Patient‐incurred costs in a differentiated service delivery club intervention compared to standard clinical care in Northwest Tanzania

Abstract

Introduction Placing all clients with a positive diagnosis for HIV on antiretroviral therapy (ART) has cost implications both for patients and health systems, which could, in turn, affect feasibility, sustainability and uptake of new services. Patient‐incurred costs are recognized barriers to healthcare access. Differentiated service delivery (DSD) models in general and community‐based care in particular, could reduce these costs. We aimed to assess patient‐incurred costs of a community‐based DSD intervention (clubs) compared to clinic‐based care in the Shinyanga region, Tanzania. Methods Cross‐sectional survey among stable ART patients (n = 390, clinic‐based; n = 251, club‐based). For each group, we collected socio‐demographic, income and expenditure data between May and August 2019. We estimated direct and indirect patient‐incurred costs. Direct costs included out‐of‐pocket expenditures. Indirect costs included income loss due to time spent during transport, accessing services and off work during illness. Cost drivers were assessed in multivariate regression models. Results Overall, costs were significantly higher among clinic participants. Costs (USD) per year for clinic versus club were as follows: 11.7 versus 4.17 (p < 0.001) for direct costs, 20.9 versus 8.23 (p < 0.001) for indirect costs and 32.2 versus 12.4 (p < 0.001) for total costs. Time spent accessing care and time spent in illness (hours/year) were 38.3 versus 13.8 (p < 0.001) and 16.0 versus 6.69 (p < 0.001) respectively. The main cost drivers included transportation (clinic vs. club: 67.7% vs. 44.1%) for direct costs and income loss due to time spent accessing care (clinic vs. club: 60.4% vs. 56.7%) for indirect costs. Factors associated with higher total costs among patients attending clinic services were higher education level (coefficient [95% confidence interval]) 20.9 [5.47 to 36.3]) and formal employment (44.2 [20.0 to 68.5). Differences in mean total costs remained significantly higher with formal employment, rural residence, in addition to more frequent visits among clinic participants. The percentage of households classified as having had catastrophic expenditures in the last year was low but significantly higher among clinic participants (10.8% vs. 5.18%, p = 0.014). Conclusions Costs incurred by patients accessing DSD in the community are significantly lower compared to those accessing standard clinic‐based care. DSD models could improve access, especially in resource‐limited settings.

Cross-sectional study of the burden and determinants of non-medical and opportunity costs of accessing chronic disease care in rural Tanzania

“…People living with HIV in rural Tanzania cross even larger distances, travelling an average of 2.81 hours in total and staying 2.32 hours at the clinic, but spend slightly less on transportation (US$1.09) than in our sample 11. The opportunity cost of illness was also lower (US$3.79), with patients being ill for 16 hours per year on average, which is potentially due to the restriction of the sample to stable patients with HIV.…”

“…People living with HIV in rural Tanzania cross even larger distances, travelling an average of 2.81 hours in total and staying 2.32 hours at the clinic, but spend slightly less on transportation (US$1.09) than in our sample. 11 The opportunity cost of illness was also lower (US$3.79), with patients being ill for 16 hours per year on average, which is potentially due to the restriction of the sample to stable patients with HIV. Specifically for patients with cardiovascular diseases, another study reported annual transport costs of US$14 in rural areas and US$24 in urban areas, with average waiting times of 2 hours and 4 hours, respectively.…”

“…10 However, the introduction of a decentralised community-based HIV care programme in Tanzania substantially reduced both the indirect and direct costs of accessing HIV care, indicating that such an intervention or policy implementation could yield promising results for reducing the indirect costs of care seeking for people living with chronic conditions. 11 While research on the non-medical and opportunity costs of seeking NCD care in SSA is more limited, past work has indicated that these costs can be substantial for some patients, and some of them even completely forgo seeking care in order to avoid the impoverishing effect of direct medical or non-medical costs of care. 6 12-15 In Mali, the indirect costs of diabetes mellitus were estimated to make up 61% of the total costs, 6 while in rural Malawi the direct costs of NCDs formed the largest cost element, with 56.8% of the total.…”

“…The accumulation of travel costs and productivity loss associated with illness and care seeking can therefore surpass the direct cost of care, representing 55% of costs for HIV infections and 71% of costs for HIV/TB coinfections 10. However, the introduction of a decentralised community-based HIV care programme in Tanzania substantially reduced both the indirect and direct costs of accessing HIV care, indicating that such an intervention or policy implementation could yield promising results for reducing the indirect costs of care seeking for people living with chronic conditions 11…”

“… 10 However, the introduction of a decentralised community-based HIV care programme in Tanzania substantially reduced both the indirect and direct costs of accessing HIV care, indicating that such an intervention or policy implementation could yield promising results for reducing the indirect costs of care seeking for people living with chronic conditions. 11 …”