A cost minimization analysis technique adopting the healthcare providers’ point of view as at the time of data collection was conducted. This was done to illustrate the cost variations from the standalone pathways to the integrated clinical pathway. A model was developed to calculate total direct costs associated with managing patients in the standalone HBV and HIV clinics compared to the costs when the two clinics were merged and both HBV-mono-infected and HIV infected patients were seen through one clinical pathway.
2.1 Data collection
Data and relevant information was collected in two phases prospectively from the standalone and integrated pathways. In both facilities, we sought expert opinions from key staff who were purposively selected to provide information about the respective costing elements. These included: Medical superintendents, Hospital administrators, Nurses, Clinicians, Laboratory technicians and Accountants. This was done to ascertain types and, in some cases, amounts of on-site resources (e.g. clinic staff, staff salaries and benefits, medications recurring consumables and administrative costs). Costs for off-site resources (e.g. linkage officers, community out reaches, transportation costs) which were not directly linked to the pathway were not determined. In addition, we reviewed administrative records such as delivery notes, invoices, payment vouchers and budgets to ascertain staff salaries and allowances for support staff, costs of medications and laboratory tests, costs of consumables and utilities, costs of transportation and equipment. Finally, we conducted time use surveys in each section of the pathway in both clinics before and during the integration to establish the proportion of total work time clinic staff spent providing care.
2.2 Description of the Clinical Pathways.
In both hospitals, we surveyed the standalone and the integrated clinics to determine patient flow in the clinical pathway. We mapped patient flow in the standard standalone clinics for both HBV and HIV clinics in both hospitals and then designed a standard integrated pathway incorporating HBV patients into HIV clinical pathway in each of the hospitals in accordance with the guidelines for HIV and HBV treatment.
2.3 Costing methodology
2.3.1 Costing Inputs.
The study captured only financial costs to measure the amount of money spent on a resource used in the running of the standalone and the integrated clinical pathway. These were inputs used in the delivery of services along the pathway that could be directly assigned to patients. We considered case-specific direct costs that were collected based on the services received by the patient along the pathway before and during the integration. For example, an HBV infected patient on treatment required services of the pharmacy whereas the one on monitoring did not. These inputs included: physical infrastructure used for client care; medical equipment; medical consumables and supplies used; laboratory testing; drugs; and staff time in caring for clients. Labor costs of administrative staff; overhead expenses (such as office supplies, communication, etc.), biosafety requirements and data management systems. There were no user fees involved. Patient costs on treatment in rural health centers, private transportation and indirect cost (such as cost of food, accompanying family members, lost labor time etc.) were not considered. Drug costs within the hospital were only considered when directly associated with HBV or HIV treatment regimen.
2.3.2 Cost data sources
Cost estimates were obtained from clinic inputs and procurement invoices. Additional information was obtained from budgetary documentation reviews, procurement guides, and publicly available product information. Expert opinion was sought from suppliers, implementing partners, local distributer and health workers. Previous costing studies within and outside Uganda were reviewed to validate some of the estimates (4). More cost data was obtained from the hospital administration and accounts department, implementing partners, available literature, expert opinion, National medical stores price catalogue and health facility records such as delivery notes, budgets and invoices among others.
2.3.3 Costing Approach
This study predominantly used activity based (bottom-up) approach except for some overheads where a top-down analysis was used (12). This costing approach was based on the concept that activities consume resources to produce an output. It measures the cost and performance of activities, resources and cost objects. Resources are assigned to activities, then activities are assigned to cost objects based on their use (13). In this study, the entire treatment process was divided into several activities at different sections of the pathway. We modelled the total annual costs per patient as a sum of the five cost categories: personnel, medications, laboratory testing, other recurrent costs (Utilities and consumables) and fixed costs along the clinical pathway.
2.3.4 Quantification and valuation of inputs.
Model inputs involved only health facility inputs. Project inputs from implementing partners such additional staff and top-up allowances provided to staff were excluded from the analysis in both facilities. Resources associated with the standalone and integrated pathways were measured through observation of standard operating procedures as health workers and supporting staff performed their duties in their respective sections within the pathway. Staff salary for example was allocated based on the time spent on the reference case as a proportion of monthly worktime. The useful life span of medical equipment used was considered according to the manufactures’ instructions where possible or an estimated time period from expert opinion. Building space occupied was given an assumed expected lifetime of 30 years. All costs were estimated as of mid-year prices of 2020 and converted to US dollars using published Bank of Uganda exchange rates. The time horizon for cost analysis was one year and thus discounting for future costs was not done. A unit cost per patient per year was calculated by summing up the unit costs determined from each cost center in the pathway. We estimated per person per year (pppy) costs obtained as a sum total of the costs incurred for all clinic visits in one year. The model did not include long-term effects of missed appointments or unintentional delays in pathway. Sensitivity analysis done was majorly centered on the varying patients’ numbers per month, the number of refill of visits per year and the frequency of monitoring laboratory tests done annually. These varied by patient condition as determined by the medical team from time to time. We also varied the costs of consumables because their values were majorly obtained from expert opinion and fluctuating market prices.
2.4 Costing assumptions
We assumed an average number of four visits per year for both HBV and HIV stable regular patients since the frequency of appointments varied based on patients’ level of adherence, rate of missing appointments, viral load levels and distance to the facility among others. We assumed a male HBV/HIV mono-infected patient on first line treatment as a reference case in assigning the costs. In the cost minimisation analysis, we assumed equivalence in patient health outcomes for the standalone and the integrated pathways since the medications received by the patients was the same in both pathways. The study also assumed that all the overhead costs of infrastructure, laboratory tests, drug prescriptions, sample collection requirements and bio-safety requirements were equal for the standalone and integrated pathways in both facilities.
The useful life of the medical equipment was assumed to vary between 2 to 5 years and 20% of that use was allocated to HBV patients in the standalone clinics since the clinic used to operate one day a week (five working days) in both facilities. The useful life of the furniture in the clinics was assumed to vary between 5-10 years depending on the type and 100% of that use was allocated to patient use. We also assumed that the standalone clinics were independent of each other and that all patients from the HBV clinics were integrated into the existing HIV clinic structures.