Summaryintroduction There is growing international evidence that artemisinin-based combination therapy (ACT) is one of the few effective measures available to 'Roll Back Malaria'. However, concerns about the costs and affordability of ACT are obstacles to its widespread implementation. This paper explores some economic aspects of the implementation of artemether-lumefantrine (AL) to replace sulphadoxine-pyrimethamine (SP) in the KwaZulu Natal (KZN) province, South Africa.methods Recurrent and capital costs for malaria treatment were compared at baseline and post-intervention for nine clinics and a sentinel rural district hospital. Changes in the unit costs of, and total expenditure on, malaria services were calculated and the cost effectiveness of AL relative to SP was assessed.results The number of outpatient malaria cases and inpatient admissions both declined by 94% between 2000 and 2002. After accounting for the role of concurrent improvements in vector control, it was conservatively estimated that 36% of the decline in outpatient cases and 46% for inpatient admissions was attributable to changing the first-line drug to AL. Although AL is considerably more expensive than SP, its improved cure rate and reduced malaria transmission resulted in an estimated US$ 201 065 cost saving in 2002 alone for the subdistrict studied.discussion In the context of effective vector control and low efficacy of existing monotherapy, ACT can reduce total expenditure on malaria services. However, the relevance of these findings requires careful consideration in countries with currently effective treatment policies and higher intensity malaria transmission.

This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as “established on treatment” can join a suitable DSDM.Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients’ resource utilization data, top-down collection of above-delivery level and delivery-level providers’ fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96–100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models’ costs were largely due to clients’ ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66–16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of “saved” staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.

Background In Uganda, there are persistent weaknesses in obtaining accurate, reliable and complete data on local and external investments in immunization to guide planning, financing, and resource mobilization. This study aimed to measure and describe the financial envelope for immunization from 2012 to 2016 and analyze expenditures at sub-national level. Methods The Systems of Health Accounts (SHA) 2011 methodology was used to quantify and map the resource envelope for immunization. Data was collected at national and sub-national levels from public and external sources of immunization. Data were coded, categorized and disaggregated by expenditure on immunization activities using the SHA 2011. Results Over the five-year period, funding for immunization increased fourfold from US$20.4 million in 2012 to US$ 85.6 million in 2016. The Ugandan government was the main contributor (55%) to immunization resources from 2012 to 2014 however, Gavi, the Vaccine Alliance contributed the majority (59%) of the resources to immunization in 2015 and 2016. Majority (66%) of the funds were managed by the National Medical Stores. Over the five-year period, 80% of the funds allocated to immunization activities were spent on facility based routine immunization (expenditure on human resources and outreaches). At sub-national level, districts allocated 15% of their total annual resources to immunization to support supervision of lower health facilities and distribution of vaccines. Health facilities spent 5.5% of their total annual resources on immunization to support outreaches. Conclusion Development partner support has aided the improvement of vaccine coverage and increased access to vaccines however, there is an increasing dependence on this support for a critical national program raising sustainability concerns alongside other challenges like being off-budget and unpredictable. To ensure financial sustainability, there is need to operationalize the immunization fund, advocate and mobilize additional resources for immunization from the Government of Uganda and the private sector, increase the reliability of resources for immunization as well as leverage on health financing reforms like the National Health Insurance.

Background: Like many countries in sub-Saharan Africa, Uganda has scaled up differentiated service delivery models (DSDMs) for HIV treatment, but little information is available about the relative costs of the models. We estimated the total annual cost per patient and total cost per patient virally suppressed in five DSDMs, including facility- and community-based models and the standard of care. Methods: We conducted a cost/outcome study from the perspective of the service provider, using retrospective patient record review of a cohort of patients over a two-year period, with bottom-up collection of patient resource utilization data, top-down collection of above-delivery level and delivery-level provider fixed operational costs, and local unit costs. We enrolled adults on ART (>18 years old) enrolled in 47 DSDMs located at facilities or community-based service points in four regions of Uganda with at least 24 months of follow-up data. DSDMs assessed included facility-based groups (FBG); fast-track drug refills (FDR); community client-led ART delivery (CCLAD); community drug distribution points (CDDP); and facility-based individual management (FBIM), which is the standard of care model for new, complex, and virally unsuppressed patients. Viral suppression was defined as <1000 copies/ml. Results: Retention in care was 98% for the sample as a whole [96-100%]. Over viral suppression was 91%, which varied from 86% among patients in FBIM (with the largest share of complex / virally unsuppressed patients) to 93% among CDDP patients. The mean cost to the provider (Ministry of Health or NGO implementers) was $152 per annum per patient treated, ranging from $141 for FBG to $166 for FDR. Differences among the costs of the models were largely due to ARV regimens and proportions of patients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66-16.43 per patient. Conclusions: Differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care (FBIM). While large budgetary savings might not be immediately realized, the reallocation of saved staff time could improve health system efficiency as facilities and patients gain more experience with DSD models.