Costing

Background

There are many aspects to consider when talking about costs of a (new) intervention. Costs for procurement, staffing costs, system setup and running costs to name few. Costs can be calculated per patient or per (part of) the health system response. Actual costs alone of implementing an intervention are only part of the equation, the costs effectiveness in comparison to the standard of care and the increase in health outcomes for patients needs to be taken into account as well. In this section costs will be outlined for the DATs and ICT infrastructure and overall implementation costs.

 

Goals - After reading this section you will know

  • What costs categories are relevant for implementing a DAT intervention

  • The overall and detailed cost estimates for implementing an DAT intervention

  • Cost considerations at scale

 


Costs are split out per DAT and the required infrastructure including the adherence platform.



Core DAT

Product / Component

Description

Costs range ($)

Note



Core DAT

Product / Component

Description

Costs range ($)

Note

1a

EMM sleeves

Paper sleeves

Printing, shipping and sleeving of medication blister packs

~$5 - $10 per patient course

Shipping and sleeving costs can vary the most.

1b

Toll-free phone lines (hosted or portable), SMS shortcodes or USSD

Procurement of 99DOTS portable or configuration of national toll free number by a telecom provider)

~$100 - $3,000 per month

High variability in costs per country and between toll-free lines, SMS shortcodes and USSD

1c

Inbound phonecall, SMS, or USSD

Total inbound call cost (per treatment day per patient)

~$0.00 - $0.10 per patient per day

Costs can be included in phone line hosting costs or separately



2a

EMM boxes

EMM module

Printed circuit board and casing

~$20 - $30 per patient

Can be re-used

2b

Battery

1800mAh capacity, compatible with EMM module

~$4 - $5 per patient

Can be re-used

2c

Magnet

Sensor

~$0.50 - $1 per patient

Can be re-used

2d

Container

Cardboard or plastic box (no re-use)

~$0.50 - $2 per patient

Often not re-used

2e*

USB charger and cables

USB charger for single battery charger

~$1 - $3 per patient

Applicable with EMM module that have an integrated USB charging port

Can be re-used

2f*

Multi battery charging module

Charger for multiple batteries

~$50 - $100 per facility or [X] batteries in use

For EMM modules that requires batteries to be taken out of the module for charging

2g

SIM card (optional)

When EMM boxes are sending real-time data

~$1 per patient

Only applicable when adherence data is send between facility visits

Can be re-used

2h

SIM (re)activation (optional)

Costs for (re)activation of SIM cards

~$1 per activation

For first time use or re-activation

Only applicable when adherence data is send between facility visits

2i

Mobile data (optional)

Data costs for [X] months

~$1 - $2 per patient per month

On average 6 months for DS-TB patients, 9-24 months for DR-TB patients.

Only applicable when adherence data is send between facility visits

*Either a usb charger or a multi battery charger

3a

Video Supported Treatment

Dedicated server**

Dedicated server for storage of VOT patient videos

~$5.000 - $10.000 per country

Can be the same server as for the adherence platform

3b

Mobile devices

Smartphone or tablet

~$0* - $150 per patient

Devices can be re-used. *If patients are enrolled on VOT making use of personal devices there are no costs for this budget item.

3c

Mobile data (optional)

Data costs for [X] months

~$2 - $10 per patient per month

Uploading one video per day by patients



4a

Adherence platform

Dedicated server**

Dedicated (in-country) hosting of the adherence platform

~$5.000 - $10.000 per country

Hosting of the adherence platform. Can be separate from a file server (for e.g. storage of videos)

4b

Hosted server**

Hosting of server space

~$50 - $150 per month

Public or private, in-country or global

4c

License

License for use of an adherence platform

~$0 - $10 per patient per month

License costs vary per vendor and country. Waiver of license costs can be applicable for LMICs

4c

Outbound SMS

Educational, motivational, reminders, adherence overview to patients and healthcare workers

~$0.01 - $0.20 per patient per day

Depends on the average number of SMS send. Estimated between 2-5 per week.

4d

 

Mobile data (optional)

Data costs for accessing the adherence platform by healthcare workers

~$2 - $10 per patient per month

In absence of a landline internet connection or WIFI, mobile data is required to access the platform

** Either a dedicated server or hosted server


Implementation costs

Next to the costs the DATs and the required infrastructure, there are costs for the implementation of the DAT intervention. The following activities should be considered when setting up the DAT intervention either as a project or as part of programmatic implementation. It is not easy to put a price tag on the following activities, as this is much dependent on the country setting and project setting.

  • Technical assistance

There are several international TA providers that have experience with supporting digital health interventions. Where donor funding is available, technical assistance from international organisations is often included to support in-country capacity building. In addition, many DAT developers/vendors have ample experience and can provide technical assistance for the implementation of their products.

  • IT support

With every digital health intervention, a certain level of IT support is required. This can include for example first-line and second-line IT support. Second-line included often (inter)national on distance support. First-line support is aimed at local support and troubleshooting. Especially DATs that have a local hardware component (e.g. EMM boxes), adequate first-line support is a necessity.

Training and supervision

New interventions require training and supervision at several moments in time. Staff needs to be trained at least before roll out of an intervention, but refresher training's and follow-up training on new functionalities or adaptations of the interventions are important as well. In settings where there is a high turn over of staff, training of staff is critical for continuation of the DAT intervention. Embedding supervision and support into routine supervision support visits is important as well to when moving towards programmatic implementation. In addition, the need for ongoing quality control as part of capacity building is critical so that staff do not get complacent about entering and using the data in the system to actually support the patients.

  • Supply chain and commodity management

The supply chain is worthwhile to mention separately, as most DAT interventions come with some sort of commodities that have to be distributed to health facilities and patients. If possible the distribution of DATs should be integrated in the existing supply chain to the facilities as much as possible. There are several questions to be answered first before setting up the supply chain. For example, in case of EMM boxes, where will the boxes be assembled? How and where will the batteries be charged? or for EMM sleeves, where will the sleeving of the medication take place, centrally or at the health facilities?

Cost at scale

Many cost items can be directly allocated to a patient or the duration of a patient course. Costs per patient are usually constant but can be influenced in case of volume aggregation. Ordering larger quantities of items can reduce the cost per patient. Next to that there are cost related to the ICT infrastructure that is used by all patients. Dividing the infrastructure cost by the number of patients gives you a per patient cost. Obviously, the higher the patient numbers, the lower the per patient cost. Per patient cost of infrastructure is therefor more cost efficient at scale. Simply put, the minimal ICT infrastructure is largely the same for 1 patient as for 1,000 patients on DAT. Still there is a factor of scale for certain infrastructure components e.g. more server space and higher server bandwidth are required for reliable access to the adherence platform.

Re-use rate

Several components can be re-used by multiple patients. For example, the EMM module, battery and magnet can often be used by multiple patients. The cardboard or plastic containers are usually used only once. As the EMM module is the most expensive component of the EMM box, reusing the module for 2-4 times can have a significant impact on the per patient costs.


Tools and resources

  File Modified

Microsoft Excel Spreadsheet Template DAT use calculator.xlsx

Sep 12, 2019 by Job van Rest

Microsoft Excel Spreadsheet DAT budget template.xlsx

Sep 16, 2019 by Job van Rest

PDF File DAT costing tool_McGill_2019.pdf

Oct 31, 2019 by Rachel Powers

Tools and resources