A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: lessons from the national TB control program in Zimbabwe in 2018.

BACKGROUND: Insufficient cost data and limited capacity constrains the understanding of the actual resources required for effective TB control. This study used process maps and time-driven activity-based costing to document TB service delivery processes. The analysis identified the resources required to sustain TB services in Zimbabwe, as well as several opportunities for more effective and efficient use of available resources. METHODS: A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel's practical capacity and capacity cost rates were calculated on five cost domains. An MS Excel model calculated diagnostic and treatment costs. FINDINGS: Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Considerable variations were observed among the facilities in how health care professionals performed client registration, taking of vital signs, treatment follow-up, dispensing medicines and processing samples. The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost components were personnel (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). CONCLUSION: TDABC is a feasible and effective costing and management tool in low-resource settings. The TDABC process maps and treatment costs revealed several opportunities for innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could produce better and more uniform TB treatments at significantly lower cost in Zimbabwe.

Feasibility and yield of screening for diabetes mellitus among tuberculosis patients in Harare, Zimbabwe.

SETTING: A resource-limited urban setting in Zimbabwe with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV). OBJECTIVES: To determine the feasibility and yield of diabetes mellitus (DM) screening among TB patients in primary health care facilities. DESIGN: A descriptive study. RESULTS: Of the 1617 TB patients registered at 10 pilot facilities, close to two thirds (60%) were male and 798 (49%) were bacteriologically confirmed. The median age was 37 years; two thirds (67%) were co-infected with HIV. A total of 1305 (89%) were screened for DM, and 111 (8.5%, 95% CI 7.0-10.2) were newly diagnosed with DM. Low TB notifying sites were more likely than high TB notifying sites to screen patients using random blood glucose (RBG) (83% vs. 79%; P < 0.04). Screening increased gradually per quarter over the study period. There were, however, notable losses along the screening cascade, the reasons for which will need to be explored in future studies. CONCLUSION: The study findings indicate the feasibility of DM screening among TB patients, with considerable yield of persons newly diagnosed with DM. Scaling up of this intervention will need to address the observed losses along the screening cascade.