Economic evaluations of differentiated service delivery should include savings and ancillary benefits, not only health system costs: authors’ reply

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We thank Claassen et al.[1] for their thoughtful comments. The models of care included in our analysis [urban adherence groups, community adherence groups, home antiretroviral therapy (ART) delivery (through the Community HIV Epidemic Control; CHEC model), and mobile ART] were indeed more expensive than conventional care. This is not surprising, as each of the models layered additional services on top of existing conventional care [2]. We are pleased that in the time since our article was submitted for publication, new models of care have been introduced in Zambia that may marginally reduce costs to the provider, due primarily to the reduction in number of clinic visits required in those newer models [3–5]. In their comments, Claassen et al.[1] were critical of the exclusion of savings to patients and other benefits of differentiated service delivery models to offset their higher costs to providers. The guiding principle for our analysis, however, was to ensure that costs and outcomes were measured consistently between all models of care. To that end, we decided to include only the aspects of each model that could be directly compared with all the other models of care described in our manuscript. For the CHEC model, about which Claassen et al.[1] write, this was the ‘stable in care’ portion of model. We recognize that there may be other ancillary benefits to the CHEC model not captured in our analysis, and this may also be the case with other models of care. Other recent research has found that provider costs are similar between differentiated models of care and conventional care, or slightly lower, but can result in significant savings to the patient [3,4]. This is important but it was beyond the scope of our protocol and article. We chose retention in ART care as the primary outcome for our analysis for a similar reason. Although we agree with Claassen et al.[1] that viral suppression is an excellent indicator of patient success on treatment, it is also true that only patients who are retained in care can have a viral load measurement. Given this limitation, the fact that many patients were missing viral load measurements and that retention in ART care as defined in our manuscript was available for all the patients included in our study, retention in care made more sense as a primary outcome. We used the 9–15-month window after differentiated service delivery model entry as our primary outcome date because of the fact that all models of care require, at a minimum, annual visits to the health facility, which should be recorded in the electronic medical record system. This was the only consistent indicator of outcomes available for the entire cohort. We agree that a holistic view and capturing of all costs and benefits of each model would undoubtedly be a useful exercise to further understand how we can maximize these benefits. Our decision to take the provider cost approach is because of the fact that healthcare budgets are highly constrained and are frequently the limiting factor in how healthcare resources are allocated. We answered the question we were asked by policy makers and funders, and we hope that others will answer other questions. Acknowledgements Conflicts of interest There are no conflicts of interest.

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