title: Using Top-down and Bottom-up Costing Approaches in LMICs: The Case for Using Both to Assess the Incremental Costs of New Technologies at Scale.
abstract: OBJECTIVE
  Estimating the incremental costs of scaling-up novel technologies in low-income and middle-income countries is a methodologically challenging and substantial empirical undertaking, in the absence of routine cost data collection. We demonstrate a best practice pragmatic approach to estimate the incremental costs of new technologies in low-income and middle-income countries, using the example of costing the scale-up of Xpert Mycobacterium tuberculosis (MTB)/resistance to riframpicin (RIF) in South Africa.
  
  
  METHODS
  We estimate costs, by applying two distinct approaches of bottom-up and top-down costing, together with an assessment of processes and capacity.
  
  
  RESULTS
  The unit costs measured using the different methods of bottom-up and top-down costing, respectively, are $US16.9 and $US33.5 for Xpert MTB/RIF, and $US6.3 and $US8.5 for microscopy. The incremental cost of Xpert MTB/RIF is estimated to be between $US14.7 and $US17.7. While the average cost of Xpert MTB/RIF was higher than previous studies using standard methods, the incremental cost of Xpert MTB/RIF was found to be lower.
  
  
  CONCLUSIONS
  Costs estimates are highly dependent on the method used, so an approach, which clearly identifies resource-use data collected from a bottom-up or top-down perspective, together with capacity measurement, is recommended as a pragmatic approach to capture true incremental cost where routine cost data are scarce.
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Lucy
authors.initials: L
authors.lastname: Cunnama
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Edina
authors.initials: E
authors.lastname: Sinanovic
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Lebogang
authors.initials: L
authors.lastname: Ramma
authors.affiliation: Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.
authors.forename: Nicola
authors.initials: N
authors.lastname: Foster
authors.affiliation: National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa.
authors.forename: Leigh
authors.initials: L
authors.lastname: Berrie
authors.affiliation: National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa.
authors.forename: Wendy
authors.initials: W
authors.lastname: Stevens
authors.affiliation: National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa.
authors.forename: Sebaka
authors.initials: S
authors.lastname: Molapo
authors.affiliation: National Priority Programmes, National Health Laboratory Services, Johannesburg, South Africa.
authors.forename: Puleng
authors.initials: P
authors.lastname: Marokane
authors.affiliation: Aurum Institute for Health Research, Johannesburg, South Africa.
authors.forename: Kerrigan
authors.initials: K
authors.lastname: McCarthy
authors.affiliation: Aurum Institute for Health Research, Johannesburg, South Africa.|School of Public Health, University of Witwatersrand, Johannesburg, South Africa.|London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Gavin
authors.initials: G
authors.lastname: Churchyard
authors.affiliation: London School of Hygiene and Tropical Medicine, London, United Kingdom.
authors.forename: Anna
authors.initials: A
authors.lastname: Vassall
mesh_terms: D003362:Cost-Benefit Analysis; D003627:Data Interpretation, Statistical; D003906:Developing Countries; D017048:Health Care Costs; D006801:Humans; D062069:Inventions / Q000191:economics*; D009169:Mycobacterium tuberculosis / Q000302:isolation & purification; D013019:South Africa; D013673:Technology Assessment, Biomedical; D014397:Tuberculosis, Pulmonary / Q000175:diagnosis* / Q000188:drug therapy / Q000191:economics
keywords: LMICs; cost analysis; diagnostics; economies of scale; scale-up; tuberculosis