Bulletin of the World Health Organization

Cost and cost-effectiveness of PPM-DOTS for tuberculosis control: evidence from India

Katherine Floyd, VK Arora, KJR Murthy, Knut Lönnroth, Neeta Singla, Y Akbar, Matteo Zignol, & Mukund Uplekar



To assess the cost and cost-effectiveness of the Public–Private Mix DOTS (PPM-DOTS) strategy for tuberculosis (TB) control in India.


We collected data on the costs and effects of pilot PPM-DOTS projects in Delhi and Hyderabad using documentary data and interviews. The cost of PPM-DOTS was compared with public sector DOTS (i.e. DOTS delivered through public sector facilities only) and non-DOTS treatment in the private sector. Costs for 2002 in US$ were assessed for the public sector, private practitioners, and patients/attendants. Effectiveness was measured as the number of cases successfully treated.


The average cost per patient treated was US$ 111–123 for PPM-DOTS and public sector DOTS, and US$ 111–172 for non-DOTS treatment in the private sector. From the public sector’s perspective, the cost per patient treated was lower in PPM-DOTS projects than in public sector DOTS programmes (US$ 24–33 versus US$ 63). DOTS implementation in either the public or private sectors improved treatment outcomes and substantially lowered costs incurred by patients and their attendants, compared to non-DOTS treatment in the private sector (US$ 50–60 for DOTS compared to over US$ 100 for non-DOTS). The average cost-effectiveness of PPM-DOTS and public sector DOTS was similar, at US$ 120–140 per patient successfully treated, compared to US$ 218–338 for non-DOTS private sector treatment. Incremental cost-effectiveness analysis showed that PPM-DOTS can improve effectiveness while also lowering costs.


PPM-DOTS can be an affordable and cost-effective approach to improving TB control in India, and can substantially lower the economic burden of TB for patients.