HEALTH ECONOMICS COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES The case of Malawi
Item
- Title
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HEALTH ECONOMICS
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
COST ANALYSIS AND COST
CONTAINMENT IN TUBERCULOSIS
CONTROL PROGRAMMES
The case of Malawi
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COST ANALYSIS AND COST
CONTAINMENT IN TUBERCULOSIS
CONTROL PROGRAMMES
The case of Malawi
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Distr.: GENERAL
Original: English
HEALTH ECONOMICS
4
HEALTH
ECONOMICS
COST ANALYSIS AND COST
CONTAINMENT IN TUBERCULOSIS
CONTROL PROGRAMMES
The case of Malawi
Holger Sawert,
Global Tuberculosis Programme. WHO
WHO TASK FORCE ON
HEALTH ECONOMICS
May 1996
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
HEALTH ECONOMICS
Documents in the «Task Force on Health Economics* series are :
A bibliography of WHO literature.
WHO/TFHE/93.1 e-mail access:
A guide to selected WHO literature.
WHO/TFHE/94.1 e-mail access:
heconI @who.ch (English)
heconlf@who.ch (French)
hccon2@who.ch (English)
hecon2f@who.ch (French)
*
Une demarche participative de reduction des couts hospitaliers.
Hospices cantonaux vaudois (Suisse).
hecon3@who.ch (French)
WHO/TFHE/95.1 e-mail access:
hecon3e@who.ch (English)
Environment, health and sustainable development:
the role of economic instruments and policies.
WHO/TFHE/95.2 e-mail access:
hecon4@who.ch (English)
hecon4f@who.ch (French)
Identification of needs in health economics in developing countries.
WHO/TFHE/95.3 e-mail access:
hecon5@who.ch (English)
Health economics: a WHO perspective.
WHO/TFHE/95.4 e-mail access:
WTO: what’s in it for WHO?
WHO/TFHE/95.5 e-mail access:
hccon6@who.ch (English)
hecon8@who.ch (English)
hecon8f@who.ch (French)
Technical briefing note:
Privatization in health.
WHO/TFHE/TBN/95.1 e-mail access:
hecon7@who.ch (English)
He -»oo
Ha
05142
INWO
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© World Health Organization. 1996
This document is not a formal publication of the World Health Organization
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reserved
by the Organization. The document may, however, be freely reviewed, abstracfSCTT’e^reducea. and translated,
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in part or in whole, but not for sale or for use in conjunction with commercial purposes.
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COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
TABLE OF CONTENTS
I. INTRODUCTION
i
II. BASIC CONCEPTS............................................................................
3
A. ECONOMIC OR FINANCIAL COSTS?..............................
3
B. ASSESSING ECONOMIC COSTS..........................................
4
1. The viewpoint............................................................................
4
2. Cost categories.........................................................................
5
a) Capital costs / Recurrent costs.....................................
5
b) Costs at different programme levels.............................
6
c) Costs for specific activities............................................
7
3. Sampling....................................................................................
8
4. The concept of unit costs.......................................................
8
5. The problem of joint costs.....................................................
9
6. Average, incremental and marginal costs..............................
11
7. Comparing costs at different capacity use levels.................
13
8. The effect of inflation.............................................................
14
9. Using results for international comparisons and publications
14
III. THE CASE OF MALAWI..............................................................
16
A. INTRODUCTION TO THE MALAWI SETTING.............
16
B. CALCULATION OF ECONOMIC COSTS FOR
17
THE EXISTING PROGRAMME.......................................
1. Demographic and TB-specific statistics.......................
17
2. Determination of the programme structure.................
17
3. Determination of activities performed at
17
each level of the programme.......................................
4. Currently utilized inputs.................................................
18
5. Economic costs of inputs...............................................
19
19
a) Data sources.......................................
(1) Recurrent costs..................................................
19
(2) Capital costs......................................................
19
(3) Exchange rate....................................................
20
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
iii
HEALTH K0N0MK5
(4) Price deflator series............................
20
(5) Cost allocation for overhead costs.....
20
20
(6) Total costs and unit costs
.
c) Cost calculation: specific activities.........
21
21
21
21
22
(1) Hospital bed-days.................................
22
(2) Laboratory procedures........................
23
(3) X-Ray...................................................
25
26
26
26
27
b) Cost calculation: general cost categories
(1) Salaries..................................................
(2) Maintenance and overhead costs.......
(3) Drug costs............................................
d) Costs at various programme levels........
(1) Costs at central level..........................
(2) Costs at regional level.........................
(3) Costs at district level...........................
(4) Costs at health center level...............
e) Average costs per patient.......................
C. COSTS OF PROGRAMME MODIFICATIONS
1. Cost savings through ambulatory therapy.......
28
29
32
32
2. Cost savings through HIV testing before
33
thiacetazone replacement..................................
D. CONCLUSIONS.........................................................
E. DISCUSSION.................................................................
1. Comparison to previous studies.........................
2. Should thiacetazone be replaced?......................
3. Should patients be screened with radiography?
4. Reducing costs and ensuring quality of care....
iv
34
34
34
36
37
38
IV. APPENDIX: DATA TABLES..............
39
V. ANNOTATIONS AND REFERENCES
60
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
9
HEALTH ECONOMICS
LIST OF FIGURES AND TABLES
.........
13
23
Figure 3: Distribution of costs for sputum microscopy
24
Figure 4: Cost distribution at central level
Figure 6: Cost distribution at district level
26
27
28
Figure 7: Cost distribution at health center level
29
Figure 8: Cost per patient by programme level
Figure 9: Distribution of treatment costs
30
30
Figure 11: Distribution of costs for diagnosis
31
Table 1: Step down allocation of overhead costs
10
Table 2: Currently used drug regimens in Blantyre district
21
Table 3: Cost per patient at district level
28
Table 4: Average total costs per patient
29
Figure 1: The importance of the output level
Figure 2: Distribution of hospitalization costs
Figure 5: Cost distribution at regional level
Table 5: cost savings through ambulatory therapy for smear-negative patients 32
\
Table 6: Comparison of thiacetazone replacement policies
33
Appendix 1 :Population size: Malawi
39
Appendix 2: Tuberculosis incidence: Malawi
40
Appendix 3: List of currently utilized inputs
41
Appendix 4: annual staff salaries
Appendix 5: Allocation of overhead costs at Queen Elizabeth Hospital
45
Appendix 6: Costs of drug regimens currently in use in Malawi
47
Appendix 7: Calculation of the cost per hospital bed-day
49
Appendix 8: Cost calculation for sputum microscopy
50
Appendix 9: Cost calculation for laboratory extension
51
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
46
HEALTH ECONOMICS
Appendix 10: Cost calculation for sputum cultures....................
52
Appendix 11: Cost calculation for HIV tests..............................
53
Appendix 12: Cost calculation for conventional x-ray................
54
Appendix 13: Cost calculation for miniature radiography..........
55
Appendix 14: Cost calculation for the central programme level
56
Appendix 15: Cost calculation for the health center level........
57
Appendix 16: Cost calculation for the district level....................
58
Appendix 17: Cost calculation for regional level........................
59
a
9
vi
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
I. Introduction
The achievement of allocative and technical efficiency is a fundamental goal for the
management of economic systems. The search for the most efficient combination of
resources and the use of each resource in the most efficient way is mandatory to
optimize the production of desired outputs. A driving force behind this process is the
limited availability of resources. Both at the private and the societal level we are
constantly forced to make choices between alternative options to spend available
funds, and the obtainment of optimal utility levels depends on our ability to make
those choices that fulfill both efficiency criteria. For many years, the field of health
care appeared as an exception to this rule: “health” was taken as an absolute, of
which “the highest possible level” had to be obtained without regard to available
resources. In fact, the fulfillment of every health care need was regarded as a societal
obligation in many countries.
Over the past decades, it has become apparent that this fundamental departure from
basic economic rules has become unsustainable. Restrictions will have to be im
posed and choices among possible health care interventions will have to be made, as
in other aspects of our lives. While this is a new experience for patients and health
care providers in industrialized countries (and thus violently opposed by many), the
situation has been well known in low-income countries. Here, the choice is very
often not only between various health interventions, but whether to spend money on
health care at all, instead of building streets, constructing water-dams or training
schoolteachers.
How then are these choices made? One possibility is that the decision making proc
ess is limited to the exercise of political power. This may lead to a situation where the
distribution of health care funds addresses the specific needs of minorities, while
societally important health issues remain underfunded.
*
In the form of cost-effectiveness analysis, health economists attempt to rationalize
the decision-making process. The underlying idea is simple: realizing that not all
health care interventions can be funded, an attempt is made to specify the costs for
each intervention and relate them to the outcomes that it can achieve. If outcomes
(or “effectiveness”) of interventions are measured in comparable units, “cost-effec
tiveness ratios" can be calculated, i.e. the cost per unit of outcome for each interven
tion. As a result, those interventions that will provide the largest health gains for a
given and restricted budget can be specified. Allocating the health care budget for
these interventions will result in the most efficient use of funds and will produce the
highest societal benefits.
Especially for the situation in low-income countries, this approach has become more
influential in political argumentations during recent years25. The underlying con
cepts and techniques should therefore be known to managers of specific health care
programs to be able to compete successfully for the limited funds that are available.
Tuberculosis has been identified as the leading cause of death from infectious disCOST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
HEALTH ECONOMICS
eases in adults worldwide1. However, the viewpoint of cost-effectiveness demands
that this fact alone should not justify the allocation of scarce resources to fight the
disease. Instead, it needs to be demonstrated that any proposed tuberculosis control
intervention represents a choice promoting economic efficiency in the health care
sector. If tuberculosis control managers want to make a convincing point for their
intervention, they need to provide clear information on two aspects: outcomes of
their activities and economic costs incurred. The demonstration of outcomes de
pends on the availability of an accurate recording system that shows numbers of
patients treated and cured. Based on this information, the overall epidemiological
impact of control interventions can be estimated through the use of epidemiological
models. Finally, the combination of cost data and information on the epidemiologi
cal impact allows the determination of cost-effectiveness ratios9-2. Previous work in
this field related to tuberculosis has led to the identification of short-course chemo
therapy for tuberculosis as one of the most cost-effective of all available health inter
ventions25.
The cost analysis of tuberculosis control interventions can be performed with two
purposes: to compare the efficiency of currently existing programs with those of
other health care interventions (e.g., vaccinations or the provision of safe water); or,
to determine if the current program can (and should) be modified to maximize health
benefits with available resources. Based on these objectives, the topic of this docu
ment is therefore to determine the economic costs of
•
existing tuberculosis control activities
•
modifications to existing activities
2
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
//. Basic concepts
A. Economic or financial costs?
You are running a miniature TB control program, which consists of one nurse in a
small TB clinic. Besides seeing patients at the clinic and handing out drugs, the
nurse visits non-compliant patients on a motorcycle. Fortunately, she receives help
from the local women’s club, whose members spend afternoons as voluntary clinic
aides. During the current year, the nurse receives an annual salary of $6,000.-, you
have expenses for TB drugs of $4,000.-, and fuel and maintenance for the motorcy
cle add up to $2,000.-. You assume no inflation or changes in TB incidence rates,
and calculate a total cost of $12,000.- to run your program in the following year. The
minister of health approves your budget and acknowledges your excellent account
ing capabilities.
In the same year, you are asked by the minister of economic planning to prove the
cost-effectiveness of your program. Since you are treating 100 patients per year, you
write a report saying that the cost per patient treated is $120,-. The minister of eco
nomic planning accuses you of gross misinformation. Your experience prompts you
to consider the difference between financial and economic costs.
The figure that is reported in a budget for the minister of health represents the finan
cial cost of a program. It is usually equivalent to the expenses captured on expendi
ture sheets, with the limitation that only expenditures for items actually consumed
during the year should be counted: if there are drug expenses of $2,000.- but only
drugs worth 1,000.- are used (e.g., because of stocking up for the next year), the
financial drug costs are $1,000 per year.
The term “economic cost” is more comprehensive than financial cost. It includes all
resources consumed for the program, even if there is no monetary expenditure for
them. For the miniature program outlined above, resources that were used but not
included in the expenditure sheet are: the health center, the motorcycle and the vol
untary labor. Health center and motorcycle fall under the category of “capital” costs3.
What is the economic cost of using these items? One way of clarifying this point is
the notion that capital items have a limited lifespan. A building will normally last no
longer than 20-30 years, so during one year a certain percentage of the lifetime
worth of a building is “used up”. The same is true for the motorcycles, which usually
last for a shorter period of between 2-5 years. Another concept that can be used to
explain the economic cost for these items is that of “opportunity costs”: by using a
resource for one activity, one is forgoing the opportunity of using it for another.
Economic costs are the costs of forgoing the best possible alternative use for a re
source. An alternative use of the health center or the motorcycle would be to rent it
on the housing or vehicle market. The current market price for such rentals gives us
an indication of the opportunity we are forgoing by using them for TB control. Simi
larly, the ladies from the women’s club are forgoing the opportunity of earning an
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
3
HEALTH ECONOMICS
income on the regular job market. We cannot assume that they will remain so be
nevolent in the future. Although they currently receive no salary, their economic
costs should be valued (e.g., by using the regular wage rate for comparable labor, or
by an assessment of the opportunity cost of leisure time).
There are other examples of the differences between financial and economic costs.
They usually occur when government regulations have led to gross market distor
tions, so that market prices no longer reflect the opportunity cost of a resource. Of
practical importance are artificially low exchange rates that governments may fix to
decrease the price of imports. Since these rates do not reflect the actual scarcity of
foreign exchange, their use may lead to problems in sustaining programs that heav
ily rely on foreign exchange to buy inputs on the world market. The economic value
of foreign exchange is reflected in so-called “shadow” exchange rates. Other exam
ples of “shadow” prices are those for subsidized imports or unskilled labor for
which a minimum wage level may not reflect the true opportunity cost.
As a general rule, assessing the economic cost of an intervention is more compre
hensive than calculating financial costs because it includes items like capital costs
that do not occur on expenditure records. However, we will discuss below the im
portant concept of “incremental” and “marginal” economic costs, which are often
similar to financial costs. In certain circumstances, these cost categories are of more
practical interest to decision-makers than the total economic costs, and the cost as
sessment can be facilitated. However, many situations will require the calculation of
the total economic costs of an intervention. We will therefore describe the methodol
ogy for this purpose first4 5-6.
B. Assessing economic cost
1. The viewpoint
In our discussion of economic costs, we have until now assumed the viewpoint of
the Ministry of Health or other health care providers. The implicit question for the
purpose of cost-effectiveness analysis was “How can the provider obtain the maxi
mal amount of health gains under given budget constraints?” If the analysis is ex
tended to the assessment of an intervention from a societal perspective, there are
additional cost categories that should be taken into account. An example of costs
that we have omitted are the costs to patients. These usually consist of the patients’
“direct” expenditures for transportation or fees and the “indirect” costs of forgoing
worktime for clinic visits etc. Inclusion of these costs can lead to widely differing
results, e.g., when we consider the different costs for the Ministry of Health and
patients of programs based on home visits or hospitalization. Despite its potential
usefulness, assessments of the overall societal costs and savings from tuberculosis
control interventions have not yet been performed extensively. This is partly due to
the methodological difficulties in assessing indirect patient and household costs.
Also, policy makers may be more influenced by data that have direct implications
for their budgets, so that the political usefulness of a full societal cost analysis can be
4
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
limited. For the purpose of this manual, we limit ourselves to assessing costs from a
provider viewpoint. However, if the economic gains and losses resulting from an
intervention show a gross maldistribution between various economic agents in a
society, an expansion of the analysis to account for a societal viewpoint should be
considered.
2. Cost categories
For an assessment of the economic costs of an intervention, it is necessary to identify
all resources consumed for its production. The variety of different inputs can be
categorized in various ways to organize the costing procedure and facilitate the evalu
ation of study results. Some of these categorizations can be combined to address
specific questions during the evaluation.
a) Capital costs I Recurrent costs
We already mentioned two examples of capital cost items: buildings (e.g., health
center) and vehicles (e.g., motorcycles). In general, economists identify those items
as capital resources whose useful life is longer than one year. Apart from buildings
and vehicles, this category includes expenses for equipment such as microscopes
and x-ray machines, as well as expenses for staff training or public education cam
paigns that occur rarely (i.e., less than once a year). The economic costs for these
activities have to be calculated in a special way that takes into account their useful
life and the discount or interest rate (see below).
Recurrent costs are costs for all those program inputs that have a useful life of less
than one year. Often, the largest expenditures under this category are made for sala
ries. Other recurrent costs occur for drugs, supplies (such as syringes, sputum slides,
x-ray files, stationary etc.), frequent training or public education activities and main
tenance of buildings and vehicles. The exact assessment of the recurrent costs of an
intervention is often crucial for its long-term sustainability. A beautiful new health
center will lose its appeal quickly if no funds are available for its upkeep. Patient
follow-up activities will become impossible if no funds are available for vehicle
repair. The success of a program will critically depend on the availability of drugs
and diagnostic material. It is therefore very important to be exhaustive in the listing
of the recurrent resources needed.
Taken together, a basic classification of cost items that will reoccur throughout any
costing procedure is:
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
5
HEALTH ECONOMICS
Capital Costs
Vehicles
Equipment
Buildings
Training, non recurrent
Public education, non recurrent
Recurrent Costs
Salaries
Supplies (drugs, diagnostics etc.)
Vehicles, operation and maintenance
Buildings, operation and maintenance
Training, recurrent
Public education, recurrent
b) Costs at different programme levels
We have outlined above a “minimal” TB program that consisted of just one nurse in
one health care center. Unfortunately, reality is much more complex. A national
tuberculosis control program will consist of several levels that all contribute to en
sure the delivery of adequate patient care at the peripheral level. Since the program
could not function without any of these structural levels, the costs for each of them
has to be included into the cost analysis. A typical TB program will consist of the
peripheral, district, provincial and central level. At all of these levels, capital and
recurrent costs occur, although the specific items in these cost categories may differ.
We may therefore extend the structure of our cost table in the following way:
6
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Program level:
Central
Provincial
District
Peripheral
Capital Costs
Vehicles
Equipment
Buildings
Training, non recurrent
Public education, non recurrent
Recurrent Costs
Salaries
Supplies (drugs, diagnostics etc.)
Vehicles, operation and maintenance
Buildings, operation and maintenance
Training, recurrent
Public education, recurrent
c) Costs for specific activities
At each level of the TB program, various activities are performed that complement
each other or represent separate program components. The required inputs should
be determined separately for each activity for two reasons: to ensure that all ancillary
services that are performed at higher levels are included in the cost of health care
delivery at the peripheral centers; and to be able to identify those activities that con
sume the most resources as targets for special managerial attention. As an example,
we give a possible list of functions that are performed at the district level of a TB
control program. A similar list must be established for the peripheral, provincial and
central levels. For some activities, inputs may be shared with other activities within
the program or with other health care interventions. The topic of the necessary allo
cation of costs will be addressed below.
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
7
HEALTH ECONOMICS
Program level: district
Activity:
Supervision
coordination
treatment
district IB
preparation
of laboratory
of referral
register
of reports
activities
cases
Capital Inputs
Recurrent Inputs
3. Sampling
To collect data on all costs that occur at the central level of a program should be a
manageable task. However, collecting data on all activities that occur in every dis
trict or peripheral unit will usually be impossible. It is also unnecessary. The method
to get around this problem is called “sampling”. The term stems from statistical theory
and the underlying concept is that by choosing a representative sample of the total
population under study (e.g., the total population of district offices or peripheral
health centers), one is able to draw conclusions (or, to “make inferences”) about the
average conditions in that population. How are the number and site of the sample
units to study determined? Since the sampling method is rooted in statistical theory,
there are elaborate methods to determine the number of samples one needs to study
to draw “statistically significant” conclusions. Also, various methods exist to ensure
the representativeness of the chosen units (e.g., random, systematic, cluster or strati
fied sampling). While these methods will increase the statistical merits of a study,
they are unfortunately unpractical in many occasions. Time and financial constraints
will usually prohibit the visit of a large enough sample to give statistical power. For
the same reason, the choice of peripheral units is usually restricted to those that are
accessible within the time limit of a study. The method that is most likely chosen
may be called “judgment sampling”, which means that, together with people who
know the entire program, an informed judgment is made about which peripheral
units will provide data that can be considered representative for the whole program.
It may be difficult to convince a statistician of the merits of this approach, but in
practical terms it is doubtful whether the increased effort for statistical sampling will
make important differences to the results of a study.
4. The concept of unit costs
Once data on all cost items related to a program at a specific health center or pro
gram level are collected, one needs to decide about an appropriate method of pres8
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
entation. Reporting the total costs of the whole program or only those of one center
will not be very helpful for comparing the performance of different centers or plan
ning new activities: the size of the covered population may differ widely between
centers, and the different number of services performed will result in large differ
ences of total costs. The quantity of analysis should therefore be defined as an out
put unit. Outputs of a program are physical units like x-rays, sputum smears, distrib
uted courses of chemotherapy etc. Costs should be reported as costs per one of these
units, i.e. cost per x-ray, cost per sputum smear, cost per distributed course of chemo
therapy. As a result, the costs of all the ingredients that are necessary to produce the
outcomes of programs can be calculated. An outcome is the aggregate result of the
production of outputs, e.g. a case of TB diagnosed and treated. For both outputs and
outcomes one will usually find performance records at the examined site, e.g. number
of sputum examinations performed, number of cases diagnosed, or number of pa
tients who completed treatment during a year. The calculation of unit costs is then
simply unit cost = total cost per activity / total number of units produced. Outcomes
can be translated into program effects, which are general units that usually allow the
comparison between various health interventions, e.g. deaths averted or years of life
saved. Usually, some theoretical assumptions are necessary to calculate these ef
fects, and one is not able to find actual reports of these at the health center. Ulti
mately, the cost per chosen unit of measurement for these effects can be used in a
cost-effectiveness analysis. However, one should realize that unit costs for outputs
or outcome measures may actually be more useful for the managerial task of assess
ing technical efficiency (see page 18).
5. The problem ofjoint costs
As stated above, each level of a program will perform not only one, but a variety of
services. Also, inputs from activities performed at different levels will be necessary
to perform certain services at others (for example, sputum smears performed at a
district laboratory are necessary to guide treatment at a peripheral health center).
Further, a health center usually does not only deliver tuberculosis control activities,
but a variety of different primary health care services. Whenever the inputs needed
to produce a specific service are shared with the production of another, the problem
of joint cost allocation occurs. This means that one has to decide which share of a
common input is used for a specific activity. The first step to tackle this problem is to
determine an allocation basis. For a building, this may be the space used by a pro
gram activity; if personnel performs various tasks, salaries can be allocated based on
the share of total worktime spent for an activity; time shares can also be determined
for shared equipment; hospital administration costs can be allocated based on the
number of personnel in a department etc. The costs of shared (or overhead-) inputs
can be directly allocated to each final cost center of interest, based on the allocation
criteria chosen. When the number of inputs required to produce a program output is
large, the method of “step-down allocation’’ can be employed. For this method,
inputs are ordered hierarchically, starting with those inputs that are shared by the
greatest number of other activities, e.g., building space. At every step of the allocaCOST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
9
HEALTH ECONOMICS
tion procedure, inputs are allocated to a range of “intermediate cost centers” based
on specific allocation criteria, thereby ensuring that an appropriate share of all “over
head” costs is allocated to the “final costs centers” i.e., the outputs of interest. A
simple illustration of this procedure is given in Table I.
Table 1: Step down allocation of overhead costs
x-ray
laboratory
wards
4000
10000
10000
20000
200
100
200
200
1300
8200
400
4100
200
10200
400
10200
400
21300
2600
8600
4300
430
10600
860
10600
860
23900
6450
4730
11460
473
11460
473
30350
3784
11933
11833
34144
Cost center building space
maintenance
administra-tion
laundry
Allocation
criteria
actual
space
occupied
building
space
no. of
personnel
no. of
beddays
cost
2000
4000
8000
0
4000
*>
allocate
building space
allocate
maintenance
allocate
administration
allocate
laundry
Final cost
centers
It must be pointed out that there is a certain degree of subjectivity and arbitrariness
involved in any allocation process. Should central office costs be allocated based on
the space that a specific program occupies, or rather based on the share of the total
budget that it consumes? How certain is it that a nurse devotes 30% of her time to TB
control activities, and not 25 or rather 40%? Whenever it is likely that the uncer
tainty around assumptions has an important effect on the result of the cost assess
ment, one may consider to perform a sensitivity analysis to determine the actual
effect of changes of assumptions on unit costs (e.g., by changing the share of the
nurse’s salary in the calculation stepwise between 25 and 40%). If the resulting cost
ranges are unacceptably large or would lead to opposing decisions regarding alter
native interventions, one should devote more time to assessing allocation shares to
reduce the uncertainty around cost figures.
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6. Average, incremental and marginal costs
You have costed the diagnostic services at one health center and determined a total
cost for sputum examinations of $2,000.- From the laboratory reports you learn that
1,000 smears were performed during one year. Consequently, you calculate a unit
cost of $2 per smear. Now imagine that your program is expanding and you expect
1,500 smears to be performed during the coming year. What will the cost of this
level of activity be? $3,000? - Probably not, as we will show in this chapter.
Another example: You are setting up a new TB control program in an area with an
existing primary health care structure. You know that there is some spare room in the
district health office that you can use for the TB officer. Also you plan to use the
existing staff at health centers for case-holding activities. What are the costs for
office space and health center staff?
The problem we are touching on is the important distinction between the average,
the marginal and the incremental costs of an activity. The two examples we have
mentioned above describe two different aspects of this problem: one is the relation
of the cost of a given activity to the level of output (analyzed as marginal costs), the
other concerns the costs of a new activity for which parts of the already existing
facilities and infrastructure will be used (analyzed as incremental costs). We will
investigate both aspects in turn.
We have defined unit costs as the total cost of an activity divided by the number of
output units produced. The specific economic term for this type of cost is the aver
age cost of a unit of output. A very important observation is that this figure repre
sents only one value on the cost function of the activity. Specifically, the average
cost may be higher or lower than the value calculated, depending on what level of
outputs a program currently achieves. The reason for this is that only a part of the
input costs has a linear relationship with the number of output units produced (i.e.,
will increase the same amount for every additional unit produced). We call these
costs the variable costs of an activity. The cost of other inputs, however, will remain
stable, whatever level of output is achieved. These are the fixed costs of the activity.
Costs that will remain stable over a certain range of output but will increase in a
stepwise fashion if the range is exceeded are called semi-fixed. To illustrate these
terms, we consider the cost of TB diagnosis with sputum smears. For each smear,
one new slide and a certain amount of staining solution is needed. The cost of these
inputs will be linearly related to the total number of slides produced, they are there
fore variable costs. The costs for the microscope or laboratory technician, however,
behave differently: only one microscope is needed, whether one or twenty slides are
examined per day; its cost (and similarly, the cost for the microscopist) does not
depend on the number of slides produced, they are fixed costs for this activity. How
ever, we can imagine a situation where the workload for diagnosis becomes so large
that it can no longer be handled by one microscopist. At this point, a second
microscopist must be employed (and probably, a second microscope bought). The
cost for these inputs has become semi-fixed. With these distinctions of the compo
nents of total costs in mind, we can analyze the different concepts of average and
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
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HEALTH ECONOMICS
marginal cost: the average cost reflects all elements of the total cost of inputs used at
a specific level of output; the marginal cost consists of only those cost components
that would change if the current level of output changes (precisely, the marginal cost
of an activity is the cost of producing exactly one more unit of output). It is obvious
that variable costs will always be a part of marginal cost, whereas true fixed costs
will never be included. However, very few fixed costs will be totally independent of
the level of production. Rather, they will behave in a semi-fixed way: once a certain
level of production is exceeded, an additional unit of these inputs has to be bought.
The problem in the calculation of marginal costs is therefore to decide how much
capacity of fixed inputs is currently used. For our further discussion, we will assume
that the economic cost of already existing and currently unused capacity is zero.
This means that the marginal cost of a program expansion will be equal to the aver
age variable costs in a situation of excess capacity for fixed inputs.
This postulate can be challenged. We remember that the opportunity cost of a re
source is the cost of forgoing the best alternative use. Certainly, the best alternative
to using, e.g., an x-ray machine for a TB programme is not not to use it at all. It could
be employed for another disease control programme; one could also sell it or rent it
to private providers. However, health care programs regularly do not exploit their
full therapeutic or economic capacity. In reality, the alternative to using an existing
facility with excess capacity will be its unproductivity. In these situations, the mar
ginal economic cost is in fact zero. When the average unit costs for an existing
intervention are determined, an attempt should therefore always be made to concur
rently determine the level of capacity use for its fixed inputs.
Adding new program components to existing facilities represents another area where
the analysis of the specific costs related to output changes is important. As men
tioned above, the term “marginal” refers only to the production of an extra unit of an
existing activity. It is therefore preferable to use the term “incremental” cost for this
case, although the use of both terms is sometimes handled interchangeably. For the
decision-maker who evaluates the economic merits of any such interventions, the
additional costs they will impose, in relation to their presumed outputs and effects,
are of primary importance. Therefore, if existing facilities can be used without di
minishing any other ongoing activities (i.e., in the case of excess capacity with zero
opportunity cost), these items should not be included in the assessment of economic
costs. The guiding question should be, “ what would the total cost of my program be
with and without the new intervention?” Only the costs that occur in addition to the
current cost level should be used for the economic analysis. It should be noted that
the incremental economic costs of an added program component are often similar to
its financial costs. In this case, budget figures can be directly used in an analysis of
economic costs7, and vice versa.
If the incremental costs of an activity are of prime importance for the decision-maker,
what is the role of the somewhat laborious assessment of total economic costs? The
primary aim of this activity is to draw generalizable conclusions from the cost study.
Incremental costs of an activity are specific for the location in which they were
12
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
assessed. They may be fundamentally different in other settings with different pre
existing conditions. Since average costs include all resources consumed for an activ
ity, they should be the same for all locations , and therefore allow an economic
assessment without having to decide whether the necessary incremental resources
are comparable.
7. Comparing costs at different capacity use levels
Various conditions in a tuberculosis control program can lead to the under-utiliza
tion of capacity: for equity reasons, the government may decide to cover geographi
cally remote areas with health care facilities, even though the population density
may be too low to operate at full capacity; excess capacity may have been built in
anticipation of a future increase of use or random variations in usage levels; if excess
capacity exists without a plausible explanation, it may be a sign of technical ineffi
ciency of a program. Whatever the reason, it should be noted that the existence of
excess capacity has important implications for the interpretation of cost-effective
ness ratios. If the average costs per unit of effect are measured in a situation of
under-utilization of inputs and compared with an alternative program that operates
at full capacity, a difference in cost-effectiveness ratios may be solely based on uti
lization levels, and not on the “inherent” cost-effectiveness of the interventions un
der investigation. This is illustrated in Figure 1: although program B has higher aver
age costs than program A for each specific output level, a higher cost may be deter
mined for program A if the two programs are compared at different output levels.
One may want to repeat the costing study with sample programs operating at the
same level of resource utilization. Alternatively, one can perform a sensitivity analy
sis under different assumptions about resource use.
Figure 1: The importance of the output level
140
120
w 100
w
3
5
-» FYogramA
80
♦ FYogram B
0)
O)
2
o
<
60
40
20
Number of Output Units
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
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HEALTH ECONOMICS
8. The effect of inflation
When cost data are collected, they will probably be obtained for different years in
the past. To ensure the validity of results, all prices should be converted to a “stand
ard” year, and this year should be noted in the report. Neglecting this procedure may
have important impacts on the results of a study: some expenditure records for capi
tal items like buildings may date back a number of years; especially in countries with
high inflation those costs may be completely incomparable to what one would have
had to pay for these items in recent years. Price levels for various years can be
determined from the official consumer price index or deflator series, which can be
obtained from the planning or finance ministry . The indices are usually based on
one standard year, whose value is usually given as 100. The price level in each year
is then given in relation to the standard year. The process of adjusting prices in
various years to the price level for the standard year in your study is as follows:
1. Divide the purchase price of the respect input by the price level or deflator
for the purchase year.
2. Multiply the result by the price level or deflator for the standard year in your
study.
9. Using results for international comparisons and publications
If the results of an analysis are judged to be sufficiently important for publication in
an international journal or as a help for decision-making in countries different from
the study country, it is important that the results are modified to ensure their applica
bility in different circumstances. Probably the most important modification is to ex
press results as average costs per output unit in addition to the marginal or incremen
tal terms that were calculated for a specific country’s situation. The reason for this is
that one cannot make any assumption about existing infrastructure in other settings,
so the results for one country may lead to misleading conclusions about the financial
requirements in other settings. The provision of average cost data together with a
detailed costing of the required inputs will make the results much more useful for a
different setting.
A second important aspect for international comparisons is that one needs to express
the results of a study in terms of hard currency. This task is straightforward: multiply
the cost of each input in local currency (adjusted for the standard price level) by the
exchange rate for the international currency you decide to use that was valid for the
“standard year”10. This will result in the costs in international currency for the stand
ard year. One can also express the currency costs for a different year by performing
an additional price adjustment procedure as outlined above, this time using the deflator
or price index series for the currency chosen.
Finally, traded and non-traded goods need to be distinguished. “Traded” in this con
nection means traded on the international market, and this category normally com
prises all items that have to be paid for in convertible currency. The reason for this
distinction is that one can assume these prices to be very similar in different coun
tries, as price differences usually only arise from different transport costs. On the
14
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
other hand, there may be important differences between countries for those inputs
that are not traded on the world market. Probably the most important category in this
respect is salaries. Depending on the general economic situation in a country, there
may be vast differences in the expenditure that will occur for various categories of
personnel. One possible approach to this problem is to express expenditures for
non-traded goods as a percentage of the GDP in a specific country, assuming that
most of the costs vary proportionally to this general economic indicator. However, it
may be more useful for the actual budgetary planning process to provide detailed
lists of all necessary inputs, and then determine local prices for each specific coun
try.
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III. The Case of Malawi
To illustrate the practical performance of a cost analysis, we will now describe a cost assessment per
formed for the National Tuberculosis Programme in Malawi in March 1995.
A. Introduction to the Malawi setting
The National Tuberculosis Control Programme in Malawi was reorganised in 1984.
It has adopted the WHO-recommended control strategy based on passive case find
ing, diagnosis mainly by sputum smears, short-course chemotherapy with patient
observation and cohort analysis of treatment outcomes. The goals of the NTP are the
detection of at least 70% of infectious cases and the cure of at least 85% of detected
cases . Since the introduction of the new strategy in 1984, the number of detected
cases has more than tripled. Much of the increase in case numbers can be ascribed
to the impact of the HIV epidemic. Malawi has been severely hit by this epidemic.
Currently, HIV prevalence rates reach 30% in women of child bearing age in city
populations, and HIV prevalence rates in tuberculosis patients are reported to be
greater than 70% for some districts . Diagnostic and therapeutic facilities for TB
control have been overwhelmed by the increasing case load during recent years.
With current occupancy rates of more than 200% in some hospital TB wards, and a
further rise of case numbers expected for the coming years, the tuberculosis control
programme’s management is in need of a reassessment of its diagnostic and thera
peutic strategies.
The consideration of the costs connected to each programme modification is of para
mount importance in the Malawian setting. As indicated by its GDP per capita,
Malawi ranks as one of the poorest countries in the world. Although a large share of
drug costs and programme management expenditures is currently provided by do
nor agencies, the Ministry of Health is still responsible for many cost items, of which
staff salaries and the costs incurred during hospital treatment are especially impor
tant. Partly due to the effects of recent structural adjustment policies, financial con
straints for all government activities are expected to be even more pronounced dur
ing the coming years. Therefore, the Ministry of Health must seek to optimise its
expenditure patterns in order to cope with the expected tuberculosis case numbers.
The increase of case numbers has been especially large in city settings. The largely
urban district of Blantyre alone accounts for more than 10% of the annual case load.
Also, this district reports the highest incidence rates, the latest available figure being
440 per 100,000 in 199413 . It seemed appropriate to focus on the expenditure
patterns in a city setting for the present study, since it can be expected that urban
areas will continue to see the highest increases in HIV- and tuberculosis incidence
rates. In this respect, the analysis presented here differs from previous reports on the
cost of tuberculosis control in Malawi 14,13, which focused on rural districts. Time
requirements for the study were two weeks for the on-site collection of data, not
including the time for the preparation of the report.
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COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
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B. Calculation of economic costs for the existing programme
1. Demographic and TB-specific statistics
Demographic information was available from the Malawi government 1987 popula
tion and housing census. To estimate the population size in 1994, it was assumed
that the average population growth rate of 3.7% per annum from 1977 to 1987 was
sustained thereafter, which can be regarded as a conservative estimate. Appendix 1
shows the available information for 1977 and 1987, as well as estimated data for 1994.
Information on TB case notification was provided by the NTP Programme Manager.
There has been a sharp increase in the number of reported cases since the restructur
ing of the programme in 1984. Between 1984 and 1994, the total case number rose
from 5,334 to 19,496. Of the 19,496 cases reported in 1994, 5,988 (30.7%) were
pulmonary smear-positive, 8,958 (46.0%) were pulmonary smear-negative, 504
(2.6%) were relapses, and 4,046 (20.8%) were extrapulmonary cases. In relation to
the estimated population size for 1994, the total notification rate was 188 / 100,000,
as compared to a rate of 95 / 100,000 in 1987. The respective figures for smear
positive cases are 58 / 100,000 in 1994 and 41 / 100,000 in 1987. The notification
rates differ widely between districts, ranging from a peak of 440 / 100,000 in Blantyre
district to a low of 61 / 100,000 in Dedza district (Appendix 2).
2. Determination of the programme structure
The general structure of the programme has been described in previous reports by
the International Union against Tuberculosis and Lung Disease (IUATLD) as well as
by the WHO advisor to the National TB Programme . The accuracy of this infor
mation was verified in discussions with the Programme Manager. The Malawi Na
tional Tuberculosis Programme has three organizational levels: central, regional and
district. The structure of the programme is similar to the country’s administrative
structure. The central office of the tuberculosis programme is part of the Ministry of
Health and is located at the Community Health Sciences Unit. The regional tubercu
losis officers are based at the three regional health centers, and a district tuberculosis
officer is appointed to each district health center. Health services in the district are
delivered at the district hospital and peripheral health centers. At the health centers,
tuberculosis control activities are integrated into the general services, and no staff is
employed full-time for this purpose. In Blantyre district, Queen Elizabeth Central
Hospital also performs the functions of a district hospital. There are, in addition, 39
dispensaries and clinics.
3. Determination of activities performed at each level of the programme
The relevant information was obtained from discussions with the Programme Man
ager and, for each programme level, confirmed in discussions with the staff involved.
The following activities are currently performed on a routine basis at each level of
the programme:
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
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HEALTH ECONOMICS
Health clinics:
History and physical examination
“Chronic cough register”
Sputum collection and transport to district hospital
Drug distribution in continuation phase
Follow-up on defaulters
Health education
District hospital and medical office:
All activities as performed at the health center, in addition:
Sputum microscopy
X-ray
Patient register
Hospitalized intensive phase (not for smear-negative pts. In Blantyre district)
Drug storage and distribution
Supervision of health clinics
Staff training
Preparation of quarterly reports
Regional health office:
Planning of regional activities
Drug storage and distribution to districts
Training and supervision of district staff
Preparation of reports to the central level
Central level:
Evaluation of incoming reports
Preparation of reports to the ministry
General planning of control activities
Coordination of research activities
Training and supervision of regional and district staff
Budgeting of all training activities, stationery and drug supplies
Participation in clinical activitiesCentral reference laboratory: sputum cultures, drug
sensitivity testing, training of laboratory staff, quality control
4. Currently utilized inputs
Information on the inputs used to perform the various activities at each programme
level was obtained in discussions with the Programme Manager and verified through
interviews with staff at each programme level. Since the purpose of the study was
the assessment of economic costs, costs for capital inputs in the form of buildings
and equipment were determined in addition to those for recurrent inputs occurring
on financial expenditure records.
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COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
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The analysis is structured in two ways: for each program level, we first give the
inputs necessary for all activities (e.g., buildings), followed by a list of inputs spe
cific for each of the activities listed above; in a second step, inputs are categorized
(e.g., as capital or recurrent cost items), and a summary list of all inputs utilized at
each programme level is provided. The detailed lists of activities and inputs are
provided in Appendix 3.
5. Economic costs of inputs
a) Data sources
(1) Recurrent costs
Information on recurrent expenditures for the Malawi health sector is available from
expenditure records compiled at the Ministry of Health. The data is disaggregated
for the central ministry level, several central institutions like the Community Health
Sciences Unit , the three Regional Health offices, as well as expenditures for each
district. The district expenditure figures comprise the expenditures for the district
hospitals as well as health centres in each district. The information on hospital ex
penditures was confirmed through discussions with a senior accountant at Queen
Elizabeth Hospital, Blantyre. Detailed information on laboratory expenditures was
obtained through interviews with staff at the Central Reference Laboratory, Lilongwe,
and the laboratory at Queen Elizabeth Hospital. Expenditures for radiological inves
tigations were determined in discussions with the chief radiologist at Kamuzu Cen
tral Hospital, Lilongwe, and Queen Elizabeth Hospital. The costs of drugs, training
activities, travel expenses, stationery and sputum containers are funded by IUATLD,
and separate expenditure records for these items are kept at the NTP Programme
Manager’s office in Lilongwe. The cost of training activities for HIV counsellors
was determined in discussions with the Regional Health Officer, Blantyre district.
Current prices for consumables are contained in the price catalogue of the Central
Medical Store, latest edition 4/95.
(2) Capital costs
No construction costs could be obtained for the buildings at Queen Elizabeth Central
Hospital. The economic cost of capital inputs therefore had to be estimated by the
cost of comparable units in different settings. Construction costs for new health centers
and TB wards were provided at the Ministry of Works, Lilongwe. Construction costs
for a new laboratory annex were provided by Professor A.D. Harries, College of
Medicine, Blantyre. Capital costs for laboratory and x-ray facilities were based on
the cost estimate for the construction of a new District Hospital (Machinga District),
and space for laboratories and x-ray facilities was allocated according to the situa
tion at a District Hospital. Cost information for hospital equipment was derived from
a tender for the equipment of Machinga district hospital, submitted to the Ministry of
Health 11/94. The cost of vehicles and bicycles was provided by the Programme
Manager of the NTP. Construction costs for a new Regional Health Office to be built
in Blantyre district were obtained from the Regional Health Officer.
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HEALTH ECONOMICS
Capital costs were annuitized using a nominal discount rate of 12%'7. We assumed
a lifetime of 20 years for buildings and x-ray machines, 10 years for laboratory and
x-ray equipment, 5 years for cars, 2 years for motorcycles and bicycles.
(3) Exchange rate
Average annual exchange rates since 1987 were provided by the Ministry of Fi
nance, and weekly exchange rate were provided from 1994 onwards. At the time of
the study (March 1995), the exchange rate had been stable since November 1994 at
14.36 Kwacha per US dollar. This exchange rate was used for the conversion of all
local prices into 1995 US dollar prices.
(4) Price deflator series
GDP deflators were provided for the period of 1987 to 1995 by the Ministry of
Finance. We used the deflator series for government consumption of goods and
services, and all prices were deflated to 1995 levels.
(5) Cost allocation for overhead costs
For the allocation of overhead costs at Queen Elizabeth Hospital, hospital wards, xray department and laboratory were the final cost centres. Administration was re
garded as an intermediate cost centre. In a first step, overhead costs for activities
directly related to administration and all costs for transportation were allocated to the
administration cost centre. Secondly, administration costs were allocated to the final
cost centres, based on the number of staff employed in each cost centre. Overhead
costs for maintenance were allocated to the intermediate and final cost centres based
on building space occupied. The overhead costs allocated to the final cost centres
were allocated to TB-specific activities based on the number of bed-days (for TB
wards) and the share of TB-specific activities (for laboratory and x-ray). The costs of
drugs and medical supplies were directly determined for each activity.
Overhead costs for health centres were determined based on the total expenditure
for Blantyre district recorded at the Ministry of Health, divided by the number of
health centres in the district. These costs were allocated to TB-specific activities
based on the proportion of all visits at health centres related to the diagnosis and
treatment of tuberculosis.
Overhead costs for the regional health office and the Community Health Sciences
Unit (location of the NTP management offices) were allocated on the basis of build
ing space occupied by the relevant offices.
(6) Total costs and unit costs
Total costs were derived for specific activities such as laboratory tests, x-rays and
hospital bed-days. Also, total costs were determined for each organisational level of
the National Tuberculosis Control Programme. Information on the total number of
laboratory tests and x-rays produced was provided by the staff involved in each
activity, and was used to calculate the respective unit costs. The number of patients
treated in 1994, for the whole country as well as for regional and district levels, was
provided by the NTP Programme Manager. These figures were used to determine the
cost per patient treated.
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COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
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b) Cost calculation: general cost categories
(1) Salaries
Salaries for government services in Malawi were increased by an average of 25% in
April 1995. This latest salary increase was taken into account. Information on the
grading of staff was obtained during interviews with the chief hospital accountant at
Queen Elizabeth Hospital, as well as with the staff involved. In addition to salaries,
a housing allowance of 15% is paid. There is also a bonus payment, which is de
pendent on the staff grade. Appendix 4 shows a listing of average salaries including
benefits for each grade. All cost calculations provided in the appendix indicate the
grade of each personnel category listed.
(2) Maintenance and overhead costs
Expenditure records for Queen Elizabeth Central Hospitals are available from the
Ministry of Health. The latest available data were for the year 1993/94. The table in
Appendix 5 shows the categorisation of expenditures used by the Ministry of Health.
10% of the staff of Queen Elizabeth Central Hospital are employed in administra
tion, and total salary expenditures were allocated accordingly. For the final cost
centres “x-ray”, “laboratory”, and “wards” staff salaries were determined based on
the specific staff utilisation for each activity. The total allocated overhead costs were
4,588,255 Kwacha. The allocation to intermediate and final cost centres was per
formed as described in the methods section.
(3) Drug costs
Except for thiacetazone-INH tablets, drugs to the programme are currently supplied
free of charge by IUATLD. Purchases are made through the International Dispen
sary Association (IDA) in Amsterdam, except for ethambutol/isoniazid tablets, which
are purchased directly from the manufacturer. The calculation of drug costs was
based on information on the free-on-board (FOB) prices (excluding insurance and
shipping) from the IDA price catalogue 12/94 and invoices for ethambutol/isoniazid
provided by IUATLD. A flat 15% was added to account for shipping/handling
charges. Since no specific costing of the drug distribution system was performed, we
also added a flat 10% to the drug costs to account for these costs . The wholesale
prices for thiacetazone-INH tablets supplied by the government were obtained from
the price list of the central medical stores. In the district of Blantyre, the following
drug regimens are currently used:
Table 2: Currently used drug regimens in Blantyre district
Category 1 : (short course) 1S3 R3 H3 Z3 /IS R HZ Z6TH/HE
Category 2 : (re-treatment) 2SRHZE Z1RHZE / 5R3H3E3
Category 3 : (standard modified) 2R3 H3 Z3 / 2HE/TH / 4H
In order to facilitate the analysis of costs by programme level, we divided the costs
of each regimen into costs for the intensive phase, delivered at the hospital level, and
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
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HEALTH ECONOMICS
costs for the continuation phase, delivered at the health centre level. Average cost
per regimen in 1994 were $20.42 (category 1, TH), $39.48 (category 1, EH), $9.19
(category 3, TH), $13.33 (category 3, EH), $60.87 (category 2). A detailed list of
drug costs, also providing information on the cost of standard chemotherapy, is pro
vided in Appendix 6.
c) Cost calculation: specific activities
(1) Hospital bed-days
Queen Elizabeth Hospital has one female and one male ward specifically assigned to
the care of tuberculosis patients. The female ward contains 18 beds, the male ward
50. However, bed occupancy rates averaged 200% in 1994. Except for food, no
additional provisions are made for patients who exceed ward capacity: these patients
bring their own bedding and usually accommodate themselves in the space under
the regularly installed beds. In 1995, a new tuberculosis ward will be built at Machinga
district hospital, containing 34 beds. To determine the capital costs of the TB wards
at Queen Elizabeth Hospital, it was assumed that the present facilities are compara
ble to two wards of this size. Information on numbers of admissions and length of
hospital stays was unavailable. The calculation of bed-days was therefore based on
information on the number of beds and average occupancy rates provided by de
partment clerks. Among all inpatient bed-days, the proportion for tuberculosis pa
tients accounts for approximately 10%. This proportion was used for the allocation
of running/maintenance costs and overhead salaries.
The specific care for tuberculosis patients is usually limited to the daily provision of
drugs and emergency interventions. The daily cost of hospital food was determined
as 3.31 Kwacha, based on averaged daily kitchen expenditure records for February
1995. In addition to the regular food, tuberculosis patients receive 200 ml of milk
each day at a cost of 1.68 Kwacha.
Based on the cost calculation shown in Appendix 7, an average cost of $2.09 was
calculated. The distribution of input cost categories is shown in Figure 2. Since the
average fixed costs for bed-days are dependent on occupancy levels, costs would
generally be higher under the assumption of “normal” occupancy rates.
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COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
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Figure 2: Distribution of hospitalization costs
Equipment (7.10%)
Personnel (17.60%)
Buildings (20.40%)
Food (16.60%)
Maintenance (38.30%)
The incremental cost for tuberculosis-specific activities was determined as the cost
for food and staff salaries only, at $ 0.72 per day. For the analysis of policy
changes, only the effects of changing incremental costs were determined.
(2) Laboratory procedures
(a) Sputum smears
Smear examinations in Queen Elizabeth Hospital are currently performed using
Auramin-Phenol staining and a fluorescent light microscope. It was assumed that
this microscope was utilised exclusively for TB diagnostic procedures, whereas other
necessary equipment is currently shared to perform other bacteriological investiga
tions. To allocate building costs, it was assumed that laboratory facilities occupy
10% of the space of a district hospital, and TB specific diagnostic procedures ac
count for 20% of the laboratory workload. Currently, there are three staff involved
in preparing sputum examinations at Queen Elizabeth Hospital, however, no staff is
allocated full-time for this purpose. Prices for supplies were derived from the cata
logue of the central medical store. In the case where specific supplies were not listed,
they were obtained from recent purchase orders by the College of Medicine in
Blantyre. During 1995, a total of 24,555 slides were prepared at the laboratory at
Queen Elizabeth Hospital, based on the laboratory register. Based on this informa
tion, a total cost of $ 12,059 and an average cost of $ 0.49 per slide were calculated
(cost calculation in Appendix 8). Marginal costs were expressed as the average
variable costs for supplies only, and were calculated at $0.07 per slide. The distribu
tion of input costs is shown in Figure 3.
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
23
HEALTH ECONOMICS
Figure 3: Distribution of costs for sputum microscopy
personnel (9.90%)
equipment (22.80%)
buildings (9.30%)
overhead (43.20%)
supplies (14.80%)
Based on discussions with the senior laboratory technician, it was determined that
the number of slides produced in 1994 represents the capacity limit at the present
input level. Limiting factors are building space and personnel. We therefore per
formed a scenario analysis under the assumption that a laboratory extension would
be built exclusively for TB diagnostic purposes, and three staff would be employed
full-time, using fluorescence microscopy. Under these assumptions, the chief labo
ratory technician estimated that the capacity for slide production could be doubled
to an annual 50,000 slides. The cost calculation for this scenario is shown in Appen
dix 9. The total cost would rise to $ 13,633. The incremental cost per slide would
thus be $ 0.13 (incremental cost: $ 3,358; additional slides: 25,000). The average
cost per slide would fall to $ 0.31 under this scenario.
(b) Sputum cultures
In Malawi, sputum cultures are currently only prepared at the central tuberculosis
reference laboratory located at the Community Health Sciences unit in Lilongwe on
a routine basis.
In 1994, a total of 1,169 sputum cultures were performed. The cost
calculation based on the information provided at CHSU on staff requirement and
consumed supplies is shown in Appendix 10. The total economic cost per culture
was $ 6.20, marginal costs (expressed as average variable costs for supplies only)
were $ 0.71 per culture. The large difference between the full and marginal costs
reflects the high proportion of fixed costs in the calculation. This can be ascribed to
the current low output at the central reference laboratory, which was due to the lack
of adequately trained staff in 1994. It is expected that the output will be much
greater in 1995, which will reduce the average cost per culture produced.
(c) HIV testing
Prices for all equipment currently used for HIV testing in Malawi were provided by
the chief laboratory manager of the AIDS division of the Ministry of Health in
24
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Lilongwe, at Queen Elizabeth Hospital, the current strategy for TB patients is to
perform one ELISA test only. Confirmations of positive results are not performed in
patients with clinical signs of AIDS. In patients without these signs, a second ELISA
is performed as confirmation test. 20 volunteers were trained in Blantyre district to
perform pre- and post test counselling services. The cost for one day of training was
specified as 200 Kwacha by the regional Health Officer. The volunteers currently
offer their services without monetary compensation. To assess the economic cost of
their activities, it was assumed that their salary would be comparable to that of a
health surveillance assistant (grade SC 1), and each counselling would take one hour.
The full cost calculation is shown in the appendix. In 1994, the laboratory at Queen
Elizabeth Hospital performed a total of 14,000 HIV tests. Based on this figure, the
full economic cost per test was $ 1.78, the marginal cost, as indicated by the average
variable costs for the test kits and necessary laboratory supplies, was $ 0.88 per test.
The detailed cost calculation is shown in the appendix.
(3) X-Ray
Building costs were allocated based on the assumption that x-ray facilities comprise
10% of the space of district hospitals, of which 50% are devoted for screening pur
poses for tuberculosis patients. Current prices for a standard x-ray machine and
standard darkroom equipment were derived from the tender for a new district hospi
tal in Machinga, supplied to the Ministry of Health in November 1994. Currently,
one x-ray machine and three staff are exclusively used to perform chest x-rays for
screening purposes. Prices for supplies were derived from the catalogue of the gen
eral medical stores. During 1994, 12,000 chest x-rays were performed for TB diag
nostic purposes at Queen Elizabeth Hospital. Based on this information, the full
economic cost per film was $ 2.82. Average variable costs for material only were $
0.96 per film. See cost calculation in Appendix 12.
Miniature radiography has been suggested as a means to reduce the cost of radio
graphic diagnosis. A miniature radiography camera has been installed in 1991 at
Queen Elizabeth Hospital, but has not been used yet because of uncertainty about
the cost implications. We therefore assessed the cost per film under use of this tech
nology in addition to the cost of conventional x-ray technology. It is important to
notice that under the current caseload, the full capacity of each film roll for miniature
radiography cannot be exploited. Instead, smaller pieces of film would be separated
from the main roll every day and developed. Under these conditions, experiences in
other countries have shown that about 350 exposures can be made per roll of 100*100
mm film (45 m) . The cost calculation for the use of miniature radiography is given
in Appendix 13. Although the marginal cost per film decreases substantially to $0.35 ,
the average cost per film is slightly higher than the cost under the conventional
technique ($ 3.13). This result is due to the higher capital cost of the miniature radi
ography equipment.
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
25
HEALTH ECONOMICS
(d) Costs at various programme levels
(1) Costs at central level
The Programme Management office is located at the Community Health Sciences
unit in Lilongwe. In addition to the running costs of this office, costs for the
countrywide training and supervision activities as well as for the supply of stationery
and sputum containers to the programme facilities were also allocated to the central
level. Funding for these items is provided by IUATLD, and the Programme Manager
keeps separate expenditure records for these activities. A detailed cost calculation
for the costs at central level is provided in Appendix 14. Total costs at central level
were $ 138,016 in 1994. The total number of tuberculosis cases reported to the
NTP in 1994 was 19,600, therefore the average cost per patient treated was $ 7.04.
Figure 4 shows the proportionate distribution of central level costs for each cost
category.
Figure 4: Cost distribution at central level
j—Buildings (6.20%)
/
Vehicles (14.00%)
Training (28.80%)
Equipment (0.80%)
- Personnel (3.80%)
Maintenance (11.60%)
Supervision (11.90%)
Treatment (0.00%)—7
Supplies (17.70%)
Diagnosis (5.20%)
(2) Costs at regional level
The Regional Tuberculosis Officer is based at the Regional Health Office in Blantyre.
He is responsible for supervisory and planning activities for the southern region.
Total expenditures at this level in 1994 were $ 43,389 (detailed calculation shown in
Appendix 17). The cost per patient treated was $ 3.84, based on a total number of
patients in the southern region of 11,293 in 1994. The diagram below shows the
share of the total costs incurred for each cost category. The largest cost item is
transportation, due to the fact that the regional tuberculosis officer has a car at his
sole disposition.
26
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Figure 5: Cost distribution at regional level
Buildings (11.80%)
Vehicles (44.50%)
Maintenance (31.60%)
Equipment (2.60%)
Personnel (9.50%)
(3) Costs at district level
Queen Elizabeth Hospital is the site of diagnostic facilities for TB patients in Blantyre
district, as well as for hospital treatment during the intensive phase of therapy. A
“chronic cough room’’ is part of the outpatient department. This facility, which is
staffed by two health assistants, is used for the screening of patients with chronic
cough symptoms, who are referred for x-ray and sputum diagnosis if indicated. Con
struction costs for this separate building were available. Blantyre district has two
district tuberculosis officers, one responsible for the urban area, located at Queen
Elizabeth Hospital, the other responsible for the rural areas, located at the district
health office. Since no construction costs for a district health office could be ob
tained, the cost for a regional health office was used, which probably represents an
overestimation of building costs. The cost calculation in
Appendix 16 includes the previously calculated average costs for hospital beddays. Overhead costs were therefore only determined for the district tuberculosis
offices. A new drug regimen for smear-negative patients has been introduced in
Blantyre district as described above. Treatment under this new regimen is fully
ambulatory. New smear-positive patients under short course chemotherapy spend
an average of 60 days for hospital treatment, patients under the re-treatment regimen
spend an average of 90 days on the wards. For the cost calculation shown in the
appendix, only the drug costs for the intensive phase of therapy were included,
while drug costs for the continuation phase were attributed to the health centre level.
A total cost of $ 157,742 was determined for all activities in Blantyre district. Table
3 shows the cost per patient for each category.
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
27
HEALTH ECONOMICS
Table 3: Cost per patient at district level
no.
Cat.1 (TH)
Cat. 1 (EH)
Cat. 3 (TH)
Cat. 3 (EH)
Cat. 2
AVERAGE
Kwacha
203
474
543
1268
59
2547
1,861.63
1,861.63
341.06
341.06
2,640.97
889.35
Kwacha 95
Dollar
2,163.88
2,163.88
341.06
341.06
3,094.34
889.35
150.69
150.69
23.75
23.75
215.48
61.93
The distribution of cost categories at the district level is shown in the diagram below.
The predominant cost categories are treatment and diagnosis, which will be ana
lysed in more detail below.
Figure 6: Cost distribution at district level
Diagnosis (27.33%)
—Maintenance (0.20%)
-Personnel (3.40%)
Vehicles (0.40%)
Juildings (3.30%)
Treatment (65.37%'
(4) Costs at health center level
Patients under the new smear-negative regimen are mainly referred to two specific
health centres, whose staff level has been increased to ensure the adequate monitor
ing of therapy and follow up on defaulters. The cost calculation shown in Appendix
15 reflects the higher staffing level required for the intensified level of ambulatory
care. In 1994, Blantyre district reported an HIV prevalence of 70% in new smear
positive cases, who received an ethambutol-containing regimen (EH) in the continu
ation phase. A similar distribution was assumed for smear-negative cases. These
distributions are reflected in the case numbers for each treatment category. Based on
these figures, the average costs per patient at the health centre level were $34.45 for
smear-positive cases (TH), $53.51 for smear-positive cases (EH), $42.82 for smear
negative cases (TH), $46.96 for smear-negative patients (EH), $46.05 for re-treat
ment patients. The average costs for all patients treated at the district level was
$53.71. The diagram below shows the cost distribution for a health centre staffed
for the new smear-negative regimen, which reflects the high level of personnel costs
required.
28
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Figure 7: Cost distribution at health center level
r- Equipment (2.10%)
|
Vehicles (0.50%)
Buildings (11.30%)
Personnel (37.90%)—
Treatment (29.80%)
Maintenance (12.00%)
Diagnosis (6.40%)
e) Average costs per patient
Average costs per patient treated in each category were calculated by summing the
costs incurred at each level of the programme structure. Results are displayed in the
table below.
Table 4: Average total costs per patient
Kwacha 1995
Kw acha
Cost per patient:
Cat. 1 (TH)
494.74
494.74
$34.45
Distr.
2,131.88
2,434.13
$169.51
Prov.
50.19
80.89
55.17
101.12
$3.84
$7.04
Central
2,757.70
3,085.16
$214.84
BU
Distr.
768.44
2,131.88
Prov.
50.19
80.89
768.44
2,434.13
55.17
101.12
$53.51
$169.51
$3.84
$7.04
3,031.40
3,358.86
$233.90
614.84
349.52
50.19
80.89
614.84
349.52
55.17
101.12
$42.82
$24.34
$3.84
$7.04
1,095.44
1,120.65
$78.04
674.35
349.52
50.19
80.89
674.35
349.52
55.17
101.12
$46.96
$24.34
$3.84
$7.04
1,154.95
1,180.16
$82.18
661.22
3,296.67
80.89
661.22
3,750.04
55.17
101.12
$46.05
$261.14
$3.84
$7.04
4,088.97
4,567.55
$318.07
685.57
982.39
80.89
685.57
982.39
55.17
101.12
$47.74
$68.41
$3.84
$7.04
1,799.04
1,824.25
$127.04
TOTAL
Cat.l(EH)
Central
TOTAL
Cat. 3 (TH)
BU
Distr.
Prov.
Central
TOTAL
Cat.3(EH)
BU
Distr.
Prov.
Central
TOTAL
Cat. 2
BU
Distr.
Prov.
Central
TOTAL
AVERAGE
Dollar
BU
BU
Distr.
Prov.
Central
TOTAL
50.19
50.19
The large difference in the costs of treating smear-negative and smear-positive pa
tients is noteworthy. To explain this difference, we analysed the cost distribution for
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
29
HEALTH ECONOMICS
the treatment of a smear-positive case in detail. The diagram below shows the distri
bution of the total costs of treating a smear-positive patient with an ethambutol con
taining regimen by programme level.
Figure 8: Cost per patient by programme level
BU (16.00%)
Central (3.30%)
-Prov. (1.80%)
Distr. (78.90%
The largest share of costs occurs at the district level. We have shown above that the
most important cost items at the district level are costs for treatment and diagnosis.
These categories were therefore analysed in further details. The graph below shows
the distribution of treatment costs at the district levels.
Figure 9: Distribution of treatment costs
lat.l (TH) (3.50%)
-^>-Cat.1 (EH) (8.20%)
/-Cat.2 (2.40%)
•rug Distribution (1.40%)
beddays (84.50%'
It is evident that the costs for hospitalisation of patients outweigh the costs incurred
for the various drug regimens. An analysis of the cost distribution for hospitalisation
at the district level is shown in Figure 2.
30
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
For the situation at Queen Elizabeth Hospital, large proportions of the total costs are
incurred for overhead and maintenance expenditures. Since Queen Elizabeth Hos
pital serves as a tertiary care hospital, it can be assumed that these costs would be
lower for regular district hospitals. For an analysis of cost savings to be achieved
through ambulatory therapy, we therefore accounted only for the costs incurred for
personnel and food, which should be similar in different settings.
The share of total costs of diagnosis incurred for the various diagnostic methods are
shown below. Evidently, the greatest cost savings could be achieved by limiting the
number of x-rays performed.
Figure 11: Distribution of costs for diagnosis
slides (25.40%)
chest x-ray (70.90%)
HE-kOO
05142
S(r
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL
,
31
HEALTH ECONOMICS
C. Costs of programme modifications
1. Cost savings through ambulatory therapy
The primary purpose for the introduction of the new drug regimen for smear-nega
tive cases in Blantyre district was to reduce the workload for hospital staff to be able
to cope with the increasing number of patients. During the course of the study, we
addressed the question whether this new policy had any implications for the total
health care expenditures devoted to the care of tuberculosis patients. We compared
the costs of treating patients under the new policy, i.e. fully ambulatory treatment
using a revised drug regimen, with the costs of treating patients with a standard drug
regimen and hospitalisation during the first month of treatment. In order not to over
estimate the economic burden through hospital treatment, we evaluated only the
impact of incremental costs directly related to the care of tuberculosis patients (i.e.,
personnel costs and food) for this analysis. As mentioned before, currently only two
health centres in Blantyre districts have received additional staffing for monitoring
and follow- up activities. We assumed that for a district-wide implementation of the
new policy, an additional two staff members at the STA salary level would be neces
sary at the ten health centres currently implementing tuberculosis control activities
(total 20 at 14,000 Kwacha). Training requirements are assumed to be 2 weeks per
year (per diem 200 Kwacha). We also assumed that bicycles would be necessary as
transport medium for follow-up visits (total 20 at 300 Kwacha annual cost). Table 5
shows that with the currently implemented strategy the costs of health care for tuber
culosis patients could be reduced by a total of $ 37,775 in Blantyre district, even if
one accounts for the additional personnel and transport requirements' .
Table 5: cost savings through ambulatory therapy for smear-negative patients
'Standard" Strateev
NewStrateev
T
E
543
1268
DruKcuti
$3,5(X).4I
$41,095.88
Dn*aati
Hopitalcnti
$11,661.39
$27,231.38
HwMricuti
Totri
$15,161.80
$68,327.26
Total
Grand T<Mal:
S83.4K9
No.ofprtiati
T
E
543
I26«
$4,990.20
$16,907.32
$0.(1)
$0.00
$4.9>X12O
$16,907.32
AddMon
$I9.49K.6I
Ti^nn
$3,899.72
Hcydca
$417.83
Grand Total:
Difference:
$45,714
$37,775.38
We also analysed the potential savings through a restructuring of care for smear
positive cases to be delivered on a fully ambulatory basis. Assuming an average
length of stay of 60 days per smear-positive case, the hospitalisation of the 677
patients treated in 1994 resulted in incremental costs of $ 29,246. Even if one as
sumes that 30% of these patients required hospitalisation because of severe illness, a
32
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
4
HEALTH ECONOMICS
policy change to ambulatory therapy would result in a saving of $ 20,470. This
amount would be sufficient to employ an additional 20 staff (STA grade) at the
health centre level for patient monitoring and follow-up purposes. These staff could
be employed to increase the number of health centres offering ambulatory therapy
for tuberculosis in the district.
2. Cost savings through HIV testing before thiacetazone replacement
With the advent of the HIV epidemic, serious and sometimes fatal side-effects have
been observed during treatment with thiacetazone in HIV-positive patients. Two
strategies have been proposed to avoid adverse drug reactions. First, thiacetazone
could be completely replaced by ethambutol for all tuberculosis patients treated,
regardless of their HIV status. Second, thiacetazone replacement could be based on
the result of an HIV test. In Blantyre district, the second policy has been adopted.
As shown in the section on laboratory procedures, the full economic cost of per
forming HIV testing in Blantyre district is $ 1,78 per test. In Table 6, the cost of
testing the total number of patients treated in 1994 and replacing thiacetazone for
ethambutol in the 70% of patients who were reported to be HIV- positive in 1994 is
compared with a complete thiacetazone replacement strategy. It can be seen that the
strategy of HIV-testing all patients has led to a cost saving of $ 1,694 in the year
1994. Above an HIV-prevalence of 78 %, the costs of full thiacetazone replacement
would be less than the costs under the current strategy.
Table 6: Comparison of thiacetazone replacement policies
Full TH replacement
Sm+
Sm-
677
$ 12,903.74
no. of patients
additional drug costs
1811
$7,504.40
$20,408.13
TOTAL:
HIV Testing
HIV-Prevalence:
0.70
Sm-
Sm+
e
HIV test
677
$ 1205.06
1811
$3223.58
HIV-pos. patients
add. drug costs
474
$9,032.62
1268
$5253.08
no. of patients
TOTAL:
Difference:
$18,714.33
$1,693.80
The analysis changes when only the marginal costs of HIV-testing (approximated
by the average variable costs for supplies only) are considered. This may be appro
priate for the situation in Blantyre district, where the equipment is already in place,
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
33
HEALTH ECONOMICS
and counsellors deliver their services free of charge. Under this assumption, HIVtesting is preferable to a policy of complete thiacetazone replacement up to an HIV
prevalence of 89 %.
D. Conclusions
In the current structure of the Malawian National Tuberculosis Control Programme,
the highest costs occur at the district level. At this level, the costs incurred for diag
nosis and treatment are the most important cost categories. Within the “treatment”
category, the largest share of expenditures occurs for the hospitalisation of patients.
Through the introduction of a new drug regimen for smear-negative patients which
is delivered on a fully ambulatory basis, substantial savings in the delivery of health
care to tuberculosis patients could be achieved in Blantyre district. This result re
mains stable, even when accounting for the increased staff level necessary for the
supervision of ambulatory therapy at health centres. Additional savings would be
possible by delivering care for smear-positive patients during the intensive phase of
therapy on an ambulatory basis.
Within the diagnosis cost category, the largest share of expenditures occurs for the
preparation of chest x-rays. A change from the current conventional x-ray technique
to miniature radiography will lead to cost savings with regard to marginal costs for
films and supplies. However, average economic costs are actually higher, due to the
higher capital costs of miniature radiography equipment.
The current strategy of HIV testing tuberculosis patients to decide on a replacement
of thiacetazone in the continuation phase has led to small cost savings, if compared
to a policy of complete thiacetazone replacement. However, complete thiacetazone
replacement becomes the more cost-saving option should the HIV prevalence among
tuberculosis patients continue to rise.
E. Discussion
1. Comparison to previous studies
The results of the cost analysis performed in this study can be compared to the
results of a previous analysis of the costs of the NTP in Malawi performed in 199022.
Average unit costs for short-course chemotherapy with hospital treatment are higher
in the present study. De Jonghe et al. reported a figure of $160.53. This compares to
a cost of
$ 215 ($ 254 for costs deflated to 1989, using the 1989 exchange rate)
for a patient under a thiacetazone containing regimen in the present study. Programme
management costs were higher in the study by De Jonghe et al. than in the present
study ($30.82 and $10.88 per case treated, respectively). The main reason for this
can be seen in the steep rise of case numbers since 1990, which was not accompa
nied by substantial expenditure increases at the programme management level. The
higher cost per case in the present study, despite a decrease in programme manage
ment cost, can be attributed to differences in the reported costs for hospitalisation
34
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
and ambulatory care. De Jonghe et al. reported an average cost per hospital day of
$ 0.99 and $1.41 for two district hospitals, which compares to a cost of $ 2.09 in the
present study. Deflating all prices to 1989 levels and using the dollar exchange rate
for 1989 results in an even higher average cost of $ 2.61 per patient day. It is not
clear whether capital costs were included in the study by De Jonghe at al., which
accounted for 15% of all costs in the present study. Also, the costs comparable to
“overhead and administration”, which were less than 30% in the previous study,
account for nearly 50% in the analysis presented here. This is most likely due to the
different types of hospitals under investigation (district hospital and tertiary level
institution).
Mills23 reported a cost between $1.11 and $4.05 (costs in Kwacha converted to US
Dollars at the 1988 exchange rate) per patient day in her study of seven district
hospitals in Malawi. These figures were excluding capital costs, which they report as
nearly 50% of total hospital costs (although no allocation to the tuberculosis wards
was performed). However, the costs of drugs and “medical supplies” during hospi
tal treatment were included and accounted for 25 to 37% of all recurrent costs. Ex
cluding these costs, the recurrent costs amount to $ 0.80 to $ 2.60. The figure of $
2.60 was reported for Chiradzulu district hospital, which at the time reported a bed
occupancy rate of 64% in the TB ward. This compares to an average bed occupancy
rate of 200% at Queen Elizabeth Hospital. It can therefore be assumed that the
reason for the remaining cost difference lies in returns to scale due to the very high
annual number of patients treated at Queen Elizabeth Hospital.
For the cost of ambulatory care, which we assume to be comparable to the cost at the
health centre level (excluding drug costs) in the present study, the figure of $1.89
reported by De Jonghe et al. compares with a figure of $ 33.60 in the present stud
ies. The reasons for this substantial difference remain unclear, since the study by De
Jonghe et al. provides no detailed information on the cost categories included in
their calculation of average unit costs for the delivery of ambulatory care.
The study by De Jonghe et al. reported an average cost per sputum slide of $0.43,
similar to the cost in the present study. However, in the previous study, labour costs
were reported as $0.25 per slide, compared to a cost of $0.05 per slide in the study
presented here. The main reason for the difference in cost must be seen in different
assumptions about laboratory productivity. De Jonghe et al. assumed an average
productivity of 20 slides per day for laboratory assistants using the Ziehl-Neelsen
staining method. With three staff employed only part-time for the purpose, the labo
ratory at Queen Elizabeth Hospital achieves a productivity of more than 90 slides
per day, assuming 260 work days per year. This high productivity can be ascribed to
the use of the fluorescent microscope technique, which leads to much faster slide
evaluation. The results in this study thus confirms previous arguments for the use of
fluorescence microscopy in laboratories with high workloads24-25 . The average cost
per slide could be decreased further by employing more staff to use the microscope
at the capacity limit. For the conditions in an average district hospital using conven
tional Ziehl-Neelsen staining methods, this high workload cannot be assumed, and
the use of conventional microscopy is still justified because of its lower capital costs.
In general, drug costs were higher in the study based on 1989 cost data. For inCOST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
35
HEALTH ECONOMICS
stance, the cost for short-course chemotherapy was reported as $31.93 which com
pares to a cost of $20.42 in the present study. However, it must be noted that the
price reported refers to a thiacetazone containing regimen. For the ethambutol con
taining regimen, the current cost is actually higher than the 1989 cost at $ 39.48 per
case.
In conclusion, the present study confirms the overall low cost of care for tuberculo
sis patients described in previous studies, although some differences for specific
cost categories exist.
2. Should thiacetazone be replaced?
The role of thiacetazone as a component of multidrug-therapy of tuberculosis has
been the subject of an extensive debate in the recent literature
’ ' . Although
the potential toxicity of this drug was known even in the pre-HIV era, it has been
widely used in tuberculosis control because of its very low cost. With the advent of
the HIV epidemic, multiple reports have shown an increased incidence of severe
and sometimes fatal side-effects in HIV positive patients. The mortality directly at
tributable to side-effects of thiacetazone has been estimated at 3%
in HIV-posi
tive patients. WHO has therefore recommended to abandon the use of thiacetazone
for the treatment of patients at a high risk of HIV infection . However, it was also
recognised that financial constraints might prohibit the complete discontinuation of
therapy with thiacetazone in resource-poor countries. As one alternative Nunn et al.
recommended the screening of TB patients with HIV tests before using a thiacetazone-free regimen. This was the strategy adopted in Blantyre district at the time of
this study. Our analysis shows that some cost savings have actually been achieved
by this strategy. However, a future increase of HIV-seropositivity would make the
strategy of full thiacetazone replacement the more cost saving option. To evaluate
this result, it should be noticed that the calculations were based on the cost of one
ELISA test performed for diagnosis, which was the recommendation for patients
with clinical signs of an HIV infection at Queen Elizabeth Hospital. Regardless of
the presence of clinical signs, WHO recommends to perform a confirmatory test, if
the tests are performed for individual diagnosis . Under the simplifying assumption
that the average cost per ELISA-test would be the same under increased output lev
els, the implementation of a policy of two tests per diagnosis would make a thiaceta
zone replacement strategy cost-saving at an HIV prevalence of 56%. The costs of
replacing thiacetazone can be related to the effects of this policy to calculate a cost
effectiveness measure. Under the assumption that fatal side-effects occur in 3% of
HIV-positive patients treated with thiacetazone, 52 deaths have been averted in
Blantyre district during 1994 by avoiding this drug . The incremental cost for the
complete replacement of thiacetazone by ethambutol in all patients would have been
$ 20,408. It should be noticed that the overall incremental costs to the programme
are likely to be lower, since we do not account for the costs of hospital stays due to
drug reactions, which would be minimised under this scenario . Only accounting
for additional drug costs, the cost per death averted by^this strategy is $ 392, or,
using an effectiveness measure used by the World Bank , a cost of $ 42 per DALY
i
36
i
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
saved36. This calculation ranks thiacetazone replacement among the most cost-ef
fective health care interventions available”’. Its implementation should therefore have
a high priority in relation to other health interventions, i.e., reducing funding for
more expensive interventions and using the freed funds for thiacetazone replace
ment will result in a higher gain of deaths averted or years of life saved. We concede
that idiosyncrasies of programme organisation may make it practically difficult to
adopt the viewpoint of cost-effectiveness analysis. In Malawi for instance, most drugs
are donated by external donors. Recommending that thiacetazone replacement should
take precedence over other health interventions is unlikely to affect their drug bill,
which will always be higher under a replacement strategy. If the additional funds
required exceed those available to the donors, negotiations with national authorities
will be necessary regarding the redistribution of cost savings (e.g., through limiting
hospitalisations and abandoning HIV screening) for drug purchases.
3. Should patients be screened with radiography?
Under the current level of inputs the sputum microscopy services at Queen Elizabeth
Hospital have reached their productivity limit. With patient numbers still expected to
rise, a decision has to be made on the most appropriate methods for screening and
diagnosis. In general^ WHO recommends the use of sputum microscopy as the standard
diagnostic method . We have shown that the laboratory output at Queen Elizabeth
Hospital could be doubled at very low incremental costs and decreasing average
costs. Under the policy for laboratory expansion, the average costs for the recom
mended strategy of three slides per patient ($ 0.93) are well below the average costs
of performing conventional chest x-rays, although the difference to the marginal
cost for x-ray supplies only ( $ 0.96) is minimal. The question about the “correct”
cost category (marginal or average) to use for policy analysis is not easy to answer.
X-Ray machines usually have a very long useful life, probably more than the twenty
years assumed in this analysis. Thus, in places like Queen Elizabeth Hospital, where
the equipment is already in place, it appears acceptable to analyse the marginal cost
only. Under this condition, cost savings through microscopy instead of x-ray screen
ing do not appear very pronounced. Further, x-ray costs can be reduced substan
tially by the use of miniature radiography. The marginal costs of supplies for mini
ature radiography ($0.35 ) are comparable to the incremental costs of smears after
increasing laboratory outputs ($0.31).
The decision about the use of sputum smears or x-rays for screening should be
based on considerations that go beyond an analysis of costs only. First, it must be
realised that the screening of large numbers of sputum smears negative for AFB is
likely to reduce the quality of services, with implications for both the sensitivity and
specificity of this test. Second, in the absence of radiography, the diagnosis of smear
negative patients is based on clinical signs only, which may lead to an over-diagno
sis of this category of patients, with cost implications due to unnecessary treatment.
In conclusion, it appears reasonable to recommend the use of x-ray for screening
purposes in Queen Elizabeth Hospital. Cost savings could be achieved by the use of
miniature radiography. For different locations, recommendations must be based on a
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
37
HEALTH ECONOMICS
careful analysis of the current situation. If no x-ray facilities exist and equipment has
to be purchased from the Ministry of Health budget, the use of x-rays should be
discouraged, as the average costs of this technique are substantially higher than the
cost of microscopy. If local authorities have to bear only the costs of supplies , e.g.,
because equipment is donated, the use of x-rays for patient screening appears justi
fied in locations with very high caseloads. In these circumstances, the use of mini
ature radiography is preferable to conventional x-ray technique.
4. Reducing costs and ensuring quality of care
The results of this study show that substantial savings can be achieved in the deliv
ery of health care to tuberculosis patients by delivering care on a completely ambu
latory basis. This result is in accordance with previous observations,
, although
we are now able to substantiate this argument with a detailed analysis of the costs of
ambulatory care at the health centre level. However, the main reason for avoiding
hospital therapy is currently the severe state of overcrowding in tuberculosis wards.
At Queen Elizabeth Hospital, bed occupancy rates presently average 200%, and
case numbers are projected to increase during the coming years. Working condi
tions for staff as well as the state of physical surroundings for patients may be no
longer acceptable. Should a decision to reorganise the care for smear-positive pa
tients be made, prime importance must be given to ensure compliance rates similar
to those under hospital care in the ambulatory setting. This will require the increase
of staff level at health centres. It appears to be mandatory that any cost savings
through decreased hospital costs should be used for this purpose. In fact, it does not
appear to be necessary to attempt a further decrease in tuberculosis treatment costs.
The present data confirms the overall low cost of care for tuberculosis patients in a
developing country setting. The status of tuberculosis care as one of the most costeffective health interventions therefore singularly depends on high cure rates achieved,
and every effort must be made to sustain these in an ambulatory setting.
38
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
IV. Appendix: Data tables
Appendix 1: Population size: Malawi
POPULATION SIZE
Northern Region
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
TOTAL
72,316
106,923
105,803
62,450
301,361
648,853
1994
1987
(estimated)
96,794
125,410
191,772
148,014
138,381
179,291
94,902
122,958
433,696
561,91 1
911,787
1,181,342
Central Region
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
TOTAL
194,436
94,370
87,437
247,603
132,276
704,1 17
158,833
298,190
226,454
2,143,716
323,453
158,044
120,860
322,432
189,173
976,627
249,843
41 1,787
358,767
3,110,986
419,077
204,767
156,590
417,754
245,099
1,265,351
323,705
533,525
464,831
4,030,699
Southern Region
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
TOTAL
302,341
341,836
352,334
176,184
408,062
71,405
322,000
477,546
194,425
108,758
496,578
515,265
441,615
210,912
589,525
121,513
431,157
638,062
316,733
204,374
3,965,734
643,383
667,595
572,171
273,265
763,809
157,436
558,622
826,695
410,370
264,794
1977
2,754,891
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
5,138,139
39
HEALTH ECONOMICS
Appendix 2: Tuberculosis incidence: Malawi
population size
case numbers
1994(estimated)
1994
rate per 100,000
125,410
191,772
179,291
122,958
561,911
1,181,342
113
236
613
308
951
2221
90
123
342
250
169
419,077
204,767
156,590
417,754
245,099
1,265,351
323,705
533,525
464,831
4,030,699
355
247
138
765
465
2892
383
323
414
5982
643,383
667,595
572,171
273,265
763,809
157,436
558,622
826,695
410,370
264,794
5,138,139
682
659
2142
893
3361
293
791
1070
637
765
11293
Northern Region
Chitipa
Karonga
Nkhata Bay
Rumphi
Mzimba
TOTAL
188
Central Region
Kasungu
Nkhotakota
Ntchisi
Dowa
Salima
Lilongwe
Mchinji
Dedza
Ntcheu
TOTAL
85
121
88
183
190
229
118
61
89
148
Southern Region
Mangochi
Machinga
Zomba
Chiradzulu
Blantyre
Mwanza
Thyolo
Mulanje
Chikwawa
Nsanje
TOTAL
19496
106
99
374
327
440
186
142
129
155
289
220
188
Malawi
TOTAL
10,350,180
40
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 3: List of currently utilized inputs
Health Centers:
I. common inputs:
1. building
2. standard equipment
3. maintenance
II. specific inputs:
A. history and physical examination:
1. personnel: medical assistant, nurse
B. chronic cough register:
1. personnel: health assistant
2. stationery: register book
C. sputum collection and transport to district hospital:
1. personnel: medical assistant
2. equipment: sputum container
3. stationery: container labels, laboratory request forms
4. transport to DH: public transport
D. drug distribution in continuation phase:
1. personnel: medical assistant
2. drugs: continuation phase for each regimen
E. follow-up on defaulters:
1. personnel: health assistant
2. equipment: bicycle
3. travel costs: per diem, allowance (only if overnight stay)
F. health education:
1. personnel: medical assistant
2. equipment: none (talk)
District level:
I. common inputs:
1. buildings: district health office, district hospital
2. standard equipment
3. maintenance
II. specific inputs:
A. history and physical examination:
1. personnel: medical officer, medical assistant, nurse
B. chronic cough register:
1. personnel: health assistant
2. stationery: register book
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
41
HEALTH ECONOMICS
C. sputum collection:
1. personnel: medical assistant
2. equipment: sputum container
3. stationery: container labels, laboratory request forms
D. drug distribution in continuation phase:
1. personnel: medical assistant
2. drugs: continuation phase for each regimen
E. health education:
1. personnel: medical assistant
2. equipment: none (talk)
F. sputum microscopy and laboratory register:
1. personnel: laboratory chief, lab. technician, lab. assistant, lab attendant
2. equipment: standard lab. equipment, microscope, safety cabinet, autoclave
3. supplies: loops, slides, slide containers, slide racks, sterilizing bags, slide
marker, staining solution (Ziehl-Neelsen, Auramin-Phenol for fluorescence)
4. stationery: laboratory register
G. x-ray:
1. building: darkroom
2. personnel: x-ray technician, darkroom attendant
3. equipment: x-ray machine, automatic processor, standard x-ray equipment
4. supplies: films, developer, fixer, film envelopes
H. patient register:
1. personnel: district tuberculosis officer (DTO)
2. stationery: register book
3. transport: motorcycle, fuel, maintenance
I. hospitalized intensive phase:
1. building: TB ward
2. equipment: standard ward equipment
3. personnel: medical officer, nurse
4. drugs: intensive phase drugs for standard regimens
5. supplies: food
6. patient transport: travel warrant (go/return)
J. supervision on health clinics:
1. personnel: DTO
2. transport: motorcycle, fuel, maintenance
3. travel costs: per diem, allowance
K. staff training:
1. personnel: DTO
2. equipment: overhead-, slide projector
3. supplies: education material
4. stationery: notebooks
42
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
5. travel costs: travel warrants, per diem, allowance
L. preparation of quarterly reports:
1. personnel: DTO
2. stationery: quarterly report forms
3. transport: mail
Regional level:
I. common inputs:
1. buildings: district health office, district hospital
2. equipment: computer, printer
3. maintenance
II. specific inputs:
A. planning of regional activities:
1. personnel: regional tuberculosis officer (RTO), medical assistant
B. supervision of districts
1. personnel: RTO
2. transport: car, fuel, maintenance
3. travel costs: per diem, allowance
C. staff training:
1. personnel: RTO
2. equipment: overhead-, slide projector
3. supplies: education material
4. stationery: notebooks
5. travel costs: travel warrants, per diem, allowance
D. preparation of reports to central level:
1. personnel: RTO
2. stationery: quarterly report forms
3. transport: mail
Central level:
I. common inputs:
1. buildings: community health sciences unit
2. equipment: computer, printer
3. maintenance
II. specific inputs:
A. planning of country-wide activities:
1. personnel: programme manager (PM), assistant manager, TB registry clerk,
secretary
B. supervision of regions and districts
1. personnel: PM
2. transport: car, fuel, maintenance
3. travel costs: per diem, allowance
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
4.3
HEALTH ECONOMICS
C. staff training:
1. personnel: PM
2. equipment: overhead-, slide projector
3. supplies: education material
4. stationery: notebooks
5. travel costs: travel warrants, per diem, allowance
D. preparation of reports to ministry:
1. personnel: PM
E. central laboratory:
1. building: central laboratory
2. personnel: laboratory chief, lab. technician, lab. assistant, lab attendant
3. equipment: standard lab. equipment, microscope, safety cabinet, incubator,
autoclave
4. supplies: loops, slides, slide containers, slide racks, sterilizing bags, slide
marker, staining solution (Ziehl-Neelsen, Auramin-Phenol for fluorescence),
glass dishes, glass bottles, culture medium
5. stationery: laboratory register
44
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 4: annual staff salaries
Personnel
Annual cost (Kwacha)
20,000.00
14,000.00
11,500.00
10,000.00
11,500.00
7,500.00
4,500.00
60,000.00
23,200.00
20,000.00
sister (STO)
nurse(STA)
nurse(TA)
attendant (SCI)
clerk (TA)
domestic (SCIII)
non-grade
physician
lab.chief (PO)
labtechn.(STO)
radiogr.(TO)
tech. (TA)
assistant (SCI)
lab.chief
techn. (TA)
PM(P8)
assistant (STO)
registry clerk (TA)
secretary (TO)
driver (SCI)
RTO(STO)
assistant (TO)
clerk(TA)
driver (SCI)
17,400.00
11,500.00
7,500.00
23,200.00
11,500.00
31,500.00
20,000.00
11,500.00
17,500.00
10,000.00
20,000.00
17,500.00
11,500.00
10,000.00
Additional monthly bonus payment (included in above figures):
grade:
P5 - P8:
CTO/PO:
STO/TO:
STA/TA:
SCI - SC IV:
Unclassified:
600.-
400.300.200.150.100.-
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
45
HEALTH ECONOMICS
Appendix 5: Allocation of overhead costs at Queen Elizabeth Hospital
allocation
costs
wards
lab
Administration x-ray
allocation
costs
allocation
costs
allocation
costs
PfflSCNAL EMa.UMRTTS
001 Salaries
002 Non-Established Staff
007Temporary Employment
017 St udent sAI Iowanee
031 Housi ng Al lowance
7311000
500000
0
0
99392
TOTAL PfflSCNAI. EMCLUMBMTC
7910392
0.1
791039.2
0
0
0
o
o
o
190000
3645
160000
0.1
1
o.i
19000
3645
16000
0.05
0
0.05
0.05
0
0.05
0
1026496
47413.5
29919
7500
18328
414.7
9999.6
22624.3
372
332508
7000
397
34629
980
120000
0
100600
4476.9
99850
200
17620
0
0
0
14
0
0
0.05
0
0
0
0.05
0.05
0.05
0
0
0.05
0
0
0
0
0
0
0
0
0.05
0
0
0
0.05
0.1
0
0.05
0
0
0.05
0
0
0
0.05
0.1
0
0.05
9500
0
8000
0
0
23706.75
0
0
0
207.35
4999.8
11312.15
0
0
3500
0
0
0
0
0
0
0
0
2238.45
0
0
0
4985.6
63500
0
7
0.8
0
0.8
0
0
0.8
0
0
0
0.8
0.8
0.8
0
0
0.8
0
0
0
0
0
0
0
0
0.8
0
0
0
0.9
0.8
0
0.8
152000
0
128000
1231843 excluded
1026496
i
474135
o.i
29919
7500
18328
1
4147
o.i
99996
o.i
226243
o.i
i
372
332508
70000
0.1
397
1
1
34629
1
980
120000
1
3023054 excluded
4103585 excluded
o
0
100600
44769
0.1
99850
200
1
17620
99712
0
0
635000
0
140
0.1
9500
0
8000
0
0
23706.75
0
0
0
207.35
4999.8
11312.15
0
0
3500
0
0
0
0
0
0
0
0
2238.45
0
0
0
4985.6
63500
0
7
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
GCCOS AND SffMCS
105 Cleaning Mat erials
106Computer Costs
107 Consumable st ores
115 Food Provision
116 Fuel and Lubricants
117 Heat ing and Light ing
118 Hiring Costs
119Hoqjitality Scpenses
121Hotel Charges
123lnternalTraining
124 L/Qant Transf. & Di st ur. A
128 Maintenance of Buildings
130 Maim enanceof Off ice Equipment
131Maintenanceof Motor Vehicles
132 Maintenanceof Equipment
137 Post age & Post al Charges
138 Print ing Costs
140 Publicat ion & Advert ising
141 Putd i c Tr an^xx t
142 Purchase of DrugsS vaccinal ions
143 Purchased Medical Stores
145 Rents
146 Stationery
147 Subsist ence Allowance
148 Tel ephone Char ges
149 Telex & Telegraph Charges
ISOTransport Claims
152Uniforms Protect.Gothing
153 Vfat er and Sanitation
167 Board Meet ings
184 Purchase of RrefightingC
TOTAL GOODS AND SffMCES
0
0
0
0
0.05
0
0
0
0.05
0.05
0.05
0
0
0.05
0
0
0
0
0
0
0
0
0
0
35815.2
0
0
0
89740.8
508000
0
112
12,155,668.00
CAPITAL FCRMAT1 CM
302 Const ruction of Boreholes
303Const ruction of Buildings
307Purchaseof computer Equipment
308Purchaseof Equipment & Plants
309 Purchase of Fur nit ure& Fittings
313 Purchase of OfficeBjuipment
316 Rehabilitation of Buildings
320 RehabiI i t at ion of Wat er Suppl i es
321 Replacement of Equipment & Plants
322Replacement of Rjrniture&
323 Replacement of Motor Vehicles
0
42457
0
0
16391
0
0
0
0
15000
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
73848
TOTAL CAPITAL FCRMATICN
Totals:
2.711,02620
131.957.10
131,957.10
SUM
46
0
0
379308
0
0
0
3317.6
79996.8
180994.4
0
0
56000
0
0
0
0
1.613.284.80
4,588,225.20
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 6: Costs of drug regimens currently in use in Malawi
2HRZS/6HT
Dfl
Cat'T
Kwacha
drug
'fcOsiperftn farc-tisive
/).00
KW)
an
R191
007
OOO
0.24
RH 150/100
0.07
RH 300/150
0,Q
0.00
RHZ
O.Jfl
0.00
H100
o.ai
am
ZSOO
1092
E 400
0,04
E4W/H15O
6 00
S I
5.75
w« te r/» y ring« I a t> e4te?
5.8c.
T >11 <■ > C M
HT
W0/5#
0.00
(:.0l
aw'
cwu
33.70
I
I
w
ooo
aoo
o,u
; o.u
aoi
total
o.oo
ow
ow
w
0,00
1124
0,00
0.00
0,00
10,92
0X)0
0,06
75
fJW
0.00
14?
^^0
6.00
W2
L42
3532
0<»
o.a>
0,00
0,00
aoo
0,00
2HRZS/6IH
Dfl
Card
izpsi ptifun aneitofoe:
oao
i> 11
2
/<
Mis
ao?
ooo
0.07
0,t>
024
000
an
am
001
6(1(1
ow
¥1.92
000
01)0
.5.75
3W
000
0.O1
ooo
ow
%
%
004
().O6
0,14
J
a»
* 4
|
33.70
33
JO
Cat.2
'
7 •
>
I
§
J
i:
IL. . . . . . . . . . . .
oil
(Hl
DJ»?
Q.U?
an
aw
0,0)
606
0,64 :
0,06
0.H
0 14
001
001
93 88
n.w
<1 00
0*4
O.O*
0,54
0 37
0 53
1,14
1,15
o,a?
0,67
' 9L13
47,00
aw
aw
ow
aw
OW
wi
aoo
aw
aoo
OW
oxio
0,24
ow
000
000
KL92
ow
34.20
5.75
5W
UW
0(«)
OOO
000
000
OW
0:06;
34.20
34.20:
0.00
0.00:
0.00
: OW:
owj
0.00
: awi
ow
ow
34.20 67.01
67.91
34.20
0.55
0.56:
OW
0.84
OftO
0,34
0,37
6zS3
IM
1)5 :
ao?
6,07
infCftsive
0,<M>
tl.Vi;
9W
04M;
0<Mi
0,00
oi n
aw
ow
47.99
0,00
000
0w
■
:
41,13
VW
<• Oft
47.90
4S.W
0,00
HM?
2l»3.2r
Cftftf.
O'M)
o.w"
aw
aw
■ aw
aw
aw
aw
n-Hj
9W
0,1 H!
0,00
0,00
aw
0,66
23W
0.60
0.00
p,0O
2X5,57
47,9^
4X.35
(too
0.00
..........
fKwacha
ftw
0,00
0.00
».O6
ow
r>u n
aoo
O.55
0.55
as*
Q.56
0,96
.0,96
0*4
0*4
ftW
006
ft54
0.54
0 37
ft.53
053
l.M
<M
Iff
I
»
607
007
•0,07
0.07
OW
20U6.
0.1)0
OW
6.00
ft.OO
40 Kj
19
000
000
B
O.oo’
aw
281.30 285.57
inifcoMve
ow
0 00
05 ss
.J w
11.K7
aoo
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S.28
o.oa
aot)
o.w
o,oo
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o.oo'
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o oof
28L39
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24,09
O.IX)
nio
totnli
: 0:00'
(I Uiii
tU?
petun;
’XW&oxt pe?
vo.
odo'
ft.no'
6,94
0.94
2339
O.tX)
ertBL
OOQ
O.IMt
4 SO’?
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pvrua mU'JWve:
2
?
aw
0,55
6,56
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pct w
0.94
o.oo
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I . Dfl ..
peruB> jnieOxive
0^4
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0,00
0.00
ooo
600
OW
000
2339
2.139
6.00
0.(H)
36,10
6.21
8 28
: 600
9.00 ;
90 ;
: 04ioo
81.08 35.07 116.14
ow
voi:i.
a,w
:
0O«
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000
Q <,<|
0 '4!
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19529
OW
142.76
65,55
64 F5
OW
0W
O00
000
0.00
...... 0,00
676.92
292.76
o.w
OW
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
0 00
0 00
195 J»9
000
50143
68*5
69.13
0.0U
:..; o.aa,
9<>O8
47
HEALTH ECONOMICS
2HRZ/2HE/4H
j
Dfl
Cat, 3
£o«tpet(Hi. Intensive
KUIO
0.11
R150
RM iWHi
RH3WH
067
067
0.12
RHZ
HIW
an
o.oi
I
I
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0.00
6.43
0.00
0.00
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624
0,00
0,00
0,00
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10 27
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U:t4jk?
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|
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0,07
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<W7
I
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0.O0
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6.00
0.00
2.6?
6,24
2 0.00
7.60
060
. 0.00
0 00
i 0 00
7,60
i 0,00
0,00
12 66
7W;ifeiperBtt: i mtt Wiwe
otiu
0.00
5.V64
OOO
GOB
O.BD
53.B8
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0.00
0.00
BOO
BOO
BOO
V.55
0.56
4) Mi
W
0 54
lk,W
0.53
LU
LB
i
ccwt.
BOB
0,00
5 J 04
0,00
0,00
22^9
5308
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63 >16
000
000
006
04)0
0.00
060
■ 0.00 :
0.00
22 29
i 000 i
0.00
; 65.46 i
0,00
: 0,00
>
660
669
600
105.72 85.75
m*47
Mwucha
A
0.2
as
<W
6.00
0,60
(UH
;0X)6i
0.00
0.00
0<>4 i
0.06
014
■ox®
0,00
I
2.{
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(
t
*.
%
HI
i 001
i (LOL
TOl^osiperun imctuiive
0.00
0.oo’
0.00
0.00
0.00
0.00
0.00
0X10
: 0.00
0,00
j 0.60
0.00
: 0.00
4.0
i 4.14
000
0.00
000
0.00
oxo
w#
o.oo
4.H
4.W
0X)O
0.24.
i
COftf.
0XK1
Q.(K>
2.61
0,94
0.94
0.55
0,55
00.56
56
0.98
098
0iOMi
84
00 06
09
0.34
0.34.
00.37
37
0.33
0.33
LU
LU
LIS
0,07
0,67
i iM
____
2.61 _11
____
8*48
O.07
0.0?
cont
0,06
000
m
702
ooo
060
0.00
000
000
000
2L75
0.00
BOB
0.00
0.OB
0,00
O.BB
ODO
0.00
34 28
U5b
000
23 73
21^5
92-57
BOB
0.00
03)0
600
O.0B
06D
060
060
U28
34 56
BOO
060
ouo
0.00
o.oo
ODO
ooo
1SHT711EH
)
Kwacha
£cwtperm): imenslve
2
O.H
0X17
007
>
f
i
%
|
&
■>¥
('
i
■■
0X«)
i
0.00
:
0.60
060 i
0.00 :
0,00 :;
0,00 i
0.00 :
5.70 i
060
060
0,00
0,00
41S1
O’
4 11
ow
o.u
4,j4
0.00
000
on
? (
?. ( :
0 K)
0.01
io.06
U.<M
0.06
0.D1
0.01
■;
i
13*95
48
perun inteasKe
eont
O.fXL
i
o,oo
uffl
0.00
0.00
i41.81
O.BO
0,00
O.BB
0.00
0.00
0 00
0 00
47^1
4.H
4.14
O.BB
• wi
55J5
094
655 ■
656
098
0,«4
0.00
^ 4.
0*5?
0^3
LU
115
06?
067
cont.
660
0.00
O.00
0.00
0.00
0.00
0.00
0.00
340.02
0,00
0.00
BXJO
: o.oo
<*-00
600
OOO
060
' 060
•060
: 090
4; 57
34.28
.34.56
0.00
0.00
i
060 i
•
0.W
0.00
0.00
0.00
000
0.00
OXJ0
0X6
396.07
34,50
0.00
0.00
116-44 349*03 465.46
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 7: Calculation of the cost per hospital bed-day
Hospital bed-day
year of coat
unit coal
number
lilelime
allocation
yearly equiv
del lai od I or year
Tolal
$ TOTAL I or eachangeyear $ TOTAL deflated I or year
1995
1995
1896
281,06147
$19.572 53
$19,572 53
Buildings
750.000 00
TBward
1994
1990
1990
20
20
20
100.409 09
0.00
000
100
000
000
Total:
200,818 17
000
$0 00
$0 00
$0 00
000
200.8B.V
28106147
$® ,572 53
$19.572 53
000
000
$0 00
Equipment
tXKl
6B
5313 20
1995
100
63 943 95
63 943 95
$4 452 92
$4 452 92
68
? 814 56
1995
10
10
940 35
locker
498 13
100
33.873 01
33873.01
$2 358 84
$2,358 84
1990
1990
10
10
000
000
000
000
000
000
$0 00
$0 00
$0 00
$0 00
000
000
000
000
$0 00
$0 00
$0 00
000
000
$0 00
$0 00
97,8®.97
9 7.8®.9 7
$6.8nn
$6.81177
$2 785.5?
$3,899 72
$3,203 34
$2 785 52
$1,39? 76
$800 84
$1,392 78
$800 84
$3.133 70
$1253 48
$3,03 70
1990
1990
10
000
10
1990
10
0.00
000
Total:
$0 00
Personnel
?
■fller(STO)
nurse (3TA)
nurse(TA)
aliendanl (SCI)
clerk (TA)
20,000.00
1995
100
40.000 00
40.000 00
14.000 00
1995
1995
100
56.000 00
56.000 00
100
46.000 00
46.000 00
20,000 00
11,500 00
11.500.00
dome® ic(SCIII)
non-grade
$3,899 7?
$3,203 34
t
10.000 00
11500.00
1995
1995
100
100
20 000 00
11,500 00
6
7 500 00
4,500 00
1995
100
100
45.000 00
W.000 00
45 000 00
18 000 00
0 10
6 000 00
000
6 000 00
000
$417 83
$0 00
$417 83
$0 00
242.500.00
242,600.00
$®,887.®
$16,887.19
60.000 00
000
physician
1995
1995
1990
Total:
$1,253 48
Overhead
161.328 48
225.792 41
$6.723 71
216.882 10
303 544 25
$21 138 18
$6 723 71
$? I 138 18
1990
1990
000
000
$0 00
$0 00
$0 00
$0 00
1990
000
000
000
000
clinical wardaovor head
1.613?84 80
1994
0 10
adminifl ral ion
?.7110?6?0
1994
0.06
1990
Total:
$0 00
$0 00
000
000
$0 00
$0 00
378^0.58
529,3 36.68
$36,88188
$36,86188
229 650 00
000
000
000
229.650.00
$15.992 34
000
000
$0 00
$0 00
000
000
$0 00
$15.99? 34
60.00
$0 00
$0 00
Food
food
45030
500
1995
1990
1990
1990
1990
1990
Total:
100
000
$0 00
$0 00
000
000
$0 00
$0 00
229,650.00
229,650.00
$15,992.34
$15,992.34
T148.ttB.71
472 ,S0.00
1380.385.10
S98.Q5.70
$96,06.70
472,00.00
$32,879.53
$32,879.53
26.02
30.06
10.28
$2.09
$0.72
$2.09
$0.72
Total:
full
marginal (personnel ZI ood)
BHJQAYS:
46930
COST PSt DAY:
full
marginal (peraonnel I food)
10.28
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
49
HEALTH ECONOMICS
Appendix 8: Cost calculation for sputum microscopy
smear
yearofcost lifetime yearlyequiv. allocation Total
numberunit cost
deflat ed f or year: $ TOTAL for exchange year:
1995
1995
16,065.45
0.00
0.00
16,065.45
16,065.45
0.00
0.00
16,065l45
$1,118.76
$0.00
50.00
$nre.76
1.00
0.50
0.50
0.50
0.20
25,414.93
5,309.52
1,415.87
2.654.76
2,541.49
0.00
0.00
37,336.58
25,414.93
7,431.11
1,415.87
2,654.76
2,541.49
0.00
0.00
39,458.17
$1,769.84
$517.49
$98.60
$184.87
$176.98
$0.00
$0.00
$2,747.78
0.10
0.40
0.30
2,320.00
8.000.00
6,900.00
2,320.00
8,000.00
6,900.00
$161.56
$557.10
$480.50
0.00
17,220.00
0.00
17,220.00
$0.00
$1,199.16
26,391.42
27,110.26
0.00
0.00
0.00
0.00
53,50 tea
36,936.95
37,943.03
0.00
0.00
0.00
0.00
74,879.98
$2,572.21
$2,642.27
$0.00
$0.00
$0.00
$0.00
$5,214.48
1,400.10
409.26
114.88
225.00
73.09
102.87
125.00
16.451.85
3.147.95
3,500.00
25,550.00
1,400 10
409.26
114.88
225.00
73.09
102.87
125.00
16.451.85
3,147.95
3.500.00
25,550.00
$97.50
$28.50
$8.00
$15.67
$5.09
$7.16
$8.70
$1,145.67
$219.22
$243.73
$1779.25
149,673.72
25,550.00
173,173.61
25,550.00
$12,059.44
$1,779.25
6.10
1.04
7.05
$0.49
$0.07
Buildings
i
DH/lab
6,000,000.00
1995
1990
1990
20
20
10
803,272.68
0.00
0.00
0.02
0.00
0.00
Total:
Equipment
microscope(fluoros)
safety cab.
autoclave
centrifuge
general lab equipment
143,600.00
60,000.00
16,000.00
30,000.00
71,800.00
1995
1994
1995
1995
1995
1995
1990
23,200.00
20,000.00
11,500.00
1995
1995
1995
0.00
1990
131,957.10
2,711,026.20
1994
1994
1990
1990
1995
1990
280.02
136.42
114.88
225.00
73.09
102.87
125.00
0.67
0.13
3,500.00
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
10
10
10
10
10
10
10
25.414.93
10,619.05
2,831.75
5,309.52
12.707.46
0.00
0.00
Total:
Personnel
lab.chief (PO)
labtechn.(STO)
TA
i
2
Total:
Overhead
I aborat ory ov erh ead
administration
1
1
0
Total:
0
0.20
0.01
Supplies
5
3
1
1
Auramine
phenol
permanganate
alcohol
HCI
gloves
masks
containers
slides
microsc ope lamp
24555
24555
Total:
Total:
full
marginal(supplies)
slides:
24555
COST PER SLIDE
full
marginal (supplies)
50
1.04
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 9: Cost calculation for laboratory extension
smear
yoar ol com
unit coat
number
deflatodfor year:
Total
allocation
yearlyoqmv
lifetime
1996
Buildings
50.000.00
lab
0.00
1995
1990
1990
20
10
10
6,693.94
0.00
000
o
0
Total:
6.693.94
0.00
0.00
6.693.94
0.00
0.00
$466.15
$0.00
$0.00
6,693.94
6,693.94
$466 15
25.414.93
10,619.05
2.831.75
5.309 52
1.270.75
0.00
0.00
25.414.93
14.862.23
2.831.75
5,309.52
1.270.75
0.00
0.00
$1,769.84
$1,034.97
$197.20
$369.74
$88.49
$0.00
$0.00
45,446.99
49,689.17
$3,460.25
2.320.00
20.000.00
000
23,000 00
0.00
2,320.00
20,000 00
000
23.000 00
0.00
45,320.00
46,320.00
$161.56
$1,392.76
$0.00
$1,601.67
$0.00
$3,155.99
26,391.42
27.110.26
0.00
0.00
0.00
0.00
53,50168
36.936.95
37,943.03
0.00
0.00
0.00
0.00
74,879.98
$2,572.21
$2,642.27
$0.00
$0.00
$0.00
$0.00
$5.2U.48
2.800.20
818.52
22976
450.00
146.18
205 74
250.00
33,500.00
6.410.00
0.00
2.800.20
818.52
229.76
450.00
146.18
205.74
250 00
33.500 00
6.410.00
0.00
$195.00
$57.00
$16.00
$31.34
$10.18
$14.33
$17.41
$2,332.87
$446.38
$0.00
44,81040
44,81040
$3,120.50
195,772.01
221,393.60
$15,417.37
3.92
4.43
$0.31
Equipment
U3.600.00
60.000.00
16.000.00
30.000.00
71.800.00
microscopei I(fluoros)
safely cab.
autoclave
centrifuge
general lab
1995
1994
1995
1995
1995
1995
1990
10
10
10
10
10
10
10
25.4 U.93
10.619 05
2.831.75
5.309.52
12.707.46
0.00
0.00
0.1
Total:
Personnel
23,200 00
20.000.00
lab.chief (PO|
lablechn.(STO)
TA
2
11.500.00
0.00
o.t
1995
1995
1995
1995
1990
Total:
Overhead
131.967.10
2.711,026.20
0.00
0.00
laboratory overhead
admi nisi rat ion
o
o
1994
1994
1990
1990
1995
1990
0.00
0
0
0
Total:
0.00
0.00
0 00
0.00
0.20
0.01
0.00
0.00
Supplies
10
6
2
2
2
2
2
50000
50000
Auramine
permanganate
alcohol
HCI
gloves
masks
containers
slides
280.02
136.42
114.88
225.00
73.09
102.87
125.00
0.67
0.13
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
Total:
Total:
slides:
60,000
COST PER SLIDE
-.A
05142
1 A documentation ) '
\
uN”
____________________________ _________________ Ng 1
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMniES--^
51
HEALTH ECONOMICS
Appendix 10: Cost calculation for sputum cultures
culture
number
year of cost lifetime yearly equiv. allocation Total
unit cod
deflat edf or year. $TOTALfor exchange year:
1995
1995
Buildings
1 6,000,00100
CHSU/lab
0.00
1995
1990
1990
20
20
10
803,272.68
0.00
0.00
0.05
0.00
0.00
40,163.63
0.00
0.00
40,163.63
40,163.63
0.00
0.00
40,®3.63
$2,796.91
$0.00
$0.00
$2,796.91
1995
1994
1995
1995
1995
1990
1990
10
10
10
X)
10
t)
10
5,309.52
X).619.05
2,831.75
5,309.52
12,707.46
0.00
0.00
1.00
0.25
0.25
0 25
0.10
5,309.52
2.654.76
707.94
1,327.38
1,270.75
0.00
0.00
5,309.52
3,715.56
707.94
1,327.38
1,270.75
0.00
0.00
11270.35
12,33115
$369.74
$258.74
$49.30
$92.44
$88.49
$0.00
$0.00
$858.71
Total:
Equipment
incub.
safety cab.
autoclave
centrifuge
general lab
1
1
1
30,000.00
60,000.00
16,000.00
30,000.00
71800.00
Total:
Personnel
lab chief (PO)
labtechn.(STO)
STA
TA
i
1
1
23,200.00
20,000.00
14,000.00
11500.00
0.00
1995
1995
1995
1995
1990
0 10
0.25
0 25
0.25
2,320.00
5.000.00
3,500.00
2,875.00
0.00
■B.69500
2,320.00
5,000.00
3,500.00
2.875.00
0.00
13,695.00
$161.56
$348.19
$243.73
$200.21
$0.00
$953.69
371,®6.00
1994
1990
1990
1990
1995
1990
0 05
18,559.80
0.00
0.00
0.00
0.00
0.00
18,559.80
25,975.96
0.00
0.00
0.00
0.00
0.00
25,975.96
$1,808.91
$0 00
$0.00
$0.00
$0.00
$0 00
$1808.91
6.89
200
2,80120
1995
1995
1995
1990
1990
1990
1995
1995
1995
1990
8,057.68
1,000.00
2,800.20
0.00
0.00
0.00
0.00
0.00
0.00
0.00
11857.88
8,057.68
1,000.00
2,800.20
0.00
0.00
0.00
0.00
0.00
0 00
0.00
11857.88
$561.12
$69.64
$195.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$825.78
Total:
Overhead
lab/CHSU
Total:
Supplies
1169
500
bottles
eggs
medium (total)
Total:
»
Total:
full
marginal (supplies)
cultures:
95,546.67
11857.88
104,023.62
$7,243.98
11,857.88
$825.76
81.73
10.14
88.99
10.14
$6.20
$0.71
1169
COST PH^ culture:
full
marginal (supplies)
52
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 11: Cost calculation for HIV tests
HIV-TEST
year ol cost
unit cost
number
yearly oquiv. allocation
lit el ime
de Haled I or year: $TOTAL(orexchangoyear:
Total
1995
1985
8,032 73
0.00
0.00
8,0 32.73
8,032.73
0.00
0.00
8,032.73
$559.38
$0.00
$0 00
$559.38
0.00
1.290.69
20.774.49
3,043.47
0.00
0.00
0.00
25,108.65
0.00
1.290.69
20.774 49
3.043.47
0.00
0.00
0.00
25,108.65
$0.00
$89.88
$1,446.69
$211.94
$0 00
$0.00
$0.00
$1,74 8.51
Buildings
1 6.000.000.00
OH/ lab
1995
1990
1990
20
20
10
803.272 68
0.00
0.00
1995
1995
1995
1995
1990
1990
1990
5
6
5
5
10
10
10
0.00
430.23
20.774.49
3,043.47
0.00
0.00
0.00
0.01
0.00
0.00
Total:
Equlpm ent
3
pipelte
Elisa Reader
pump
1.550.88
74.887.40
10.971.04
1.00
1.00
1.00
Total:
Personnel
lab.chiol (PO)
lochn.(TA)
23,200.00
11,500.00
1995
1995
1995
1990
1990
0.10
1.00
2.320.00
11,500.00
0.00
0.00
0.00
13,820.00
2.320.00
11.500.00
0.00
0.00
0.00
13,820.00
$161.56
$800.84
$0.00
$0.00
$0.00
$96 2.40
131,667.10
1994
1994
1994
1990
1995
1990
0.10
13.195.71
0.00
27,
'.110.26
0.00
0.00
0.00
40,305.97
18.466.48
0.00
37,943.03
0.00
0.00
0.00
56,411.51
$1,286.11
$0.00
$2,642.27
$0.00
$0.00
$0.00
$3.928.38
Total:
Overhead
laboratory overhoad
1 2.711.026.20
adm inist rat ion
Total:
0.01
Supplies
140
70
1,615.50
3.653.90
215.40
1.096.39
136.42
62.47
118.47
245.70
1,378.56
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
22.617.00
3.653.90
215.40
15,349.40
3.819.76
62.47
118.47
34.397.94
96.499.20
0.00
176.733.55
22.617.00
3.653.90
215.40
15.349.40
3.819.76
62.47
118.47
34.397.94
96.499.20
0.00
176,733.55
$1,575 00
$254 45
$15,00
$1,066.90
$266.00
$4.35
$6.25
$2,395.40
$6,720.00
$0.00
$12,307.35
14000
6.21
1995
72,916.67
72,916.67
$5,077.76
1990
1995
0.00
0.00
0.00
0.00
$0.00
$0.00
1990
0.00
0.00
$0.00
72,916.67
72,916.67
$5,077.76
4,000.00
0.00
4,000.00
0.00
$278.55
$0.00
1990
1990
0.00
0.00
0.00
0.00
$0.00
$0.00
1990
1990
0.00
0.00
4,000.00
0.00
0.00
4,000.00
$0.00
$278.55
full
340,917.57
357.023.10
$24,862.33
marginal
176.733.55
176,733.55
$12,307.35
24.36
12.62
26.60
$1.78
$0.88
14
blood boule
aloro box
Markers
Vials
Ups
I roughs
lips
Vac/needlos
ELISA
14
26
Total:
Counselling
Type:
allendant / hr
Total:
T raining
Type:
course
20
200
Total:
1995
1990
$0.00
Total:
Teets:
14000
COST PER TEST:
full
m arglnal
12.82
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
53
HEALTH ECONOMICS
Appendix 12: Cost calculation for conventional x-ray
x-ray
year of cosf
number unit cost
yearlyequiv. allocation Total
lifetime
deflated for year: $TOTALfor exchangeyear
1995
1995
Buildings
darkr./lab.
DH/x-ray
250,000.00
6,000,000.00
0.00
1995
1995
1990
20
20
10
33,469.70
803,272.68
0.00
0.50
0.025
0.00
16,734.85
20,081.82
0.00
36,816.66
16,734 85
20,081.82
0.00
36,816.66
$1,165.38
$1,398.46
$0.00
$2,563.83
714,912.60
230,635.96
1995
1995
1995
1990
1990
1990
1990
20
10
10
10
10
10
10
95,711.63
40,818.91
0.00
0.00
0.00
0.00
0.00
1.00
0.50
0.10
95,711.63
20,409.46
0.00
0 00
0.00
0.00
0.00
116,12108
95,711.63
20,409.46
0.00
0.00
0.00
0.00
0.00
116,12108
$6,665.16
$1,421.27
$0.00
$0 00
$0.00
$0.00
$0.00
$8,086.43
17,400.00
11.500.00
7,500.00
0 00
0.00
1995
1995
1995
1990
1990
1.00
1.00
100
17,400.00
11,500.00
7,500.00
0.00
0.00
36,400.00
17.400.00
11,500.00
7,500.00
0.00
0.00
36,400.00
$1,211.70
$800.84
$522.28
$0.00
$0.00
$2,534.82
65,978.55
27,110.26
0.00
0.00
0.00
0.00
93,088.81
92,342.38
37,943.03
0.00
0.00
0.00
0.00
130,285.41
$6,430.53
$2,642.27
$0.00
$0.00
$0.00
$0.00
$9,072.80
145.320.00
5.23180
3,014.10
12.000.00
0.00
0 00
0.00
0.00
0.00
0.00
165,565.90
145,320.00
5.231.80
3,014.10
12,000.00
0.00
0.00
0.00
0.00
0.00
0.00
165,565.90
$10,119.78
$364.33
$209.90
$835.65
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$1X529.66
447,992.46
165,565l90
485,189.06
$33,787.54
165,565.90
$1X529.66
37.33
13.80
40.43
13.80
$2.82
$0.96
Total:
Equipment
machine
equipment (incl.dev.)
Total:
Personnel
radiogr.(TO)
tech. (TA)
ass st ant (SCI)
1
i
Total:
Overhead
x-ray overhead
administration
131.957.10
2,711,026.20
1994
1994
1990
1990
1990
1990
12.11
74.74
35.46
1.00
1995
1995
1995
1995
1990
1990
1995
1995
1995
1990
o
0
Total:
0.500
0.010
Supplies
12000
70
85
12000
films
developer(30l)
fixer (251)
envelopes
Total:
Total:
full
marginal (supplies)
films:
12000
COST PS?FILM:
full
marginal (supplies)
54
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 13: Cost calculation for miniature radiography
MR
number
year of cost
unit cost
yearly equiv
lifetime
def lai ed for year:
Total
allocation
TOTALS
1995
Buildings
darkr./lab.
hosp.
0
250000
6000000
0
1995
20
20
1990
10
1995
16.734.85
20.081.82
0.00
16.734 85
20,081.82
0.00
$1,165.38
$1,398.46
$0.00
36,816.66
36,816.66
$2,563.83
230.699 91
10.204.73
0.00
0.00
0.00
0.00
0.00
230.699.91
10.204.73
0.00
0.00
0.00
0.00
0.00
$16,065.45
$710.64
$0.00
$0.00
$0.00
$0 00
$0.00
240,904.64
240,904.64
$16,776.09
1.740.00
2.875.00
1.875.00
2.875.00
0.00
1,740.00
2,875.00
1,875.00
2,875 00
0.00
$200.21
$130,57
$200.21
$0.00
9,365.00
9,365.00
$652 16
65.978.55
27.110.26
0.00
0.00
0.00
0.00
92.342.38
99.889.24
0.00
0.00
0.00
0.00
$6,430.53
$6,956.08
$0.00
$0.00
$0.00
$0.00
93,088.81
192,23162
$13,386 60
50.260.00
5.231.80
3.014.10
1.800.00
0.00
0.00
0 00
0.00
0.00
0.00
50,260.00
5.231.80
3,014.10
1,800.00
0.00
0.00
0.00
0.00
0.00
0.00
$3,500.00
$364.33
$209 90
$125.35
$0.00
$0.00
$0.00
$0 00
$0.00
$0.00
60,305.90
60,305.90
$4,199.58
440,48102
60,305.90
539,623.83
60,305.90
$37,578.26
$021
36,616.66
36,816.66
2.563 83
$140
240.904.64
240.904.64
16,776.09
33.469.70
803.272.68
0
0
0
Total:
Equipment
1.723,200.00
230.635.96
machine
equipment (incl.dev.)
1995
1995
1995
1990
1990
1990
1990
20
10
10
10
10
10
10
230.699.91
40.818.91
0 00
0.00
0.00
0.00
0.00
1.00
0.25
0.10
0.00
0.00
0.00
0.00
Total:
Pe reonnel
17.400.00
11.500.00
radiogr (TO)
tech. (TA)
assistant (SCI)
7.500 00
0
11.500 00
0.00
1995
1995
1995
1995
1990
(I 10
0.25
0.25
0.25
0.00
Total:
Overhesd
0
0.00
0
131,957.10
2,711.026.20
0.00
0.00
0.00
0.00
x-rai
iy overhead
admi
linistration
0
0.50
0.01
0 00
0.00
1994
1990
1990
1990
1995
1990
0.00
Total:
$121.17
Supplies
films
developer
fixer
envelopes
35
70
85
12000
1,436.00
74.74
35.46
0.15
0.10
0.10
0.20
1995
1995
1995
1995
1990
1990
1995
1995
1995
1990
Total:
Total:
lull
marginal
Buildings
Equipment
Personnel
Overhead
Supplies
TOTAL:
films:
$4,199.58
$0 05
9,365.00
9,365.00
652.16
$1.12
$0.35
93,088.81
192.231.62
13,386.60
60.305.90
60.305 90
4.199.58
$3.13
440.481.02
539.623.83
37,578.26
36.71
6.03
44.97
6.03
$3.13
$0.36
12,000.00
COST PER FILM:
full
marginal
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
55
HEALTH ECONOMICS
Appendix 14: Cost calculation for the central programme level
Central
unit coil
number
year ol cost III ollme yearly oquiv
allocation
Total
$1OTAL for exchange year
dot lai ad lor year
1995
1996
120,490.90
80.327 27
40.183 63
0 00
120,490.90
$5,693 82
$2,796.91
$0 00
$8,390.73
277.409 73
277.409 73
$19,318 23
0 00
0 00
0 00
0 00
0.00
0 00
$0 00
$0 00
$0 00
277.409.73
2 77.4 09.73
$10,318.23
15.934 42
0 00
0 00
0 00
0 00
0 00
0 00
15,934 42
0 00
0.00
0.00
0.00
0 00
0 00
15.9 34.4 2
15,934.42
$1,109 64
$0.00
$0 00
$0 00
$0 00
$0 00
$0 00
$1,109.64
31.500 00
5.000 00
11.500 00
17 500 00
10.000 00
31.500.00
5.000.00
11.500 00
17.500 00
10 000 00
$2,193 59
$348 19
$800 84
$1 218 66
75,50 0.00
75,500.0 0
$5,2 57.66
51.951 92
0 00
0 00
0 00
178.536 26
0 00
0 00
0 00
$3 617.82
$0 00
$12,432 89
$0 00
$0 00
$0 00
164,683.60
230.488.18
$16,050.71
104,023 62
0 00
104,023 62
0 00
0 00
0 00
0.00
0 00
0 00
0 00
0 00
0 00
Build Inga
8.000.000.00
olllca/CHSU
lab/CHSU
8.000,000 00
1995
1995
1990
20
20
20
803,272 68
803,272 68
0 00
0 10
0.05
Total:
80.327.27
40.163 83
0 00
Vehlclea
1.000.000.00
Aul omoblle
277.409.73
0 00
0 00
0 00
1995
1990
1990
1990
1 00
Total:
Equlpm ent
57,440.00
computar
1995
1990
1990
1990
1990
1990
1990
10
10
10
15,934 42
0.00
0 00
0 00
0 00
0 00
0.00
1.00
Total:
Paraonnal
31.500.00
20.000 00
11.500 00
17.500 00
PM (P8)
assist ant (STO)
rogiilry clerk (1 A)
secretary (TO)
10,000 00
drlver(SC I)
1995
1995
1995
1995
1995
0.25
Total:
$696 38
Overhead / Maintenance
3/1.100 00
olhce/CHSU
lab/CHSU al cull ure coelalH
127.504.00
1994
1994
1994
1990
1990
1990
Total:
01
i
37.119 60
0 00
127.564 00
0 00
Dlagnoele
88 99
1109
cull urei
0 00
0 00
0 00
0 00
104.023.62
104,023.62
$7,243 98
$0 00
$0.00
$0 00
$0 00
$0 00
$0 00
$0.00
$7,243.98
1994
250.148 00
350.102 00
$24,380 40
1990
0 00
0 00
$0 00
1990
0 00
$0 00
1990
1990
1990
1990
0 00
0 00
0 00
0 00
0 00
1990
1990
1990
1995
1990
1990
1990
1990
1990
1990
1990
Total:
Supplies
250.148 00
total M alionary
Total:
0 00
0 00
0.00
$0 00
$0 00
0 00
0 00
0 00
0 00
0.00
0 00
0 00
$0 00
$0.00
$0.00
$0 00
$0 00
260.148.00
360,102.60
$24,380.40
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
O 00
0 00
0 00
0 00
0 00
$0.00
$0.00
$0.00
so oo
$0.00
$0 00
$0 00
$0 00
$0.00
$0.0 0
$0.00
169.144 00
0 00
0 00
0 00
236,730 87
0 00
0 00
$16,485 44
$0.00
$0 00
0 00
$0 00
16 9,144.00
236.730.87
$16,48 5.44
408.145 00
0 00
0 00
0.00
$39,779.41
$0.00
$0 00
0 00
4 08,14 6.00
571,232 34
0 00
0 00
0 00
0.00
0 00
571,2 32.34
$39,779.41
1,586,479.27
1,981,912.67
$138,016.20
Treatm ent
1990
1090
1990
1990
1990
1990
1990
1990
Total:
Supe rvlelon
10S.144 00
lolallraval
1994
1990
1990
1990
Total:
T raining
typa:
I olal I raining
400 145.00
1994
1990
1990
1990
1990
1990
Total:
SUMS:
56
0 00
$0 00
$0.00
$0 00
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 15: Cost calculation for the health center level
Health Center
yearly equiv
lifetime
numberunll coat
allocation
T otel
STOTAI for eacbange year
deflated for year
1006
IMS
14.030 50
0 00
0 00
14,030 60
0 00
0 00
$4,030.50
14,030.50
$977 06
$0 00
SO 00
59 77.05
674 64
674 54
0.00
0 00
0 00
6 74.64
Buildings
624,000.00
health center
0 00
1995
1990
1990
20
20
10
70,162 48
0.00
0 00
0 20
0.00
0 00
Total:
Vehicles
670 00
bicycle
337.27
0 00
0 00
0 00
1995
1990
0 60
0.00
0 00
0.00
6 74.54
Total:
$46 97
$0 00
$0 00
SO 00
$46.97
Equlpm ent
100,000.00
•landardHC equipment
2.677 68
0 00
0 00
0 00
0.00
0 00
0.00
2.677.58
2,677.58
so oo
$186.4 6
2.000 00
14 .000 00
11.600.00
20.000 00
0 00
2.000 00
14.000 00
11.500 00
20.000 00
0 00
S800 84
St 392 76
SO 00
47.500.00
4 7.600.00
$3,30 7.80
16 .000 00
0 00
0 00
0 00
0.00
0.00
15,000.00
0 00
0 00
0 00
0 00
0 00
15.000.00
$1,044 67
SO 00
SO 00
$0 00
SO 00
SO 00
$1,044.57
0.00
0 00
0.00
0 00
0 00
0 00
0.00
8.000 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
$657 10
SO 00
$0 00
SO 00
SO 00
8,000.00
8,000.00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0.00
0.00
0.00
0 00
0 00
0 00
0 00
0 00
0 00
0.00
0.00
$0.00
$0 00
$0 00
SO 00
$0 00
$0 00
0.00
0.00
$0.00
186.11
9.709 36
6.146 80
17,424 14
1.171 03
3,361 74
0 00
4 16.00
166 II
9.709 36
6.146 80
17.424.14
1.171 03
3,361 74
0 00
4 16 00
$676.14
$368 4 I
$1,213 38
S8I 66
$234 10
SO 00
S28.97
$37,396.19
$37,306.19
$2,604.12
1990
1990
1990
1090
0 00
0 00
0 00
0 00
0.00
0 00
0 00
0 00
0 00
0.00
$0.00
1990
1990
1990
1990
1990
1990
0 00
0 00
0 00
0 00
0 00
0 00
0.00
0.00
0.00
0 00
0 00
0 00
1995
1990
1990
1990
1990
1990
1990
Total:
20
s
s
10
10
13,387 88
0.00
0 00
0.00
0 00
0.00
0 00
0 70
2,677 68
0.00
0 00
0 00
0 00
0 00
0.00
SWA 46
SO 00
SO 00
$0 00
$0 00
SO 00
Ptrionntl
medical aaalalant (STO)
nurse (S I A)
aaaxiant (TA)
aurv. assistant (SCI)
I
20.000.00
14.000.00
11,500.00
10.000 00
1996
1995
0 00
1990
0 10
0 60
::::
Total:
$139 28
$974 93
Overheod / M olntenanci
heatl h cent er
60,000.00
1995
1990
1990
1990
1990
1990
0 30
15,000.00
Total:
DlegnoelB
2000
4 00
1995
1996
1995
1996
1990
1990
1990
1990
Total:
8.000.00
so oo
so 00
$0 00
$667.10
Supplies
coaled al central level!
1996
1990
1990
1990
1990
1990
1996
1996
1996
1990
Total:
so oo
SO.00
so 00
SO.00
Treotm ent
11 87
285 67
131 97
34
39
91
Cat 3(TH)
cajafm
292 78
3.361 74
Drug Distribution
4 oo
104
follow up'rlps
1996
1996
1996
1995
1996
1996
1990
1995
Total:
Supervision
coaiedal central level!
Total:
$0.00
$0 00
$0 00
$0.0 0
Trelnlng
coatedat cenlrallevel!
Total:
SUMS:
0.00
0.00
$0 00
$0.00
$0 00
SO.00
SO 00
SO 00
$0.00
126,277.80
126,277.80
8,724.08
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
57
HEALTH ECONOMICS
Appendix 16: Cost calculation for the district level
$ JSTHTCT
number
yearly equiv
y•■r ol cost
unit coat
allocation 4 O TA I.
STO1AL I or exchange yaar
daflaiad for year:
• U III) IN CS
5.500.000.00
6 000.000 00
DHO
OPD
1995
1995
1990
20
736,333.29
803,272 68
0.00
0 10
0.01
Total:
8 1,6 6 6.06
73.633.33
8.032 73
0 00
81,666.06
$5,127.67
$559 38
$0 00
$6,687.05
0 00
11,045 82
0 00
0 00
0 00
11,045 82
0 00
0 00
11,04 5.8 2
11,04 6.82
$0 00
$769 2 1
$0 00
$0 00
$76 9.2 1
0 00
0 00
0.00
0 00
0 00
0.00
0 00
0.00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0.00
$0.00
73.633.33
8.032 73
0 00
6 I*: ii icii: S
18,668.00
Motorcycle
1990
1995
1990
1990
2
0 00
11.045 82
0.00
0 00
1 00
Total:
W ii ii'M i: n i
1995
1990
1990
1990
1990
1990
1990
:?
10
10
:?
10
0 00
0 00
0 00
0 00
0 00
0 00
0 00
Total:
$0 00
$0.00
$0 00
$0 00
$0 00
$0 00
$0 00
o i:rsonn i: i
01O(S1A)
14.000 00
1996
1 00
28,000.00
28,000 00
S1.949.86
heallh asaiaianl (SCI)
10.000 00
1995
1 00
30,000.00
30.000 00
$2,089.14
Clerk (IA)
11.500 00
1995
I 00
11,500 00
11.500.00
0.00
1990
0 00
0 00
$0.00
10.000 00
1995
16.000.00
16.000 00
$ I 114 2 1
8 6.60 0.0 0
86,600.00
$6,9 54.04
5.000 00
OPD:SCI
0 80
Total:
/ VIIHH i: Al)
$800 84
A IN ’ll: N ANCi:
50.000 00
OHO
5,000 oo
$348 19
0 00
0 00
$0 00
1990
0 00
0 00
$0 00
1990
0 00
0 00
$0 00
0 00
0 00
$0 00
0 00
6,0 0 0.0 0
0 00
6,000.00
$34 8.19
173,173 61
0.00
0 00
0.00
0 00
0 00
25,501 65
485.189 06
173.173 61
0 00
0 00
0.00
0 00
0 00
25,501 65
485.189 06
$12,059 44
$0 00
$0 00
$0 00
$0.00
$0.00
$1,775 88
$33,787.54
6 8 3,864.32
8 8 3,884.32
$4 7,622.86
0 00
0 00
0 00
0.00
0.00
0 00
0.00
0 00
0 00
0 00
0.00
0 00
0 00
0.00
0 00
0.00
0 00
0 00
1995
1990
0 01
1990
1990
Total:
0
$0 00
$ IACNOS IS
•hd«I
El IS A
24555
7 OS
1000
12000
25 50
40 43
1995
1990
1990
1990
1990
1990
1995
1995
Total:
3 UP PURS
coated at cenlral level1
1995
1995
1990
1990
1990
1995
1990
1990
1990
1995
Total:
0.0 0
$0 00
$0 00
$0.00
$0 00
$0.00
$0.00
$0 00
$0 00
$0 00
$0 00
$0.00
0.00
0 00
39.938 08
23.043.71
1.380.365 10
0.00
$1,6 3 3,8 4 5.9 1
57,121 57
133.377.46
0 00
0.00
39,938.08
23,043.71
1.380.365 10
0 00
$1,6 3 3,84 6.91
$3,977.83
$9,288 12
$0.00
$0 00
$2.78120
$1,604 72
$96,125 70
$0 00
$113 ,777.67
0 00
0 00
0.00
0 00
0 00
0 00
0 00
0 00
0.00
0.00
$0 00
$0 00
$0.00
$0 00
$0.00
0 00
0 00
0 00
0 00
0 00
0.00
0.00
0 00
0 00
0 00
0.00
0.00
0 00
0 00
0 00
0 00
-1 m:aim i:nt
203
Cat.1 (TH)
Cat 1(EH)
Cal.3(TH)
Cat 3(EH)
.^259
Cal 2
Drug Dlatribution
beddaya
45930
281 39
281 39
0 00
0 00
676 92
23.043 71
30 05
1995
1995
1995
1995
1995
1995
1995
1990
Total:
57.121 57
133.377 46
3 U P I: HV IS K) N
coaled at central level1
1990
1990
1990
1990
Total:
4 RA IN IN C
coaled at central level?
1990
1990
1990
1990
1990
1990
58
0.00
$0 00
$0 00
$0 00
$0 00
$0 00
$0 00
$0.00
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
Appendix 17: Cost calculation for regional level
Region
year ol coal liletime
numberunit coll
yoarlyequiv
allocation
Total
SIO1AL lor exchange year
def lated lor year
1995
1995
73.633 33
0 00
0 00
Buildings
5,500.000 00
OHO
1995
?0
736.333.29
0 00
0 00
0 10
Total:
73.633 33
0 00
0 00
73,633.33
73.833.33
$5,127 67
$0 00
$0 00
$5,127.67
277.409 73
0 00
0 00
0 00
27 7 409 73
0 00
0 00
0.00
$19.318 23
$0 00
$0 00
$0 00
2 77.4 0 0.73
277.409.73
$19 .3 18.2 3
15 934 42
0 00
0 00
0 00
0 00
0 00
0.00
15,9 3 4.4 2
15.934 42
0 00
0 00
0 00
0 00
0 00
0 00
15.9 3 4.4 2
$1,109 64
$0 00
$0 00
$0 00
$0 00
SO 00
$0.00
$1,109.64
20.000 00
17.500 00
11.500 00
10.000.00
0 00
59,0 0 0.0 0
70.000 00
17.500 00
11.500 00
10.000 00
0 00
59 .0 0 0 .0 0
$1,392 76
$1,218 66
S800 84
$696 36
$0 00
$4,10 8.6 4
Vshlclss
1.000 000,00
A ut om obtle
Moiorcycle
1995
1990
1990
6
e
277 409 73
0 00
0 00
1 00
0 00
1990
Total:
Eq u Ipm
nt
57.440 00
computer
1995
1990
1990
1990
1990
1990
1990
10
10
Io
10
15.934 4?
0 00
0 00
0 00
0 00
0,00
0 00
1 00
Total:
Pirionml
RIO(STO)
aaaisiant (IO)
clerk (TA)
driver (SCI)
20.000.00
17.500 00
11.500 00
10.000 00
0.00
1995
1996
1995
1995
1990
1 00
I 00
I 00
I 00
1.408.16 I 00
1994
1990
1994
1990
1990
1990
0 1
0
140.816 10
0.00
197,083 66
0.00
$ 13,724 49
SO 00
0
0.00
0.00
0
0 00
0 00
0 00
0 00
0 00
0 00
14 0,8 16.10
19 7,0 8 3 .6 6
SO 00
SO 00
SO 00
$0 00
$13,724 49
1990
1990
0 00
0 00
0 00
0 00
SO 00
SO 00
1990
0 00
0 00
SO 00
1990
0 00
0 00
$0 00
1990
0 00
0 00
$0 00
1990
0 00
0 00
SO 00
1990
0 00
0 00
1990
o oo
0 00
$0.00
0 .0 0
0.0 0
$0.0 0
0 00
0 00
0 00
0 00
0.00
0 00
0 00
0 00
0 00
0 00
0.0 0
0 00
0 00
0 00
0 00
0.00
SO 00
SO 00
SO 00
$0 00
SO 00
SO.00
SO 00
SO 00
$0 00
Total.
Ovsrhssd /Mslntsnsncs
RHO
1
Diagnosis
Total:
$0.00
Suppllss
1990
1990
1990
1990
1990
1990
1990
1990
1990
1990
0 00
0 00
0 00
0 00
0 00
0.0 0
SO 00
$0.00
0 00
0 00
0 00
0 00
$0.0 0
0 00
0 00
0 00
0 00
0 00
0 00
0 00
0 00
$0 00
SO 00
SO 00
SO.00
SO.00
SO 00
$0 00
SO 00
$0.0 0
$0.00
1990
0 00
0 00
$0.00
1990
0 00
0 00
$0.00
1990
0 00
0 00
$0.00
1990
0 00
0 00
0.0 0
0.0 0
SO 00
$0.00
1990
9 00
0.00
$0.00
1990
0 00
0 00
$0 00
1990
0 00
0 00
$0.00
1990
0 00
0 00
1990
0 00
0 00
1990
0 00
0 00
$0 00
0.0 0
0.0 0
$0.00
566,703.58
823,081.14
43,388 **
Trsstm s nt
1990
I9W0
1990
1990
19 90
1990
1990
1990
0.00
0 00
0 00
0 00
Sups rvls Ion
coaled at cent rat level!
Total:
Training
coaledat cent ral level*
Total:
SUM 8:
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
$0 00
$0 00
59
HEALTH ECONOMICS
V. Annotations and references
Raviglione, M. C., Snider, D. E. and Kochi, A. Global epidemiology of tuberculosis. Morbidity and
mortality of a worldwide epidemic. J. A. M.A.273,220,1995.
2
Sawert H, Kongsin S, PayanandanaV et al. 1996: An assessment of the costs and benefits of improving
tuberculosis control. The case of Thai land. Soc Sci Med. submitted for publication
3
Detailed explanations of cost categories will be given below
4
Creese A, Parker, D 1994: Cost analysis in primary health care. Geneva, World Health Organization
5
Drummond MF, Stoddart GL, Torrance GW 1987: Methods for the economic evaluation of health care
programmes. Oxford, Oxford University Press
6
Phillips M, Mills A, Dye C 1993: Guidelines for cost-effectiveness analysis of vector control. PEEM
guidelines series 3, WHO, Geneva
7
However, all expenditures for capital items should be annuitized
8
Exceptions for international comparisons are discussed below
9
This information is also contained in the International Financial Statistics published by the IMF,
Washington DC
I ()
Assuming that the exchange rate is expressed as “units local currency per unit international currency”;
if the rate is expressed as “units international currency per unit local currency”, local costs must be
divided by the exchange rate, not multiplied
1 I
Tuberculosis Programme, World Health Organization 1994: Guidelines for effectiveTB control.
WHO, Geneva
I 2 personal communication; Prof.A.D. Harries, Blantyre
I 3
Statistics available at the Central Office of the National Tuberculosis Programme, Lilongwe
I4
Murray CJ, DeJonghe E, Chum HJ et al 1991: Cost effectiveness of chemotherapy for pulmonary
tuberculosis in three sub-Saharan African countries. Lancet 338:1305-8
1 5
reports available from the Tuberculosis Division, World Health Organization, Geneva
I 6
Location of the central offices of the National Tuberculosis Control Programme
l7Official discount rate used for project appraisals in Malawi in 1995, information provided by the Ministry
of Finance
I 8
Chaulet P1992: The supply of antituberculosis drugs and national drug policies.Tubercle Lung
Dis 73:295-304
I 9
personal communication; Prof. P. Chaulet, Geneva
20
This result was obtained using a cost of $ 100.- per roll of film, similar to the cost reported from countries
that regularly use the MR technique; during the time of the study, theTB programme in Blantyre had
ordered film rolls for test purposes at a cost of $ 200.- per film; it can be assumed that the price would
drop to international levels once large quantities for routine use would be ordered
2 I
This calculation assumes the same proportion of thiacetazone replacement (70%) in both scenarios;
under the assumption that all patients under the “standard” regimen would be treated with thiacetazone
throughout, cost savings are smaller at $ 4,883
60
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS PROGRAMMES
HEALTH ECONOMICS
De Jonghe E, Murray CJL, Chum HJ et al 1994: Cost-effectiveness of chemotherapy for sputum smear
positive pulmonary tuberculosis in Malawi, Mozambique andTanzania. Int J Health Planning
Management 9:151-81
2 3 Mills AJ1991: The cost of the district hospital; a case study from Malawi. Washington DC:
The World Bank. World Bank Policy, Research and External Affairs Working Paper 742
2 4 Mitchison DA 1974: Bacteriology of tuberculosis. Trop Doctor 4:147
2 5 Githui W, Kitui F, Juma ES et al 1993: A comparative study on the reliability of the fluorescence
microscopy and Ziehl-Neelsen method in the diagnosis of pulmonary tuberculosis.
East Afr Med J 70:263- 6
26 Nunn P, Porter J, Winstanley P1993: Thiacetazone - avoid like poison or use with care?
Trans Royal Soc Trop Med Hyg 87:578-82
27 Kelly P, Bu veA, Foster SD et al 1994: Cutaneous reactions to thiacetazone in Zambia - implications for
tuberculosis treatment strategies. Trans Royal Soc Trop Med Hyg 88:113-5
2 8 OkweraA, Whalen C, Byekwaso Fet al 1994: Randomised trial of thiacetazone and rifampicincontaining regimens for pulmonary tuberculosis in HIV-infected Ugandans. Lancet 344:1323-8
22
4
2 9 Use of thiacetazone (letters). Lancet 345:62-3
3(1 Nunn P, Kibuga D, Gathua S et al 1991: Cutaneous hypersensitivity reactions due to thiacetazone in
HIV-1 seropositive patients treated for tuberculosis. Lancet 337:627-30
31 Munthali MM, Warndorff DK, Koka CW, Glynn JR, Salaniponi FLM: Fatal thiacetazone reactions in
Northern Malawi (in press)
32Anonymous 1992: Severe hypersensitivity reactions among HIV-seropositive patients with tuberculosis
treated with thiacetazone. Wkly Epidem Rec 67:1 -3
3 3 Global Programme on AIDS 1992: Recommendations for the selection and use of HIV antibody tests.
Wkly Epidem Rec 67:145-52
3 4 Total case number of 2,488 times HIV prevalence of 70% times fatality rate of 3%
35 TheWorldBank 1993: Investing in Health. World Development Report 1993. Oxford University Press
3 6 Assuming an average age of death of 23 years and an average life expectancy of 7 years for HIV
positive individuals; the respective number of DALYs lost is 9.38 due to a higher age-weighting of years
in the young adult age group
3 7 Tuberculosis Programme, WHO: Guidelines for tuberculosis control
3 8 We did not perform a specific analysis of the maintenance costs of x-ray facilities for this study;
however, under the assumption that our allocation of general hospital overhead costs provides a reason
able estimate, the cost per x-ray are slightly less than the cost of microscopy if three smears are
performed per patient
3 9 Murray C, Styblo K, RouillonA 1993:Tuberculosis, in: Jamison DT, MosleyWH, MeashamAR,
Bobadilla JL (eds.): Disease Control Priorities in Developing Countries. Oxford University Press
COST ANALYSIS AND COST CONTAINMENT IN TUBERCULOSIS CONTROL PROGRAMMES
61
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