Cost evaluation of reproductive and primary health care mobile service delivery for women in two rural districts in South Africa.

Cervical cancer screening is a critical health service that is often unavailable to women in under-resourced settings. In order to expand access to this and other reproductive and primary health care services, a South African non-governmental organization established a van-based mobile clinic in two rural districts in South Africa. To inform policy and budgeting, we conducted a cost evaluation of this service delivery model.The evaluation was retrospective (October 2012-September 2013 for one district and April-September 2013 for the second district) and conducted from a provider cost perspective. Services evaluated included cervical cancer screening, HIV counselling and testing, syndromic management of sexually transmitted infections (STIs), breast exams, provision of condoms, contraceptives, and general health education. Fixed costs, including vehicle purchase and conversion, equipment, operating costs and mobile clinic staffing, were collected from program records and public sector pricing information. The number of women accessing different services was multiplied by ingredients-based variable costs, reflecting the consumables required. All costs are reported in 2013 USD.Fixed costs accounted for most of the total annual costs of the mobile clinics (85% and 94% for the two districts); the largest contributor to annual fixed costs was staff salaries. Average costs per patient were driven by the total number of patients seen, at $46.09 and$76.03 for the two districts. Variable costs for Pap smears were higher than for other services provided, and some services, such as breast exams and STI and tuberculosis symptoms screening, had no marginal cost.Staffing costs are the largest component of providing mobile health services to rural communities. Yet, in remote areas where patient volumes do not exceed nursing staff capacity, incorporating multiple services within a cervical cancer screening program is an approach to potentially expand access to health care without added costs

Services provided in mobile unit and number of women accessing each service, by district.

<p>^ǂThese individuals would have had a clinical history taken and received a BP check, TB and STI/candidiasis symptoms screen (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0119236#sec006" target="_blank">Methods</a>).</p><p>^{^}Boxes of condoms are also delivered to community sites.</p><p>* For the Thabo Mofutsanyana district, service volumes were multiplied by 2 to have 12-months for analysis.</p><p>Services provided in mobile unit and number of women accessing each service, by district.</p

Women’s health van, South Africa.

<p>Photo by: Right to Care, 2015.</p

Variable^ǂ costs for services requiring consumables and/or medications.

<p>^ǂ Variable costs are defined as costs that varied according to the number of patients seen and the type of service provided. Some services, e.g. medical history taking, blood pressure check, and symptom screening for TB and STIs, did not utilize medications or consumables and therefore have $0 variable cost. However, all services require expenditure on fixed costs (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0119236#pone.0119236.t004" target="_blank">Table 4</a>).</p><p>Variable<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0119236#t003fn001" target="_blank">^ǂ</a> costs for services requiring consumables and/or medications.</p

Average annual fixed expenditures for both sites, in 2013 USD.

<p>^ǂ Total costs for equipment are discounted at 5% per annum and annualized over 5 years as described in Methods. If no discount was applied (0% per annum), the total would have been $12,715 or$1,970 less.</p><p>^ For the Thabo Mofutsanyana district, fixed costs were adjusted from 6 to 12 months to allow for presentation of annual figures.</p><p>* Staff costs did not vary over the 12 months analyzed and did not vary according to the number of patients seen or the types of services provided and thus are included as fixed costs.</p><p>Average annual fixed expenditures for both sites, in 2013 USD.</p

Sparsely populated Central Karoo district, South Africa.

<p>Photo by: Theo van den Handel, 2013.</p

Population and health indicators[19] for implementing districts.

<p>Population and health indicators[<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0119236#pone.0119236.ref019" target="_blank">19</a>] for implementing districts.</p