OBJECTIVE: To determine the affordability and cost-effectiveness of home-based directly observed therapy (DOT) compared to hospital-based DOT for chronically ill tuberculosis (TB) patients, and to describe the characteristics of patients and their caregivers.

DESIGN: Costs for each alternative strategy were analysed from the perspective of the health system and caregivers, in 1998 US$. Caregiver costs were assessed using a structured questionnaire administered to a sample of 50 caregivers. Health system costs were assessed using interviews with relevant staff and documentary data such as medical records and expenditure files. These data were used to calculate the average cost of individual components of care, and, for each alternative strategy, the average cost per patient treated. Cost-effectiveness was calculated as the cost per patient compliant with treatment. The characteristics of caregivers and patients were assessed using demographic and socio-economic data collected during interviews, and medical records.

RESULTS: Overall, home-based care reduced the cost per patient treated by 44% compared with hospital-based treatment ($1657 vs. $2970). The cost to the caregiver was reduced by 23% ($551 vs. $720), while the cost to the health system was reduced by 50% ($1106 vs. $2206). The cost per patient complying with treatment was $1726 for home-based care and $2970 for hospitalisation. Caregivers were predominantly female relatives (88%), unemployed (48%), with primary school education or less (82%), and with an income of less than $1000 per annum (71%). Of those patients with an HIV test result, 98% were HIV-positive.

CONCLUSION: Home-based care is more affordable and cost-effective than hospital-based care for chronically ill TB patients, although costs to caregivers remain high in relation to their incomes. Structured home-based DOT should be included as a component of the National Tuberculosis Control Programme in Botswana.