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Some economic aspects of tuberculosis control in Algeria
4
TUBER(:LE SU P PLI-~M t-NT
in fact, available. To return to the problem about allocation between the various diseases, the allocation should n o t depend upon the size of the problem posed by the disease. It should n o t depend upon the trend of the disease, but on/), on the potential impact on the problem that can be olbtained, which should be clear from the figure presented. Most important in this context is the interaction between tuberculosis and other ,sections in the community. The allocation of community resources in many developing countries to fertilizer factories will have an impact on the tuberculosis problem in an indirect way and might conceivably be more effective.than any specitic actions against this disease. The fact that this relationship is difficult to estimate.does not make it less important to bear in mind. Finally let us consider the problem for a clinician under restricted drug budget conditions. What lie tries to achieve with his budget is either tO minimize the suffering for the known paticnt~ or to minimize the epidemioloaical_ harm produczd now and in the future. In any ca, c"she is facing an allocation problem. He can for a given budget construct almost an intinitc number of drug regimens by varying the combinations of drugs used, the doses, the frequency of giving the drugs, the duration of treatment etc. And in principle there exists only one combination of these factors for a given budget that will produce minimum .,,t~tl'ering or n~inimunl cpidemiological harm. Fortunately for the clinicians, at this levcl a considerable amount of information is available which should make it possible to achieve the optimuna allocation. The allocation problem is a b-~sic economic problem. The achievement of an optimum allocation is not easy. Even when the solution is known theorclically, prestige and vested interests may prevent an optimum solution. However. the realization of the problem and at least in principle of the solution, might give considerable improvements in the planning process and in the actions taken.
SOME
E C O N O N I l C A S P E C T S O F T U B E R C U I . O S I S C O N T R O l , IN AI, GERIA By L. MO~CHTARI(with A. BENGHI:ZAI., P. CitAULET and D. LARI3AOUI) from the Bureau de la Lutte C'ontre la Ttaberculose, Algiers
Algeria has a population ol'about 12 million inhabitants i~ an area of 2,372,940 square kilometres. Tile average population density is therefore 5.1 inhabitants per" square kiiometre. There is however a great difference between the density in the north, which is fairly thickly populated with from 20 to 485 inhabitants per sq. kin.. and the south, which is desert and has only 0-3 to 0.4 inhabitznts per sq. km. Thus the public health problems are quite different'in dae north and in the south.
Public Itealth in/~lgeria Algeria is i'n a rather more fortunate position than marly African countries in terms of medical personnel, hospitals and clinics. With 1,390 doctors, 45,000 hospital beds, and 643 general clinics, Algeria has roughly I doctor per 8,600 inhabitants, 1 general clinic per 18,000 inhabitants, and 1 hospital bed per 270 inhabitants. These national averages do not give a true picture of the real situation, because there are far more doctors and hospitals in the towns than in the country areas or in the south'. The importance attatzhed to public health services in Algeria is reflected in the national budget. Since independence in 1962, the health budget has been, on average, about 300,000,000 DA p.a. This represents about 10~,,/, of governmental expenditure, and means that the State is spending, on public health services, about 25 DA per person p.a., or about $5 per person p.a.
TUBERCULOSIS
CONTROL
IN A L G E R I A
5
The Budget for Tuberculosis Control in Algeria The morbidity prevalance is between 1 and I 95/o, o/ and the infection prevalance rises steeply with age" from 6 to 14 years old approximately 255/0, from 15 to 19 50%. The rates are higher in urban areas than ira rural areas. These figures explain why so many doctors, c'Iinics and hospital beds are assigned to tuberculosis control. At present, Algeria has 95 tuberculosis physicians, 7,143 beds for tuberculous patients, and 30 clinics. On average, therefore, there is 1 doctor per 125,000 inhabitants, I 'clinic per 400,000 inhabitants and 1 hospital bed per 1,700 inhabitants. Similarly. approximately 20 ~ of the public health budget is spent on tuberculosis control. This represents an expenditure of a little over 5 DA (or $1 ) per inhabitant. This budget will be analysed under the three main sections: hospital beds, clinics, and prevention. TubercuflJ.~is HospitaLs Over the last four years, this budget has been progressively, but only marginally, reduced; from 67,()00.000 DA in 1964, it has fallen to 65,500,000 DA in 1967. Thus, on average, a bed in a tuberculosis hospital costs a little less than I0.000 DA or 82.000 p.a., and this cost has remained practically stationary for 4 years. In each hospital the budget is generally split up in the following way: Salaries 55~ equipment 8%, maintenance (bedding, laundry, heating, electricity, etc.) 9"5~o [hod 13 '5 "il. drugs 14'%. Thus over half the budget is paid out as salaries. Tulwrct~h~si~' Clini~:~" "~he budget does not include salaries.. We shall deal only with the iunds allocated for the purchase of supplies. In contrast to the hospital budget, the budget for clinics has progi'essively increased. It is now six timcs as large as it was four years ago (2,440,000 DA in 1967 and 400,000 DA in 1964). Clinics. like hospitals, spend more than 50 ~ of their funds on salaries. It is therefore reasonable to estimate that the real cost ofclinics is between 5 and 6 millions DA or $1 million per annum. Pre venlion BCG vaccination is the principal means of prevention in Algeria. Vaccinations are performed by Mother and Child Welfare Centrcs, Maternity Homes, and School Hygiene Centres, but chiefly by mobile units, teams specialized in mass sanitary action, under the direction of an epidemiologist. Tuberculosis prevention is therefore an integral part of the regular work of several services of the Ministry of Health, each of which has its own budget. The number of people vaccinated has risen sharply over the last four years chiefly through the efforts of the mobile health units. The number of doses of vaccine supplied to the different services increased from 46,113 in 1963 to roughly 900,000 in 1966. In the tirst tive months of 1967, 490,000 doses have been supplied, and the target for vaccinations this year is 1 million. As a result, the budget for the purchase of BCG (fresh BCG produced in Algeria, or imported freeze-dried BCG) has progressively risen. The budget for hospitals is more than 65,000,000 DA, which is 92% of the funds available for tuberculosis control, while the budget for clinics is about 5,000,000 DA or 1/13 of the amount spent on hospitals. The budget for the purchase of BCG is less than 1,000,900 DA. Discussion It has not been possible to consider all the economic aspects of tuberculosis control. For instance, we have not taken into account the cost of diagnosing and treating patients in general clinics, the funds allocated to tuberculosis control by the Social Security Organisation, and the cost of consultations and treatment by doctors in private practice. Likewise no estimate has been possible of the economic loss incurred through patients being away from work. Nevertheless the figures we have collected enable us to assert that even though Algeria spends a relatively large sum on tuberculosis control (about 5 D A or $ 1 per inhabitant per annum) more than 90% of the funds are spent on hospital beds.
6
T U B E R C L E SU PP1,EMI'~NT
The Algerian tuberculosis specialists are aware of this position and of the advances in chemotherapy. They llave therefore asked the Ministry of Public Health to increase the number ofclinic.~. to provide clinics With better equipment, and to reduce the number of hospital beds. This polic~, ~ beginning to be put into effect: the total number of clinics rose from 21 in 1966 to 30 in 1967. hen they were also granted a much larger budget. The number of hospital beds is going to b: reduced by about 1,400. At the same time there has been a considerable expansion in the work of prevention in 1966 and 1967. This will increase in tile coming months, as the Ministry of Health i, collaborating with the International Union against Tuberculosis in preparing a mass vaccination campaign, which is intended to cover the 6 million Algerians under the age of 20 o\'er a period of from 2 to 3 years. We hope that the modification of goals ana a continuing tinancial effort will result in tuberculosis being controlled in Algeria, and that it will eventually become a public health problem of only minor importance for tl~e country.
TUBERCULOSIS
CONTROL--COUNTING
TIlE C O S T
By Pi~:RCI!: W. Kti.~-r from the "Exist Africa Tuherculo.~'i~" h2restt~eatiorn C2,ntrt', p . o . fl:zt- 7855. :V~zirobi
As I intend to discuss cost accounting in tuberculosis control against tixe background of deu ing countries let me briefly remind you of such countries' main characteristic.~ as are relevant in this context--illustrating what I have to say from East Afric:tn ligur,:s. First, there is the matter of the low per capita annual income and of the small amount of money available for central government health expenditure. 1he ~tveragc income per head of population in East Africa is s a ",'ear. Compared to the United Kingdom tigure of s the average East African income amount.q to one shilling in the pound. The annual national health expenditure is between six and seven shillings per head of population--say one tlaird of a p o u n d - - a s against s in the United Kingdom. This means that for every one pound that can be spent on the health of the individual in Britain four pennies are available in East Africa. Secondly, the task in a developing country that has to be tackled with this anaount of money is certainly a formidable one. The infant mortality rate in 189 per 1000 live births, the death ra'te in children aged 1 ~oi 14 is 20,000 per million per year and the expectatio~ of life at birth is40 years. This can be compared with 20 per 1000, 500 per million and 70 years respectively for the United Kingdom. A m o n g a total population o f a b o u t 25 million people, there are 10 million Mantoux positive to a low dose of tuberculin and a further half a million becoming infected by the tubercle bacillus each year. There are at any one time about 300,000 people suffering from tuberculosis. Furthermore, 60,000 people contract it each year, of whom 20,000 are brought under t r e a t m e n t ~ h a l f of them successfully. Such is the rather sombre tuberculosis situation prevailing in East Africa. I suggest that East Africa is not unique in this respect. If one attempts to cost the control measures actually being taken in such a situation as t h i s ~ whether one does it on a country-wide or on a more modest district b a s i s ~ o n e immediately recognizes the virtual impossibility of such a task. The main reason is that in any particular instance the various elements of the control measures are, to a large extent, of a part-time nature. A district tuberculosis effort is under the control of the district medical officer of h e a l t h - - d o you charge one, ten or one hundred per cent of his emoluments to the anti-tuberculosis scheme ? Similarly as regards transport charges, x-ray and laboratory costs, and dispensary and health services expenditure
TUBER(:LE SU P PLI-~M t-NT
in fact, available. To return to the problem about allocation between the various diseases, the allocation should n o t depend upon the size of the problem posed by the disease. It should n o t depend upon the trend of the disease, but on/), on the potential impact on the problem that can be olbtained, which should be clear from the figure presented. Most important in this context is the interaction between tuberculosis and other ,sections in the community. The allocation of community resources in many developing countries to fertilizer factories will have an impact on the tuberculosis problem in an indirect way and might conceivably be more effective.than any specitic actions against this disease. The fact that this relationship is difficult to estimate.does not make it less important to bear in mind. Finally let us consider the problem for a clinician under restricted drug budget conditions. What lie tries to achieve with his budget is either tO minimize the suffering for the known paticnt~ or to minimize the epidemioloaical_ harm produczd now and in the future. In any ca, c"she is facing an allocation problem. He can for a given budget construct almost an intinitc number of drug regimens by varying the combinations of drugs used, the doses, the frequency of giving the drugs, the duration of treatment etc. And in principle there exists only one combination of these factors for a given budget that will produce minimum .,,t~tl'ering or n~inimunl cpidemiological harm. Fortunately for the clinicians, at this levcl a considerable amount of information is available which should make it possible to achieve the optimuna allocation. The allocation problem is a b-~sic economic problem. The achievement of an optimum allocation is not easy. Even when the solution is known theorclically, prestige and vested interests may prevent an optimum solution. However. the realization of the problem and at least in principle of the solution, might give considerable improvements in the planning process and in the actions taken.
SOME
E C O N O N I l C A S P E C T S O F T U B E R C U I . O S I S C O N T R O l , IN AI, GERIA By L. MO~CHTARI(with A. BENGHI:ZAI., P. CitAULET and D. LARI3AOUI) from the Bureau de la Lutte C'ontre la Ttaberculose, Algiers
Algeria has a population ol'about 12 million inhabitants i~ an area of 2,372,940 square kilometres. Tile average population density is therefore 5.1 inhabitants per" square kiiometre. There is however a great difference between the density in the north, which is fairly thickly populated with from 20 to 485 inhabitants per sq. kin.. and the south, which is desert and has only 0-3 to 0.4 inhabitznts per sq. km. Thus the public health problems are quite different'in dae north and in the south.
Public Itealth in/~lgeria Algeria is i'n a rather more fortunate position than marly African countries in terms of medical personnel, hospitals and clinics. With 1,390 doctors, 45,000 hospital beds, and 643 general clinics, Algeria has roughly I doctor per 8,600 inhabitants, 1 general clinic per 18,000 inhabitants, and 1 hospital bed per 270 inhabitants. These national averages do not give a true picture of the real situation, because there are far more doctors and hospitals in the towns than in the country areas or in the south'. The importance attatzhed to public health services in Algeria is reflected in the national budget. Since independence in 1962, the health budget has been, on average, about 300,000,000 DA p.a. This represents about 10~,,/, of governmental expenditure, and means that the State is spending, on public health services, about 25 DA per person p.a., or about $5 per person p.a.
TUBERCULOSIS
CONTROL
IN A L G E R I A
5
The Budget for Tuberculosis Control in Algeria The morbidity prevalance is between 1 and I 95/o, o/ and the infection prevalance rises steeply with age" from 6 to 14 years old approximately 255/0, from 15 to 19 50%. The rates are higher in urban areas than ira rural areas. These figures explain why so many doctors, c'Iinics and hospital beds are assigned to tuberculosis control. At present, Algeria has 95 tuberculosis physicians, 7,143 beds for tuberculous patients, and 30 clinics. On average, therefore, there is 1 doctor per 125,000 inhabitants, I 'clinic per 400,000 inhabitants and 1 hospital bed per 1,700 inhabitants. Similarly. approximately 20 ~ of the public health budget is spent on tuberculosis control. This represents an expenditure of a little over 5 DA (or $1 ) per inhabitant. This budget will be analysed under the three main sections: hospital beds, clinics, and prevention. TubercuflJ.~is HospitaLs Over the last four years, this budget has been progressively, but only marginally, reduced; from 67,()00.000 DA in 1964, it has fallen to 65,500,000 DA in 1967. Thus, on average, a bed in a tuberculosis hospital costs a little less than I0.000 DA or 82.000 p.a., and this cost has remained practically stationary for 4 years. In each hospital the budget is generally split up in the following way: Salaries 55~ equipment 8%, maintenance (bedding, laundry, heating, electricity, etc.) 9"5~o [hod 13 '5 "il. drugs 14'%. Thus over half the budget is paid out as salaries. Tulwrct~h~si~' Clini~:~" "~he budget does not include salaries.. We shall deal only with the iunds allocated for the purchase of supplies. In contrast to the hospital budget, the budget for clinics has progi'essively increased. It is now six timcs as large as it was four years ago (2,440,000 DA in 1967 and 400,000 DA in 1964). Clinics. like hospitals, spend more than 50 ~ of their funds on salaries. It is therefore reasonable to estimate that the real cost ofclinics is between 5 and 6 millions DA or $1 million per annum. Pre venlion BCG vaccination is the principal means of prevention in Algeria. Vaccinations are performed by Mother and Child Welfare Centrcs, Maternity Homes, and School Hygiene Centres, but chiefly by mobile units, teams specialized in mass sanitary action, under the direction of an epidemiologist. Tuberculosis prevention is therefore an integral part of the regular work of several services of the Ministry of Health, each of which has its own budget. The number of people vaccinated has risen sharply over the last four years chiefly through the efforts of the mobile health units. The number of doses of vaccine supplied to the different services increased from 46,113 in 1963 to roughly 900,000 in 1966. In the tirst tive months of 1967, 490,000 doses have been supplied, and the target for vaccinations this year is 1 million. As a result, the budget for the purchase of BCG (fresh BCG produced in Algeria, or imported freeze-dried BCG) has progressively risen. The budget for hospitals is more than 65,000,000 DA, which is 92% of the funds available for tuberculosis control, while the budget for clinics is about 5,000,000 DA or 1/13 of the amount spent on hospitals. The budget for the purchase of BCG is less than 1,000,900 DA. Discussion It has not been possible to consider all the economic aspects of tuberculosis control. For instance, we have not taken into account the cost of diagnosing and treating patients in general clinics, the funds allocated to tuberculosis control by the Social Security Organisation, and the cost of consultations and treatment by doctors in private practice. Likewise no estimate has been possible of the economic loss incurred through patients being away from work. Nevertheless the figures we have collected enable us to assert that even though Algeria spends a relatively large sum on tuberculosis control (about 5 D A or $ 1 per inhabitant per annum) more than 90% of the funds are spent on hospital beds.
6
T U B E R C L E SU PP1,EMI'~NT
The Algerian tuberculosis specialists are aware of this position and of the advances in chemotherapy. They llave therefore asked the Ministry of Public Health to increase the number ofclinic.~. to provide clinics With better equipment, and to reduce the number of hospital beds. This polic~, ~ beginning to be put into effect: the total number of clinics rose from 21 in 1966 to 30 in 1967. hen they were also granted a much larger budget. The number of hospital beds is going to b: reduced by about 1,400. At the same time there has been a considerable expansion in the work of prevention in 1966 and 1967. This will increase in tile coming months, as the Ministry of Health i, collaborating with the International Union against Tuberculosis in preparing a mass vaccination campaign, which is intended to cover the 6 million Algerians under the age of 20 o\'er a period of from 2 to 3 years. We hope that the modification of goals ana a continuing tinancial effort will result in tuberculosis being controlled in Algeria, and that it will eventually become a public health problem of only minor importance for tl~e country.
TUBERCULOSIS
CONTROL--COUNTING
TIlE C O S T
By Pi~:RCI!: W. Kti.~-r from the "Exist Africa Tuherculo.~'i~" h2restt~eatiorn C2,ntrt', p . o . fl:zt- 7855. :V~zirobi
As I intend to discuss cost accounting in tuberculosis control against tixe background of deu ing countries let me briefly remind you of such countries' main characteristic.~ as are relevant in this context--illustrating what I have to say from East Afric:tn ligur,:s. First, there is the matter of the low per capita annual income and of the small amount of money available for central government health expenditure. 1he ~tveragc income per head of population in East Africa is s a ",'ear. Compared to the United Kingdom tigure of s the average East African income amount.q to one shilling in the pound. The annual national health expenditure is between six and seven shillings per head of population--say one tlaird of a p o u n d - - a s against s in the United Kingdom. This means that for every one pound that can be spent on the health of the individual in Britain four pennies are available in East Africa. Secondly, the task in a developing country that has to be tackled with this anaount of money is certainly a formidable one. The infant mortality rate in 189 per 1000 live births, the death ra'te in children aged 1 ~oi 14 is 20,000 per million per year and the expectatio~ of life at birth is40 years. This can be compared with 20 per 1000, 500 per million and 70 years respectively for the United Kingdom. A m o n g a total population o f a b o u t 25 million people, there are 10 million Mantoux positive to a low dose of tuberculin and a further half a million becoming infected by the tubercle bacillus each year. There are at any one time about 300,000 people suffering from tuberculosis. Furthermore, 60,000 people contract it each year, of whom 20,000 are brought under t r e a t m e n t ~ h a l f of them successfully. Such is the rather sombre tuberculosis situation prevailing in East Africa. I suggest that East Africa is not unique in this respect. If one attempts to cost the control measures actually being taken in such a situation as t h i s ~ whether one does it on a country-wide or on a more modest district b a s i s ~ o n e immediately recognizes the virtual impossibility of such a task. The main reason is that in any particular instance the various elements of the control measures are, to a large extent, of a part-time nature. A district tuberculosis effort is under the control of the district medical officer of h e a l t h - - d o you charge one, ten or one hundred per cent of his emoluments to the anti-tuberculosis scheme ? Similarly as regards transport charges, x-ray and laboratory costs, and dispensary and health services expenditure