, Volume 30, Issue 1, pp 63–80 | Cite as

A Systematic Review of the Cost and Cost Effectiveness of Treatment for Multidrug-Resistant Tuberculosis

  • Christopher FitzpatrickEmail author
  • Katherine Floyd
Original Research Article



Around 0.4 million cases of multidrug-resistant tuberculosis (MDR-TB) occur each year. Only a small fraction of these cases are treated according to international guidelines. Evidence relevant to decisions about whether to scale-up treatment for MDR-TB includes cost and cost-effectiveness data. Up to 2010, no systematic review of this evidence has been available.


Our objective was to conduct a systematic review of the cost and cost effectiveness of treatment for MDR-TB and synthesize the available data.


We searched for papers published or prepared for publication in peer-review journals and grey literature using search terms in five languages: English, French, Portuguese, Russian and Spanish. From an initial set of 420 studies, four were included, from Peru, the Philippines, Estonia and Tomsk Oblast in the Russian Federation. Results on costs, effectiveness and cost effectiveness were extracted. Assessment of the quality of each economic evaluation was guided by two existing checklists around which there is broad consensus. Costs were adjusted to a common year of value (2005) to remove distortions caused by inflation, and calculated in two common currencies: $US and international dollars (I$), to standardize for purchasing power parity.

Data from the four identified studies were then synthesized using probabilistic sensitivity analysis, to appraise the likely cost and cost effectiveness of MDR-TB treatment in other settings, relative to WHO benchmarks for assessing whether or not an intervention is cost effective. Best estimates are provided as means, with 5th and 95th percentiles of the distributions.


The cost per patient for MDR-TB treatment in Estonia, Peru, the Philippines and Tomsk was $US10 880, $US2423, $US3613 and $US14657, respectively. Best estimates of the cost per disability-adjusted life-year (DALY) averted were $US598 (I$960), $US163 (I$291), $US143 (I$255) and $US745 (I$1059), respectively. The main influences on costs were (i) the model of care chosen (the extent to which hospitalization or ambulatory care were relied upon) and (ii) the second-line drugs included in the treatment regimen. When extrapolated to other settings, the best estimate of the cost of treatment varied from $US3401 to $US195 078, depending on the region and model of care.

The cost per DALY averted was lower than GDP per capita in all 14 WHO sub-regions considered, with better cost effectiveness for outpatient versus inpatient models of care.


Treatment for MDR-TB can be cost effective in low- and middle-income countries. Evidence about the relative cost effectiveness of outpatient versus inpatient models of care is limited and more data are needed from Africa and Asia — especially India and China, which have the largest number of cases. Unless there is strong evidence that hospitalization is necessary to achieve high rates of adherence to treatment, patients with MDR-TB should be treated using mainly ambulatory care.


Guideline Development Group Inpatient Model Multidisciplinary Expert Panel Health Economic Evaluation Database Purchase Power Parity Exchange Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



CF planned and managed the work, analysed and interpreted the data and produced the first draft of the manuscript; KF reviewed and revised the paper, including substantive revisions. CF finalized the paper and both authors approved the final submitted version. Dennis Falzon, Inés Garcia Baena, Carole Mitnick, Holger Schünemann and Wayne van Gemert reviewed specific components of the manuscript and offered suggestions for improvement. The Guidelines Group revising the WHO Guidelines for the Programmatic Management of Drug-Resistant Tuberculosis reviewed the GRADE profile and summary of findings and provided helpful comments. Any errors or omissions remain those of the authors. Neither author has any conflicts of interest. The work was not sponsored by any funding agency.

© World Health Organization 2011. All rights reserved. The World Health Organization has granted the Publisher permission for the reproduction of this article.


  1. 1.
    Nathanson E, Nunn P, Uplekar M, et al. MDR tuberculosis: critical steps for prevention and control. N Engl J Med 2010 Sep 9; 363 (11): 1050–8PubMedCrossRefGoogle Scholar
  2. 2.
    WHO. Multidrug and extensively drug-resistant TB (M/XDR-TB): 2010 global report on surveillance and response. Geneva: WHO, 2010Google Scholar
  3. 3.
    WHO. Guidelines for the programmatic management of drug-resistant tuberculosis: emergency update 2008. Geneva: WHO, 2008Google Scholar
  4. 4.
    WHO. Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. 2009 May 19 [online]. Available from URL: [Accessed 2011 Aug 9]
  5. 5.
    WHO. Prevention and control of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis. 2009 May 22 [online]. Available from URL: 15-en.pdf [Accessed 2011 Aug 9]
  6. 6.
    Orenstein EW, Basu S, Shah NS, et al. Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta-analysis. Lancet Infect Dis 2009 May; 9 (3): 153–61PubMedCrossRefGoogle Scholar
  7. 7.
    Johnston JC, Shahidi NC, Sadatsafavi M, et al. Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis. PLoS ONE 2009 Sep; 4 (9): e6914PubMedCrossRefGoogle Scholar
  8. 8.
    Falzon D, Jaramillo E, Schünemann HJ, et al. WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update [abstract]. Eur Respir J. Epub 2011 Aug 2Google Scholar
  9. 9.
    Higgins JPT GSe, editor. Cochrane handbook for systematic reviews of interventions. Version 5.0.2 [updated 2009 Sep]. Chichester: The Cochrane Collaboration, 2009Google Scholar
  10. 10.
    Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. 3rd ed. Oxford: Oxford University, 2005Google Scholar
  11. 11.
    Suárez PG, Floyd K, Portocarrero J, et al. Feasibility and cost-effectiveness of standardised second-line drug treatment for chronic tuberculosis patients: a national cohort study in Peru. Lancet 2002 Jun 8; 359 (9322): 1980–9PubMedCrossRefGoogle Scholar
  12. 12.
    Tupasi TE, Gupta R, Quelapio MI, et al. Feasibility and cost-effectiveness of treating multidrug-resistant tuberculosis: a cohort study in the Philippines. PLoS Med 2006 Sep; 3 (9): e352PubMedCrossRefGoogle Scholar
  13. 13.
    WHO. The economics of managing multidrug-resistant tuberculosis in countries of the former Soviet Union. Geneva: WHO, 2009. (Data on file)Google Scholar
  14. 14.
    Lopez AD, Mathers CD, Ezzati M, et al., editors. Global burden of disease and risk factors. New York: Oxford University Press and The World Bank, 2006Google Scholar
  15. 15.
    Tan-Torres Edejer T, Baltussen R, Adam T, et al., editors. Making choices in health: WHO guide to cost-effectiveness analysis. Geneva: WHO, 2003Google Scholar
  16. 16.
    Dye C, Floyd K. Tuberculosis. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease control priorities in developing countries (DCPP). New York: Oxford University Press, 2006: 289–309 [online]. Available from URL: [Accessed 2010 Dec 10]Google Scholar
  17. 17.
    Evers S, Goossens M, de Vet H, et al. Criteria list for assessment of methodological quality of economic evaluations: consensus on health economic criteria. Int J Technol Assess Health Care 2005; 21 (2): 240–5PubMedGoogle Scholar
  18. 18.
    National Institute for Health Research. Centre for Reviews and Dissemination [database; online]. Available from URL: [Accessed 2010 Jan 16]
  19. 19.
    @Risk: risk analysis add-in for Microsoft® Excel. Version 5.0.1: professional edition. Ithaca (NY): Palisade Corporation, 2008Google Scholar
  20. 20.
    UNdata. United Nations Statistics Division [database; online]. Available from URL: [Accessed 2010 Jul 1]
  21. 21.
    Management Sciences for Health. International drug price indicator guide [database; online]. Available from URL: [Accessed 2010 Oct 3]
  22. 22.
    WHO. Tables of costs and prices used in WHO-CHOICE analysis [database; online]. Available from URL: [Accessed 2010 Jul 1]
  23. 23.
    Floyd K. Guidelines for cost and cost-effectiveness analysis of tuberculosis control. Geneva: WHO, 2002 [online]. Available from URL: [Accessed 2010 Jul 1]Google Scholar
  24. 24.
    GRADEpro [computer program]. Version 3.2 for Windows. Cochrane IMS, 2008 [online]. Available from URL: [Accessed 2011 Aug 30]
  25. 25.
    PRISMA. Preferred Reporting Items for Systematic Reviews and Meta-Analyses [online]. Available from URL: [Accessed 2010 Jul 1]
  26. 26.
    Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000 Apr 19; 283 (15): 2008–12Google Scholar
  27. 27.
    WHO Commission on Macroeconomics and Health. Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health: executive summary. Geneva: WHO, 2001Google Scholar
  28. 28.
    WHO. Cost-effectiveness thresholds [online]. Available from URL: [Accessed 2010 Jul 1]
  29. 29.
    Baltussen R, Floyd K, Dye C. Cost effectiveness analysis of strategies for tuberculosis control in developing countries. BMJ 2005 Dec 10; 331 (7529): 1364PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2012

Authors and Affiliations

  1. 1.Technical Officer, Stop TB DepartmentWorld Health OrganizationGeneva 27Switzerland

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