title: Scaling Down to Scale Up: A Health Economic Analysis of Integrating Point-of-Care Syphilis Testing into Antenatal Care in Zambia during Pilot and National Rollout Implementation.
abstract: Maternal syphilis results in an estimated 500,000 stillbirths and neonatal deaths annually in Sub-Saharan Africa. Despite the existence of national guidelines for antenatal syphilis screening, syphilis testing is often limited by inadequate laboratory and staff services. Recent availability of inexpensive rapid point-of-care syphilis tests (RST) can improve access to antenatal syphilis screening. A 2010 pilot in Zambia explored the feasibility of integrating RST within prevention of mother-to-child-transmission of HIV services. Following successful demonstration, the Zambian Ministry of Health adopted RSTs into national policy in 2011. Cost data from the pilot and 2012 preliminary national rollout were extracted from project records, antenatal registers, clinic staff interviews, and facility observations, with the aim of assessing the cost and quality implications of scaling up a successful pilot into a national rollout. Start-up, capital, and recurrent cost inputs were collected, including costs of extensive supervision and quality monitoring during the pilot. Costs were analysed from a provider's perspective, incremental to existing antenatal services. Total and unit costs were calculated and a multivariate sensitivity analysis was performed. Our accompanying qualitative study by Ansbro et al. (2015) elucidated quality assurance and supervisory system challenges experienced during rollout, which helped explain key cost drivers. The average unit cost per woman screened during rollout ($11.16) was more than triple the pilot unit cost ($3.19). While quality assurance costs were much lower during rollout, the increased unit costs can be attributed to several factors, including higher RST prices and lower RST coverage during rollout, which reduced economies of scale. Pilot and rollout cost drivers differed due to implementation decisions related to training, supervision, and quality assurance. This study explored the cost of integrating RST into antenatal care in pilot and national rollout settings, and highlighted important differences in costs that may be observed when moving from pilot to scale-up.
authors.affiliation: Department of Epidemiology & Biostatistics, George Washington University School of Public Health, Washington, DC, United States of America.
authors.forename: Katharine D
authors.initials: KD
authors.lastname: Shelley
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Éimhín M
authors.initials: ÉM
authors.lastname: Ansbro
authors.affiliation: Elizabeth Glaser Pediatric AIDS Foundation, Lusaka, Zambia.
authors.forename: Alexander Tshaka
authors.initials: AT
authors.lastname: Ncube
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Sedona
authors.initials: S
authors.lastname: Sweeney
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Colette
authors.initials: C
authors.lastname: Fleischer
authors.affiliation: HIV/AIDS STI Programme, Ministry of Health, Lusaka, Zambia.
authors.forename: Grace
authors.initials: G
authors.lastname: Tembo Mumba
authors.affiliation: Elizabeth Glaser Pediatric AIDS Foundation, Washington, DC, United States of America.
authors.forename: Michelle M
authors.initials: MM
authors.lastname: Gill
authors.affiliation: Elizabeth Glaser Pediatric AIDS Foundation, Lusaka, Zambia.
authors.forename: Susan
authors.initials: S
authors.lastname: Strasser
authors.affiliation: Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Rosanna W
authors.initials: RW
authors.lastname: Peeling
authors.affiliation: Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Fern
authors.initials: F
authors.lastname: Terris-Prestholt
mesh_terms: D003362:Cost-Benefit Analysis; D005260:Female; D006801:Humans; D009313:National Health Programs / Q000191:economics; D010865:Pilot Projects; D019095:Point-of-Care Systems / Q000191:economics*; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000175:diagnosis*; D011296:Prenatal Diagnosis / Q000191:economics; D013587:Syphilis / Q000175:diagnosis*; D015024:Zambia