Chirenda J, Nhlema Simwaka B, Sandy C, Bodnar K, Corbin S, Desai P, Mapako T, Shamu S, Timire C, Antonio E, Makone A, Birikorang A, Mapuranga T, Ngwenya M, Masunda T, Dube M, Wandwalo E, Morrison L, Kaplan R
College of Health Sciences, Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe.
The Global Fund to Fight TB, HIV and Malaria, Global Health Campus, Chemin du Pommier 40, 1218 Grand-Saconnex, Geneva, Switzerland.
BMC Health Serv Res. 2021 Mar 18;21(1):242. doi: 10.1186/s12913-021-06212-x.
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.
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.
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).
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.
成本数据不足和能力有限限制了对有效结核病控制所需实际资源的理解。本研究使用流程图和时间驱动作业成本法来记录结核病服务提供流程。该分析确定了津巴布韦维持结核病服务所需的资源，以及更有效和高效利用现有资源的若干机会。
一个多学科团队应用时间驱动作业成本法（TDABC）来绘制流程图，并衡量城市综合诊所、农村地区和省级医院用于药物敏感结核病（DS-TB）的临床路径成本，以及基于社区的结核病目标筛查（Tas4TB）成本。该团队进行访谈和观察，以收集医护人员与患者在治疗路径各阶段所花费时间的数据。根据五个成本领域计算人员的实际能力和能力成本率。一个MS Excel模型计算诊断和治疗成本。
除社区结核病目标筛查外，所有卫生设施的结核病护理路径中确定了25个阶段。在医护人员如何进行客户登记、测量生命体征、治疗随访、配药和处理样本方面，各设施之间存在相当大的差异。整个DS-TB护理的人均成本为324美元，诊断成本为69美元，治疗成本为255美元。诊所的诊断和治疗平均成本高于医院（392美元对256美元）。诊所的护士成本比医院高1.6倍。主要成本组成部分是人员（130美元）和实验室（119美元）。Tas4TB的诊断成本是卫生设施环境下的两倍（153美元对69美元），主要成本驱动因素是需求创造（89美元）和痰标本运输（5美元对3美元）。
在资源匮乏地区，TDABC是一种可行且有效的成本核算和管理工具。TDABC流程图和治疗成本揭示了在公共卫生项目环境下国家结核病防治规划中进行创新改进的若干机会。重新设计实验室检测流程，并使结核病治疗随访与抗逆转录病毒治疗同步，可能会在津巴布韦以显著更低的成本提供更好、更统一的结核病治疗。
