A feasibility study using time-driven activity-based costing as a management tool for provider cost estimation: Lessons from the National TB Control Program in Zimbabwe in 2018

Abstract Background Insufficient cost data and limited capacity constrains understanding of true required resources for TB control. This study using time-drive activity-based costing documented service delivery processes, mapped resources that are required to sustain and identified areas to optimise efficiency in delivery of TB services was conducted in Zimbabwe. Methods A multi-disciplinary team applied time-driven activity-based costing (TDABC) to develop process maps and measure the cost of clinical pathways used for Drug Susceptible TB (DS-TB) at urban polyclinics, rural district and provincial hospitals, and community based targeted screening for TB (Tas4TB). The team performed interviews and observations to collect data on the time taken by health care worker-patient pairs at every stage of the treatment pathway. The personnel’s practical capacity and capacity cost rates were calculated on 5 cost domains. An MS Excel model was used to calculate diagnostic and treatment costs. Findings Twenty-five stages were identified in the TB care pathway across all health facilities except for community targeted screening for TB. Variations existed in health care professionals providing services between facilities for client registration, vital signs, treatment follow-up, medicines dispensing and sample processing.The average cost per patient for the entire DS-TB care was USD324 with diagnosis costing USD69 and treatment costing USD255. The average cost for diagnosis and treatment was higher in clinics than in hospitals (USD392 versus USD256). Nurses in clinics were 1.6 time more expensive than in hospitals. The main cost drivers were human resources (USD130) and laboratory (USD119). Diagnostic cost in Tas4TB was twice that of health facility setting (USD153 vs USD69), with major cost drivers being demand creation (USD89) and sputum specimen transportation (USD5 vs USD3). Conclusion We concluded that TDABC can be used as a costing and management tool in a low resource setting. Results from this study were used to identify areas of innovative improvements in the NTP under public health programme settings. Re-engineering laboratory testing processes and synchronising TB treatment follow-up with antiretroviral treatments could achieve significant cost savings in Zimbabwe.