title: Estimating implementation and operational costs of an integrated tiered CD4 service including laboratory and point of care testing in a remote health district in South Africa.
abstract: BACKGROUND
  An integrated tiered service delivery model (ITSDM) has been proposed to provide 'full-coverage' of CD4 services throughout South Africa. Five tiers are described, defined by testing volumes and number of referring health-facilities. These include: (1) Tier-1/decentralized point-of-care service (POC) in a single site; Tier-2/POC-hub servicing processing < 30-40 samples from 8-10 health-clinics; Tier-3/Community laboratories servicing ∼ 50 health-clinics, processing < 150 samples/day; high-volume centralized laboratories (Tier-4 and Tier-5) processing < 300 or > 600 samples/day and serving > 100 or > 200 health-clinics, respectively. The objective of this study was to establish costs of existing and ITSDM-tiers 1, 2 and 3 in a remote, under-serviced district in South Africa.
  
  
  METHODS
  Historical health-facility workload volumes from the Pixley-ka-Seme district, and the total volumes of CD4 tests performed by the adjacent district referral CD4 laboratories, linked to locations of all referring clinics and related laboratory-to-result turn-around time (LTR-TAT) data, were extracted from the NHLS Corporate-Data-Warehouse for the period April-2012 to March-2013. Tiers were costed separately (as a cost-per-result) including equipment, staffing, reagents and test consumable costs. A one-way sensitivity analyses provided for changes in reagent price, test volumes and personnel time.
  
  
  RESULTS
  The lowest cost-per-result was noted for the existing laboratory-based Tiers- 4 and 5 ($6.24 and $5.37 respectively), but with related increased LTR-TAT of > 24-48 hours. Full service coverage with TAT < 6-hours could be achieved with placement of twenty-seven Tier-1/POC or eight Tier-2/POC-hubs, at a cost-per-result of $32.32 and $15.88 respectively. A single district Tier-3 laboratory also ensured 'full service coverage' and < 24 hour LTR-TAT for the district at $7.42 per-test.
  
  
  CONCLUSIONS
  Implementing a single Tier-3/community laboratory to extend and improve delivery of services in Pixley-ka-Seme, with an estimated local ∼ 12-24-hour LTR-TAT, is ∼ $2 more than existing referred services per-test, but 2-4 fold cheaper than implementing eight Tier-2/POC-hubs or providing twenty-seven Tier-1/POCT CD4 services.
authors.affiliation: National Health Laboratory Service (NHLS), National Priority Programmes, Johannesburg, South Africa.
authors.forename: Naseem
authors.initials: N
authors.lastname: Cassim
authors.affiliation: National Health Laboratory Service (NHLS), National Priority Programmes, Johannesburg, South Africa.
authors.forename: Lindi M
authors.initials: LM
authors.lastname: Coetzee
authors.affiliation: Health Economics and Epidemiology Research Office, Department of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Kathryn
authors.initials: K
authors.lastname: Schnippel
authors.affiliation: National Health Laboratory Service (NHLS), National Priority Programmes, Johannesburg, South Africa; Department of Molecular Medicine and Haematology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Deborah K
authors.initials: DK
authors.lastname: Glencross
mesh_terms: D018791:CD4 Lymphocyte Count / Q000191:economics* / Q000295:instrumentation; D003362:Cost-Benefit Analysis; D015658:HIV Infections / Q000191:economics* / Q000821:virology; D015497:HIV-1 / Q000472:pathogenicity; D017048:Health Care Costs; D006801:Humans; D007753:Laboratories / Q000191:economics*; D008403:Mass Screening / Q000191:economics; D019095:Point-of-Care Systems / Q000191:economics*; D011379:Prognosis; D019035:Rural Health Services / Q000191:economics*; D013019:South Africa