Catalysing tuberculosis elimination in Indonesia: Health economic and policy insights from the BPaL regimen.

BACKGROUND: Indonesia diagnoses roughly 24,000 multidrug-resistant tuberculosis (MDR-TB) cases each year, 8% of the world's total. Conventional treatment runs 18-24 months, costs US$7,142-9,000 per patient, and succeeds in only 59% of cases. The WHO endorsed Bedaquiline-Pretomanid-Linezolid (BPaL) regimen has shown over 89% efficacy in controlled trials, but real-world health economic data from low- and middle-income countries remain scarce. METHODS: We conducted a retrospective cohort study of 84 patients with MDR-TB, rifampicin-resistant TB (RR-TB), or pre-extensively drug-resistant TB (pre-XDR-TB) treated at Persahabatan Hospital, Jakarta, between 2021 and 2024. We compared treatment success, costs, and operational metrics against historical controls from 2018-2020. Statistical methods included chi-square tests, multivariate logistic regression, and incremental cost-effectiveness ratio (ICER) calculations, with sensitivity analyses across ±20% cost and ±10% efficacy ranges. RESULTS: BPaL achieved 77.4% treatment success (65/84 patients) compared with 59% in historical controls (p < 0.01). Per-patient costs dropped 67%, from US$7,142-9,000 to US$2,310. The ICER was US$311.4 per additional treatment success. Hospital stays shortened by 60% (10 versus 25 days; p < 0.01), and adherence climbed from 70% to 95.2% (p < 0.01). CONCLUSIONS: BPaL is effective, affordable, and ready to scale. Integrating it into Indonesia's Jaminan Kesehatan Nasional (JKN) framework and expanding decentralised diagnostics could accelerate progress towards WHO End TB 2030 targets. Our findings offer a replicable model for other low- and middle-income settings.