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Sustaining HIV Services: HAPSAT estimates of resource needs under alternative policy scenarios

Sustaining HIV Services: HAPSAT estimates of resource needs under alternative policy scenarios. September 15, 2009 Gilbert Kombe, MD, Arin Dutta, PhD, Elaine Baruwa, PhD, Stephen Resch, PhD. Outline. Introduction to Health Systems 20/20 Why another HIV costing study? Introduction to HAPSAT

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Sustaining HIV Services: HAPSAT estimates of resource needs under alternative policy scenarios

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  1. Sustaining HIV Services:HAPSAT estimates of resource needs under alternative policy scenarios September 15, 2009 Gilbert Kombe, MD, Arin Dutta, PhD, Elaine Baruwa, PhD, Stephen Resch, PhD

  2. Outline • Introduction to Health Systems 20/20 • Why another HIV costing study? • Introduction to HAPSAT • HAPSAT compared to other costing models • HAPSAT experience in • Zambia, Ethiopia, Cote d’Ivoire • Nigeria • Next steps

  3. Health Systems 20/20 • USAID global project working to strengthen the six pillars of the health system: • Health financing, governance, human resources, HIS, pharmaceutical/commodities, operations • USAID ‘Leader with Associates’ award, Abt Associates is prime • HS 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008

  4. Costing and HIV • Costing of HIV prevention programs began in late 1990s as prevention programs started to scale up • UNAIDS published “Guidelines for Costing HIV/AIDS Prevention Strategies” in 2000 • Costing of existing HIV treatment programs (as opposed to cost projections) is more recent but coincides with large scale-up prompted by PEPFAR • “Achieving the WHO/UNAIDS ART 3 by 5 goal: what will it cost?” Guiterrez et al, Lancet 2004 • Focus has been on costing vertical HIV programs (BCC, PMTCT, ART) rather than costing a ‘Country HIV Program’ which is an increasingly integrated suite of HIV programs

  5. Key principles of costing • Economic vs. Financial Costs • Economic – financial costs plus value of input not paid for like volunteer time, patient travel costs etc. • Financial – what program pays for its inputs • Top-down vs. Bottom-up Approach • Top-down – use total program expenditures to determine program costs • Bottom-up - estimate unit costs of each input and then multiply by number of units delivered or needed in future • Capital vs. Recurrent Costs Capital – cost of inputs that last more than a year Recurrent – cost of inputs used in a year and then repurchased • HAPSAT: uses financial, bottom-up, and recurrent costs

  6. Why another HIV costing tool? • Several costing tools exist • CDC’s PACM • Futures’ SPECTRUM costing module • UNAIDS’ NASA • But none answers all of the following for a comprehensive set of HIV services: • Where are the potential resource gaps in an uncertain budget environment? • What if costs or HIV/AIDS service delivery policies change? • What about human resources needed? Labor costs? Beyond 2010? • Major changes to eligible populations, e.g., CD4≤ 350 cells/mm3

  7. HAPSAT is … • More than a new costing study • Focus on country ownership • For iterative modeling of scale-up scenarios • User-friendly tool to be institutionalized with government • Provides evidence for decision-making • Multiple scenarios – uses a stakeholder process • Compares sustainability – helps with target setting, advocating resource mobilization/rationalization, identifying trade-offs • Models expected changes to service policies, budgets, or unit costs • Comprehensive and flexible costing approach • Incorporates knowledge from previous studies in country • Updated with new issues related to HIV/AIDS policy and resources • Harmonized with other costing approaches: CDC, Spectrum

  8. Sustainability analysis • What is sustainability analysis? • Measures gap between resources needed (financial, human, organizational) and resources available over the relevant time horizon • What is more easily quantified: funds, people, equipment • What is less easily quantified: well-functioning program management • HAPSAT used to conduct sustainability analysis of national HIV programs in Zambia, Nigeria, Ethiopia, and Cote d’Ivoire 8

  9. Introduction to HAPSAT • HAPSAT based on Microsoft Excel software, models resource requirements/availability over 5-year time horizon 9

  10. Programmatic areas in HAPSAT TREATMENT CARE PREVENTION MITIGATION SHARED COSTS • ART • VCT • Pre-ART monitoring, OI p&t, home-based care, palliative care • Testing & DOTS for TB-HIV co-infection • PMTCT • Behavior Change Prevention/ABC • MARP Outreach, Youth Friendly Services, Mass Media, etc • OVC • Economic and social support programs for PLWHA • Health systems & SI , M&S grouped together as cross-cutting shared costs and overheads

  11. Policy variables allow flexibility modeling the services received HCT Unknown HIV Known HIV Cases PMTCT Not ART-Eligible ART-Eligible Nothing Nothing Pre-ART Care Non-ART Care ART 1st Line ART 2nd Line Treatment Failure 11

  12. Model assumptions: Economic Constant returns-to-scale Assumes unit costs are the same, regardless of the number of people on treatment Unit cost of inputs assumed to be constant over time with some exceptions ARVs can have price changes by year Labor cost can be subject to an annual inflation-adjusted salary escalation Costs denominated in US dollars Exchange rate for inputs sourced locally (e.g. labor) fixed for time horizon No discounting of downstream costs and benefits

  13. PEPFAR ART Costing Model (PACM) • Developed by CDC/Macro Intl. • Recently used in three countries so far; three more ongoing • Calculates costs of ART and pre-ART programs over 5-year period • Scale-up scenario described in terms of targeted no. patients on Tx. • Patients transition monthly between treatment states, for 60 months: ►Pre-ART vs. ART ► Adult vs. pediatric ►1st-line vs. 2nd-line ►Newly-initiating vs. established ►New vs. old ARV regimens • Narrow focus on ART services, comprehensive costs within that area • Recurrent costs = costs per patient-month x no. months on Tx • Investment costs calculated separately to take account of program scale-up, timing of investment spending

  14. Spectrum costing model (Futures) • Suite of tools to produce caseloads and cost of ART and OI treatment from demographic, epidemiological, and unit cost data • Requires unit costs for: • ARVs OI treatment and prophylaxis • Service delivery Lab tests • Data collection • Can use observed care, expert consensus, or norms • Draws on Cape Town Tx model for many model assumptions • Intended to be flexible • Can rely on existing or newly developed unit costs • Can reflect service provision or full program including overheads • Can reflect different coverage and cost scenarios • Leverages country work developing epidemiological projections

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  16. Harmonization: Compare models, common cost, and policy inputs Total ART costs

  17. HAPSAT: Advantages and limitations • Advantages • Gap and HRH analysis • Comprehensive view of HIV/AIDS national strategy • Stakeholder process leading to cost and scenario input • Current limitations • Limited modeling of infrastructure/investment cost • As in PACM, Spectrum: implementing partner overhead needs more modeling definition and data • Does not produce partner specific sustainability analysis, e.g. PEPFAR • More definition required on TB-HIV integration

  18. HAPSAT: Cote d’Ivoire (2009) • 5 years (2009-2013) • 2 original HIV/AIDS program scenarios • MAINTAIN level of services based on ‘flat PEPFAR funding’ • SCALE-UP ART & HCT – adding 22.8K ART per yr 2010-11 • Scale-up findings suggest that financial gaps appear 2010/11 • Capacity building and stakeholder involvement • RCI Ministry of Health and Ministry of AIDS trained • USG RCI trained • Stakeholder meeting to develop HAPSAT scenarios

  19. HAPSAT Cote d’Ivoire: Drug regimen reduction scenario Streamline number of 1st line regimens from 9 to 5 Most D4T patients on non-D4T regimens by December 2009 Increase average drug costs of 1st line regimen US$214 current Up to US$255 (well implemented switch)Up to US$344 (not so well implemented switch) 19

  20. HAPSAT Cote d’Ivoire: Drug regimen reduction scenario US$ 36 available 20

  21. HAPSAT: Zambia (2007) • 5 years (2007-2011) • 3 HIV/AIDS program scenarios • SUSTAIN current level of services • MODERATE SCALE-UP of services • FULL COVERAGE • HAPSAT findings • With fall in commodity prices, GOZ ability to increase its contribution is further reduced • USG and GFATM accounted for 58% and 20% of total budget respectively • High levels of government buy-in, collaboration • HAPSAT results used for GFATM Rd 8; other mobilization • Laboratory staffing found to be a constraint in scale-up

  22. HAPSAT Zambia: Sample output Funding Gaps for ART, PMTCT, VCT, TB-HIV, CSS, and prevention in ‘sustain’, ‘moderate’ and ‘full coverage’ scenarios FULL COVERAGE MODERATE SUSTAIN

  23. HAPSAT: Ethiopia (2009, in progress) • 6 years (2010-2015) • 5 scenarios developed in consultation with USG team (USAID, CDC) and WHO in Addis Ababa: • Maintain current enrolment rates • Maintain GOE 'Universal Coverage 2010‘ targets • 'Universal Coverage' targets for 2010 reached in 2014 • Program cascade scenario based on GFATM HCT target • Program cascade scenario based on PHCT • USG mission requested results by July 31 for COP 2010 • Prelim draft report sent 8/10 – 3 weeks from data collection • Capacity building and stakeholder involvement • PEPFAR partners, NGOs, donors interviewed • GOE: FHAPCO, FMOH consultations started

  24. HAPSAT: Nigeria (2008-9) • 2 HIV/AIDS program scenarios, as in report (5/09) • MAINTAIN current coverage • SCALE-UP according to national targets • HS 20/20 gap analysis of 3 additional scenarios • Program cascade scenario: ART access for all known eligible • Moderate scale-up (updated SCMS-GON targets) • Universal access by 2014 (80% of need) • HAPSAT findings • Strong involvement, co-authoring with NACA; high buy-in • NACA used results in application for WB MAP2 • USG team would like to use as ‘active tool’ in Partnership Framework discussions and COP planning • Proposed use in national strategic framework policy process

  25. HAPSAT Nigeria: Sample output‘Cascade’ Scenario (No queue for ART or C&S if eligible) 25

  26. HAPSAT Nigeria: Sample outputExpected financial resources for HIV program Assume GON wins GFATM Round 9 and World Bank MAP II funds 26

  27. HAPSAT Nigeria: Sample outputFinancial requirements: ‘Cascade’ scenario 27

  28. Next steps • Increasing use of findings • Have been used for COP planning, to support Global Fund applications and World Bank MAP design • Can be used to support PEPFAR Partnership Framework activities and National Strategic Planning (5-year plans, MTEF, etc) • Working with countries beyond course of the study • Specific analyses • Live capacity building (OJT) of government and USG staff

  29. Next HAPSATs • Demand is increasing • Complete 5-6 additional countries by December 2009 (to meet COP 2010 deadlines) • Starting with Haiti, September 2009 • Website • General Modeling Tool will be posted • HAPSAT “Toolkit” under construction • Methodology paper in progress • Meta-analysis paper proposed using 2009 HAPSATs

  30. General contact email: Gilbert_Kombe@abtassoc.com Technical contact email: Arin_Dutta@abtassoc.com Elaine_Baruwa@abtassoc.com Stephen_Resch@harvard.edu Website: www.healthsystems2020.org Thank youFor more information…

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