Redefining and revisiting cost estimates of routine ART care in Zambia: An analysis of ten clinics

INTRODUCTION: Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task-shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out-of-date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV-positive patients in Zambia. METHODS: We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity-based costing framework using both top-down and bottom-up methods with an assessment of process and capacity. We collected primary site-level costs and resource utilization data from government documents, patient chart reviews and time-and-motion studies conducted in 10 purposively selected ART clinics. RESULTS: The cost of providing ART varied considerably among the ten clinics. The average per-patient annual cost of ART service was $116.69 (range:$59.38 to $145.62) using a bottom-up method and$130.32 (range: $94.02 to$162.64) using a top-down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long-term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top-down and bottom-up estimates. Variability in cost across the ten clinics was associated with operational characteristics. CONCLUSIONS: Real-world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates

Evolution of Cu-Co mineralizing fluids at Nkana Mine, Central African Copperbelt, Zambia

<p>The Central African Copperbelt hosts numerous world class stratiform Cu–Co deposits in the Neoproterozoic Katanga Supergroup (<880 to ± 500 Ma). These high grade deposits resulted from multiple mineralization and remobilization stages. The Nkana Cu–Co deposit in the Zambian part of the Copperbelt is such a stratiform deposit but the location of the rich ore bodies is structurally controlled, i.e. occurring in the hinge zones of tight to isoclinal folds. Late stage mineralization and/or remobilization caused this enrichment. Three major mineralization/remobilization stages have taken place during the Lufilian orogeny. They are characterized by folded layer parallel veins, highly irregular veins crosscutting the folds, and finally unfolded massive veins.</p> <p>An evolution in the oxygen, carbon and sulphur isotopic composition is present from the layer parallel and irregular to the massive veins. The more negative δ<sup>18</sup>O values in the carbonates from the massive veins most likely reflect a decrease in the oxygen isotopic composition of the ambient, metamorphic fluids. The δ<sup>13</sup>C values range between −25‰ and −5‰ V-PDB with a trend towards less negative values in the massive veins, possibly reflecting an ongoing oxidation of organic matter in a relatively closed system. Early framboidal and massive pyrites disseminated in the host rock have distinctly negative δ<sup>34</sup>S values, i.e. between −16‰ and −9.7‰ V-CDT. The sulphur isotopic composition increases from these early diagenetic pyrites to sulphides in the successive vein generations. The δ<sup>34</sup>S values of the massive veins are positive and cluster between 1.3‰ and 2.0‰ V-CDT. This enrichment in heavy sulphur is interpreted as a result of the mixing of S remobilized from early sulphides, with S derived from the thermochemical reduction of sulphate. With time, the sulphur derived from TSR became more important. The Sr isotopic composition of the carbonates in all three vein generations shows a wide range between 0.71672 and 0.75407. All values are significantly more radiogenic than the strontium isotopic composition of Neoproterozoic marine carbonates (0.7056–0.7087). The radiogenic values indicate interaction of the mineralizing fluid with the basement or the siliciclastic sediments derived from it. All fluid inclusions measured in the different vein generations have a dominant H<sub>2</sub>O–NaCl/KCl–MgCl<sub>2</sub> composition with the presence of a gaseous component in some inclusions. Fluid inclusions in the layer parallel veins suggest entrapment around 450 °C at a depth of 8.4 km (2100 bars), i.e. during the main period of metamorphism. Secondary fluid inclusions of unknown origin in the layer parallel, irregular and massive veins have a high salinity (18.1 to >23.2 eq. wt.% NaCl) and homogenization temperatures between 100 and 250 °C. These fluids were trapped after formation of the veins, likely during retrograde metamorphism.</p> <p>The study of the veins, which formed between 580 and 520 Ma, nicely demonstrate the complexity of the metallogenesis of the Cu–Co ore deposits in the Copperbelt. Therefore, geochemical, microthermometric and geochronological analyses need to be carried out on individual generations to fully understand the evolution of ore formation through time.</p&gt

Operational characteristics of antiretroviral therapy clinics in Zambia: a time and motion analysis

Abstract Background The mass scale-up of antiretroviral therapy (ART) in Zambia has taken place in the context of limited infrastructure and human resources resulting in many operational side-effects. In this study, we aimed to empirically measure current workload of ART clinic staff and patient wait times and service utilization. Methods We conducted time and motion (TAM) studies from both the healthcare worker (HCW) and patient perspectives at 10 ART clinics throughout Zambia. Trained personnel recorded times for consecutive discrete activities based on direct observation of clinical and non-clinical activities performed by counselors, clinical officers, nurses, and pharmacy technicians. For patient TAM, we recruited consenting patients and recorded times of arrival and departure and major ART services utilized. Data from 10 clinics were pooled to evaluate median time per patient spent for each activity and patient duration of stay in the clinic. Results The percentage of observed clinical time for direct patient interaction (median time per patient encounter) was 43.1% for ART counselors (4 min, interquartile range [IQR] 2–7), 46.1% for nurses (3 min, IQR 2–4), 57.2% for pharmacy technicians (2 min, IQR 1–2), and 78.5% for clinical officers (3 min, IQR 2–5). Patient workloads for HCWs were heaviest between 8 AM and 12 PM with few clinical activities observed after 2 PM. The length of patient visits was inversely associated with arrival time – patients arriving prior to 8 AM spent 61% longer at the clinic than those arriving after 8 AM (277 vs. 171 min). Overall, patients spent 219 min on average for non-clinical visits, and 244 min for clinical visits, but this difference was not significant in rural clinics. In comparison, total time patients spent directly with clinic staff were 9 and 12 min on average for non-clinical and clinical visits. Conclusion Current Zambian ART clinic operations include substantial inefficiencies for both patients and HCWs, with workloads heavily concentrated in the first few hours of clinic opening, limiting HCW and patient interaction time. Use of a differentiated care model may help to redistribute workloads during operational hours and prevent backlogs of patients waiting for hours before clinic opening, which may substantially improve ART delivery in the Zambian context

Redefining and revisiting cost estimates of routine ART care in Zambia: an analysis of ten clinics

INTRODUCTION: Accurate costing is key for programme planning and policy implementation. Since 2011, there have been major changes in eligibility criteria and treatment regimens with price reductions in ART drugs, programmatic changes resulting in clinical task-shifting and decentralization of ART delivery to peripheral health centres making existing evidence on ART care costs in Zambia out-of-date. As decision makers consider further changes in ART service delivery, it is important to understand the current drivers of costs for ART care. This study provides updates on costs of ART services for HIV-positive patients in Zambia. METHODS: We evaluated costs, assessed from the health systems perspective and expressed in 2016 USD, based on an activity-based costing framework using both top-down and bottom-up methods with an assessment of process and capacity. We collected primary site-level costs and resource utilization data from government documents, patient chart reviews and time-and-motion studies conducted in 10 purposively selected ART clinics. RESULTS: The cost of providing ART varied considerably among the ten clinics. The average per-patient annual cost of ART service was $116.69 (range:$59.38 to $145.62) using a bottom-up method and$130.32 (range: $94.02 to$162.64) using a top-down method. ART drug costs were the main cost driver (67% to 7% of all costs) and are highly sensitive to the types of patient included in the analysis (long-term vs. all ART patients, including those recently initiated) and the data sources used (facility vs. patient level). Missing capacity costs made up 57% of the total difference between the top-down and bottom-up estimates. Variability in cost across the ten clinics was associated with operational characteristics. CONCLUSIONS: Real-world costs of current routine ART services in Zambia are considerably lower than previously reported estimates and sensitive to operational factors and methods used. We recommend collection and monitoring of resource use and capacity data to periodically update cost estimates