Makerere University School of Public Health, Kampala, Uganda.
Brandeis University, Waltham, Massachusetts, USA.
BMJ Open. 2024 Oct 9;14(10):e082062. doi: 10.1136/bmjopen-2023-082062.
In high HIV-burden countries like Uganda, financing and resource allocation for HIV services have rapidly evolved. This study aimed to employ time-driven activity-based costing (TDABC) to examine the allocation of resources and associated costs for HIV care throughout the country.
A cross-sectional study.
This study was conducted at 31 health facilities throughout Uganda: 16 level III health centres, 10 level IV health centres and 5 district hospitals.
1119 persons receiving HIV services in 2020.
We conducted TDABC to quantify costs, resource consumption and duration of service provision associated with antiretroviral therapy, prevention of mother-to-child transmission, HIV counselling and testing (HCT), voluntary medical male circumcision (VMMC) and pre-exposure prophylaxis. We also quantified disparities in resource consumption according to client-level and facility-level characteristics to examine equity. Fixed-effects multivariable regression analyses were employed to inspect factors associated with service costs and provider-client interaction time.
The mean cost of services ranged from US$8.18 per visit for HCT to US$32.28 for VMMC. In terms of disparities, those in the Western region received more provider time during visits compared with other regions (35 more minutes, p<0.001); and those receiving care at private facilities received more provider time compared with public facilities (13 more minutes, p=0.02); and those at level IV health centres received more time compared with those at level III (12 more minutes, p=0.01). Absent consumables, services for older adults (US$2.28 higher, p=0.02), those with comorbidities (US$1.44 higher, p<0.001) and those living in the Western region (US$2.88 higher, p<0.001) were more expensive compared with younger adults, those without comorbidities and those in other regions, respectively. Inclusive of consumables, services were higher-cost for individuals in wealthier households (US$0.83 higher, p=0.03) and those visiting level IV health centres (US$3.41 higher, p=0.006) compared with level III.
Costs and resources for HIV care vary widely throughout Uganda. This variation requires careful consideration: some sources of variation may be indicative of vertical and horizontal equity within the health system, while others may be suggestive of inequities.
在像乌干达这样艾滋病毒负担高的国家，艾滋病毒服务的供资和资源分配迅速演变。本研究旨在采用时间驱动的作业成本法（TDABC）来考察全国艾滋病毒护理的资源分配和相关成本。
横断面研究。
本研究在乌干达的 31 个卫生设施中进行：16 个三级保健中心、10 个四级保健中心和 5 个地区医院。
2020 年接受艾滋病毒服务的 1119 人。
我们采用 TDABC 来量化与抗逆转录病毒治疗、预防母婴传播、艾滋病毒咨询和检测（HCT）、自愿医疗男性包皮环切（VMMC）和暴露前预防相关的成本、资源消耗和服务提供时间。我们还根据客户和设施特征量化了资源消耗的差异，以检查公平性。采用固定效应多变量回归分析来检查与服务成本和提供者-客户互动时间相关的因素。
每次就诊的服务平均费用从 HCT 的 8.18 美元到 VMMC 的 32.28 美元不等。在差异方面，与其他地区相比，西部地区的就诊时间接受更多的提供者时间（35 分钟，p<0.001）；在私人设施接受护理的人比在公共设施接受护理的人接受更多的提供者时间（13 分钟，p=0.02）；在四级保健中心接受护理的人比在三级保健中心接受护理的人接受更多的时间（12 分钟，p=0.01）。如果不考虑消耗品，老年患者（高 2.28 美元，p=0.02）、有合并症患者（高 1.44 美元，p<0.001）和西部地区患者（高 2.88 美元，p<0.001）的服务费用高于年轻患者、无合并症患者和其他地区患者。如果包括消耗品，与三级保健中心相比，较富裕家庭（高 0.83 美元，p=0.03）和四级保健中心（高 3.41 美元，p=0.006）的患者服务费用更高。
乌干达各地艾滋病毒护理的成本和资源差异很大。这种差异需要仔细考虑：一些差异的来源可能表明卫生系统内存在垂直和水平公平性，而其他差异可能表明存在不公平现象。
