Is quality affordable for community health systems? Costs of integrating quality improvement into close-to-community health programmes in five low-income and middle-income countries

This paper examines the costs and budget impact of integrating QI into existing CTC health programmes in five countries (Ethiopia, Indonesia, Kenya, Malawi, Mozambique) between 2015 and 2017. The intervention involved: (1) QI team formation; (2) Phased training interspersed with supportive supervision; which resulted in (3) QI teams independently collecting and analysing data to conduct QI interventions. Project costs were collected using an ingredients approach from a health systems perspective. Based on project costs, costs of local adoption of the intervention were modelled under three implementation scenarios.<br>The costing took a health systems perspective, taking into account health system resource and time costs (we differentiate that from health system costs, as CTC providers may not be salaried individuals whose time is explicitly valued by the health system). Specifically, we collected and report both economic and financial costs of the intervention, as well as the budget impact of national scale-up based on the financial costs only. Financial costs refer to outlay of money; economic costs encompass financial costs and opportunity costs of time, even where people are already salaried or are volunteers and their time is ‘free’. An ingredients approach was used to assess the costs of each phase of the intervention in the following categories: staff time (encompasses volunteer time), lodging/ transport, communication, venue, refreshment, stationery. In our model, costs incurred during the training are treated as capital costs while the QI implementation represents recurrent costs of the intervention. The useful life of the training is taken as 4 years (ie, all participating staff would receive full retraining in year 5). Details of specific cost adjustments made at each of the steps of the intervention when calculating country costs can be found in Supplementary File 2.<br>