pulmonary TB (category-1) was USD 39.04 with a difference in number of microscopy during the follow up period. Drug cost

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per patient is same (USD 22) in both the cases. The inflation adjusted total cost stands at BDT 3700 (USD 44.1).

Table-3.2b: Cost per patient: New Smear-ve Xpert MTB/Rif -ve Pulmonary TB patient (Category I TB patient), 2016

Investigation Unit

cost 2016 (BDT)

Diagnostic/baseline investigation


Total Investigation

cost/pt. (BDT)

Drug cost/pt (BDT)

Total cost/pt (BDT)



Smear Microscopy 23.44 2 46.88 1 23.44

1348.14

1709.60

3057.7 Xpert MTB/Rif 927.78 1 927.78 CXR 350 1 350 Total: BDT 1324.7 23.44 =1348.14 1709.60** 3057.7

USD 17.21 21.83 *39.04 Inflation adjusted total cost for 2019 BDT (USD)

3,700.4 (44.1)

*Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT; **See Annexure-C, page-64

3.3 Cost per patient of first line treatment: Category-II (Total cost of drugs and investigations per patient for 2016)

Table-3.2c shows the total cost required for the management of each of re-treatment smear positive pulmonary TB patients (category-II) was BDT 8064.42 (USD 102.98) inclusive of all investigations and drug costs for six months’ duration. The cost of drugs and investigations per patient was around BDT 6669.42 (USD 85.17) and BDT 1395.02 (USD 18) respectively in 2016. After adjusting inflation for 2019 the total cost stands at BDT 9,759.4 (USD (116.2).

Table- 3.2c: Cost per re-treatment case of smear +ve/ Xpert MTB/Rif +ve Pulmonary TB Patient (Cat II), 2016

Investigation Unit

cost 2016

(BDT)

Diagnosis/baseline investigation


Total Investigation Cost (BDT)

Drug Cost/pt. (BDT)

Total Cost (BDT) Number

of tests Cost

(BDT) Number of tests

Cost (BDT)

Smear Microscopy

23.44 2 46.88 3 70.32 1395.02 6669.42 8064.42

Xpert TB/Riff 927.78 1 927.78

CXR 350 1 350 Total BDT 1324.7 70.32 1395.02 6669.42** 8064.42

USD 17.81 85.17 *102.98 BDT in 2019 (USD)a)

9,759.4 (116.2)

*Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT; **See Annexure-C, page-64 a) Inflation adjusted total cost for 2019

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As per the NTP circular dated 23rd January 2019 (Annexure- E) following decisions were made by the National TB Technical Committee of Bangladesh as advised by the WHO;

1. Existing Category -II regimen for retreatment of TB patients shall not be used henceforth. 2. All retreatment TB patients shall be considered for GeneXpert test. 3. In case of Rifampicin resistant patients, MDR-TB treatment shall be followed. 4. In case of Rifampicine sensitive patients, following regimens shall be implemented.

a. Levofloxacin shall be used along with 4FDC for 6 months for pulmonary +ve and EPTB b. For pulmonary –ve patients 4FDC shall be applied for continuous six months c. For TB meningitis, Bone TB and neurological TB- Levofloxacin shall be used along with 4FDC for 12

months.

3.4 New Levofloxacin-based treatment regimen from 2019 onwards

In line with the above-mentioned revised treatment regimen and diagnostic algorithm; the total costs of treatment (drugs and investigations) per patient have been re-estimated as shown in Table-3.2d – Table 3.2k for July 2019 onwards. Therefore, the unit costs of 2016 (except LPA and drug cost) have been adjusted for inflation of 2019 henceforth.

Table-3.2d: Cost per patient of adult retreatment cases: Pulmonary+ ve/EPTB (Lymph node, Skin, GI tract, Kidney etc.) Levofloxacin + 4FDC based 6 months DOTS regimen (July 2019 onwards):

Investigation * Unit

Cost (BDT)

Diagnosis Follow up investigations

Total Investigation

Cost (BDT)

Drug Cost (BDT)

Total Cost (BDT) # of

tests Cost (BDT)

# of tests

Cost (BDT)

Smear Microscopy

28.4 2 56.7 3 85.1 3,703.1

4,924.8

8,627.9

Xpert MTB/Ri

1,122.8 1 1,122.8

CXR 423.6 1 423.6 LPA 2100 1 2100 Total BDT 3,503.1 85.1 3,703.1 4,924.8 8,627.9 USD = 102.7

(Exchange rate of 2019: 1 USD=84 BDT) *Inflation adjusted for 2019; ** See Annexure –C.1, page 84

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Table- 3.2e: Cost per patient: New cases of Lymph node TB, 2019 onwards (Cat -1) Investigation Adult Children

Total Investigation cost/pt. (BDT)

Total Drug cost/ pt (BDT)

Total cost (Inv+Drug)


Total cost (Inv+Drug) Baseline

Investigation Unit Cost (BDT)

FNAC 180i) 180 1,709.6 ii)

1,891 1,409.4 iii) 1,589 USD iv) 2.1 2.1 20.4 22.5 16.8 18.9

i) Inflation-adjusted total cost for 2019; BDT (USD) ii) See Annexure-C; iii) Considering 3FDC/RHZ(75/50/150) for 2 months and RH(75/50) for 4 months( See Annexure-C for unit costs); iv)Exchange rate of 2019: 1 USD=84 BDT; N.B: Number of Tests required for Follow up depends on the physician’s decision.

Table-3.2f: Cost per patient: Retreatment cases of Lymph node TB 2019 onwards Investigation Adult Children

Total Investigation cost/pt. (BDT)


Total cost (Inv+Drug)


Total cost (Inv+Drug) Baseline

Investigation Unit Cost (BDT)

FNAC 180i) 180 4,924.8 ii)

5,104.8 6,271.2 ii) 6,451.2 USD iii) 2.1 2.1 58.6 60.8 74.7 76.8

i) Inflation-adjusted total cost for 2019; BDT (USD) ii) See Annexure-C; iii) Exchange rate of 2019: 1 USD=84 BDT; N.B: Number of Tests required for Follow up depends on the physician’s decision.

Table-3.2g: Cost per patient of adult retreatment cases: Pulmonary–ve: 4FDC for 6 months DOTS: 2019 onwards

Investigation *Unit cost BDT

Diagnosis Follow up investigation


Drug Cost (BDT)


Tests

Cost (BDT)

# of tests

Cost (BDT)

Smear Microscopy

28.4 2 56.7 3 85.1 3,364.6

3,558.6

6,923.2

Xpert MTB/Rif

1,122.8 1 1,122.8

LPA 2100 1 2100

Total BDT 3,279.5 85.1 3,364.6 3,558.6 6,923.2 USD 82.4

(Exchange rate of July 2019: 1 USD=84 BDT) *Inflation adjusted for 2019; ** See Annexure –C.1, page 84

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Table-3.2h: Cost per patient of adult retreatment cases with T B meningitis, Bone TB and Neurological TB: Levofloxacin + 4FDC for 12 months DOTS, 2019 onwards

Investigation *Unit

cost (BDT)

Diagnosis Total Investigation Cost (BDT)

Drug Cost (BDT

Total Cost (BDT

Number of tests

Cost (BDT)

Smear Microscopy (CSF/Joint Fluid)

28.4 2 56.7 3,279.5 9,849.6 13,129.1

Xpert MTB/Rif 1,122.8 1 1,122.8

LPA 2100 1 2100

Total BDT 3,279.5 3,279.5 9,849.6** 13,129.1 USD =156.3

(Exchange rate of July 2019: 1 USD=84 BDT) *Inflation adjusted for 2019; ** See Annexure –C.1, page 84

Table-3.2i: Cost per patient of child retreatment with Pulmonary+ ve/EPTB (lymph node, skin, GI tract, kidney), Levofloxacin + 3FDC + E100 for 6 months DOTS: 2019


cost (BDT)



Drug Cost (BDT)


tests Cost (BDT)

# of tests

Cost (BDT)

Smear Microscopy

28.4 2 56.7 3 85.1 3,788.2

6,271.2

10,059.4

Xpert MTB/Rif

1,122.8 1 1,122.8 - -

CXR 423.6 1 423.6 - - LPA 2100 1 2100 - - Total (BDT) 3,703.1 85.1 3,788.2 6,271.2** 10,059.4 USD = =119.8

(Exchange rate of July 2019: 1 USD=84 BDT); *Inflation adjusted for 2019; ** See Annexure –C.1, page 84

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Table-3.2j: Cost per patient of child retreatment; Pulmonary-ve: 3FDC + E100 for 6 months DOTS: 2019 onwards


cost (BDT)



Drug Cost (BDT)


tests Cost (BDT)

# of tests

Cost (BDT)

Smear Microscopy

28.4 2 56.7 3 85.1 3,364.6

5,815.8

9,180.0

Xpert MTB/Rif

1,122.8 1 1,122.8 - -

LPA 2100 1 2100 - -

Total(BDT) 3,279.5 85.1 3,364.6 5,815.8** 9,180.0 USD =109.3 (Exchange rate of July 2019: 1 USD=84 BDT); *Inflation adjusted for 2019; ** See Annexure –C.1, page 84

Table-3.2k: Cost per patient of child retreatment with TB meningitis, Bone TB and neurological TB: Levofloxacin + 3FDC + E100 for 12 months DOTS: 2019 onwards


cost (BDT)

Diagnosis Total Investigation Cost (BDT)

Drug Cost (BDT)


of test s Cost

(BDT) Smear microscopy (CSF/Joint fluid)

28.4 2 56.7 3,279.5

12,542.4

15,821.9

Xpert MTB/Rif 1122.8 1 1122.8 LPA 2100 1 2100

Total BDT 3,279.5 3,279.5 12,542.4** 15,821.9

USD = = 188.4 (Exchange rate of July 2019: 1 USD=84 BDT), ** See Annexure –C.1, page 84

*Inflation adjusted for 2019

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3.5 Cost of second line treatment: Drug resistant (DR) TB:

For treating drug resistant TB patients, following costs are incurred upon the supply side – in addition to costs for ant-tubercular drugs and investigations.

Monthly social support to DR-TB patients: In addition to drugs and investigations, each DR- TB patient gets Tk. 1500 per month as social support. Also they receive a number of supplementary tests e.g. CBC, electrolyte, Liver, Kidney and Thyroid function tests, audiometry, ECG etc. plus, ancillary drugs for co-morbidities/adverse side effects of TB drugs. In addition, cost is also involved in specimen transportation.

Provider’s incentive: Each of the health workers providing home care to DR patients gets Tk. 1800/patient/month.

Cost per MDR patient under long regimen: This is estimated considering 20 months’ duration of treatment at domiciliary (18 months) and hospital level (2 months) as described in NTP’s national

guidelines and operational manual (5th

edition 2013).

Table-3.3: Based upon the number and time of investigation (e.g. baseline and follow up during and after

treatment) as shown in guidelines on programmatic management of drug resistant TB (PMDT 2nd

edition 2013), estimation of serum electrolyte followed by audiometry consume relatively higher cost (BDT 6800 and 5600) in each patient under long regimen treatment – as both being done eight times during the follow up period. The next higher costs are consumed by serum creatinine (BDT 2400), TSH (BDT 2400) and culture (BDT 2197) per patient under long regimen. Table-3.3 also reveals that the total cost of drugs and investigations per MDR patient under long regimen stands at BDT 1, 38,998.43 (USD1775.20). The cost of investigations and drugs per patient stands at BDT 30,141.17 (USD 384.94) and BDT 1, 08, 857.26 (USD1390.25) respectively. It is evident that 62% of the total cost is made up of drugs while 38% goes for investigations in long regimen treatment of MDR cases. After adjusting inflation for 2019 the total cost stands at BDT 1, 68,212.4 (USD 2,002.5). Table-3.3a depicts the grand total cost per MDR long regimen patient for 20 months (including drugs, investigations, ancillary drugs, social support allowance, specimen transportation, provider’s incentive) – which stands at BDT 2,12,998 (USD 2,721). However, considering the new treatment regimen and diagnostic algorithm (Table- 3.4) the grand total cost per patient under long regimen stands at BDT 3,50,166.50 (USD 4,168.6) – as shown in Table-3.4a.

29

Table-3.3: Drugs and investigation cost per MDR long regimen patient for 20 months in 2016

Investigation

Unit cost (BDT)

Baseline

investigation



Drug cost/pt. for long regimen (BDT)

Total Cost per patient

(BDT)

During treatment After treatment

30,141.2

1,08,857.3

=1,38,998.4

# of tests Cost (BDT) # of

tests Cost

(BDT) # of tests

Cost (BDT)

Audiometry 700 1 700 8 5600 ECG 300 1 300 Chest X-ray 350 1 350 3 1050

Smear microscopy 23.4 1 23.4 29 679.8 4 93.8 Culture(solid) 137.3 1 137.3 12 1647.7 4 549.2 Xpert MTB/Rif 927.8 1 927.8 - - DST (if culture positive) 1232.2 1 1232.2 - -

Complete Blood Count (CBC) 300 1 300 2 600 Serum Creatinine 300 1 300 8 2400

Serum Electrolytes 850 1 850 8 6800 Serum Bilirubin 300 1 300

SGPT 300 1 300 3 900

Alkaline Phosphatase 300 1 300 - - Blood Glucose 250 1 250 - -

Thyroid-stimulating hormone (TSH) 800 1 800 3 2400

HIV test 50 1 50 - - Pregnancy Test 300 1 300 - - Total cost BDT 7,420.7 22,077.5 643 30,141.2 1,08,857.3 =1,38,998.4 USD 384.9 1390.3 = 1775.2 Inflation adjusted for 2019 BDT (USD)

= 1, 68,212.4 = (2,002.5)

*Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT

30

Table- 3.3a: Grand total cost per patient of MDR long regimen patient for 20 months in 2016

Cost centre Cost per patient in BDT

Cost per patient in USD

Drug cost/ MDR (Long regimen) TB patient 1,08,857.3 1,390.25 *Ancillary drugs (Tk.550 per month x 20 months)

11,000 140.48

Investigation cost/ MDR (Long regimen) TB patient 30,141.2 385

*Specimen transportation cost (Tk.200 per month X 18 months)

3,600 46

Social support/pt (Tk.1500/month x 18 months)

27,000 345

Provider’s incentive (Tk.1800 per month x 18 months)

32,400 414

Total cost 2,12,998.5 2,721 Inflation adjusted for 2019 BDT (USD) 2,57,765.5 3,068.6

*National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013

**Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT However, considering the new treatment regimen and diagnostic algorithm (Table- 3.4) the grand total cost per patient under long regimen stands at BDT 3,50,166.50 (USD 4,168.6) – as shown in Table-3.4a.

31

Table-3.4: Cost per patient: MDR TB Patient under new longer regimen (20 months) treatment from 2019

Investigation

*Unit cost BDT

Baseline

investigation

Follow up investigations Total Investigatio

n Cost (BDT)

Total drug Cost

(BDT)

Total Cost (BDT)

During treatment Post treatment phase

# of tests

Cost (BDT)

# of tests

Cost (BDT)

# of tests

Cost (BDT)

38,576.1

222,037.5

260,613.6

Chest X-ray 423.6 1 423.6 3 1,270.7 Smear microscopy 28.4 1 28.4 29 822.6 4 113.5 Culture(solid) 166.2 1 166.2 12 1,994.0 4 664.7 Xpert MTB/Rif 1,122.8 1 1,122.8 - DST(if culture positive) 1,491.1 1 1,491.1 -

LPA 2,100 1 2100 - Complete Blood Count (CBC) 363.1 1 363.1 2 726.1

Serum Creatinine 363.1 1 363.1 8 2,904.4 Serum Electrolytes 1,028.6 1 1,028.6 8 8,229.2

Serum Bilirubin 363.1 1 363.1 - SGPT 363.1 1 363.1 3 1,089.2 Alkaline Phosphatase 363.1 1 363.1 -

Blood Glucose 302.5 1 302.5 - Thyroid-stimulating Hormone 968.1 1 968.1 3 2,904.4

ECG 363.1 1 363.1 -

Audiometry 847.1 1 847.1 8 6,777.0 HIV test 60.5 1 60.5 - Pregnancy Test* 363.1 1 363.1 - Total BDT 11080.4 26,717.6 778.1 38,576.1 222,037.5 2,60,613.6

USD =3,102.5

32

Table-3.4a: Grand total cost per patient for MDR long regimen patient for 20 months from 2019

Cost centre Cost per patient in BDT


Drug cost/ MDR (Long Regimen) TB pt 222,037.50 2,643.3

*Ancillary drug (Tk.550per month x 20 months)

13,311.90 158.5

Investigation cost/ MDR (Long Regimen) TB pt 38,576.10 459.2 *Specimen transportation cost (Tk.200 Per month X 18 months)

4,356.60 51.9

Social support/pt (Tk.1500/month x 18months)

32,674.70 389.0

Provider’s incentive (Tk.1800 per month x 18months)

39,209.70 466.8

Total cost 3,50,166.50 4,168.6 *National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013 (Exchange rate of 2019: 1 USD= 84 BDT)

Cost per MDR patient under short regimen in 2016: is estimated considering an average 9 months’ duration of treatment with 2 months at hospital level and 7 months at domiciliary level. Table-3.5 shows that the total cost of drugs and investigations per patient under short regimen stands at BDT 97, 338.59 (USD 1243.14) considering 9 months’ duration of treatment in 2016. The total cost of drugs and investigations under short regimen is around BDT 41, 659.84 (USD 532) less than the total cost of long regimen. Seventy-two percent of the total cost of drugs and investigations in short regimen is made up of drugs and 28% by investigations. Table-3.5a depicts the grand total cost per MDR patients under short regimen which stands at BDT 1, 26,789 (USD 1,619).

33

Table-3.5: Drug and investigation cost per MDR patient under 9-month short regimen in 2016

Investigation Unit cost BDT

Diagnosis/baseline investigation

Follow up investigation Total Investigation cost (BDT)

Drug cost/pt (BDT)

Total cost per patient

(BDT) During treatment Post treatment

# of tests

Cost (BDT)

# of tests

Cost (BDT)

Number of tests

Cost (BDT)

Audiometry 700 1 700 4 2800

27,142.95

70,195.64

=97, 338.59

ECG 300 1 300 7 2100

Chest X-ray 350 1 350 1 350 2 700 Smear microscopy 23.44 2 46.88 10 234.4 2 46.88 Culture(solid) 137.3 1 137.31 10 1373.1 2 274.62 Xpert MTB/Rif 927.78 1 927.78 2 1855.5

DST (if culture positive) 1232.2 1 1232.16 2 2464.32 - - Complete Blood Count 300 1 300 2 600 - - Serum Creatinine 300 1 300 4 1200 - - Serum Electrolytes 850 1 850 4 3400 - - Serum Bilirubin 300 1 300 - - SGPT 300 1 300 5 1500 - - Alkaline Phosphatase 300 1 300 - - Blood Glucose 250 1 250 - - Thyroid-stimulating hormone (TSH)

800 1 800 1 800 - -

HIV 50 1 50 - - Pregnancy Test 300 1 300 - - Total cost: BDT 7,444.13 16,821.82 2877 27,142.95 70,195.64 =97,338.59

USD 346.65 896.49 = 1243.14 Inflation adjusted for 2019 BDT (USD)

1,17,797.8 (1402.3)

34

Table - 3.5a: Grand total cost per MDR patient under 9 months shorter treatment regimen in 2016

Cost centers Cost per patient in BDT


Drug cost/ MDR (Short Regimen) TB pt 70195.64 896 *Ancillary Drugs (Tk.550per month x 9 months)

4,950 63

Investigation cost/ MDR (Short Regimen) TB pt 27,142.95 347 *Specimen transportation cost (200 Per month x 7 months)

1,400 18


10,500 134


12,600 161

Total cost 1, 26,789 1,619 Inflation adjusted for 2019 BDT (USD) 1, 53,436.9 1,826.6 *National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013

*Exchange rate of 2016: 1 USD= BDT 78.3 and for 2019 1USD= BDT 84

Considering 2019’s diagnostic algorithm and new treatment regimen with 9 months duration; the grand total cost per patient under short

regimen stands at BDT 1, 24,258.1 (USD 1,479.3) – as shown in Table-3.6a which is around BDT 29,179.8 (USD 347) less than 2016’s previous short treatment regimen (Table 3.5a) for MDR TB .

35

Table-3.6: Cost per patient of new shorter treatment regimen for MDR TB for 9 months duration from 2019

Investigation Inflation adjusted

unit cost

for 2019 (BDT)

Diagnosis Follow up investigations Total Investigation

Cost (BDT)

Total drug Cost

(BDT)

Total Cost (BDT)


# of tests

Cost (BDT)



Chest X-ray 423.6 1 423.6 1 423.6 2 847.1

34,958.7

53,659.8

88,618.5

Smear microscopy 28.4 2 56.8 10 283.7 2 56.7 Culture(solid) 166.2 1 166.2 10 1,661.7 2 332.3 Xpert MTB/Rif 1,122.8 1 1,122.8 - 2 2,245.6 DST (if culture positive) 1,491.2 1 1,491.2 2 2,982.4 LPA 2,100 1 2,100 - Complete Blood Count 363.1 1 363.1 2 726.1 Serum Creatinine 363.1 1 363.1 4 1,452.2

Serum Electrolytes 1,028.6 1 1,028.6 4 4,114.6

Serum Bilirubin 363.1 1 363.1 -

SGPT 363.1 1 363.1 5 1,815.3

Alkaline Phosphatase 363.1 1 363.1 -

Blood Glucose 302.5 1 302.5 - TSH 968.1 1 968.1 1 968.1

Audiometry 847.1 1 847.1 4 3,388.5

ECG 363.1 1 363.1 7 2,541.4

HIV 60.5 1 60.5 -

Pregnancy Test 363.1 1 363.1

Total BDT 11,119.6 20,357.4 3,481.7 34,958.7 53,659.8 88,618.5 USD = 1,055.0

36

Table-3.6a: Grand total cost per patient of MDR short regimen for 9 months duration from 2019 onwards

Cost centre Cost per patient in BDT Cost per patient in USD

Drug cost/ MDR (Short regimen) TB pt. 53,659.8 638.8 *Ancillary Drugs (Tk.550 per month x 9 months) 5,990.4 71.3

Investigation cost/ MDR (Short regimen) TB pt. 34,958.7 416.2 *Specimen transportation cost (200 Per month x 7 months) 1,694.2 20.2

Social support/pt (Tk.1500/month x 7 12,706.8 151.3

Provider’s incentive (Tk.1800 per month x 7 months) 15,248.2 181.5

Total cost 1, 24, 258.1 1,479.3

*National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013

(Exchange rate of 2019: 1 USD=84 BDT)

Cost per XDR TB patient under 24-month long regimen in 2016: is estimated considering 24 months of duration of treatment with

22 months at domiciliary and 2 months at hospital level as described in NTP’s PMDT 2013. Table-3.7 shows that 95% of the total cost

represents drugs only while 5% is spent on investigations (2016). Table-3.7a depicts the grand total cost per XDR patient stands at BDT

6,71,376 (USD 8,575) in 2016- which was highest among total treatment cost of all categories of TB in 2016. If we adjust this cost for inflation

in 2019 it goes up further to BDT 8,12,482.7 (USD 9,672.4)

37

Table-3.7: Drugs and investigation cost per XDR patient under long regimen for 24 months in 2016

Investigation

Unit cost (BDT)

Diagnosis/baseline investigations

Follow up investigations Total

Investigation Cost (BDT)

Drug cost/pt (BDT)

Total Cost

per patient (BDT)

During treatment After treatment # of tests Cost

(BDT) # of tests Cost

(BDT) # of tests

Cost (BDT)

Chest X-ray 350 1 350 3 1050

30,690.41

5,50,485.13

5,81,175.54

Smear microscopy 23.44 1 23.44 29 679.76 4 93.76 Culture (solid) 137.31 1 137.31 16 2196.96 4 549.24

Xpert MTB/Rif 927.78 1 927.78

DST(if culture positive) 1232.16 1 1232.16

Complete Blood Count 300 1 300 2 600

Serum Creatinine 300 1 300 8 2400 Serum Electrolytes 850 1 850 8 6800

Serum Bilirubin 300 1 300

SGPT 300 1 300 3 900 Alkaline Phosphatase 300 1 300

Blood Glucose 250 1 250

Thyroid-stimulating hormone (TSH)

800

1

800

3

2400

Audiometry 700 1 700 8 5600

ECG 300 1 300

HIV test 50 1 50 Pregnancy Test 300 1 300

Total cost 2016 BDT 7,420.69 22,626.72 643 30,690.41 5,50,485.13 =5,81,175.54 USD 391.95 7030.46 =7422.42 Inflation adjusted for 2019 BDT (USD)

7,03,324.4 (8,372.9)

38

Table-3.7a: Grand total cost per XDR patient for 24 months in 2016

Areas of Expenditure Cost per patient in BDT Cost per patient in USD

Anti-tubercular drug cost/XDR TB patient (Pt) 5,50,485.13 7,030.46 *Ancillary Drugs (550per month x 24 months) 13,200 169

Investigation cost/ XDR TB pt 30,690.41 391.95 *Specimen transportation cost (200 Per month X 22 months) 4,400 56

Social support/pt (Tk.1500/month x 22 months) 33,000 421.45

Provider’s incentive (Tk.1800 per month x 22 months) 39,600 506

Total cost (2016) 6,71,376 8,575 Inflation adjusted for 2019 BDT (USD) 8,12,482.7 9,672.4

*National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013 *Exchange rate of 2016: 1 USD= BDT 78.3 and 2019: 1 USD=84 BDT

Cost per MDR with additional resistance (pre-XDR) patient from 2019:

Table-3.8: With the change in algorithms in 2019, the total cost of drugs and investigations per patient of MDR with additional resistance for 20 months

duration stands at BDT 3,98,979.50 (USD 4,749.8)- which is BDT 182,196 less compared to drugs & investigation cost of XDR patients in 2016. Table-

3.8a reflects the grand total cost i.e. inclusive other costs per patient of MDR with additional resistance (Pre-XDR) is BDT 4, 72,979.5 (USD 5,630.7) –

which shows substantial decrease by BDT 3,39,503.2 (USD 4041.7) in total cost compared to 2016’s previously used XDR regimen.

39

Table-3.8: Drugs and investigation cost per patient of MDR with additional resistance for 20 months’ duration from 2019 onwards

Investigation Unit

cost (BDT)

Diagnosis Follow up investigations Total Investigation Cost (BDT)

Total drug Cost (BDT)

Total Cost (BDT)


Number of tests

Cost (BDT)

Number of tests

Cost (BDT)

Number of tests

Cost (BDT)

Audiometry 847.1 1 847.1 8 6,777.0

38,576.1

360,403.4

3,98,979.50

ECG 363.1 1 363.1 - Chest X-ray 423.6 1 423.6 3 1,270.7 Smear microscopy 28.4 1 28.4 29 822.6 4 113.4

Culture(solid) 166.2 1 166.2 12 1,994.0 4 664.7

Xpert MTB/Rif 1,122.8 1 1,122.8 -

DST (if culture positive) 1,491.1 1 1,491.1 - LPA 2,100.0 1 2,100.0 -

CBC 363.1 1 363.1 2 726.1

Serum Creatinine 363.1 1 363.1 8 2,904.4 Serum Electrolytes 1,028.6 1 1,028.6 8 8,229.2

Serum Bilirubin 363.1 1 363.1 - SGPT 363.1 1 363.1 3 1,089.2 Alkaline Phosphatase 363.1 1 363.1 - Blood Glucose 302.5 1 302.5 -

TSH 968.1 1 968.1 3 2,904.4

HIV 60.5 1 60.5 - Pregnancy Test 363.1 1 363.1 - Total BDT 11,080.3 26,717.6 778.1 38,576.1 360,403.4 3,98,979.50

USD = 4,749.8

40

Table-3.8a: Grand total cost per patient of MDR with additional resistance for 20 months duration from 2019

Cost Centre

Cost per patient in BDT Cost per patient in USD

Anti-tubercular drug cost/ Pre XDR TB pt 360,403.4 4,290.5

*Ancillary drug (Tk.550 per month x 20 months)

11,000.0 131.0

Investigation cost/ TB pt 38,576.1 459.2 *Specimen Pre XDR transportation cost (Tk.200 Per month x 18 months)

3,600.0 42.9


27,000.0 321.4


32,400.0 385.7

Total cost 4, 72,979.5 5,630.7 *National Guidelines and Operational Manual for Programmatic Management of Drug Resistant TB (PMDT), April 2013


41

3.6 Cost per person for prevention of TB

Year 2016-2018: Isoniazid Preventive Therapy (IPT) among under-five children

During the base year 2016; Isoniazid (INH/H) for 6 months was given to children less than 5 years of age,

who were household contacts or close contacts with a TB index case, i.e. yet not developed TB disease but

had risk of developing TB disease.

To exclude TB disease before providing IPT, MT, smear microscopy and Chest X-ray as appropriate were

done and followed-up microscopy was done every 2 months after initiation of IPT.

Table-3.9: Isoniazid Preventive Therapy (IPT) for <5 years old Children for 6 months (Applicable for year 2016-2018)

Investigation Unit

cost (BDT)

Tests to exclude TB disease

Follow up tests (every 2

monthly)


Drug Cost (BDT)

Total Cost (BDT)

Number of tests

Cost (BDT)

Number of tests

Cost (BDT)

Smear Microscopy

23.44 2 46.88 3 70.32

567.2

1,903.54

CXR 350 1 350

MT 100 1 100

Total BDT 496.88 70.32 567.2 1,903.54 2,470.74

Total USD =31.55

Inflation adjusted for 2019 BDT

(USD)

2,990.0 (35.60)

(Exchange rate of 2016: 1 USD=78.3; 2019 1 USD= 84 BDT

3.7 Year 2019 onwards: 3HP Preventive Therapy- Cost per person

Preventive Treatment/Post Exposure Treatment (PET) for household contacts of index tuberculosis patients using 12- dose regimen of weekly Isoniazid (H) plus Rifapentine (P) is currently recommended by NTP as a new approach called preventive therapy.

Under this new approach; all household members should be screened to exclude TB disease through clinical evaluation by a doctor and investigation such as MT, chest X-ray and sputum examination. Household contacts over 2 years of age will be given WHO recommended once weekly regimen of 3HP for 3 months. All contacts receiving 3HP are expected to be followed monthly till the end of their medication. Children under 2 years of age are given IPT as per the National guidelines. Table-3.10a shows the per capita cost of preventive therapy for children 2 -12 years stands at BDT 2537.6 (USD

42

30.2) - while Table 3.10b depicts the preventive therapy for adults and older children (>12 years) stands at BDT 4,201.8 (USD 50.02)- with higher drug cost in the later.

Table-3.10a: 3HP Preventive Therapy for children 2 to 12 years old (3 months weekly therapy: H=Isoniazid, P=Rifapentin, applicable from 2019 onwards)

Investigation Unit cost

(BDT)* Inflation adjusted

Tests to exclude TB disease

Follow up tests


Drug Cost (BDT)


of tests Cost

(BDT) Number of tests

Cost (BDT)

Smear Microscopy

28.4

2

56.7

3

85.1

686.40

1,851.2

2,537.2

CXR 423.6 1 423.6

MT 121 1 121

Total BDT 601.3 85.1 686.40 1,851.2 2,537.6 Total USD =30.20 (Exchange rate of 2019: 1 USD=84 BDT)

Table-3.10b: 3HP Preventive therapy for adults and children aged 12 years and older (3 months weekly therapy, H=Isoniazid, P=Rifapentin): Applicable from 2019 onwards

Investigation Unit

cost (BDT)

Tests to exclude TB

Follow up tests

Total Investigation

Cost (BDT)

Drug Cost (BDT)


of tests Cost (BDT)

Number of tests

Cost (BDT)


686.40

3,515.4 4,201.8

CXR 423.6 1 423.6

MT 121 1 121

Total(BDT) 601.3 85.1 686.40 3,515.4 4,201.8 Total USD =50.02


43

Table-3.10c: 6-months long Isoniazid Preventive Therapy (IPT) for <2 years old children (to be followed as before in 2019 onwards)

Investigation Unit cost (BDT)

Tests to exclude

TB

Follow up tests Total Investigation Cost (BDT)

Drug Cost (BDT)

Total Cost (BDT)

Number of tests

Cost (BDT)

Number of tests

Cost (BDT)


686.4

1,269.02

CXR 423.6 1 423.6

MT 121 1 121

Total BDT 601.3 85.1 686.4 1,269.02 1,955.4 Total USD =23.3


44

3.8 Estimated number of TB services/interventions: Table-3.11 shows the estimated total number of TB services (i.e. quantity of interventions) calculated and projected by TIME module based on WHO’s historical

data on TB epidemiology, NTP’s diagnostic algorithm and Annual Report 2017 and UNHLM parameters for 2018-22 . It shows a decreasing trend of TB diagnosis

by microscopy. Contrary to microscopy increasing trend of TB diagnosis by Gene Xpert and X-ray is observed throughout the projected years. This predicted

change in use of TB diagnostic tools is linked with the more resources committed to purchase of Gene Xpert and digital X-ray machine in the current operational

plan of Bangladesh NTP. Resistance testing with LPA for 1st and 2nd line drugs shows increasing trend from 2019 onwards as it is emphasized in the revised

diagnostic algorithm since 2019.

Table-3.11: Total number of TB services of base year (2016) and projected years (2017-22) as per TB impact module

Types of TB services 2016 2017 2018 2019 2020 2021 2022

Diagnosis microscopy 3,670,204 3,652,448 3,627,988 3,639,596 3,633,140 3,632,070 3,594,588 Follow Up microscopy 454,606 471,548 492,837 503,857 511,212 513,733 513,331 Diagnosis culture 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Drugs susceptibility testing 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Diagnosis GeneXpert 10,783 26,798 58,604 72,118 97,270 123,111 172,000 Resistance testing LPA: For first-line drugs, previously treated TB cases

- - - 19,694 20,775 23,046 24,223

Resistance testing with LPA: For second-line drugs - - - 2,131 2,799 4,603 5,363 Diagnosis X-rays 2,696 28,761 68,143 90,126 126,762 157,755 213,859 First-line TB treatment: Initial treatment for Adult (Cat I)

195,178 210,775 229,533 244,591 259,141 272,571 285,925

First-line TB treatment: Initial & Previously treated treatment for children

23,461 24,611 26,182 27,201 28,029 28,585 28,939

First-line TB treatment: Previously treated for Adult (Cat II)

13,963 15,208 16,652 - - - -

Lfx based regimen for child retreatment cases (Pul+) - - - 684 704 759 772 IPT children under 5 years of age 47,734 51,397 55,843 - - - -

45


3 HP for children 2 to 11 years old - - - 59,444 71,889 84,923 98,718 3 HP for adult and children more than 12 Years of age - - - 141,533 164,746 188,718 213,888 New regimen for child retreatment. cases (Pul-) - - - 361 371 401 408 New child retrt. cases- Meningitis, bone, Neurological TB

- - - 114 117 126 129

New Lfx based regimen for Adult rtrt. cases (Pul+ve/EPTB)

- - - 8,141 7,654 7,450 6,734

New regimen for adult retrt. cases (Pul-) - - - 5,694 6,023 6,700 7,065 New regimen for adult retrt. cases- Meningitis, bone, and Nurological TB

- - - 178 188 209 221

IPT for children <2 years of age - - - 28,307 34,946 41,937 49,359 Longer regimen for MDR-TB 915 955 905 - - - - Shortened nine-month treatment regimen for MDR-TB 201 384 586 - - - - XDR TB Regimen 12 14 15 - - - - MDR new shorter regimen (9 months) - - - 1,066 1,699 3,282 4,398 MDR new longer regimen (20 months) - - - 1,066 1,100 1,321 965 MDR with additional resistance (6 months Bedaquiline regimen)

- - - 2,131 2,799 4,603 5,363

HIV testing and counseling for TB patients 63,700 61,629 59,096 55,551 51,244 46,761 42,155 Audiometry 1,220 1,352 1,506 2,153 2,827 4,649 5,417 ECG 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Complete Blood Count (CBC) 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Serum Creatinine 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Serum Electrolyte 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Serum Bilirubin 552 602 663 1,107 1,597 2,045 2,310 SGPT 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Alkaline Phosphatase 552 602 663 1,107 1,597 2,045 2,310 Blood Glucose 552 602 663 1,107 1,597 2,045 2,310

46


Thyroid Function Test (TSH) 1,220 1,352 1,506 2,153 2,827 4,649 5,417 Chest X-ray for Follow-up Investigations of MDR-TB Patients

1,220 1,352 1,506 2,153 2,827 4,649 5,417

Pregnancy Test 552 602 663 1,107 1,597 2,045 2,310 FNAC (Fine Needle Aspiration Cytology) 8,732 7,835 6,810 5,437 3,836 2,014 - MT 47,734 51,397 55,843 229,283 272,580 314,530 361,964

47

According to new treatment regimen (2019) there will be no category-II treatment from 2019 onwards

which is reflected in the corresponding row of Table-3.11. Instead of cat-II treatment, the number of

new Levofloxacin based regimen for retreatment cases since 2019 has been estimated for 2019-22.

Number of patients receiving long regimen of MDR treatment would reduce while number of MDR

patients under new shorter regimen (9 months) would increase anticipating scale up of new short

regimen over 2019-22. Similar trend of decreasing number of MDR new longer regimen (20 months)

is estimated during 2019-22.

3.9 Total cost for TB services by base year and target years

Table-3.12 shows that the total cost of smear microscopy, Gene Xpert and X-ray services would

gradually increase from the base year total cost through the total cost of 2022. Cost for Gene Xpert and

X-ray services would substantially increase over the target years- that are linked with the expected

emphasis on diagnosis by Gene Xpert and digital x-ray. Besides; increase in treatment cost is observed

in cases of MDR new short regimen, new long regimen and MDR with additional resistance (pre-XDR)

patients during 2019-22. This is evident due to planned switch over to new treatment algorithm during

2019-22. A consistent increase in cost for baseline & follow-up investigations is observed for MDR-TB

patients over the target years.

Table-3.12 Total costs of drugs, supplies and investigations for TB services from 2016-2022 in Million BDT (Excluding wastage)

Types of services 2016 2017 2018 2019 2020 2021 2022

Diagnosis microscopy 86.02 91.48 96.83 103.22 109.17 115.39 120.48 Follow Up microscopy 10.65 11.81 13.15 14.29 15.36 16.32 17.21 Diagnosis culture 0.40 0.47 0.56 0.85 1.19 2.06 2.53 Drugs susceptibility testing 0.77 0.91 1.08 1.64 2.29 3.97 4.88 Diagnosis GeneXpert 13.01 34.54 80.50 105.26 150.43 201.29 296.69 Resistance testing LPA: For first- line drugs, previously treated TB cases

- - - 50.05 55.94 65.61 72.75

Resistance testing with LPA: For second-line drugs

- - - 5.42 7.54 13.10 16.11

Diagnosis X-rays 0.94 10.76 27.16 38.17 56.89 74.85 107.05 First-line TB treatment: Initial treatment for Adult (Cat I)

333.68 385.09 446.52 606.81 681.18 757.50 838.31


39.01 43.75 57.98 57.08 62.31 67.19 71.76


93.12 108.40 126.45 - - - -

Lfx based retrt. regimen for child retrt. cases (Pul+)

- - - 5.19 5.66 6.45 6.93

48

Types of services 2016 2017 2018 2019 2020 2021 2022 IPT children under 5 years of age

90.86 104.56 121.06 - - - -

3 HP for children 2 to 11 years old

- - - 133.17 170.64 213.12 261.36

3 HP for adult and children more than 12 Years of age

- - - 602.11 742.59 899.34 1,075.35

New regimen for child retrt. cases (Pul-)

- - - 2.54 2.77 3.16 3.39

New child retrt. cases- menigitis, bone, nurological TB

- - - 1.73 1.89 2.15 2.31


- - - 48.52 48.33 49.74 47.43

New regimen for adult retrt. cases (Pul-)

- - - 24.52 27.48 32.32 35.96

New regimen for adult retrt. cases- Meningitis, bone, and Nurological TB

- - - 2.12 2.38 2.80 3.11

IPT for children <2 years of age - - - 51.80 67.75 85.96 106.74 Longer regimen for MDR-TB 76.54 85.09 85.39 - - - - Shortened nine-month treatment regimen for MDR-TB

8.42 17.21 25.91 - - - -

XDR TB Regimen 5.60 6.49 7.10 - - - - MDR new shorter regimen (9 months)

- - - 40.89 69.08 141.08 199.45

MDR new longer regimen (20 months)

- - - 226.71 247.97 314.83 242.72

MDR with additional resistance (6 months Bedaquiline regimen)

- - - 666.58 927.58 1,612.64 1,982.33

HIV testing and counseling for TB patients

3.18 3.29 3.36 3.35 3.28 3.16 3.01

Audiometry 7.07 8.38 9.94 15.10 21.01 36.53 44.91 ECG 0.83 0.98 1.16 1.77 2.46 4.27 5.25 Complete Blood Count (CBC) 0.50 0.59 0.70 1.06 1.48 2.57 3.16 Serum Creatinine 3.03 3.59 4.26 6.47 9.01 15.66 19.25 Serum Electrolyte 8.59 10.17 12.07 18.34 25.52 44.36 54.53 Serum Bilirubin 0.17 0.19 0.23 0.40 0.61 0.83 0.99 SGPT 1.60 1.89 2.24 3.41 4.74 8.24 10.13 Alkaline Phosphatase 0.17 0.19 0.23 0.40 0.61 0.83 0.99 Blood Glucose 0.14 0.16 0.19 0.34 0.51 0.69 0.83 Thyroid Function Test (TSH) 3.55 4.21 5.00 7.59 10.56 18.35 22.56 Chest X-ray for Follow-up Investigations of MDR-TB Patients

1.71 2.02 2.40 3.65 5.08 8.82 10.85

Pregnancy Test 0.05 0.06 0.07 0.12 0.18 0.25 0.30 FNAC (Fine Needle Aspiration Cytology)

1.31 1.26 1.16 0.99 0.74 0.41 -

MT 4.77 5.49 6.36 27.75 34.95 42.64 51.77 Subtotal 795.67 943.03 1,139.07 2,879.42 3,577.14 4,868.50 5,743.37 Ancillary drugs for adverse effect 8.85 11.10 13.29 32.57 41.22 49.40 58.42

49

Types of services 2016 2017 2018 2019 2020 2021 2022 Total drugs, supplies & investigations costs 804.52 954.13 1,152.36 2,911.99 3,618.36 4,917.90 5,801.79

3.10 Total cost of TB services including health systems costs

The total cost shown in Table-3.13 includes costs of GOB, BRAC and Damien. The total cost for base

year 2016 was estimated to BDT 3,853.89 million (USD 49.22 million) which would increase to BDT

12,906.11 million (USD 146.93 million) in 2022 given the availability of resources committed,

attainment of service coverage and efficient use of fixed assets.

Table-3.13: Total cost of TB program including Health Systems cost in million BDT: 2016- 2022. (Inflation adjusted for 2017-22)

Cost components 2016 2017 2018 2019 2020 2021 2022 Total cost

OHT estimates 2016-22 Human Resources 2,326.36 2,628.42 2,953.45 3,209.94 3,484.75 3,783.87 4,056.95 22,443.74 Infrastructure (medical equipment, renovation, construction of new facilities)

387.52

924.18

633.17

596.48

598.00

1,714.99

1,800.58

6,654.92

Medicines, supplies, and Investigations (including wastage) 827.44 981.18 1,184.28 3,011.20 3,745.34 5,092.71 6,011.94 20,854.09

Programme costs 312.57 456.20 538.02 780.96 876.73 983.37 1,036.64 4,984.48 Total of OHT estimate: million

BDT 3,853.89 4,989.97 5,308.91 7,598.58 8,704.82 11,574.94 12,906.11 54,937.22

million USD 49.22 61.91 63.58 90.46 102.10 133.75 146.93 648.0

USD to BDT conversion rate* 78.3 80.5 83.5 84.0 85.3 86.5 87.8 -

* For 2020-22, per year 1.5% BDT depreciation was considered

Figure-1 shows that the highest proportion of the total cost (40.9%) was from human resources followed

by medicines (anti-TB and ancillary drugs) supplies and investigations including wastage (38.0%) while

the infrastructure accounted for 12.1% of the total cost. The program cost that included freight,

transport/vehicle, social support, provider’s incentive, advocacy campaign, monitoring-supervision,

repair & maintenance, utility, stationeries comprised around 9.1% of the total cost (see list of items under

program cost in table-3.14).

50

Human Resources Infrastructure Medicines, commodities, and supplies Program Costs

Infrastructure 12.1%

Human Resources 40.9% Medicines,

commodities, and supplies 38.0%

Program Costs 9.1%

Figure-1: Percentage distribution of total cost by cost components during 2016-22

Figure-2: The trend of increase in core cost components i.e. medicine, supplies and investigations, HR, infrastructure and program cost over the target years is shown in figure-2.

Figure-2: Cost of core components of health systems 2016-22

Medicine supplies and investigation costs show a sharp increase from 2018 through 2022- which is attributable to purchase of new drugs for implementing new treatment regimen, LPA for DR patients and new preventive therapy. As per procurement and expansion plan detailed in OP, it is estimated that the cost of infrastructure (e.g. medical equipment, renovation, construction of new facilities) would increase

Program Costs Infrastructure Human Resources Medicine costs

2022 2021 2020 2019 YEAR

2018 2017 2016

7,000.0 6,000.0 5,000.0 4,000.0 3,000.0 2,000.0 1,000.0

-

IN M

ILLI

ON

BD

T

51

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0% 2016 2017 2018 2019 2020 2021 2022

Capital costs Operating costs

from 2020 to 2022 due to planned purchase of medical equipment e.g. Gene Xpert, LED microscope, digital X-ray machine and construction of new facilities. However; the HR shows a linear increase of cost over the target years.

Table-3.14: Program management costs for TB programme

Program cost 2016 2017 2018 2019 2020 2021 2022 Monitoring and Evaluation 17.78 19.01 20.25 21.52 22.80 24.11 25.43 Communication, Media and Outreach 22.08 23.60 25.15 26.73 28.32 29.94 31.59 Advocacy 0.31 0.84 1.05 1.18 1.22 1.30 1.38 General Program Management (Water, electricity, petrol and Oil, printing, Binding, Stationeries, seals & stamps, cleaning and washing)

112.28

140.17

160.23

174.23

187.44

197.64

164.88

Other (collaborative TB/HIV activities, TB research, community involvement, overtime, postage, uniform, casual labor, freight cost and transport, social support for TB patients and incentive for provider)

160.12

272.58

331.33

557.29

636.94

730.39

813.36

In million BDT 312.57 456.20 538.02 780.96 876.73 983.37 1,036.64

Figure 3 shows that the majority of the costs consumed are capital cost of the facility per year except for the year 2016. Most of the capital investments were made in 2017 and are expected to be in 2021 and 2022 according to the resources committed in the OP.

Figure-3: percentage distribution of capital costs and operating costs for facilities from 2016-22

Figure 4 shows the percentage distribution of cost components related to the human resource. Around 80% of the human resources costs represent salaries followed by benefits (15%) and in-service trainings (5%) from base year to projected years.

52

2022 2021 2020

Training

2017 2018 2019

Salaries Benefits

2016

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Microscopy 4.1%

Xpert centres Hospitals

7.3% 4.4%

Community 24.4%

DOTs 59.8%

Figure-4: Percentage distribution of human resources components from 2016-22

3.11 Cost by service delivery channel

Table-3.15 and Figure-5 show the proportion of drugs, supplies and investigation cost stands highest (59.8%) at the DOTS Centre delivery channel followed by community (24.4%). This is linked to higher number of cases treated at DOTS Centre and preventive therapy and DOTS at domiciliary level compared to other delivery channels. On the other hand; hospitals consume relatively less cost (7.3%) for drugs and investigations as only drug resistant (MDR, XDR and MDR with additional resistance) patients are treated there for a shorter period of time compared to the whole duration of treatment. Also, social supports to the patients and providers incentives are not applicable during the period of hospitalization.

Figure-5: Costs of drugs, supplies and investigations by delivery channels

53

Table-3.15: According to OHT estimate, the total cost of drugs, supplies and investigations in the base year 2016 should be BDT 795.7 million - which is BDT 112 million more than the actual expenditure (BDT 683.8 million; Expenditure Report, 2015-16, Bangladesh NTP) incurred upon NTP for drugs, supplies and investigations in the fiscal year 2015-16.

Table-3.15. Cost of drugs, supplies and investigations of TB interventions by delivery channels (excluding wastage and ancillary drugs) in BDT: 2016-22

Delivery channels 2016 2017 2018 2019 2020 2021 2022 Total

Community 95.6 110.1 127.4 814.8 1,015.9 1,241.1 1,495.2 4,900.1

DOTS Centre 553.6 642.0 744.1 1,668.6 2,058.3 2,950.8 3,388.7 12,006.3

Microscopy Centre 96.7 103.3 110.0 117.5 124.5 131.7 137.7 821.4

Hospitals 36.7 53.1 77.0 189.4 252.1 379.1 472.5 1,460.0

X-pert centers 13.0 34.5 80.5 105.3 150.4 201.3 296.7 881.7

Total 795.7 943.0 1,139.1 2,895.6 3,601.3 4,904.0 5,790.8 20,069.5

3.12 Funding gap:

To estimate funding gap we considered calendar year 2018-2022 for both NSP and OP budgets and compared with the OHT estimates for similar period.

In 2018, the estimated total funding gap was around 40 million USD which would increase to around USD 112.89 million in 2022 when compared with OP budget in calendar years (Table- 3.16). Thus, the total funding gap between OHT estimate and OP budget would stand at around USD 392 million for 2018-2022.

Table-3.16: Funding gap between OHT estimate and OP budget 2018-22 (calendar year)

Calendar years

OHT cost estimate 2018-2022 OP budget 2018-22* Funding gap Million BDT Million USD Million BDT Million USD Million BDT Million USD

2018 5,308.9 63.6 1,977.48 23.68 3,331.43 39.90 2019 7,598.6 90.5 1,927.60 22.95 5,670.98 67.51 2020 8,704.8 102.1 2,501.57 29.34 6,203.25 72.76 2021 11,574.9 133.8 2,977.79 34.41 8,597.15 99.34 2022 12,906.1 146.9 2,989.79 34.04 9,916.32 112.89 Total 46,093.4 536.8 12,374.2 144.4 33,719.1 392.4

* Extrapolated the OP budget for July-Dec 2022 using the given budget for Jan-June 2022

54

OHT estimated cost of service provision for TB Allocated resource for TB in NSP

2022 2021 2020 2019 2018

80 60 40 20 0

Estimated gap for 18-22 BDT 20,286.1 million (USD 235.18 million)

100

Estimated gap for 2018 BDT 737.3 million (USD 8.85 million)

160 140 120

Table-13.17 compares OHT estimates with more recent NSP budget (2018-22)- which shows reduced gap in funding during 2018-22 due to more allocation in NSP budget (OP USD 144 million vs. NSP USD 302 million). The funding gap between OHT estimate and NSP budget in 2018 was USD 8.85 million which would increase to USD 81 million in 2022 with a total funding gap of USD 235 million over the whole period (Table-3.17). The annual funding gap is notable since 2019 and onwards due to inclusion of new treatment regimen, diagnostics and preventive therapy.

Table-3.17: Funding gap between OHT estimate and NSP budget 2018-22 (calendar year)

Years

OHT cost estimate 2018-22 NSP budget 2018-22 Funding gap 2018-22

Million BDT Million USD Million BDT Million USD Million BDT Million USD

2018 5,308.9 63.6 4,571.6 54.75 737.30 8.85 2019 7,598.6 90.5 4,787.2 56.99 2,811.40 33.51 2020 8,704.8 102.1 5,188.1 60.85 3,516.70 41.25 2021 11,574.9 133.8 5,471.9 63.23 6,103.00 70.57 2022 12,906.1 146.9 5,788.5 65.9 7,117.60 81.00 Total 46,093.4 536.8 25,807.2 301.72 20,286.10 235.18

Figure-6: Funding gap between OHT cost estimate and allocated budget in NSP 2018-22

55

3.13 Cost of icddr, b TB Screening & Treatment Centre

Table-3.18 shows the total estimated cost of icddr, b TB Screening and Treatment Centre (TBSTC) in 2018 was BDT 59, 34.720 for 10 centers across the country. The capital costs comprised of medical equipment (e. g, Gene Xpert, digital X-ray etc.) and logistics (AC, refrigerator, furniture etc.) were estimated considering 3% depreciation rate, useful life time and adjusted for inflation. The major cost drivers for these facilities are human resources followed by medical equipment (Annexure- i).

Table-3.18: Cost of icddr, b TB Screening and Treatment Centre (TBSTC) in 2018

Cost Components

Total cost per center (BDT) in 2018

Total # of Center

Grant total (BDT)

% share of total cost

Human resources 25,36,654

10

25,366,541 42.7% Utilities 3,60,000 3,600,000 6.1% House rent 10,26,000 10,260,000 17.3% Medical equipment 19,39,093 19,390,930 32.7% Logistics 72,973 729,729 1.2% Grant total 59,34,720 5,93,47,200 100%

Table- 3.18a depicts the service coverage achieved by icddr, b TBSTC during 2016-18 which shows increase in number of tests conducted and TB patient identified for DOTS enrollment by these 10 Centres.

Table-3.18a: Diagnostic and treatment services by icddr, b TBSTC during 2016-2018

Details 2016 2017 2018 Total % Presumptive tested 19,640 30,255 58,054 107,949 98% DOTS enrolled TB patient - 950 1,159 2,109 2% Total 19,640 31,205 59,213 110,058 100%

3.13 CONCLUSIONS

• Under the new treatment regimen of 2019; the cost per patient for shorter treatment regimen of MDR and Pre-XDR/MDR with additional resistance patients are substantially less than previous treatment regimens of 2016 (Table-3.3a – 3.8a).

• The total cost for base year 2016 was estimated to BDT 3,853.89 million which would increase to BDT 12,906.11 million in 2022 given the availability of resources committed, attainment of service coverage and efficient use of fixed assets (Table-3.13).

• OHT cost estimates revealed a funding gap of USD 235 million when compared with NSP budget of 2018-22 (Table-3.17 and Figure-6)

• The highest proportion of the total cost (41%) was from human resources followed by medicine, supplies and investigations including wastage (38%) and program cost (9%) while the infrastructure accounted for 12% of the total cost. The program cost included freight, transport/vehicle, social support cost, providers incentive, advocacy campaign, monitoring supervision, utility, stationeries, repair & maintenance (Figure-1)

56

• Around 80% of the human resource costs represent salaries followed by benefits (15%) and in- service trainings (5%) from base year to projected years (Figure-4)

• Medicines and supplies cost show a sharp increase from 2018 through 2022- which is attributable to purchase of new drugs for implementing new treatment regimen and preventive therapy effective from 2019 onwards. As per procurement and expansion plan detailed in OP, OHT estimated that the cost of infrastructure (e.g. medical equipment, renovation, construction of new facilities) would increase from 2020 to 2022. However; the HR shows a linear increase of cost over the target years (Figure-2).

• The majority of the costs consumed at the facility level appeared as capital cost of the facility per year except for the base year 2016. Most of the capital investments were made in 2017 followed by 2021 and 2022 according to the resources committed in the OP (Figure-3).

• According to OHT estimate, the total cost of drugs, supplies and investigations in base year 2016 was BDT 796 million - which is BDT 112 million more than the actual expenditure (BDT 684 million; Expenditure Report, 2015-16, Bangladesh NTP) incurred upon NTP for drugs, supplies and investigations in the fiscal year 2015-16 (Table-3.15).

• Among the five selected delivery channels; DOTs Centre accounted for the highest proportion of the total cost for drugs, supplies and investigations (60%) followed by community (24%). This is linked to higher number of cases treated at DOTs and preventive therapy at the community compared to other delivery channels (Figure-5)

3.14 RECOMMENDATIONS • The OHT estimates related to unit costs of TB treatment inputs (drugs, supplies and investigations)

and total cost per patient estimated for 2019 and onwards should be considered for costing of the next National Strategic Plan for TB control.

• The funding gap as revealed between OHT estimate and NSP budget 2018-22 (USD 235 million)

indicates the amount of additional investment required for delivering TB services effectively. Therefore; policy planners should consider these estimates to advocate for increased funding for Bangladesh NTP to match with the costs.

• Given the relatively low cost of shorter treatment regimen of MDR and MDR with additional

resistance than previous treatment regimens of 2016, shorter treatment regimen for MDR/MDR with additional resistance should be scaled up.

• Based on the current estimates; further studies should look at the cost of providing TB services with future changes in diagnostic and treatment algorithm.

57

4. REFERENCE 1. National TB Control Programmme (NTP); Bangladesh; National Guidelines & Operational

Manual for Tuberculosis Control, 5th Edition, 2013.

2. National TB Control Programmme, Bangladesh (NTP); National Guidelines for the

Management of Tuberculosis in Children, 2nd Edition, 2016.

3. National TB Control Programmme, Bangladesh; (NTP); National Guidelines and Operational

Manual for Programmatic Management of Drug Resistant TB (PMDT), 2nd edition, April 2013.

4. National TB Control Programmme, Bangladesh; (NTP), Standard Operating Procedure: Quality

Assurance of AFB Microscopy (Z-N and FM method) 2nd Edition, October 2013.

5. National TB Control Programmme, Bangladesh; (NTP), Expansion Plan of Programmatic

Mangement of Drug Resistant TB (PMDT), 2nd Edition, November 2013

6. National TB Control Programmme (NTP); Bangladesh; Tuberculosis Control in Bangladesh: Annual Report, October 2017

7. Directorate General of Health Services (DGHS); Ministry of Health and Family Welfare, Health Bulletin 2016, 2017, 2018

8. Ministry of Health and Family Welfare (MOHFW); Operational Plan for TB-Leprosy-ASP 2016-2022

9. National TB Control Programme (NTP); Bangladesh; National Strategic Plan for TB Control,

2018-2022

58

5. Annexure:

Annex- A: Technical Working Group for TB costing study

Organization Name National TB Control Program (NTP)

Prof. (Dr.) Md. Shamiul Islam Line Director TB-L & ASP Dr. Salim Hamid, Dr. Asaduzzaman

Health Economics Unit, MOHFW Dr. Bashar, Dr. Anwar Sadat

BRAC’s TB program Dr. Mahfuza Rifat , Dr. Sardar Munim, Dr. Saifur Reza, Dr. Farhan Kabir

Damien Foundation, Bangladesh Dr. Aung, Dr. Deepak UPHC Service Delivery Program Dr. Emdadul Hoque USAID Dr. Pushpita Samina, Dr. Charles Lerman. Challenge TB Dr. Sayedur Rahman, Oscar Cordon, icddr,b’s TB theme lead Dr. Sayera Banu, Dr. Shahriar Ahmed Institute of Health Economics, Dhaka University

Prof. Syed A Hamid, Nafiz Iftekher, Md. Azharuddin

HEED Bangladesh Shimon Maradi Health Finance & Governance (HFG) Project Dr. Shamima Akhter, Dr. Mursaleena Islam

IRD Dr. Hamidah Hussain, Dr. A J M Faisal

Study consultants: Nadia Carvalho Carel Pretorious, Matt Hamilton (Avenir Health) and Dr. Md. Mojibur Rahman

59

6. Annexure- B: Price list of drugs and supplies used in the treatment inputs

Annexure- B.1: Drugs and supplies used for investigations

Drugs/reagents/supplies Unit Unit price (BDT)

Price source

FM-LED 700-smears Per smear 9 NTP

Z-N-700-smears Per smear 12 NTP

Sputum cup 1 piece 5 NTP

N-95 mask 1 piece 65 NTP

Reagent kit (Cartidge + Reagent + dropper)

1 kit 861.30 NTP

75% ethanol/Hexisol, 1 liter 400 ESP , DGHS

Immersion oil 100 ml 723 Stop TB website/GDF

Lens tissue (paper) 1 piece 7.04 Stop TB website/GDF

Tissue paper 1 box 52 Market price

5% phenol 1 L 1491.50 Market price

Falcon tube 1 piece 40 NTP

Gloves 1 pair 20 NTP

Biohazard bag 1 roll, 25 bags, 36" X 48" 44 Gallon

13 Stop TB website/GDF

Marker pen 1 piece 50 Market price

Absorbent paper 100 pieces 70 Market price

Audiometry Per test 700 NTP/MOHFW

ECG Per test 300 NTP/MOHFW

Chest X-ray Per CXR 350 NTP/MOHFW

Complete Blood Count Per test 300 NTP/MOHFW

Serum Creatinine Per test 300 NTP/MOHFW

Serum Electrolyte Per test 850 NTP/MOHFW

Serum Bilirubin Per test 250 NTP/MOHFW

SGPT Per test 300 NTP/MOHFW

Alkaline Phosphatase Per test 300 NTP/MOHFW

Blood Glucose Per test 250 NTP/MOHFW

60


Price source

Thyroid Function Test (TSH) Per test 800 NTP/MOHFW

HIV Test Per test 50 ESP, DGHS

Pregnancy test (for the women of childbearing age)

Per test 300 NTP/MOHFW

FNAC (Fine Needle Aspiration Cytology) Per test 150 NTP/MOHFW

MT Per test 100 NTP/MOHFW

Cetyl pyridine chloride (CPC) NaCl solution

5 ml 7.16 Stop TB website/GDF

4% NaOH solution 2 ml 1.20 Stop TB website/GDF

Phosphate buffer solution 41.3ml 23.42 Stop TB website/GDF

Culture media 7 ml 6.60 Stop TB website/GDF

Disposable pasteur pipettes, graduated, non-sterile,

155 mm, 3 ml

1 Piece 1.83 Stop TB website/GDF

Microscope slide, lime-soda-glass

1 Piece 0.80 Stop TB website/GDF

INH powder 0.2 microgram per ml of culture media

6.61 Stop TB website/GDF

Rifampicin powder 40.0 microgram per ml of culture media


Dihydro Streptomycin(DS) powder

4.0 microgram per ml of culture media


Ethambutol (E) powder 2.0 microgram per ml of culture media


P- nitro benzoic acid (PNB) powder

500 micro gram per ml of culture media


Sterile 0.01% Tween 80® 0.1 ml 0.05 Stop TB website/GDF

MGIT 960 growth supplement kit (OADC+PANTA)

per test 109.62 Stop TB website/GDF

BACTEC™ MGIT™ 960 SIRE kit, One kit is sufficient for 40 test


BBL MGIT Tubes for use in Bactec MGIT 960 (7ml)


BACTEC™ MGIT™ PZA Tubes


BBL middle brook 7H9 Broth with glycerol 5ml


BBl MGIT Tube for Manual method (4ml)


MGIT 960 PZA kit per test 169 Stop TB website/GDF

Disposable loops 10 µl per piece 2.55 Stop TB website/GDF

61


Price source

Distilled water per test 52.8 Stop TB website/GDF

Kanamycin lyophilized drug, 830 µg/ vial


Moxifloxacin lyophilized drug, 498 µg /vial


Amikacin lyophilized drug, 332 µg/ vial


Capreomycin lyophilized drug, 830 µg/ vial


Ofloxacin lyophilized drug, 664 µg / vial


62

Annexure- B.2: Unit price of drugs used for treatment inputs from 2016-2018

Drugs/reagents/supplies Unit Unit Price (BDT)

Price Source

RHZE 150/75/400/275 Per tablet 4.7 Stop TB website/GDF RH 150/75 Per tablet 2.4 Stop TB website/GDF RHZ (75/50/150) Per tablet 3.1 Stop TB website/GDF E100 Per tablet 7.0 Stop TB website/GDF RH(75/50) Per tablet 2.3 Stop TB website/GDF WFI(5) / Water for injection, 5 ml ampoule 7.0 Stop TB website/GDF S/ Inj Streptomycin 1gm vial 50.1 Stop TB website/GDF Single use syringes, sterile/ S&N-5/23Gx1 and Safety Box Syringe & needle (auto-disabling), 23G Syringe & needle

Per piece

3.9

Stop TB website/GDF

3FDC / RHE(75/150/275) Per tablet 3.9 Stop TB website/GDF Isoniazide (H) 100mg dispersible Tab Per tablet 7.05 Stop TB website/GDF Km(1000)/ Inj Kanamycin 1 gm vial 185 Stop TB website/GDF Z(500)/ Pyrazinamide 500mg Per tablet 2.34 Stop TB website/GDF Lfx(250)/ Levofloxacin 250mg Per tablet 2.34 Stop TB website/GDF Eto(250)/ Ethionamide 250mg Per tablet 5.48 Stop TB website/GDF Cs(250)/ Cycloserine 250mg Per capsule(s) 22.7 Stop TB website/GDF Pyridoxin 20mg Per tablet 0.28 Market Price Cfz(100)/ Clofazimine 100 mg Per capsule 85.34 Stop TB website/GDF E(400)/ Ethambutol 400mg Per tablet 2.35 Stop TB website/GDF H(300)/ Isoniazid 300mg Per tablet 1.48 Stop TB website/GDF Mfx(400) / Moxifloxacin 400mg Per tablet 30.22 Stop TB website/GDF Pto(250) / Protionamide 250mg Per tablet 7.04 Stop TB website/GDF Cm (1000 mg)/ Capreomycin powder for injection 1g

Per vial 368.00 Stop TB website/GDF

PAS(H)-4-(S)-30 PAS acid,Granuels,Sachets

Per tablet 104.39 Stop TB website/GDF

Amx/Clv(500/125), amoxicillin/clavulanic acid film coated tablets, blisters


Lnz600/ Linezolid 600mg,film coated tablets,sachets


GDF= Global Drug Facility, retrieved during April – May 2018 Exchange rate of 2016: 1 USD=78.3 BDT

63

Annexure- B.3: Unit price of drugs used for treatment inputs from 2019

Drugs/reagents/supplies Unit Unit Price (BDT)

Price Source

RHZE 150/75/400/275 Per tablet 6.59 Stop TB website/GDF

RHZ (75/50/150) Per tablet 3.59 Stop TB website/GDF

E100 Per tablet 7.18 Stop TB website/GDF

Lfx (250)/ Levofloxacin 250mg Film coated tablet(s)


H(300)/ Isoniazid 300mg Film uncoated tablet(s)


Rifapentin (P) 150mg Tab Per tablet 52.5 Stop TB website/GDF

Isoniazide (H) 100mg dispersible Tab Per tablet 8.4 Stop TB website/GDF

Amikacin 500 mg Per vial 58.38 Stop TB website/GDF

Z(500)/ Pyrazinamide 500mg Per tablet 2.74 Stop TB website/GDF

Bedaquiline 100 mg Per tablet 178.72 Stop TB website/GDF

Cs(250)/ Cycloserine 250mg Per capsule(s) 22.09 Stop TB website/GDF

Single use syringes, sterile/ S&N-5/23Gx1 and Safety Box

Syringe & needle (auto-disabling), 23G Syringe & needle

per piece

4.2

Stop TB website/GDF

Pyridoxin 20mg Per tablet 3.88 Market Price

Cfz(100)/ Clofazimine 100 mg Per capsule 82.52 Stop TB website/GDF

E(400)/ Ethambutol 400mg Per tablet 3.12 Stop TB website/GDF

H(300)/ Isoniazid 300mg Per tablet 1.68 Stop TB website/GDF Mfx(400) / Moxifloxacin 400mg Per tablet 22.36 Stop TB website/GDF

Pto(250) / Protionamide 250mg Per tablet 10.08 Stop TB website/GDF

Lnz600/ Linezolid 600mg,film coated tablets, sachets


Delamanid (DLM )50mg Per tablet 212.5 Stop TB website/GDF

GDF= Global Drug Facility, retrieved during May 2019 Exchange rate of 2019: 1 USD=84 BDT

64

Annexure- C: Treatment inputs and unit cost for TB intervention of the base year (2016)

Drug/Supply Percent receiving this aspect of the

treatment

Note Number of units

Times per day

Days per case

Units per case

Unit cost (BDT) (2016)

Cost per average case (BDT) (2016)

Diagnosis Microscopy Per smear Microscopy- Light Emitting Diode (LED) fluorescence microscopy (FM)

82 1.0 1.0 1.0 1.0 9.00 7.38

Per smear Microscopy-Ziehl-Neelsen (ZN) Method

18 1.0 1.0 1.0 1.0 12.00 2.16

Gloves, 1 pair 100 0.1 1.0 1.0 0.1 20.00 2.00 75% ethanol/Hexisol, 1 L 100 0.0 1.0 1.0 0.0 400.00 4.00 Immersion oil, 100 ml 100 For 100X

objective 0.0 1.0 1.0 0.0 723.49 7.23

Tissue paper 100 to absorb immersion oil on

stained slides before storing.

0.0 1.0 1.0 0.0 52.00 0.52

Lens tissue (paper), 1 piece 100 to clean microscope lenses

0.0 1.0 1.0 0.0 7.04 0.14

Total cost 23.44 Follow-up Microscopy Per smear Microscopy- Light Emitting Diode (LED) fluorescence microscopy (FM)

82 1 1 1 1 9.00 7.38

Per smear Microscopy-Ziehl-Neelsen (ZN) Method

18 1 1 1 1 12.00 2.16

Gloves, 1 pair 100 0.1 1 1 0.1 20.00 2.00 75% ethanol/Hexisol, 1 L 100 0.01 1 1 0.01 400.00 4.00

65

Drug/Supply Percent receiving this

aspect of the treatment


Times per day

Days per case

Units per case



Immersion oil, 100 ml 100 0.01 1 1 0.01 723.49 7.23 Tissue paper 100 0.01 1 1 0.01 52.00 0.52 Lens tissue (paper), 1 piece 100 0.02 1 1 0.02 7.04 0.14 Total cost 23.44 Culture Solid Culture Sputum Cup 100 2.0 1.0 1.0 2.0 5.00 10.00 Falcon tube 80 1.0 1.0 1.0 1.0 40.00 32.00 5ml Cetyl pyridine chloride (CPC) NaCl Solution

80 for sample transfer

1.0 1.0 1.0 1.0 7.16 5.73

2ml 0f 4% NaOH solution 80 For sample decontamination

1.0 1.0 1.0 1.0 1.20 0.96

41.3 ml of Phosphate buffer solution 80 1.0 1.0 1.0 1.0 23.42 18.74 7 ml Culture media 80 1.0 1.0 1.0 1.0 6.60 5.28 Gloves, 1 pair 100 1.0 1.0 1.0 1.0 20.00 20.00 N-95 mask 100 1mask can be used

for 8 hours, assuming a lab

tech can perform 3 tests per day

0.3 1.0 1.0 0.3 65.00 21.67

Marker pen 100 1 pen 30 days and 3 patients each day

0.0 1.0 1.0 0.0 50.00 0.56

Absorbent Paper, 100 pieces 100 15 pieces/day=10.5tk

. assuming 3 tests/day.

0.1 1.0 1.0 0.1 70.00 3.50

Disposable pasteur pipettes, graduated, non-sterile, 155 mm, 3 ml

100 1.0 1.0 1.0 1.0 1.83 1.83

66




Times per day

Days per case

Units per case



Microscope slide, lime-soda-glass 100 1.0 1.0 1.0 1.0 0.80 0.80 75% ethanol/Hexisol, 1 L 100 Disinfactant,

1L/week,Covers 100 patients

0.0 1.0 1.0 0.0 400.00 0.57

Total cost 121.64

Liquid culture MGIT 960 growth supplement kit (OADC+PANTA)

20 1.0 1.0 1.0 1.0 109.62 21.92

BBL MGIT Tubes for use in Bactec MGIT 960 (7ml) - 100 tubes/pkg

20 1.0 1.0 1.0 1.0 152.68 30.54

BACTEC™ MGIT™ PZA Tubes - 25 20 1.0 1.0 1.0 1.0 187.92 37.58 BBL middle brook 7H9 Broth with glycerol 5ml

20 1.0 1.0 1.0 1.0 199.60 39.92

BBl MGIT Tube for Manual method (4ml)

20 1.0 1.0 1.0 1.0 152.68 30.54

MGIT 960 PZA kit 20 1.0 1.0 1.0 1.0 169.00 33.80 Disposable loops 10 µl 20 1.0 1.0 1.0 1.0 2.55 0.51 Distilled water 1 L 20 0.1 1.0 1.0 0.1 528.00 10.56 Total cost 327.00 Culture and DST For Liquid DST BACTEC™ MGIT™ 960 SIRE kit, One kit is sufficient for 40 test

20 1.0 1.0 1.0 1.0 142.30 28.46

BACTEC™ MGIT™ PZA Tubes - 25 20 1.0 1.0 1.0 1.0 187.92 37.58 BBL MGIT Tubes for use in Bactec MGIT 960 (7ml) - 100 tubes/pkg

20 5.0 1.0 1.0 5.0 152.68 152.68

Kanamycin lyophilized drug, 830 µg/ vial 20 1.0 1.0 1.0 1.0 29.36 5.87

67




Times per day

Days per case

Units per case



Moxifloxacin lyophilized drug, 498 µg /vial 20 1.0 1.0 1.0 1.0 29.36 5.87 Amikacin lyophilized drug, 332 µg/ vial 20 1.0 1.0 1.0 1.0 29.36 5.87 Capreomycin lyophilized drug, 830 µg/ vial 20 1.0 1.0 1.0 1.0 29.36 5.87 Ofloxacin lyophilized drug, 664 µg / vial 20 1.0 1.0 1.0 1.0 29.36 5.87 Distilled water 1 L 20 1.0 1.0 1.0 1.0 528.00 105.60 Disposable loops 10 µl 20 1.0 1.0 1.0 1.0 2.55 0.51 MGIT 960 PZA kit 20 1.0 1.0 1.0 1.0 169.00 33.80 BBl MGIT Tube for Manual method (4ml)

20 1.0 1.0 1.0 1.0 152.68 30.54

BBL middle brook 7H9 Broth with glycerol 5ml

20 1.0 1.0 1.0 1.0 199.60 39.92

MGIT 960 growth supplement kit (OADC+PANTA)

20 1.0 1.0 1.0 1.0 109.62 21.92

Solid DST Sputum Cup 100 2.0 1.0 1.0 2.0 5.00 10.00 Falcon tube 80 1.0 1.0 1.0 1.0 40.00 32.00 5ml Cetyl pyridine chloride (CPC) NaCl solution

80 for sample transfer

1.0 1.0 1.0 1.0 7.16 5.73

2ml 0f 4% NaOH solution 80 for sample decontamination

1.0 1.0 1.0 1.0 1.20 0.96

41.3 ml of Phosphate buffer solution 80 1.0 1.0 1.0 1.0 23.42 18.74 7 ml Culture media 80 1.0 1.0 1.0 1.0 6.60 5.28 Gloves, 1 pair 100 1.0 1.0 1.0 1.0 20.00 20.00 N-95 mask 100 1mask can be used

for 8 hours, assuming a lab

tech can perform 3 tests per day

0.3 1.0 1.0 0.3 65.00 21.67

68




Times per day

Days per case

Units per case



Marker pen 100 1 pen 30 days and 3 patients each day

0.0 1.0 1.0 0.0 50.00 0.56

Absorbent Paper, 100 pieces 100 15 pieces/day=10.5tk

. assuming 3 tests/day.

0.1 1.0 1.0 0.1 70.00 3.50

Disposable pasteur pipettes, graduated, non-sterile, 155 mm, 3 ml

100 1.0 1.0 1.0 1.0 1.83 1.83

Microscope slide, lime-soda-glass 100 1.0 1.0 1.0 1.0 0.80 0.80 75% Ethanol/Hexisol, 1 L 100 Disinfactant

1L/week, Covers 100 patients

0.0 1.0 1.0 0.0 400.00 0.57

INH powder 80 final conc. In culture media for test strain is 0.2

micro gram per ml

1.0 1.0 1.0 1.0 6.61 5.29

Rifampicin powder 80 final conc. In culture media for test strain is 40.0

micro gram per ml

1.0 1.0 1.0 1.0 8.70 6.96

Dihydro Streptomycin (DS) powder 80 final conc. In culture media for test strains is 4.0

micro gram per ml

1.0 1.0 1.0 1.0 6.60 5.28

Ethumbutol (E) powder 80 final conc. In culture media for test strains is 2.0

micro gram per ml

1.0 1.0 1.0 1.0 6.60 5.28

69




Times per day

Days per case

Units per case



P- nitro benzoic acid (PNB) powder 80 final conc. in culture media for test strain is 500

micro gram per ml

1.0 1.0 1.0 1.0 6.80 5.44

0.1 ml Sterile 0.01% Tween 80® 80 1.0 1.0 1.0 1.0 0.05 0.04 Total cost 630.29 Xpert Moleculer Xpert Reagent kit (Cartidge + Reagent + dropper)

100 1.0 1.0 1.0 1.0 861.30 861.30

75% Ethanol/Hexisol, 1 L 100 Disinfactant, 1L/week, Covers

100 patients

0.0 1.0 1.0 0.0 400.00 0.57

5% Phenol, 1 L 100 1L/Week, covers 50 Patients

0.0 1.0 1.0 0.0 1,491.50 4.27

Falcon tube 100 1.0 1.0 1.0 1.0 40.00 40.00 Gloves, 1 pair 100 3 pair gloves used

per day for 10 patients

0.3 1.0 1.0 0.3 20.00 6.00

N-95 mask 100 1 mask used per day for 10 patients

sample

0.1 1.0 1.0 0.1 65.00 6.50

Biohazard bag, 1 piece 100 2 bags/day for 10 sample

0.2 1.0 1.0 0.2 13.78 2.76

Marker pen 100 1 pen 15 days and 10 patients each

day

0.0 1.0 1.0 0.0 50.00 0.33

70




Times per day

Days per case

Units per case



Absorbent Paper, 100 pieces 100 10 patients sample run per day;

therefore per day paper needed 15

pieces and per unit paper needed for

one test is 15/10, I box contain 100

paper

0.0 1.0 1.0 0.0 70.00 1.05

Sputum Cup 100 1.0 1.0 1.0 1.0 5.00 5.00 Total cost 927.78 X-Rays Test, Chest X-ray 100 1.0 1.0 1.0 1.0 350.00 350.00 Total cost 350.00 First line: Initial treatment for adult (Cat I) DOTS at domiciliary Level

New smear positive bacteriologically Positive PTB ,New smear Negative, New Extra pulmonary TB, New concomitant/associated HIV/AIDS

DOTS Intensive phase (Daily):38-54 kg RHZE 150/75/400/275 100 3.0 1.0 60.0 180.0 4.70 845.64 DOTS Continuation phase (Daily):38-54 kg

RH 150/75 100 3.0 1.0 120.0 360.0 2.40 863.96 DOTS Continuation phase (Daily):55-70 kg

Total cost 1,709.60

71




Times per day

Days per case

Units per case



First line TB treatment: Initial+ previously treated treatment for children(DOTS at domiciliary level)

12-15kg,Smear Negative pulmonary Tb (without extensive involvement);Tb lymph node (intrathoracic/ extrathoracic)

3FDC / RHZ(75/50/150) 80 Intensive phase (Daily)_12-15kg

3.0 1.0 60.0 180.0 3.13 450.67

RH(75/50) 80 Continuation phase (Daily)_12-

15kg

3.0 1.0 120.0 360.0 2.35 676.51

12-15kg, Smear Positive pulmonary Tb, Smear negative pulmonary Tb with extensive involvement, Severe EP TB (except TBM and Osteoarticular TB), Previously treated cases, All forms of TB in HIV+ cases (Except TBM and osteoarticular TB)

RHZ (75/50/150) 20 Intensive phase (Daily)_12-15kg

3.0 1.0 60.0 180.0 3.13 112.75

E100 20 Intensive phase (Daily)_12-15kg

3.0 1.0 60.0 180.0 7.05 253.80

RH(75/50) 20 Continuation phase (Daily)_12-

15kg

3.0 1.0 120.0 360.0 2.35 169.13

Total cost 1,662.87 First line TB treatment: previously treated for adult (CAT II), DOTS at domiciliary level

72




Times per day

Days per case

Units per case



Sputum smear-positive PTB with history of treatment of one month or more, relapse, Treatment failure after cat 1 treatment, After loss to follow up, Others

RHZE 150/75/400/275 100 38-54 kg, Intensive phase (Daily)

3 1 90 270 4.70 1,268.46

WFI(5) / Water for injection, 5 ml ampoule

100 Intensive phase (Daily)

1 1 60 60 7.04 422.40

S/ Inj. Streptomycin 1gm Vial 100 38-54 kg- 750 mg, , Intensive phase

(Daily)

1 1 60 60 50.11 3,006.58

Single use syringes, sterile/ S&N-5/23Gx1 and Safety Box Syringe & needle (auto- disabling), 23G Syringe & needle

100 Intensive phase (Daily)

1 1 60 60 3.92 234.90

RHE (150/75/275) 100 38-54kg, continuation phase

daily

3 1 150 450 3.86 1,737.09

Total cost 6,669.42 IPT children under five years of age, Community level

Isoniazide (H) 100mg dispersible Tab 100 10-15kg average weight for less

than five years old children

1.5 1.0 180.0 270.0 7.05 1,903.54

Total cost 1,903.54 Longer regimen for MDR-TB, DOTS at domicilliary Level

Km(1000)/ Inj. Kanamycin 1 gm powder for injection

100 38-54kg, 8 months 1.0 1.0 180.0 180.0 185.00 33,300.03

73




Times per day

Days per case

Units per case



Z(500)/ Pyrazinamide 500mg Film uncoated tablet(s)

100 38-54kg, 20 months

4.0 1.0 540.0 2,160.0 2.34 5,055.24

Lfx(250)/ Levofloxacin 250mg Film coated tablet(s)

100 38-54kg, 20 months

3.0 1.0 540.0 1,620.0 2.34 3,791.43

Eto(250)/ Ethionamide 250mg Film coated tablet(s)

100 38-54kg, 20 months

3.0 1.0 540.0 1,620.0 5.48 8,877.96

Cs(250)/ Cycloserine 250mg Capsule(s) 100 38-54kg, 20 months

3.0 1.0 540.0 1,620.0 22.71 36,785.34


100 38-54kg, 8 months 1.0 1.0 180.0 180.0 3.92 704.70


100 38-54kg, 8 months 1.0 1.0 180.0 180.0 7.04 1,267.19

Pyridoxin 20mg 100 7.5 1.0 540.0 4,050.0 0.28 1,135.26 Total cost 90,917.15 Longer regimen for MDR-TB, DOTS at Hospital level

Km(1000)/ Inj. Kanamycin 1 gm powder for injection

100 38-54kg, 8 months 1.0 1.0 60.0 60.0 185.00 11,100.01


100 38-54kg, 20 months

4.0 1.0 60.0 240.0 2.34 561.69


100 38-54kg, 20 months

3.0 1.0 60.0 180.0 2.34 421.27

Eto(250)/ Ethionamide 250mg Film coated tablet(s)

100 38-54kg, 20 months

3.0 1.0 60.0 180.0 5.48 986.44

Cs(250)/ Cycloserine 250mg Capsule(s) 100 38-54kg, 20 months

3.0 1.0 60.0 180.0 22.71 4,087.26

74




Times per day

Days per case

Units per case




100 38-54kg, 8 months 1.0 1.0 60.0 60.0 3.92 234.90


100 38-54kg, 8 months 1.0 1.0 60.0 60.0 7.04 422.40

Pyridoxin 20mg 100 7.5 1.0 60.0 450.0 0.28 126.14 Total cost 17,940.11 Shortened nine month treatment regimen for MDR-TB, DOTS at domiciliary level

Km(1000)/Inj. Kanamycin 1 gm powder for injection

100 38-54kg, 4 months 1.0 1.0 60.0 60.0 185.00 11,100.01

Cfz(100)/ Clofazimine 100 mg Capsule(s) 100 38-54kg, 9months 1.0 1.0 210.0 210.0 85.34 17,921.39 E(400)/ Ethambutol 400mg Film coated tablet(s)

100 38-54kg, 9 months 3.0 1.0 210.0 630.0 2.35 1,480.36


100 38-54kg, 4 months 2.0 1.0 60.0 120.0 1.48 177.58

Mfx(400) / Moxifloxacin 400mg Film coated tablet(s)

100 38-54kg, 9 months 2.0 1.0 210.0 420.0 30.22 12,692.35

Pto(250) / Protionamide 250mg Film coated tablet(s)

100 38-54kg, 4 months 3.0 1.0 60.0 180.0 7.04 1,267.19


100 38-54kg, 4 months 1.0 1.0 60.0 60.0 3.92 234.90


100 38-54kg, 4 months 1.0 1.0 60.0 60.0 7.04 422.40


100 38-54kg, 9 months 4.0 1.0 210.0 840.0 2.34 1,965.93

75




Times per day

Days per case

Units per case



Total cost 47,262.12 Shortened nine month treatment regimen for MDR-TB, DOTS at Hospital level

Km(1000)/ Kanamycin 1 gm powder for injection

100 38-54kg, 4 months 1.0 1.0 60.0 60.0 185.00 11,100.01

Cfz(100)/ Clofazimine 100 mg Capsule(s) 100 38-54kg, 9months 1.0 1.0 60.0 60.0 85.34 5,120.40 E(400)/ Ethambutol 400mg Film coated tablet(s)

100 38-54kg, 9 months 3.0 1.0 60.0 180.0 2.35 422.96


100 38-54kg, 4 months 2.0 1.0 60.0 120.0 1.48 177.58


100 38-54kg, 9 months 2.0 1.0 60.0 120.0 30.22 3,626.39


100 38-54kg, 4 months 3.0 1.0 60.0 180.0 7.04 1,267.19


100 38-54kg, 4 months 1.0 1.0 60.0 60.0 3.92 234.90


100 38-54kg, 4 months 1.0 1.0 60.0 60.0 7.04 422.40


100 38-54kg, 9 months 4.0 1.0 60.0 240.0 2.34 561.69

Total cost 22,933.52 XDR TB regimen DOTS at domiciliary level

Cm (1000 mg)/ Capreomycin powder for injection 1g

100 38-54kg, 12 months total

1.0 1.0 300.0 300.0 368.00 110,399.95

76




Times per day

Days per case

Units per case





1.0 1.0 300.0 300.0 3.92 1,174.50



1.0 1.0 300.0 300.0 7.04 2,111.99



4.0 1.0 660.0 2,640.0 2.34 6,178.63



2.0 1.0 660.0 1,320.0 30.22 39,890.25

Cs(250)/ Cycloserine 250mg Capsule(s) 100 38-54kg, 24 months total

3.0 1.0 660.0 1,980.0 22.71 44,959.86

PAS(H)-4-(S)-30 PAS acid, granuels, sachets


2.0 1.0 660.0 1,320.0 104.39 137,795.25



3.0 1.0 660.0 1,980.0 7.83 15,503.40

Cfz(100)/ Clofazimine 100 mg Capsule(s) 100 38-54kg, 24 months total

1.0 1.0 660.0 660.0 85.34 56,324.37

Lnz600/ Linezolid 600mg, film coated tablets, sachets


1.0 1.0 660.0 660.0 117.45 77,517.00

Pyridoxin 20mg 100 38-54kg, 24 months total

7.5 1.0 660.0 4,950.0 0.28 1,387.53

Total cost 493,242.73 XDR TB regimen DOTS at Hospital level

Cm (1000 mg)/ Capreomycin powder for injection 1g


1.0 1.0 60.0 60.0 368.00 22,079.99

77




Times per day

Days per case

Units per case





1.0 1.0 60.0 60.0 3.92 234.90



1.0 1.0 60.0 60.0 7.04 422.40



4.0 1.0 60.0 240.0 2.34 561.69



2.0 1.0 60.0 120.0 30.22 3,626.39

Cs(250)/ Cycloserine 250mg Capsule(s) 100 38-54kg, 24 months total

3.0 1.0 60.0 180.0 22.71 4,087.26

PAS(H)-4-(S)-30 PAS acid,Granuels,Sachets


2.0 1.0 60.0 120.0 104.39 12,526.84



3.0 1.0 60.0 180.0 7.83 1,409.40

Cfz(100)/ Clofazimine 100 mg Capsule(s) 100 38-54kg, 24 months total

1.0 1.0 60.0 60.0 85.34 5,120.40



1.0 1.0 60.0 60.0 117.45 7,047.00

Pyridoxin 20mg 100 38-54kg, 24 months total

7.5 1.0 60.0 450.0 0.28 126.14

Total cost 57,242.40 Baseline and Follow up Investigations for MDR and XDR TB Cases

HIV testing and counseling for TB patients, hospital level

Test, HIV VIA Elisa 100 1.0 1.0 1.0 1.0 49.90 49.90 Total cost 49.90

78




Times per day

Days per case

Units per case



Audiometry, hospital level Baseline Investigations of MDR-TB Patients

Test, Audiometry 100 1.0 1.0 1.0 1.0 700.00 700.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

Test, Audiometry 18 No. of Tests Required in

Intensive Phase

1.0 1.0 4.0 4.0 700.00 504.00

Longer Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 8 months Intensive and 12 months Continuation Phase)

Test, Audiometry 82 No. of Tests Required in

Intensive Phase

1.0 1.0 8.0 8.0 700.00 4,592.00

Total cost 5,796.00 ECG, hospital level Baseline Investigations of MDR-TB Patients

Test, ECG 100 1.0 1.0 1.0 1.0 300.00 300.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 5 months Intensive and 4 months Continuation Phase

Test, ECG 18 4 Tests Required in Intensive Phase

& 3 Tests

1.0 1.0 7.0 7.0 300.00 378.00

79




Times per day

Days per case

Units per case



Required in Continuation

Phase

Total cost 678.00 Complete Blood Count (CBC), hopital level


Test, Complete Blood Count (CBC) 100 1.0 1.0 1.0 1.0 300.00 300.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 5 months Intensive and 4 months Continuation Phase

Test, Complete Blood Count (CBC) 18 1 Test Required in Intensive Phase & 1 Test Required in continuation phase

1.0 1.0 2.0 2.0 300.00 108.00

Baseline Investigations of MDR TB Patients

Total cost 408.00 Baseline Investigations of MDR-TB Patients

Test, Serum Creatinine 100 1.0 1.0 1.0 1.0 300.00 300.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

80




Times per day

Days per case

Units per case



Test, Serum Creatinine 18 4 Test Required in Intensive Phase

1.0 1.0 4.0 4.0 300.00 216.00


Test, Serum Creatinine 82 8 Test Required in Intensive Phase

1.0 1.0 8.0 8.0 300.00 1,968.00

Total cost 2,484.00 Serum Electrolyte Baseline Investigations of MDR-TB Patients

Test, Serum Electrolyte 100 1.0 1.0 1.0 1.0 850.00 850.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

Test, Serum Electrolyte 18 4 Tests Required in Intensive Phase

1.0 1.0 4.0 4.0 850.00 612.00


Test, Serum Electrolyte 82 8 Test Required in Intensive Phase

1.0 1.0 8.0 8.0 850.00 5,576.00

Total cost 7,038.00 Serum Bilirubin Baseline Investigations of MDR-TB Patients

81




Times per day

Days per case

Units per case



Test, Serum Bilirubin 100 Baseline Investigations of

MDR-TB Patients

1.0 1.0 1.0 1.0 300.00 300.00

Total cost 300.00 SGPT Baseline Investigations of MDR-TB Patients

Test, SGPT 100 1.0 1.0 1.0 1.0 300.00 300.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

Test, SGPT 18 4 Tests Required in Intensive Phase & 1 Test Required in Continuation

Phase

1.0 1.0 5.0 5.0 300.00 270.00


Test, SGPT 82 3 Test Required in Intensive Phase

1.0 1.0 3.0 3.0 300.00 738.00

Total cost 1,308.00 Alkaline Phosphatase Test, Alkaline Phosphatase 100 Baseline

Investigations of MDR-TB Patients

1.0 1.0 1.0 1.0 300.00 300.00

Total cost 300.00

82




Times per day

Days per case

Units per case



Blood Glucose Test, Blood Glucose 100 Baseline

Investigations of MDR-TB Patients

1.0 1.0 1.0 1.0 250.00 250.00

Baseline Investigations of MDR-TB Patients

Total cost 250.00 Thyroid Function Test (TSH) Baseline Investigations of MDR-TB Patients

Test, Thyroid Function Test (TSH) 100 1.0 1.0 1.0 1.0 800.00 800.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

Test, Thyroid Function Test (TSH) 18 1 Test Required in Intensive Phase

1.0 1.0 1.0 1.0 800.00 144.00


Test, Thyroid Function Test (TSH) 82 1 Test Required in Intensive Phase & 2 Tests Required in continuation

phase

1.0 1.0 3.0 3.0 800.00 1,968.00

Total cost 2,912.00 Chest X-ray for Follow-up Investigations of MDR-TB Patients

83




Times per day

Days per case

Units per case



Baseline Investigations of MDR-TB Patients

Test, Chest X-ray 100 1.0 1.0 1.0 1.0 350.00 350.00 Shorter Regimen: Follow-up Investigations of MDR-TB Patients (Calculated by 4 months Intensive and 5 months Continuation Phase

Test, Chest X-ray 18 1 Test Required in Intensive Phase, 2

test required in post treatment

phase

1.0 1.0 3.0 3.0 350.00 189.00


Test, Chest X-ray 82 1 Test Required in Intensive Phase & 2 Tests Required in continuation

phase

1.0 1.0 3.0 3.0 350.00 861.00

Total cost 1,400.00 Pregnancy Test Baseline Investigations of MDR TB Patients

Test, Pregnancy test (for the women of childbearing age)

30 1.0 1.0 1.0 1.0 300.00 90.00

Total cost 90.00

84

Annexure- C.1: Treatment inputs and unit cost for new TB intervention from 2019

Drug/Supply Percent receiving this aspect of the

treatment


Times per day

Days per case

Units per case



LPA

Resistance testing LPA: For first-line drugs, previously treated TB cases

100 Used unit cost from secondary sources

1.00 1.00 1.00 1.00 2100.00 2100.00

Total cost 2100.00


100 Used unit cost from secondary sources

1.00 1.00 1.00 1.00 2100.00 2100.00

Total cost 2100.00

New Lfx based Regimen for Adult Retreatment Cases (Pul+ ve/EPTB), DOTS at domiciliary level

RHZE 150/75/400/275 100 38-54kg 3.00 1.00 180.00 540.00 6.59 3,558.60


100 38-54kg 3.00 1.00 180.00 540.00 2.53 1,366.20

Total cost 4,924.80

New Regimen for Adult Retreatment Cases (Pul-ve), DOTS at domiciliary level

RHZE 150/75/400/275 100 38-54kg 3.00 1.00 180.00 540.00 6.59 3,558.60

Total cost 3,558.60

New Regimen for Adult Retreatment Cases- Meningitis, Bone and Neurological TB, DOTS at domiciliary level

85

Drug/Supply Percent

receiving this aspect of the

treatment


Times per day

Days per case

Units per case



RHZE 150/75/400/275 100 38-54g 3.00 1.00 360.00 1,080.00 6.59 7,117.20


100 3.00 1.00 360.00 1,080.00 2.53 2,732.40

Total cost 9,849.60

New Lfx based Regimen for Child Retreatment Cases (Pul+ve/EPTB), DOTS at domiciliary level


100 12-15kg 1.00 1.00 180.00 180.00 2.53 455.40

E100 100 12-15kg 3.00 1.00 180.00 540.00 7.18 3,877.20

3FDC / RHZ(75/50/150) 100 12-15kg 3.00 1.00 180.00 540.00 3.59 1,938.60

Total cost 6,271.20

New Regimen for Child Retreatment Cases (Pul-ve) , DOTS at domiciliary level

3FDC / RHZ(75/50/150) 100 12-15kg 3.00 1.00 180.00 540.00 3.59 1,938.60

E100 100 12-15kg 3.00 1.00 180.00 540.00 7.18 3,877.20

Total cost 5,815.80

New Child Retreatment Cases Meningitis, Bone, Neurological TB, DOTS at domiciliary level

3FDC / RHZ(75/50/150) 100 12-15kg 3.00 1.00 360.00 1,080.00 3.59 3,877.20

E100 100 12-15kg 3.00 1.00 360.00 1,080.00 7.18 7,754.40


100 12-15kg 1.00 1.00 360.00 360.00 2.53 910.80

86

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case



Total cost 12,542.40

3 HP Preventive Therapy for Adults and Children more than 12 years of age, Community level


100 3 months once weekly. Bodyweight 38-54kg. Dose 15mg per Kg, Rounded up

to nearest 50 or 100mg; max 900mg (Ref CDC)

2.50 1.00 12.00 30.00 1.68 50.40

Rifapentin (P) 150mg Tab 100 3 months once weekly. Bodyweight 38-54kg.

Dose: bodyweight 32.1Kg to 49.9 Kg= 750mg; More

than 50Kg 900mg max. (Ref CDC)

5.50 1.00 12.00 66.00 52.50 3,465.00

Total cost 3,515.40

3 HP Preventive Therapy for Children 2 to 12 years old, Community level

Isoniazide (H) 100mg dispersible Tab

65 3 months, once weekly. Bodyweight 12-15 Kg, 2- 8

years of age

4.00 1.00 12.00 48.00 8.40 403.20


35 3 months, once weekly. Bodyweight 12-15 Kg, 8- 11 years of age. Max dose

900 mg

2.00 1.00 12.00 24.00 1.68 40.32

Rifapentin (P) 150mg Tab 100 3 months, once weekly. Average dose for

bodyweight

2.50 1.00 12.00 30.00 52.50 1,575.00

87

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case



Total cost 2,018.52

IPT for Children <2 years of age, Community level

Isoniazide (H) 100mg dispersible Tab

100 5-10 Kg, average weight for less than 2 years of age

children.

1.00 1.00 180.00 180.00 7.05 1,269.03

Total cost 1,269.03 MDR New Shorter Regimen, DOTS at domiciliary level (7months)

Amikacin 500 mg 100 2 months at DOTs level 2.00 1.00 60.00 120.00 58.38 7,005.60


100 1.00 1.00 60.00 60.00 4.20 252.00

Cfz (100)/ Clofazimine 100 mg Capsule(s)

100 1.00 1.00 210.00 210.00 82.52 17,329.20

E(400)/ Ethambutol 400mg Film coated tablet(s)

100 3.00 1.00 210.00 630.00 3.12 1,965.60


100 2.00 1.00 60.00 120.00 1.68 201.60


100 1.00 1.00 210.00 210.00 22.26 4,674.60


100 3.00 1.00 60.00 180.00 10.08 1,814.40


100 4.00 1.00 210.00 840.00 2.74 2,301.60


88

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case



MDR New Shorter Regimen, DOTS at Hospital level (2 months)

Amikacin 500 mg 100 2 months at DOTs level 2.00 1.00 60.00 120.00 58.38 7,005.60


100 1.00 1.00 60.00 60.00 4.20 252.00

Cfz(100)/ Clofazimine 100 mg Capsule(s)

100 1.00 1.00 60.00 60.00 82.52 4,951.20

E(400)/ Ethambutol 400mg Film coated tablet(s)

100 3.00 1.00 60.00 180.00 3.12 561.60


100 2.00 1.00 60.00 120.00 1.68 201.60


100 2.00 1.00 60.00 120.00 22.26 2,671.20


100 3.00 1.00 60.00 180.00 10.08 1,814.40


100 4.00 1.00 60.00 240.00 2.74 657.60


MDR New Longer Regimen ,DOTS at Domiciliary level (18months)

Bedaquiline 100 mg 100 400mg once daily for first and second weeks. Third week to 24th week 200mg

thrice weekly.

1.05 1.00 120.00 125.40 178.72 22,411.49

89

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case




100 1.00 1.00 540.00 540.00 117.60 63,504.00


100 3.00 1.00 540.00 1,620.00 2.53 4,098.60

Cs(250)/ Cycloserine 250mg Capsule(s)

100 3.00 1.00 540.00 1,620.00 22.09 35,785.80


100 1.00 1.00 540.00 540.00 82.52 44,560.80


100 4.00 1.00 540.00 2,160.00 2.74 5,918.40

Pyridoxin 20mg 100 7.50 1.00 540.00 4,050.00 3.88 15,714.00


MDR New Longer Regimen, DOTS at Hospital level(2 months)

Bedaquiline 100 mg 100 400mg once daily for first and second weeks. Third week to 24th week 200mg

thrice weekly.

1.05 1.00 60.00 62.70 178.72 11,205.74


100 1.00 1.00 60.00 60.00 117.60 7,056.00


100 3.00 1.00 60.00 180.00 2.53 455.40


100 3.00 1.00 60.00 180.00 22.09 3,976.20


100 1.00 1.00 60.00 60.00 82.52 4,951.20


100 4.00 1.00 60.00 240.00 2.74 657.60

90

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case



Pyridoxin 20mg 100 7.50 1.00 60.00 450.00 3.88 1,746.00


Pre XDR (6 months Bedaquiline Regimen), DOTS at domiciliary level (18months)

Bedaquiline 100 mg 100 400mg once daily for 1st and 2nd week . 3rd to 24th

week 200 mg thrice weekly.

1.05 1.00 120.00 125.40 178.72 22411.49

Delamanid 50mg 100 50mg, 2Tabs twice daily for six months

4.00 1.00 120.00 480.00 212.50 102000.00


100 12 months 1.00 1.00 300.00 300.00 117.60 35280.00


100 20 months 3.00 1.00 540.00 1620.00 22.09 35785.80


100 20 months 1.00 1.00 540.00 540.00 82.52 44560.80


100 20 months 3.00 1.00 540.00 1620.00 10.08 16329.60


100 20 months 4.00 1.00 540.00 2160.00 2.74 5918.40

Pyridoxin 20mg 100 20 months 7.50 1.00 540.00 4050.00 3.88 15714.00 Total cost 278000.09 Pre XDR (6 months Bedaquiline Regimen),DOTS at Hospital level(2 months)

Bedaquiline 100 mg 100 400 mg once daily for 1st and 2nd week. 3rd to 24th

week 200 mg thrice weekly.

1.05 1.00 60.00 62.70 178.72 11,205.74

91

Drug/Supply Percent


treatment


Times per day

Days per case

Units per case



Delamanid 50mg 100 50 mg, 2 tabs twice daily for six months

4.00 1.00 60.00 240.00 212.5 51,000.00


100 1.00 1.00 60.00 60.00 117.60 7,056.00


100 3.00 1.00 60.00 180.00 22.09 3,976.20


100 1.00 1.00 60.00 60.00 82.52 4,951.20


100 3.00 1.00 60.00 180.00 10.08 1,814.40


100 4.00 1.00 60.00 240.00 2.74 657.60

Pyridoxin 20mg 100 7.50 1.00 60.00 450.00 3.88 1,746.00


92

Annexure-D: Unit cost of Z-N and LED microscopy

Reagents and supplies cost (BDT)

TB diagnosis: Z-N Microscopy Drug/Supply Percent receiving

this aspect of the treatment


Times per day

Days per case

Units per case Unit cost (BDT) (2016)


Per smear Microscopy- Ziehl-Neelsen (Z-N) method

100 1 1 1 1 12.00 12.00

Gloves, 1 pair 100 0.1 1 1 0.1 20.00 2.00 75% ethanol/Hexisol, 1 L

100 0.01 1 1 0.01 400.00 4.00

Immersion oil, 100 ml 100 For 100X objective

0.01 1 1 0.01 723.49 7.23

Tissue paper 100 to absorb immersion oil on stained slides before storing.

0.01 1 1 0.01 52.00 0.52

Lens tissue (paper), 1 piece

100 to clean microscope lenses

0.02 1 1 0.02 7.04 0.14

Total cost 25.89

93

Reagents and supplies cost only (BDT)

TB diagnosis: LED Microscopy

Drug/Supply Percent receiving this aspect of the treatment


Times per day

Days per case

Units per case Unit cost (BDT) (2016)


Per smear Microscopy- Light Emitting Diode (LED) fluorescence microscopy (FM)

100 1 1 1 1 9.00 9.00

Gloves, 1 pair 100 0.1 1 1 0.1 20.00 2.00 75% ethanol/Hexisol, 1 L

100 0.01 1 1 0.01 400.00 4.00

Immersion oil, 100 ml 100 For 100X objective

0.01 1 1 0.01 723.49 7.23

Tissue paper 100 to absorb immersion oil on stained slides before storing.

0.01 1 1 0.01 52.00 0.52

Lens tissue (paper), 1 piece

100 to clean microscope lenses

0.02 1 1 0.02 7.04 0.14

Total cost 22.89

94

Annexure-E: NTP’s Circular on Lfx based regimen for retreatment

97

Annexure-F: Target population for TB interventions

Intervention Target population TB diagnosis: Microscopy Diagnosis microscopy Direct entry Follow Up microscopy Number of new TB cases, including relapse MT test Number of contacts of new TB cases TB diagnosis: Culture Diagnosis culture MDR and XDR cases TB diagnosis: Culture and DST Drugs susceptibility testing MDR and XDR cases TB diagnosis: Xpert (molecular) Diagnosis GeneXpert Number of GeneXpert tests TB diagnosis: LPA (molecular) Resistance testing LPA: For first-line drugs, previously treated TB cases

Previously treated, including relapse


Non-XDR cases

TB x-rays Diagnosis X-rays Number of chest X-rays First-line TB treatment First-line TB treatment: Initial treatment for Adult (Cat I)

Number of new non-MDR cases, excluding relapse (adults)


Number of new non-MDR cases, including relapse (children)


Number of previously treated non-MDR cases, including relapse (adults)

Lfx based retrt. regimen for child retrt. cases (Pul+)

Number of previously treated non-MDR cases, including relapse (children)

IPT children under 5 years of age Number of new TB cases 3 HP for children 2 to 11 years old Number of new TB cases 3 HP for adult and children more than 12 Years of age

Number of new TB cases

New regimen for child retrt. cases (Pul-) Number of previously treated non-MDR cases, including relapse (children)

New child retrt. cases- meningitis, bone, neurological TB

Number of previously treated non-MDR cases, including relapse (children)

New Lfx based regimen for adult rtrt. cases (Pul+ve/EPTB)


New regimen for adult retrt. cases (Pul-) Number of previously treated non-MDR cases, including relapse (adults)

New regimen for adult retrt. cases- Meningitis, bone, and neurological TB


IPT for children <2 years of age Number of new TB cases MDR and XDR TB Longer regimen for MDR-TB Non-XDR cases Shortened nine-month treatment regimen for MDR-TB

Non-XDR cases

XDR TB Regimen XDR cases

98

Intervention Target population MDR new shorter regimen (9 Months) Non-XDR cases MDR new longer regimen (20 months) Non-XDR cases MDR with additional resistance (6 months Bedaquiline regimen)

Non-XDR cases

Collaborative TB and HIV/AIDS interventions HIV testing and counseling for TB patients Number of new pulmonary, bacteriologically confirmed,

HIV- TB cases (adults) TB diagnosis: Baseline & Follow-up Investigations of MDR-TB Patients

Audiometry MDR and XDR cases ECG MDR and XDR cases Complete Blood Count (CBC) MDR and XDR cases Serum Creatinine MDR and XDR cases Serum Electrolyte MDR and XDR cases Serum Bilirubin Number of new MDR cases, including relapse SGPT MDR and XDR cases Alkaline Phosphatase Number of new MDR cases, including relapse Blood Glucose Number of new MDR cases, including relapse Thyroid Function Test (TSH) MDR and XDR cases Chest X-ray for Follow-up Investigations of MDR-TB Patients

MDR and XDR cases

Pregnancy Test Number of new MDR cases, including relapse FNAC (Fine Needle Aspiration Cytology) Number of new and relapse extra-pulmonary TB cases

99

Annexure G: Population in need of TB intervention from 2016-2022

Name of the interventions 2016

2017

Years 2020

2021

2022 2018 2019

TB diagnosis: Microscopy Diagnosis microscopy 100 100 100 100 100 100 100 Follow Up microscopy 250 250 250 250 250 250 250 MT test 100 100 100 100 100 100 110 TB diagnosis: Culture Diagnosis culture 100 100 100 100 100 100 100 TB diagnosis: Culture and DST Drugs susceptibility testing 100 100 100 100 100 100 100 TB diagnosis: Xpert (molecular) Diagnosis GeneXpert 130 130 130 130 130 130 130 TB diagnosis: LPA (molecular) Resistance testing LPA: For first-line drugs, previously treated TB cases

100 100 100 100 100 100 100

Resistance testing with LPA: For second-line drugs 100 100 100 100 100 100 100 TB x-rays Diagnosis X-rays 100 100 100 100 100 100 100 First-line TB treatment First-line TB treatment: Initial treatment for Adult (Cat I)

100 100 100 100 100 100 100


100 100 100 100 100 100 100


100 100 100 100 100 100 100

LFx based retrt. regimen for child retrt. cases (Pul+) 100 100 100 100 100 100 100 IPT children under 5 years of age 100 100 100 100 100 100 100 3 HP for children 2 to 11 years old 100 100 100 100 100 100 100 3 HP for adult and children more than 12 Years of age

100 100 100 100 100 100 100

New regimen for child retrt. cases (Pul-) 100 100 100 100 100 100 100 New child retrt. cases- meningitis, bone, neurological TB

100 100 100 100 100 100 100


100 100 100 100 100 100 100

New regimen for adult retrt. cases (Pul-) 100 100 100 100 100 100 100 New regimen for adult retrt. cases- Meningitis, bone, and neurological TB

100 100 100 100 100 100 100

IPT for children <2 years of age 100 100 100 100 100 100 100 MDR and XDR TB MDR new shorter regimen (9 Months) 100 100 100 100 0 0 0 Shortened nine-month treatment regimen for MDR- TB

100 100 100 100 0 0 0

XDR TB Regimen 100 100 100 100 100 100 100 MDR new shorter regimen (9 Months) 0 0 0 100 100 100 100 MDR new longer regimen (20 months) 0 0 0 100 100 100 100

100


2017

Years 2020

2021

2022 2018 2019


0 0 0 100 100 100 100

Collaborative TB and HIV/AIDS interventions HIV testing and counseling for TB patients 100 100 100 100 100 100 100 TB diagnosis: Baseline & Follow-up Investigations of MDR-TB Patients

Audiometry 100 100 100 100 100 100 100 ECG 100 100 100 100 100 100 100 Complete Blood Count (CBC) 100 100 100 100 100 100 100 Serum Creatinine 100 100 100 100 100 100 100 Serum Electrolyte 100 100 100 100 100 100 100 Serum Bilirubin 100 100 100 100 100 100 100 SGPT 100 100 100 100 100 100 100 Alkaline Phosphatase 100 100 100 100 100 100 100 Blood Glucose 100 100 100 100 100 100 100 Thyroid Function Test (TSH) 100 100 100 100 100 100 100 Chest X-ray for Follow-up Investigations of MDR-TB Patients

100 100 100 100 100 100 100

Pregnancy Test 100 100 100 100 100 100 100 FNAC (Fine Needle Aspiration Cytology) 20 20 20 20 20 20 20

101

Annexure H: Coverage of TB interventions from 2016-22


2017

Years 2019

2020

2021

2022 2018

TB diagnosis: Microscopy Diagnosis microscopy 100 100 100 100 100 100 100 Follow Up microscopy 80 80 80 80 80 80 80 MT test 21 21 21 81 91 100 100 TB diagnosis: Culture Diagnosis culture 100 100 100 100 100 100 100 TB diagnosis: Culture and DST Drugs susceptibility testing 100 100 100 100 100 100 100 TB diagnosis: Xpert (molecular) Diagnosis GeneXpert 100 100 100 100 100 100 100 TB diagnosis: LPA (molecular) Resistance testing LPA: For first-line drugs, previously treated TB cases

0 0 0 100 100 100 100

Resistance testing with LPA: For second-line drugs 0 0 0 100 100 100 100 TB x-rays Diagnosis X-rays 100 100 100 100 100 100 100 First-line TB treatment First-line TB treatment: Initial treatment for Adult (Cat I)

100 100 100 100 100 100 100


100 100 100 100 100 100 100


100 100 100 0 0 0 0

LFx based retrt. regimen for child retrt. cases (Pul+) 0 0 0 36 36 36 36 IPT children under 5 years of age 21 21 21 0 0 0 0 3 HP for children 2 to 11 years old 0 0 0 21 21 21 21 3 HP for adult and children more than 12 Years of age

0 0 0 21 21 21 21

New regimen for child retrt. cases (Pul-) 0 0 0 19 19 19 19 New child retrt. cases- meningitis, bone, neurological TB

0 0 0 6 6 6 6


0 0 0 61 61 61 61

New regimen for adult retrt. cases (Pul-) 0 0 0 32 32 32 32 New regimen for adult retrt. cases- Meningitis, bone, and neurological TB

0 0 0 1 1 1 1

IPT for children <2 years of age 0 0 0 21 21 21 21 MDR and XDR TB Longer regimen for MDR-TB 82 71.3 60.7 0 0 0 0 Shortened nine-month treatment regimen for MDR- TB

18 28.7 39.3 0 0 0 0

XDR TB Regimen 12 100 100 0 0 0 0 MDR new shorter regimen (9 Months) 0 0 0 50 60.7 71.3 82 MDR new longer regimen (20 months) 0 0 0 50 39.3 28.7 18

102


2017

Years 2019

2020

2021

2022 2018


0 0 0 100 100 100 100

Collaborative TB and HIV/AIDS interventions HIV testing and counseling for TB patients 100 100 100 100 100 100 100 TB diagnosis: Baseline & Follow-up Investigations of MDR-TB Patients

Audiometry 100 100 100 100 100 100 100 ECG 100 100 100 100 100 100 100 Complete Blood Count (CBC) 100 100 100 100 100 100 100 Serum Creatinine 100 100 100 100 100 100 100 Serum Electrolyte 100 100 100 100 100 100 100 Serum Bilirubin 100 100 100 100 100 100 100 SGPT 100 100 100 100 100 100 100 Alkaline Phosphatase 100 100 100 100 100 100 100 Blood Glucose 100 100 100 100 100 100 100 Thyroid Function Test (TSH) 100 100 100 100 100 100 100 Chest X-ray for Follow-up Investigations of MDR- TB Patients

100 100 100 100 100 100 100

Pregnancy Test 100 100 100 100 100 100 100 FNAC (Fine Needle Aspiration Cytology) 100 100 100 100 100 100 100

103

Annexure-i: One year equivalent* cost of equipment per TBSTC, icddr, b (2018)

Item Total cost of Medical equipment/

centre) X-pert 1,221,843 X-ray 433,850 X-ray film printer 50,995 De-humidifier 2,875 Online UPS 3 KVA 35,729

Online UPS 6 KVA 52,259

Desktop Computer 8,007

Refrigerator 3,176

Scanner 1,123 Printer 1,981

Generator 58,035

CCTV Camera 5,615

Air Conditioner 18,423

Height & Weight Machine 4,031

Steel Almirah 663 Lead glass & Frame for X-Ray Machine 27,222 Mobile phone, Tab, 4,362 Wheel chair 786 Fire Extinguisher 1,600

Gluco-Meter 1,344

Offline UPS for desktop 2,929

Barcode Scanner 2,246

Total cost for equipment per center 1,939,093 * Cost was discounted at 3% rate over their useful lifetime and corresponding annualization factors.

Annexure-i1: Cost of human resources per TBSTC, icddr,b (2018)

Designation

Unit

Unit cost (BDT)

Total cost (BDT)

Per TDC cost

Medical officer 1 99802.45 99802.45 9980.24 Project Physician 5 48503.00 242515.00 24251.50 Field Research Officer 1 58006.15 58006.15 5800.62 Field Research Supervisor 5 38835.49 194177.46 19417.75 Field Research Assistant 5 36635.13 183175.64 18317.56 Admin Assistant 1 38870.00 38870.00 3887.00 Health Worker 18 22836.51 411057.25 41105.72 Technical Assistant (Radiographer) 12

15144.82

181737.84

18173.78 Field Attendant (Receptionist) 14 10727.05 150178.67 15017.87 Community Volunteer 30 10828.23 324846.80 32484.68 Security Guard 11 10282.93 113112.21 11311.22

104

Cleaner 10 6938.71 69387.13 6938.71 Porter 5 13021.14 65105.68 6510.57

Total cost (BDT)

213197.23

Annexure-i2: Logistic costs TBSTC, icddr,b (2018)

Renovation/Set up items

Unit Life

year Equivalent cost per year

rate

Equivalent cost per

year Ceiling fan 6 5 0.2184 4,586 Counseling table and DOTS table

4

10

0.1172

4,688

Revolving chair 4 5 0.2184 5,154 Floor cabinet 4 5 0.2184 14,414 GXP table 1 10 0.1172 1,172 Hanging cabinet 2 5 0.2184 7,338 IT & networking 1 3 0.3535 640 Lab stool Chair 2 5 0.2184 218 Led Apron 1 2 0.5226 36,582 Movable drawer 3 3 0.3535 6,151 Patient Chair 15 3 0.3535 9,598 Reception table 5 10 0.1172 20,510 Store rack 3 5 0.2184 5,569 Wifi router 1 2 0.5226 779 Total 117,400

Equivalent cost of logistics/ year/

centre Inflation adjusted cost/ year /centre Total

2014 2017 2018 2014 2017 2018 352,199

352,199.44

469,599.26

78,892.21

181,237.14

469,599.26

729,729

Per TBSTC

72,973

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