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Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation.

Shelley KD, Ansbro ÉM, Ncube AT, Sweeney S, Fleischer C, Tembo Mumba G, Gill MM, Strasser S, Peeling RW, Terris-Prestholt F - PLoS ONE (2015)

Bottom Line: Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011.While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale.Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance.

View Article: PubMed Central - PubMed

Affiliation: Department of Epidemiology & Biostatistics, George Washington University School of Public Health, Washington, DC, United States of America.

ABSTRACT
Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider's perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.

No MeSH data available.


Related in: MedlinePlus

Economic cost drivers at surveyed pilot and rollout facilities.Central-level supervision (including QA/QC costs during pilot) accounted for over half of costs. Supervision, start-up, and health facility costs (supplies, personnel) were also major cost drivers.
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pone.0125675.g001: Economic cost drivers at surveyed pilot and rollout facilities.Central-level supervision (including QA/QC costs during pilot) accounted for over half of costs. Supervision, start-up, and health facility costs (supplies, personnel) were also major cost drivers.

Mentions: Across pilot facilities, total economic costs ranged from $1,952 to $4,799 (Table 4). Central-level costs (supervision and QA/QC) comprised the majority of costs (53.4%), followed by facility-level costs (42.8%) and start-up costs (3.8%). Overall, supervision (34.0%), supplies (26.3%), clinic personnel (16.1%), and QA/QC (19.3%) were the major cost drivers during the pilot (Fig 1). Pilot QA/QC costs ranged from $204 to $883 and supervision costs (central-level personnel and vehicle costs) averaged around $1,500 per Lusaka facility and $770 for Mongu facilities which were visited less frequently. In comparison, during rollout, the total economic costs ranged from $882 to $1,719 (Table 4); health facility costs (31.2%) comprised a lower proportion of total costs compared to the pilot given the far lower RST coverage (Fig 1). During the rollout, supervision by central level personnel (38.1%) and the associated transport costs (18.6%) were major cost drivers. Clinic personnel (16.4%), supplies (13.2%), and start-up (12.1%) were also major cost components (Fig 1). In-depth supervision and QA/QC mechanisms put in place during the pilot phase were not similarly implemented during rollout, yet central-level pilot costs (53.4%) were similar to rollout costs (56.7%), discussed below.


Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation.

Shelley KD, Ansbro ÉM, Ncube AT, Sweeney S, Fleischer C, Tembo Mumba G, Gill MM, Strasser S, Peeling RW, Terris-Prestholt F - PLoS ONE (2015)

Economic cost drivers at surveyed pilot and rollout facilities.Central-level supervision (including QA/QC costs during pilot) accounted for over half of costs. Supervision, start-up, and health facility costs (supplies, personnel) were also major cost drivers.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4430530&req=5

pone.0125675.g001: Economic cost drivers at surveyed pilot and rollout facilities.Central-level supervision (including QA/QC costs during pilot) accounted for over half of costs. Supervision, start-up, and health facility costs (supplies, personnel) were also major cost drivers.
Mentions: Across pilot facilities, total economic costs ranged from $1,952 to $4,799 (Table 4). Central-level costs (supervision and QA/QC) comprised the majority of costs (53.4%), followed by facility-level costs (42.8%) and start-up costs (3.8%). Overall, supervision (34.0%), supplies (26.3%), clinic personnel (16.1%), and QA/QC (19.3%) were the major cost drivers during the pilot (Fig 1). Pilot QA/QC costs ranged from $204 to $883 and supervision costs (central-level personnel and vehicle costs) averaged around $1,500 per Lusaka facility and $770 for Mongu facilities which were visited less frequently. In comparison, during rollout, the total economic costs ranged from $882 to $1,719 (Table 4); health facility costs (31.2%) comprised a lower proportion of total costs compared to the pilot given the far lower RST coverage (Fig 1). During the rollout, supervision by central level personnel (38.1%) and the associated transport costs (18.6%) were major cost drivers. Clinic personnel (16.4%), supplies (13.2%), and start-up (12.1%) were also major cost components (Fig 1). In-depth supervision and QA/QC mechanisms put in place during the pilot phase were not similarly implemented during rollout, yet central-level pilot costs (53.4%) were similar to rollout costs (56.7%), discussed below.

Bottom Line: Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011.While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale.Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance.

View Article: PubMed Central - PubMed

Affiliation: Department of Epidemiology & Biostatistics, George Washington University School of Public Health, Washington, DC, United States of America.

ABSTRACT
Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider's perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.

No MeSH data available.


Related in: MedlinePlus