Decentralized drug distribution of antiretroviral therapy in Eswatini: cost-saving or cost-shifting?

BACKGROUND: Decentralized drug distribution (DDD) is an approach to support people living with HIV and other chronic conditions who need periodic drug refills in low-and middle-income countries. It has the potential to preserve facility-based resources (especially labor) and reduces crowding in facilities (particularly important during the COVID-19 pandemic).
This analysis documents how the DDD approach in Eswatini changed the flow of resources during implementation and service delivery and who bore the costs/savings.
METHODS: Activity-based costing of DDD was conducted todocument the resources required to support service delivery through DDD, how DDD impacted the source of resources, and how DDD impacted the cost to service clients. Resources were valued from a financial perspective for monetary transactions or as opportunity costs if no transaction took place but how an existing resource was being used changed. The latter included the value of time for facility-based staff who were redeployed, or changes in the time clients spent seeking refills (valued at the hourly equivalent of gross domestic product per capita). Antiretroviral costs were excluded, as overall use did not change.
RESULTS: During service provision, for every US$1.00 of financial costs incurred, ~US$0.75 in opportunity costs were incurred for redeployed resources to support CDPs. These were almost equally divided between the Ministry of Health (55%) and donor-funded implementing partners (45%). Clients had a modest financial cost savings (~US$2.40/refill) but substantial opportunity cost savings (~US$47.87/refill). The ongoing financial and opportunity costs of DDD per month and refill for stakeholders are shown below (US$).

	Donor Resources		Ministry of Health Resources		Client Resources
	Per Month	Per Refill*	Per Month	Per Refill*	Per Month	Per Refill*
Financial	$27,261	$33.25	nil	-	-$1,972	-$2.40
Opportunity	$9,085	$11.08	$11,282	$13.75	-$39,250	-$47.87
Total	$36,346	$44.32	$11,282	$13.75	-$41,222	-$50.27

* Based upon ~820 refills dispensed per month (17.7% of all ART refills)
CONCLUSIONS: DDD of antiretroviral therapy is feasible and can reduce pressure on facility-based resources. The savings to clients largely offsets the additional costs associated with DDD for antiretroviral refills. Understanding how DDD introduction impacts the flow and source of resources required can inform scale-up and ongoing support of these programs.

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