Provider Costs of PMTCT Services in Zimbabwe: A Time-Driven Activity-Based Costing Analysis

doi:10.21203/rs.3.rs-8419484/v1

Background

Prevention of Mother-to-Child Transmission of HIV (PMTCT) is central to maternal and child health in Zimbabwe. However, with the growing pressures on the health financing landscape, identifying opportunities for efficiency gains is critical. This study aimed to determine the provider costs of PMTCT services, identify key cost drivers, and inform resource allocation.

Methods

A cross-sectional Time-Driven Activity-Based Costing (TDABC) analysis was conducted across ten health facilities in Zimbabwe, from clinics up to central hospitals. Data were collected on personnel, medicines and consumables, space and equipment, laboratory, and overheads. Process maps for PMTCT pathways were developed, and time equations were used to calculate unit costs per patient. Cost analysis was used to estimate the lifetime cost implications were prevention fails.

Results

Guiding a mother-baby pair through the PMTCT cascade ($549) cost less than prevention failure. Paediatric ART ($450·56) cost over twice maternal ART ($209·30), with lifetime treatment costs reaching $5 210·78 for maternal seroconversion and $9 526·18 for infant infection. Every dollar invested in PMTCT avoided $17 in treatment costs. Key cost drivers were laboratory tests (42%), medicines (28%), and personnel (16%). Costs were lowest at primary clinics ($160·84). Monitoring HIV-negative mothers cost $48·78. Deviations from testing algorithm were common due to stockouts and workload.

Conclusion

PMTCT is a cost-saving intervention that requires Zimbabwe to prioritize decentralizing services, secure the supply chain for essential commodities and personnel, and formally reviewing its testing algorithm to improve outcomes. These findings offer an evidence-based roadmap to support continued investment in PMTCT.

Health Economics & Outcomes Research

Infectious Diseases

Maternal & Fetal Medicine

ingredient costing

cost drivers

HIV transmission

budget impact

micro-costing

vertical transmission

Women and children are disproportionately affected by HIV, accounting for the majority of new infections in Sub-Saharan Africa, which is the epicentre of the global HIV epidemic. This persistent transmission underscores the critical need for highly effective prevention strategies. Prevention of mother-to-child transmission (PMTCT) is a cornerstone of this effort, yet in a context of shrinking global health funding and domestic fiscal constraints, as seen in Zimbabwe, the sustainability of such programmes is threatened. Ensuring their efficiency is not just a clinical priority but a financial necessity for safeguarding past gains.

Zimbabwe has made significant progress in reducing HIV incidence and prevalence through scaled-up ART and prevention, largely supported by donor partners such as the PEPFAR and the Global Fund. At the policy level, the country has a clear intention to mobilise resources at the domestic level for HIV response as seen through the AIDS Trust Fund. The national strategy (ZNASP) aims to eliminate vertical transmission of HIV, targeting fewer than 50 new infant infections per 100 000 births [1]. PMTCT is a pivotal intervention within this plan. While PMTCT is established as cost-effective, existing costing often relies on top-down, historical budgeting. This approach lacks the granularity to show the true resource consumption of the multi-visit, longitudinal nature of the PMTCT cascade.

Consequently, a critical evidence gap remains. There is a lack of precise micro-costing data on the integrated PMTCT care pathway in Zimbabwe. There is a need for a better understanding of how costs accumulate across the entire cascade, that is, from antenatal booking to final weaning or infant diagnosis thereof. Identification of the cost drivers along the continuum of care and the variations by level of care will aid programmers and policy makers to develop targeted interventions addressing specific inefficiencies. This is especially urgent given Zimbabwe’s commitment to increase domestic health financing and the need for smart investments as outlined in the ZNASP.

To address this, we applied the time-driven activity-based costing (TDABC) framework, a methodology that links resources directly to clinical activities to highlight inefficiencies and value. It goes beyond traditional top-down costing by linking the costs of resources directly to the specific activities and time required to deliver each service, providing a more accurate and granular view of true resource utilisation [2]. This unique strength helps to capture the multi-visit, multi-service nature of PMTCT services.

While companion papers to this one cost discrete services such as provider-initiated HIV testing and counselling, this analysis focuses specifically on the unique, integrated PMTCT pathway. As part of a larger HIV costing study, this paper aims to provide granular insights into the provider cost of PMTCT services in Zimbabwe using time-driven activity-based costing by mapping the PMTCT care pathways, estimating the provider costs, describing key sources of cost variation by level of care, and recommending improvements in cost efficiencies.

Study Design and Setting

This study employed a cross-sectional design to conduct a provider-side cost analysis of HIV services in Zimbabwe for the 2022 financial year, using the time-driven activity-based costing (TDABC) methodology [3]. The study was conducted across a purposively selected sample of public health facilities to ensure representation of different levels of care and settings (urban and rural).

Time-Driven Activity-Based Costing Framework

The TDABC framework was adapted by first mapping the complete care pathway for the entire PMTCT cascade as per national guidelines. These process maps detailed every step from registration to treatment initiation of the mother-baby pairs in care and were used to identify all associated resources and develop our data collection tools.

The activity time was collected through direct time-motion observation, where trained observers recorded the start and end times of 3 to 7 provider-client interactions for each stage of the care pathway using electronic tablets.

Sampling

Health facilities were purposively selected to represent the spectrum of public health facility types in Zimbabwe, including central hospitals, provincial hospitals, district hospitals, and primary care clinics, and to ensure maximum variability of costing data collected. This diversity was intended to ensure the cost data captured a variety of operational contexts and enabled the analysis of cost variation

Data Collection Tools and Procedures

Data collection was conducted over 18 days across a selection of public and specialization health facilities by trained research teams. This was preceded by a pilot at four facilities of different locations and service provision levels in a non-participating province to ensure clarity and validity. The finalised tools included a service mapping tool, a staff capacity questionnaire, a financial data abstraction and a time-motion observation tool. For the staff capacity questionnaire, all health facility staff involved in the provision of PMTCT services were included in the broader HIV Costing study.

We recruited qualified nurse practitioners and trained them extensively on the study protocol, TDABC principles, research ethics, and the use of Open Data Kit (ODK) for electronic data capture. Teams were supervised in the field by a designated team leader and a national-level supervisor to ensure data quality. The completed and reviewed forms were uploaded to a central server daily, which had an electronic backup done whenever new entries were made on the server, a computer, and external drives. Access to the data was restricted to the study team.

Stata 18 and SPSS were used for data cleaning, and costing models were developed in Excel.

Cost Analysis

The costing unit of analysis was the mother-baby pair. All provider costing data, including salaries and capital costs, were aligned with the 2022 financial year to match the government’s fiscal reporting. The core analytical step involved calculating a capacity cost rate (CCR) for each resource under the domains personnel, medicines and consumables, space and equipment, laboratory and indirect costs. The CCR represents the cost per unit of time (minute) for a resource and is calculated as the total annual cost divided by its annual practical capacity in minutes. For personnel, practical capacity was calculated based on available working time, after accounting for allocated hours for breaks, leave, and non-patient activities.

For equipment and space, a replacement cost approach was used [4]. The current replacement cost, sourced from recent government procurement data, was annualised using straight-line depreciation over the asset's useful life, including 10 years for furniture and large equipment like GeneXpert machines, 5 years for computers and vehicles, and a year for small tools. This annualised cost was then divided by the asset's annual practical operating minutes to yield its CCR.

The cost of medicines and consumables was directly allocated based on observed usage per service, with data obtained from facility records. Indirect costs, covering overheads such as water, security, and administration, were abstracted from consolidated facility budget expenditure estimates and budget expenditure estimates from the Ministry of Finance and Economic Development. These indirect costs were allocated to HIV services in proportion to the share of HIV-related client visits in the total facility attendance. The primary advantage of the replacement cost approach for capital items is that it accounts for the full depreciation burden borne by the services utilising the equipment. An acknowledged limitation of this linear method is that it does not reflect the time value of money. The cost of shared resources, particularly, particularly indirect costs, was allocated to HIV services based on the proportion of HIV-related patient attendances to total facility attendances. The unit cost of a service was then derived by multiplying the CCR by the time taken for each activity and summing all cost components.

Validation

To validate our models and account for uncertainties, we conducted iterative checks. We first costed the PMTCT intervention for a selected site to validate the entire process from the care pathways to the costing model before scaling the analysis. This served as an internal check on data quality and methodological robustness. Cost analysis was done, accounting for different prevention outcome scenarios to illustrate the different cost implications.

Permission to conduct the study was sought and granted from the Permanent Secretary for Health and Child Care, Provincial Medical Directorate, Directors of Health Services, and site accounting officers. Ethical approval was granted by the Medical Research Council of Zimbabwe (MRCZ/A/3101), Joint Ethics Research Committee (JREC/325/2023), as well as the Sally Mugabe Central Hospital Ethics Committee (SMCHE021023/24). Results were validated and disseminated to the MoHCC and partners.

The provider costs for PMTCT were analysed as a comprehensive, longitudinal care process. Data was collected across ten purposively sampled health facilities. The analysis is based on 703 provider-patient observations, mapping 21 stages of the PMTCT cascade from first contact with expecting mother during antenatal care up to weaning or when the child reaches 18 months of age guided by the Operational Service Delivery Manual (OSDM) [5].

Cost Accumulation Across the PMTCT Care Cascade

The cost of guiding an HIV negative pregnant woman through the standard PMTCT protocol, covering all HIV testing and follow-ups up to the end of the breastfeeding period, was $48·78 (Table 1). Costs varied by facility level, ranging from $18·57 at Zezani clinic to $117·30 at Mpilo Central Hospitals. The major cost driver within the PMTCT pathway was Early Infant Diagnosis (EID) at $48·71, substantially higher than the initial HTS within PMTCT ($10·54). The cost structure of EID is distinct from other HTS models; it was dominated by the costs of medicines ($22·63) and laboratory kits (19·06), rather than by personnel or indirect costs.

Antiretroviral Therapy (ART) Cost Burden within the PMTCT Cascade

The unit cost of initiating ART in a newly diagnosed pregnant mother was $52·14 (Table 2). The total annual provider cost to treat a new mother was $209·30. Follow − up visit costs were similar to those for standard adult ART. Paediatric ART is a particularly high-cost component. The average annual provider cost for a child under two years old was $450·56. This cost ranged from $350·11 at the clinic level to $508·79 at the central hospital level. The primary cost drivers for initiating paediatric ART were medicines ($27·98) and laboratory costs ($22·43). In contrast, the main cost driver for maternal PMTCT ART was laboratory services ($34·56). The annual cost of treating a child is more than double the cost of treating the mother.

Facility-level Cost Variation and Service Mapping

The unit labour cost of PMTCT varied by facility, from $15·97 at Bindura Provincial Hospital to $7·75 at Sally Mugabe Central Hospital (Table 3). This variation was mostly influenced by the amount of time health workers spent at each stage. At Mpilo hospital, the PC was responsible for treatment initiation and follow up as well including the re-testing at 32 weeks and delivery. Client reviews at 34 weeks until review one-year post delivery was the nurses’ role at all facilities.

There were observed differences between the OSDM and implementation, particularly during the HIV testing, with health workers citing workload and test kit supply discrepancies as the main reasons for this (Fig. 1). The study observed variations between the recommended Operational Service Delivery Manual (OSDM) and actual practices. The OSDM recommends using three sequential test kits for a client, but field observations showed that only two test kits were commonly in use. This deviation was attributed to stockouts of HIV test kits and high workload, particularly in PMTCT settings. This practice highlights a potential vulnerability in the testing protocol that could affect the quality of care within the cascade

The Economic Value of PMTCT

The total provider cost of successfully guiding a mother-baby pair through the 18-month PMTCT cascade was $549 (Table 4). This includes maternal HTS, ART initiation, and exposed infant testing and prophylaxis up to weaning. A key analytical decision was to allocate only the incremental time and resources used for PMTCT-specific services, therefore this estimate excludes the costs of general pregnancy care and child health services.

When prevention fails, the financial implications for the provider increase substantially over a lifetime. Two key seroconversion scenarios were modelled to illustrate the costs averted by successful PMTCT, using an undiscounted lifetime horizon and assuming prevention success averts one full infection.

Scenario 1: Maternal seroconversion. If a mother seroconverts, she requires lifelong ART. The first-year cost of a new PMTCT client is $209·30, decreasing to $138·93 per year for ongoing first-line treatment. Based on an average female life expectancy of 65 years and an average maternal age at delivery of 28 years in Zimbabwe as at 2023, this represents a lifetime cost of approximately $5 210·78 per mother (Table 4) [6,7].

Scenario 2: Infant seroconversion. The cost burden is greatest when an infant acquires HIV. Initiating a new paediatric ART client costs $450·56 in the first year, nearly double the cost of maternal ART. This high cost is driven by expensive paediatric formulations and the intensive laboratory monitoring. The lifetime treatment cost of care for a child initiated on ART before reaching their first birthday was estimated at $9 455·17, assuming survival to adulthood (life expectancy 63) as a stable patient [7]. Investment in PMTCT is saving at least $17 for every dollar spent per mother-baby pair where prevention is successful. This reveals the profound cost-saving nature of PMTCT.

This study is the first to apply Time-Driven Activity-Based Costing (TDABC) to HIV services in Zimbabwe, providing granular costing data crucial for strategic planning and sustainable health financing. By mapping the implementation of PMTCT care pathways, estimating the provider costs, and identifying key sources of cost variation, the study provides a comprehensive view of resource use and opportunities for efficiency.

The study demonstrates that the cost of guiding an HIV-positive mother and her exposed infant through the entire PMTCT cascade is a fraction of the cost incurred when prevention fails. This aligns with economic analyses from other settings, which highlight PMTCT as a highly cost-effective intervention [8–10]. Protecting this investment is crucial to avoid future, far greater financial liabilities for the health service provider.

Investment case for Prevention services

The cost analysis demonstrated that PMTCT is a highly cost-saving intervention across diverse settings, aligning with findings from Tanzania where it remained cost effective despite the higher average cost for pregnant women [11]. Preventing a single maternal infection averts a lifetime treatment cost. Despite the operational issues observes, including deviations from guidelines and test kit stockouts, the cost-saving nature of PMTCT remains undisputed. Improving the supply chain and reinforcing adherence to guidelines are clinically imperative and would further enhance the exceptional return on investment by ensuring every dollar spent achieved its intended preventive outcome.

The current landscape of shifting global health financing makes a relentless focus on efficient more critical than ever. Our findings suggest several pathways to maximise the value of PMTCT investments. In line with existing body of literature, the efficiency of primary care clinics supports a continued shift towards a decentralized, nurse-led model of care as this facilitates cost reduction [12].

Cost Drivers and Efficiencies within the PMTCT Cascade

The study’s micro-costing approach identified distinct cost drivers at different stages of the cascade. For the initial HIV testing of a mother, indirect costs were the primary driver suggesting foundational health system overhead were a significant component. In contrast, EID costs were driven by inputs, primarily medicine and laboratory test kits. This shift in cost structure underscores the resource-intensive nature of paediatric diagnostics and reinforces the role of these commodities as noted in regional studies [13].

The primary cost driver of provision of ART to a mother within PMTCT services was laboratory services ($34·56), whereas for paediatric ART, the cost of medicine was the largest component ($27·98). Our methodology reflects higher testing costs compared to other methodologies in previous studies [14]. The annual cost of vertical transmission, accounted for as the cost of treating an infected infant ($450·56), was more than double the cost of treating their mother, a finding consistent with other studies, though at a lower absolute cost than that reported in Zambia ($521–$624) [15]. This difference highlights the ongoing financial burden of paediatric formulations and intensive monitoring.

Bridging the Policy-Practice gap and Enhancing Program Efficiency

A critical finding from the process mapping and costing was the observable gap between policy and practice. We documented a systematic deviation from the national testing algorithm in the Operational Service Delivery Manual (OSDM), with facilities commonly using two test kits instead of the recommended three due to stockouts and high workload. This practice, also noted in other African countries like Mozambique, introduces a vulnerability that could lead to misclassification and diminish the effectiveness of the entire PMTCT cascade [16,17]. Whether these deviations significantly affect transmission outcomes remains unclear, as evaluating the rate of misclassification was beyond the scope of this study.

Furthermore, the data reveal significant efficiency gains from a decentralised, task-shifting model. The cost of PMTCT services was lowest at the clinic level compared to central hospitals, corroborating findings from studies across 22 African countries on the cost-minimising effects of task-shifting and service integration [18]. This suggests that further decentralisation of services such as point-of-care viral load testing could yield substantial efficiency gains. In the context of shifting global health financing priorities, sustained investment in HIV prevention remains essential to preserve the country’s gains.

Based on our findings, we recommend conducting a formal review of testing algorithms to determine whether a streamlined, yet effective, protocol could be adopted to enhance feasibility without compromising quality of care. Fortifying the supply chain, particularly for EID commodities will strengthen postnatal prevention efforts, which account for more than half of vertical transmissions [13]. A reliable supply of test kits and prophylactic medicines is essential to protect the investment in the entire PMTCT cascade. Policy makers should leverage the documented cost efficiencies of primary care clinics by further decentralising services, expanding point-of-care technologies and strengthening the nurse-led model of care for stable patients. Expanding these models can enhance resilience amid funding cuts and maintain the gains achieved in PMTCT.

Strengths and limitations

The study facilities were purposively selected to ensure maximum variability of findings. While this provides rich contextual data, the results may not be fully generalizable to all health facilities in Zimbabwe. The average costs presented should be interpreted as robust estimates rather than definitive national figures. Being a cross-sectional study, the data reflect a snapshot in time and may not be reflective of seasonal variations in patient-provider interactions and HIV-related patient attendances, nor the long-term trends in commodity prices and wage adjustments. The lifetime cost estimates were modelled using current treatment costs based on financial year 2022, standard survival assumptions, and a stable clinical course. The cost analysis demonstrates potential cost savings from prevention, it does not quantify the magnitude of health benefits or include sensitivity testing, as the available dataset lacked key parameters for uncertainty. The estimates exclude potential future changes in treatment guidelines, drug price and the additional costs of managing advanced HIV disease and opportunistic infections. This analysis focused on facility-based provider-patient interactions, as a concurrent community-based intervention was underway during the data collection period. A separate costing of community-based service provision is encouraged, and consideration of service delivery integration is recommended to improve service delivery opportunities to served communities.

The novelty of this study lies in its precise, pathway-based quantification of PMTCT costs and the financial value of prevention in the Zimbabwean context. By move beyond average cost estimates, it provides a clear economic narrative for policymakers. It conclusively demonstrates that the prevention of vertical transmission is not just a clinical success but a critical financial investment. The relatively low cost of preventing vertical transmission of HIV pales in comparison to the substantial, lifelong financial liability of treating a paediatric HIV infection. The findings offer a clear economic mandate to strategically prioritise upfront investment in a robust PMTCT programme, specifically by strengthening the supply chain for test kits and medicines, optimising testing protocols based on feasibility, and decentralising services to the most cost-efficient levels of care. This will safeguard past gains, improve maternal and child health outcomes, and ensure the most efficient use of the limited resources for years to come.

From the provider perspective, the study highlights the key cost drivers and actionable areas for implementation improvement. Ultimately, it reframes PMTCT as a data driven, cost saving cornerstone of Zimbabwe’s sustainable HIV response, offering policy makers and donors a clear mandate for prioritizing prevention.

Competing interests

All authors have no competing interests to disclose

Ethical considerations

This study was approved by the Joint Review Ethics Committee (JREC/325/2023), Medical Research Council of Zimbabwe (MRCZ/A/3101) and Sally Mugabe Central Hospital Ethics Committee (SMCHE021023/24).

Funding

This study was funded by the Global Fund (https://www.theglobalfund.org/en/) through the United Nations Development Programme(https://www.undp.org/) through grant number GF NFM3 HIV Grant. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. However, they did have access to periodic reports submitted to them throughout the process including the draft manuscript.

Author Contributions

SC, JC, AI, TM, SS, SC, NM, EB, LM, TBA, TP provided critical assessment and guidance during the conceptualization, study design and methodology.

Acknowledgements

We would like to acknowledge the participation of all stakeholders who contributed to the process mapping, data collection and validation of this work.

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Table 1 Cost of PMTCT Services by Health Facility

Cost of HTS in PMTCT for a negative ROC (US$)
Stage name	Sally Mugabe	Mpilo	Bindura	Gwanda	Mt Darwin	Beitbridge	Luveve	Mbare	Dotito	Zezani	Average
HTS at ANC first contact	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54
Retest at 32 week OR at delivery	22.17	21.96	11.82	10.84	5.19	4.93	4.01	5.10	5.69	3.89	9.56
three other retests (6weeks, + 6 months x 2)	66.52	65.87	35.46	32.52	15.57	14.80	12.02	15.30	17.07	11.67	28.68
Total HTS in PMTCT –ve up to weaning (mother)	116.22	117.30	58.92	55.57	25.74	24.54	19.32	24.66	26.91	18.57	48.78
Cost Domain for HTS in PMTCT +ve at first contact (mother)
Registration	3.40	3.22	1.27	1.30	0.38	0.35	0.25	0.35	0.18	0.31	1.10
Group Health Education	4.39	4.47	2.32	1.89	1.02	1.48	0.87	0.91	1.09	0.65	1.91
Vitals	3.24	3.28	1.25	1.50	0.47	0.41	0.39	0.30	0.09	0.21	1.11
Initial consultation	3.26	5.51	1.30	1.61	0.45	0.80	0.32	0.31	0.19	0.63	1.44
HIV test: conducting test	3.44	3.27	1.91	2.21	1.56	0.42	0.27	1.30	1.85	0.61	1.68
Post-test counselling	3.33	3.29	1.21	1.28	0.43	0.45	0.57	0.43	0.38	0.35	1.17
Issue results	3.25	3.24	1.21	1.24	0.34	0.51	0.25	0.24	0.12	0.11	1.05
Link to care	3.20	3.21	1.16	1.20	0.35	0.39	0.36	0.41	0.23	0.13	1.06
Total HTS in PMTCT +ve at first contact (mother)	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54
Cost Domain for HTS in PMTCT +ve at first contact (mother)
Personnel	2.10	4.10	2.66	3.40	2.87	2.45	1.61	2.65	3.94	2.73	2.85
Space	0.35	0.19	0.39	0.27	0.11	0.25	0.08	0.13	0.11	0.18	0.21
Indirect Costs	25.08	25.19	8.58	8.55	2.00	2.11	1.59	1.48	0.09	0.09	7.48
Total	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54

Table 2 Cost of PMTCT Services by Health Facility

Cost of HTS in PMTCT for a negative ROC (US$)
Stage name	Sally Mugabe	Mpilo	Bindura	Gwanda	Mt Darwin	Beitbridge	Luveve	Mbare	Dotito	Zezani	Average
HTS at ANC first contact	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54
Retest at 32 week OR at delivery	22.17	21.96	11.82	10.84	5.19	4.93	4.01	5.10	5.69	3.89	9.56
three other retests (6weeks, + 6 months x 2)	66.52	65.87	35.46	32.52	15.57	14.80	12.02	15.30	17.07	11.67	28.68
Total HTS in PMTCT –ve up to weaning (mother)	116.22	117.30	58.92	55.57	25.74	24.54	19.32	24.66	26.91	18.57	48.78
Cost Domain for HTS in PMTCT +ve at first contact (mother)
Registration	3.40	3.22	1.27	1.30	0.38	0.35	0.25	0.35	0.18	0.31	1.10
Group Health Education	4.39	4.47	2.32	1.89	1.02	1.48	0.87	0.91	1.09	0.65	1.91
Vitals	3.24	3.28	1.25	1.50	0.47	0.41	0.39	0.30	0.09	0.21	1.11
Initial consultation	3.26	5.51	1.30	1.61	0.45	0.80	0.32	0.31	0.19	0.63	1.44
HIV test: conducting test	3.44	3.27	1.91	2.21	1.56	0.42	0.27	1.30	1.85	0.61	1.68
Post-test counselling	3.33	3.29	1.21	1.28	0.43	0.45	0.57	0.43	0.38	0.35	1.17
Issue results	3.25	3.24	1.21	1.24	0.34	0.51	0.25	0.24	0.12	0.11	1.05
Link to care	3.20	3.21	1.16	1.20	0.35	0.39	0.36	0.41	0.23	0.13	1.06
Total HTS in PMTCT +ve at first contact (mother)	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54
Cost Drivers for HTS in PMTCT +ve at first contact (mother)
Personnel	2.10	4.10	2.66	3.40	2.87	2.45	1.61	2.65	3.94	2.73	2.85
Space	0.35	0.19	0.39	0.27	0.11	0.25	0.08	0.13	0.11	0.18	0.21
Indirect Costs	25.08	25.19	8.58	8.55	2.00	2.11	1.59	1.48	0.09	0.09	7.48
Total	27.53	29.48	11.63	12.22	4.98	4.81	3.29	4.27	4.15	3.00	10.54

Table 3 Health Care Worker Providing Care in PMTCT Services and Costs, Zimbabwe TDABC Study, 2023

	Stage name		Cost per facility in US$
	Stage name		Sally Mugabe	Mpilo	Bindura		Gwanda	Mt Darwin		Beitbridge	Luveve	Mbare	Dotito		Zezani
1	Registration		0·24	0·06	0·18		0·21	0·12		0·08	0·05	0·15	0·17		0·27
2	Group Health Education		0·98	1·23	1·03		0·68	0·73		1·04	0·61	0·69	1·03		0·58
3	Vitals		0·10	0·12	0·17		0·42	0·21		0·12	0·19	0·11	0·08		0·18
4	Initial consultation		0·12	2·31	0·21		0·50	0·19		0·52	0·12	0·12	0·18		0·60
5	HIV test: conducting test		0·29	0·11	0·75		1·09	1·26		0·15	0·07	1·07	1·81		0·57
6	Post-test counselling		0·19	0·14	0·12		0·20	0·17		0·18	0·37	0·23	0·36		0·33
7	Issue results		0·11	0·09	0·13		0·16	0·08		0·24	0·05	0·05	0·10		0·10
8	Link to care		0·06	0·06	0·08		0·12	0·10		0·13	0·15	0·22	0·22		0·109
9	Re-testing before ART		0·42	0·42	1·09		0·70	0·66		0·68	0·79	0·93	1·81		1·48
10	ART assessment		0·67	1·15	0·59		1·09	0·34		0·20	0·18	0·18	0·18		0·18
11	Physical examination		0·31	0·31	0·35		0·40	0·19		0·35	0·81	0·81	0·24		0·49
12	Collection of blood for baseline tests		0·39	0·39	0·17		0·34	0·20		0·31	0·56	0·23	0·10		0·22
13	Initiate ART		0·43	0·73	0·49		0·54	0·10		0·87	0·84	0·66	0·62		0·62
14	Issue laboratory results		0·08	0·07	0·12		0·37	0·70		0·21	0·18	0·31	0·10		0·43
15	Review after 1 month		0·31	0·61	1·35		0·69	0·70		0·91	0·65	0·84	0·23		0·54
16	Review at 34 weeks		0·36	0·19	0·92		0·57	0·63		0·56	0·87	1·45	0·41		0·65
17	Review at 36 weeks		0·36	0·49	1·25		0·49	0·76		0·49	0·58	1·59	0·44		0·55
18	Review after 6 months		0·73	0·36	0·64		0·52	0·83		0·71	0·74	1·75	0·25		0·57
19	Review after 1 year		0·66	0·44	1·98		0·53	0·40		0·52	0·59	0·60	0·33		0·59
20	HIV re-testing at 32 weeks		0·47	0·27	0·91		0·55	1·31		0·59	0·22	0·72	2·34		0·89
21	HIV re-testing at delivery		0·47	0·23	3·44		1·95	1·59		0·08	0·42	0·72	1·99		0·31
	Total		$7·752	9·78	15·97		12·13	11·30		8·95	9·04	13·45	12·98		10·21
Nurse		Nurse Aide	Medical Doctor			Primary Counsellor			Data Clerk		Microscopist			KEY

Table 4: Cost analysis of PMTCT in Zimbabwe, 2023

Scenario Cost of Successful prevention	Description	Cost US$	Total Cost US$
	Initial HTS	10·54
	Initial HTS	10·54
Prevention success (mother remains negative)	Re-test at 32 weeks/delivery	9·56	48·78
	Re-test at 6 weeks & 6 months postpartum	28·68
	Prevention success (mother)	48·78
Full PMTCT Cascade (cost to ensure HIV exposed infant does not seroconvert until weaned OR 18 months)	ART: New PMTCT client (pregnancy up to 3 months)	209·30	548·92
	ART :(baby is >3 months up to 15 months)	138·93
	ART: baby is >15 up to 18 months	28·48
	Prevention success (exposed infant up to 18 months of age)	123·43
Cost of Prevention Failure
Maternal HIV case	ART: New PMTCT client (pregnancy up to 3 months)		209·30
Paediatric HIV case	First year: new paediatric ART patient		450·56
*Lifetime treatment implications (undiscounted)*
Exposed infant seroconverts	General life expectancy	63 years
	First year: new paediatric ART patient	450·56
	Second year	386·10	9 526·18
	2-9 years	169·61
	over 9 years	138·93
Mother seroconverts	Maternal age at delivery	28 years
	Female life expectancy	65 years
	First year: New PMTCT client	209·30	5 210·78
	Second year onwards: Existing client	138·93

The authors declare no competing interests.

Provider Costs of PMTCT Services in Zimbabwe: A Time-Driven Activity-Based Costing Analysis

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Study Design and Setting

Time-Driven Activity-Based Costing Framework

Sampling

Data Collection Tools and Procedures

Cost Analysis

Validation

Results

Cost Accumulation Across the PMTCT Care Cascade

Antiretroviral Therapy (ART) Cost Burden within the PMTCT Cascade

The Economic Value of PMTCT

Discussion

Strengths and limitations

Conclusion

Declarations

Funding

Author Contributions

Acknowledgements

References

Tables

Additional Declarations

Status:

Version 1