Optimising TB investments in Belarus, Moldova, Kyrgyz Republic, Tajikistan and Uzbekistan: An allocative efficiency analysis

Abstract

High rates of drug-resistant tuberculosis (TB) are a barrier to achieving End TB-strategy targets in Eastern Europe and Central Asia. This analysis collates results from five country-level modelling studies to identify priorities to reduce TB burden. Allocative efficiency studies were conducted in 2023 in Belarus, Kyrgyz Republic, Moldova, Tajikistan and Uzbekistan using the Optima TB model to determine the optimised distribution of funds to maximise health outcomes with given resources. A baseline scenario of continued 2022 spending was compared to scenarios with spending optimised across prevention, screening and treatment interventions to reduce TB incidence and deaths over 2024-2030. Modelled pulmonary TB incidence ranged from 25-119 per 100,000 population, and 14 - 43% of new/relapse TB cases were drug resistant. In all countries, optimizing current spending involved: expanding shorter treatment regimens (6-9 months) for drug-resistant-TB over standard regimens (18-20 months); reducing mass screening and mandatory testing and expanding community-based active case finding focused among populations at higher TB risk; and scaling-up TB preventive treatment. It was recommended to expand contact tracing in three countries and to improve cost-effectiveness in two countries by focusing on child household contacts first. With current spending optimised, pulmonary TB incidence was projected to decrease to 19 - 95 per 100,000 population by 2030, averting 1 - 13% of new/relapse TB cases and 1 - 18% of TB-related deaths from 2024-2030 compared to continued baseline spending. In three countries, optimised allocation of 150% of current spending had minimal additional epidemic impact. There are opportunities to reallocate TB funds more cost-effectively in Eastern Europe and Central Asia, but End TB targets may remain out of reach without new and prospective interventions.

Fig 1. TB burden and spending by country.

Panels show: a) Pulmonary TB cases in relation to population size in participating countries, 2022; and b) TB spending relative to size of TB epidemic measured through total active TB cases. Sources: Optima TB 2023 country-specific models.

Fig 2. Treatment and screening unit costs.

Panels show: a) Treatment unit cost by country, TB strain and regimen duration; and b) Cost per person diagnosed (log scale) and TB yield by active case finding modality group. Notes: * Includes active case finding through community-based organisations, targeted mobile screening, and among populations at high risk of TB. Screening modalities are grouped by type, and more than one modality may be plotted for a given country. For example, three forms of community-based active case finding (ACF) were modelled in Moldova: ACF through community-based organisations, targeted mobile screening, and ACF among populations at high risk of TB. Mass screening/mandatory testing not modelled in all countries. Costs in US dollars. DR, drug resistant; DS, drug susceptible; MDR, multi-drug resistant; TB, tuberculosis; XDR, extensively drug-resistant. Source: Optima TB country-specific models, 2023.

Fig 3. Allocation of funding by TB intervention relative to total TB spending in baseline spending, 100% and 150% spending optimised to minimize drug-resistant TB and TB-related deaths.

Notes: ACF, active case finding; BCG, Bacillus Calmette-Guérin; DS, drug susceptible; MDR, multi-drug resistant; PLHIV, people living with HIV; TB, tuberculosis; TPT, TB preventive treatment; XDR, extensively drug-resistant. * Mandatory testing considered in Uzbekistan only. Source: 2023 Optima TB country models.

Fig 4. Percentage change in spending allocation with 100% spending optimised relative to baseline spending by TB intervention for five participating countries.

Notes: a, Baseline spending maintained or less than 1% increase in baseline spending; b, prisoners included in intervention for ACF among populations at higher risk; c, No spending in baseline so absolute value of spending allocation shown; c, Mandatory testing only modelled in Uzbekistan. ACF, active case finding; BCG, Bacillus Calmette-Guérin; DS, drug susceptible; MDR, multi-drug resistant; PLHIV, people living with HIV; TB, tuberculosis; TPT, TB preventive treatment; XDR, extensively drug-resistant. Source: 2023 Optima TB country models.

Fig 5. Projected change in pulmonary TB incidence and TB-related deaths from 2022 to 2030 with baseline spending continued, optimised 100% spending, and optimised 150% spending by country.