Health system perspective costing of TB, HIV and dysglycaemia (prediabetes and diabetes) in Kenya and a minimum care package policy proposal: the THANDYS study

Background
Poverty is a barrier to health equity. While it is believed that tuberculosis (TB) and Human Immunodeficiency Virus (HIV) care is free in Kenya, this is only partially true. Co-morbidities such as diabetes mellitus (DM), which are not currently subsidized, triple the risk of contracting TB and contribute to poor outcomes such as drug-resistant TB (DR-TB), while also increasing the cost of care. After TB treatment, there is a three-fold risk of death, with cardiovascular disease being a major contributor, and diabetes is directly correlated with cardiovascular risk. The lack of costing data on co-morbidities in TB/HIV care has made it challenging to define a subsidized care package for patients.

Methods
This cross-sectional, mixed methods, nested design study aimed to determine the cost of managing TB patients, with or without HIV, in addition to diabetes or prediabetes, from a health system perspective using a bottom-up (BU) approach. The study aimed to propose a minimum care package as part of efforts towards universal health coverage in Kenya. STATA was used to randomly sample 36 health facilities within Nairobi County, Kenya, representing 10 of the 17 sub-counties.

Results
The average health system costs for screening, diagnosis, and risk counseling of TB patients were USD ($) 27.26 in public and USD ($) 44.70 in private health facilities, averaging USD ($) 35.98. The costs for managing TB and HIV, TB and DM, and TB, DM, and HIV in public and private facilities respectively were USD ($) 28.17 and USD ($) 51.75, USD ($) 31.75 and USD ($) 47.93, and USD ($) 32.67 and USD ($) 54.98.

Conclusions
The cost of managing dysglycemia in TB and HIV patients is incremental, and subsidies can improve access to care. The proposed minimum care package, which includes dysglycemia care (self-monitoring, cardiovascular and ophthalmology screening, and foot care), is almost ten times less than what the health system currently pays for TB complications like DR-TB.