MITS Cost Analysis
Interim Results
Laura Morrison, Elizabeth Brown, Tia Paganelli, and Norman Goco
September 17, 2020
1
Building the evidence base for MITS
• Adoption of MITS in LMICs can improve the amount of and quality of COD data, thus
improving the epidemiological knowledge base, and informing effective interventions for
preventing mortality.
• To promote expansion of MITS, must evaluate validity, acceptability, feasibility, and costeffectiveness. (Byass 2016)
This study is an initial step towards understanding cost implications.
• Cost studies of novel practices (1) advocate for widespread adoption and (2) inform
realistic implementation.
Building the evidence base for MITS
• What is agreed upon related to costs of MITS? That they must be better understood.
(Byass 2016)
• MITS and MIA cost documentation and comparison studies in high-income countries
exist, but may not be relevant for LMIC contexts. (Weustink et al, 2009; Breeze et al, 2010)
• Cost of specific supplies (biopsy needles), requirement of complex and costly
microbiology platforms and microbiology specialists/pathologists are limitations to MIA
in Mozambique (Castillo et al, 2015)
• Perceived high cost of MITS among HCWs in Pakistan (Feroz et al, 2019)
• May require public investment
• Operational expenses < initial investment cost
Study Objective
Characterize the costs and cost drivers associated with MITS
implementation in LMIC settings from the health care
provider perspective.
Implementation costs estimate MITS’ operational requirements only (no research costs).
The provider’s perspective represents costs that clinics/hospitals or health care systems would face
in expanding/mainstreaming the use of MITS.
Cost Data Collection
• Interim results draw from a cost survey of four sites conducted between Feb - June 2020.
• Sites are geographically dispersed
• Sites are recipients of MITS Alliance grant funding
• Sites must have conducted MITS outside of training
• Cost survey delivered during in-person site visits, by e-mail; follow ups via phone interview.
• Pilots identified all relevant resources used (in-person site visits)
• Data collected from sites include:
• context-specific site information
• financial and economic data related to resources used in MITS implementation
Cost estimation
RECURRING COST
INITIAL INVESTMENT COST
Cost estimation
RECURRING COST
INCREMENTAL COST (PER CASE)
•
•
•
•
•
•
•
Sampling
Community collection (if applicable)
Testing
Test transport (if applicable)
Materials (e.g. reagents, office + lab supplies)
MITS kits (materials, labor, shipping)
Labor (staff compensation)
•Screening and
enrollment
Sample
collection
Processing
Analysis
PROGRAM ADMINISTRATION COST (ANNUAL)
• Labor (staff compensation)
• Materials (e.g. office supplies, meetings, internet)
Reporting
Cause of death
determination
not included in interim results
Cost estimation
CAPITAL COSTS
•
•
•
•
Lab equipment
Office furniture
Technology
Renovation expenses
START-UP COSTS
•
•
•
•
•
•
INITIAL INVESTMENT COST
cost * quantity * utilization by MITS program
initial training + training additional staff (labor, materials, space, MITS kits)
ethics approval process
protocol development
data management system set-up
community sensitization activities
other misc. expenses (e.g. launching expenses, implementation visits)
MITS Sites included in Cost Study
Country
classification
Site 1
Site 2
Site 3
Site 4
Low income
Lower-middle
income
Low income
Low income
Rural
Rural
Urban
Urban
University Hospital
University Hospital
University Hospital
University Hospital
100% Adults
5% Neonates
5% Stillbirths
15% Infants
75% Adults
100% Neonates
(World Bank)
Setting
MITS case
population
6% Infants
94% Adults
MITS Sampling by Site
Site 1
Sampling methods
used
(% used)
Sample collection
location
(facility or community)
Samples collected
(quantity + type)
Site 2
Site 3
Site 4
Needle Only
(100%)
Needle Only
(100%)
Needle Only
(100%)
Needle Only
(95%)
Needle +
Ultrasound
(5%)
Facility
Facility
Facility
Facility
7 samples / case
9 samples / case
9 samples / case
6 samples / case
Brain, lung, liver, blood,
CSF, marrow, lesions
Brain, lung, liver, blood,
csf, skin, pleural
effusion, lesions,
cancerous masses
Brain, lung, liver, blood,
csf, placenta, skin,
lesions, cancerous
masses
Brain, lung, liver,
placenta, lesions,
abdominal organs
MITS Sites included in Cost Study
Quantity of
tests
conducted per
case
Site 1
Site 2
Site 3
Site 4
27
22.2
12.2
1.1
Histology (5)
Microbiology (5)
Special stains (17)
Histology (5)
Microbiology (6)
Biochemistry/Serology
(9)
Hematology (2)
Special stains (.2)
Histology (4)
Microbiology (4)
IHC (1.2)
Special stains (3)
Histology (1)
Special stains (.1)
(average)
Type of tests
conducted per
case
(average)
Interim Results
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Incremental cost to conduct MITS (cost per case)
$1 200
$1 000
$889
$1,028
$906
$800
$858
$609
$600
$400
$200
$-
*
*
*
MITS kits
Materials
Labor
Test transport
Testing
Sample collection
S Site
I T E 11
$398
$19
$211
$$261
$-
S Site
I T E 22
$398
$17
$386
$0
$228
$-
S Site
I T E 33
$398
$28
$314
$5
$161
$-
S Site
I T E 44
$398
$35
$165
$$11
$-
• MITS kits, Labor, and Testing costs drive the marginal cost of conducting MITS.
• MITS kits cost may be reduced if produced at scale or sourced locally.
Average
AV
ERAGE
$398
$24
$269
$1
$165
$-
Average cost per test
$75,03
Biochemistry/Serology
$58,80
IHC
$53,54
Special stains
$48,55
Histology
$37,23
Microbiology
Hematology
$6,67
• Test costs vary little by site.
• Tests not performed at sites include molecular, cytology, TAC PCR, Traditional PCR.
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Testing cost per case
27
tests/case
$261
22.2
tests/case
12.2
tests/case
1.1
tests/case
$228
15.6
tests/case
$165
$161
$11
SITE 1
SITE 1
SITE 2
SITE 2
SITE 3
SITE 3
SITE 4
SITE 4
AVERAGE
AVERAGE
• While calculated costs per test are similar, the number of tests performed per case
is the most important determinant of testing cost.
• More tests are run for middle and low-cost tests (e.g. special stains, histology).
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Labor cost per case
Staff
compensation
(per case)
Total Staff
$211
$386
$314
$165
$269
SITE 1
SITE 2
SITE 3
SITE 4
AVERAGE
11
9
6
8
8.5
Pathologists
3
Lab Techs
1.8
Social Scientists
• Considerable
variation in staff
positions by site,
suggesting flexibility
in support roles to
pathologists/
specialists.
Microbiologists
Other staff
•Screening and
enrollment
16
Clinical specialist,
Nurse counselor,
MITS specialist,
MITS assistant,
Accountant,
Security,
Logistician
Sample collection
Processing
• Compensation may
include incentives
(hourly or per case).
Site supervisor,
Pediatrician
Data enumerator,
Physician
Analysis
Reporting
Cause of death
determination
Initial Investment Costs: Start-up and Capital
$48,818
$40,772
CAPITAL
$22 551
$29,302
$20,962
$36 505
$16 910
$6 535
START-UP
$26 268
$6,657
$14 427
$4 267
SITE 1
SITE 1
17
SITE 2
SITE 2
SITE 3
SITE 3
$2 050
$4 607
$12 392
SITE 4
AVERAGE
SITE 4
AVERAGE
• Great variation
in both start-up
and costs across
site depends
on existing
infrastructure
and
investment in
start-up
activities.
Capital Costs
Renovation
Technology
Office furniture
Lab equipment
$36,505
$22,551
$16,910
$6,535
SS IITTE 1E 1
SSII TTE E2 2
$2,505
SSII TTE E3 3
S SI ITT EE4 4
• Where required, renovation drives capital expenses.
• Specific costly and necessary lab equipment and technology needs drive cost:
e.g. autopsy table, embedding machine, cameras, laptops, and computers.
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A VA EV ERR AAG EG E
Start-up Costs
$26,267
$14,427
Training
Other misc expenses and activities
Community sensitization
Data management system
$4,267
S I T 1E 1
S I T 2E 2
S I T3E 3
$12,392
$4,606
S I T4E 4
A V E R5 A G E
• Training costs (initial and additional staff) make up, on average, 38% of start-up costs.
• Other start-up costs may depend on site-specific investment in certain activities, as hours and staff
mix vary by site.
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Implications
• The cost of MITS expansion depends greatly on the existing infrastructure of sites.
• Capital-heavy investments drive costs (other start-up costs may not be as site-dependent).
• Labor allocation demonstrates the need for highly trained staff who are costly to employ.
What can we learn about support staffing mix and implications for cost?
• This study is a first step towards additional necessary examinations of cost considerations,
including cost-comparison and cost-effectiveness studies, which further provide needed
economic justification for the expansion of MITS.
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Acknowledgements
Thank you to the MITS Alliance grantees who generously contributed their
efforts to facilitating our data collection.
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Questions?
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