Redefining and revisiting cost estimates of routine ART care in Zambia: an analysis of ten clinics

Abstract

Introduction Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task‐shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out‐of‐date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV‐positive patients in Zambia. Methods We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity‐based costing framework using both top‐down and bottom‐up methods with an assessment of process and capacity. We collected primary site‐level costs and resource utilization data from government documents, patient chart reviews and time‐and‐motion studies conducted in 10 purposively selected ART clinics. Results The cost of providing ART varied considerably among the ten clinics. The average per‐patient annual cost of ART service was $116.69 (range: $59.38 to $145.62) using a bottom‐up method and $130.32 (range: $94.02 to $162.64) using a top‐down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long‐term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top‐down and bottom‐up estimates. Variability in cost across the ten clinics was associated with operational characteristics. Conclusions Real‐world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates.

Activity-based costing for HIV, primary care and nutrition services in low- and middle-income countries: A systematic literature review and synthesis

“… 18 The lowest per patient costs was reported for two clinics in Zambia, reporting human resource per patient costs of US$3.11. 19 The cross-study weighted human resource per patient cost for HIV services is US$26.60. Equipment and capital costs are the lowest cost category with a cross-study average of US$1.68, ranging from a low of US$0.16 in one clinic in Zambia (Clinic 10) to a high of US$25.08 in one state in India (Jalna State).…”

“…Equipment and capital costs are the lowest cost category with a cross-study average of US$1.68, ranging from a low of US$0.16 in one clinic in Zambia (Clinic 10) to a high of US$25.08 in one state in India (Jalna State). 17 , 19 The cross-study average for laboratory cost is US$19.01, ranging from a low of US$1.08 in Malawi to a high of US$185.56 in Burkina Faso. 14 , 20 The cross-study average for supply costs are US$4.01, ranging from a low of US$0.59 in Zambia to a high of US$26.41 in India.…”

“… 14 , 20 The cross-study average for supply costs are US$4.01, ranging from a low of US$0.59 in Zambia to a high of US$26.41 in India. 17 , 19 The cross-study average for ART and medicines cost is US$125.41 per person, with a high of US$547.63 for India, Pandharpur, and a low of US$1.89 for Malawi, Neno District. 14 , 17 The total per patient unit cost of implementing HIV services that includes human resources, equipment and capital, laboratory, supplies, and ARTs and medicines is US$176.71 per patient per year.…”

Costs and cost-effectiveness of a comprehensive tuberculosis case finding strategy in Zambia

“…Third, our empiric cost estimates were assessed using a top-down method only and were limited to one semi-urban health clinic in Zambia. Economic cost estimates of health services may vary depending on settings in which the services are deployed, methods used to evaluate costs, and how costs associated with implementation are accounted for in the analysis [ 39 , 40 ]. While our findings may not generalize to epidemiological and health system contexts that are very different from our study, costs assessed at various points provide empiric uncertainty estimates of the cost of ACF and can be contextualized to different levels of operational and implementation efficiencies.…”

Determining the value of TB active case-finding: current evidence and methodological considerations

“…Main cost outcomes include total program costs, service unit costs (e.g., cost per Xpert test), and cost per program yield (e.g., cost per patient screened, patient tested, TB diagnosis, and treatment completion). Top-down costing may be less precise and portrays different types of costs than a bottom-up approach (typically resulting in higher cost estimates), 46,47 but this framework allows cost data to be disaggregated in a standardized and comparative manner. Prospective data collection can enable estimation of uncertainties in cost estimates associated with program operations and workloads.…”