Cost and cost-effectiveness of pediatric home-based versus facility-based TB Preventive Treatment in Ethiopia (CHIP-TB)

Tuberculosis preventive treatment (TPT) is an essential intervention recommended for all child contacts in Ethiopia under 15 years who are at risk of tuberculosis (TB) infection. We conducted a cost and cost-effectiveness analysis of home-based versus facility-based TPT provision for child contacts in Ethiopia. As part of the CHIP TB trial, a pragmatic, cluster-randomized trial conducted at eighteen clinics in Ethiopia, clinics were randomized to either a home-based model (intervention arm), administered by community health workers, or a facility-based model (standard of care) for managing child contacts. Cost data were collected from both a health service perspective and a household perspective, capturing all costs relevant to TPT. Costs were evaluated on a per-household basis, with the primary outcome being the difference in median costs per household initiating TPT. A secondary outcome assessed the cost-effectiveness as the incremental cost per additional child contact starting TPT. Probabilistic sensitivity analyses (PSA) were conducted to examine the robustness of findings. At an average cost of US$18.92 per household managed, Home-based contact management, including TPT delivery was cost-saving compared to facility-based TPT delivery (US$27.24 per household managed) assessed based on the partial-societal perspectives, largely due to reductions in household out-of-pocket costs. The home-based strategy was both less costly and had increased TPT initiation in 61.5% of the scenarios assessed in the PSA. Home-based contact management is a cost-saving alternative for households and provides comparable initiation rates to facility-based care, making it a feasible approach to improve TB preventive treatment accessibility. Although it does not entirely replace facility-based care, a hybrid model that respects household preferences and allows flexibility in delivery could enhance TB care access for socio-economically disadvantaged households, potentially reducing health inequities. The trial was registered on clinicaltrials.gov NCT04369326 on April 30, 2020. https://clinicaltrials.gov/study/NCT04369326.