Cost-effectiveness of conditional cash transfers with pre- and post-test tuberculosis counselling in South Africa: a modelling analysis

Abstract

OBJECTIVES: Tuberculosis (TB) disproportionately affects low-income populations due to socioeconomic barriers. Conditional cash transfers (CCTs) are promising strategies to improve treatment adherence, reduce economic hardship, and enhance health outcomes. However, few studies have examined their cost-effectiveness, especially when combined with TB counselling. The objective of this study is to estimate the long-term epidemiological impact and cost-effectiveness of CCT with pre- and post-test TB counselling in South Africa. METHODS: This analysis used results from a trial conducted in South Africa. Trial results on treatment initiation, treatment completion, and on-treatment mortality informed a transmission model of TB, where a CCT intervention with pre- and post-test TB counselling was offered to all adults diagnosed with drug-susceptible TB between 2025 and 2050. Epidemiological modelling results were combined with cost data to determine the cost-effectiveness of the intervention compared to business as usual (BAU) from the provider's perspective. RESULTS: Universally applying the CCT intervention between 2025 and 2050 in South Africa would lead to a cumulative reduction of 5.1%(UI: 4.6-5.6%) incident cases and 9.5%(UI: 9.1-10.2%) deaths, compared to BAU. The incremental cost of the intervention was estimated at $80.4 USD per patient, leading to a total increase of 7.1%(UI:6.8-7.6%) in the TB budget and an ICER of $144.45 per DALY averted, making it cost-effective in South Africa, at a threshold of $3,314 USD. CONCLUSIONS: CCT interventions with pre- and post-test counselling would be cost-effective in South Africa, leading to a long-term reduction in TB incidence and mortality.