Maximizing HIV Program Efficiency through Cost Analysis

1. Getting more value for money:working with countries and partners toward greater effectiveness and efficiency Peter Stegman, Senior Economist

2. Areas of work Key questions What we do What is the cost/person reached? Overview of project (HIV activities) How do unit costs differ across service delivery models? Develop costing tools and collect costing data HTC What are the resources required to achieve goals? Build models to project costs and impacts of interventions Male Circumcision What is the impact of intervention X? (on infections averted, # treated, HIV prevalence, costs averted, etc.) MARPs Conduct analysis, cost comparisons, and cost-effectiveness studies General Population Gender-Based Violence How can resources be reallocated to achieve goals more efficiently? Generate scenarios based on data analysis and projections Medicated assisted therapy PMTCT What is the cost of a more sustainable approach? (emerg. vs. expanded response) Treatment (Adult and pediatric) HIV in the workplace How can countries ensure sustainability of financing? Treatment as prevention Capacity building (to develop costing tools, conduct analysis, and use info for decision-making) Knowledge management: Share and disseminate information and best practices, generate tools for replicating work, encourage collaboration

3. Costing TO: Contribution to E2 work • Generate evidence to promote a more efficient, effective, sustainable response to the HIV epidemic • Encourage country ownership by generating country-specific data to facilitate strategic planning and by training and supporting counterparts to produce and use data • Bridge learning by generating and sharing evidence about efficiency, effectiveness, and sustainability of HIV/AIDS interventions

4. Costing TO: 3 examples of our work • Which service delivery model of voluntary male medical circumcision (VMMC) can rapidly expand coverage of VMMC services with the lowest unit cost and the highest savings per infection averted? • How can HTC be delivered in order to ensure that early treatment is available to the largest number of infected individuals? • How can low and middle income countries transition away from donor funding of HIV and AIDS programs without diminishing quality, coverage, and sustainability?

5. 1. MC in Tanzania, 2009-11 Objectives: • Determine unit costs and impact of scaling up VMMC on HIV prevalence and incidence • Estimate the costs of scaling up VMMC nationally • Identify service delivery models that most efficiently provide VMMC Approach: • Used Decision-Makers’ Program Planning Tool (DMPPT) • Three regions: Iringa, Mbeya, Kagera • Assessed demographic, behavioral & epidemiological data; salaries; consumables & equipment prices; training & management costs • Target coverage of 80% in selected provinces Results: • Delivering MC services via targeted campaigns could prove to be more efficient than routine services offered through health care centers

6. 2. HIV Testing and Counseling • While unit costs for HTC are known, there is uncertainty among policymakers about the most appropriate and effective service delivery model and the optimal allocation of HTC resources. • Recent costing studies suggest that hospital based HTC is more cost effective at identification of HIV+ individuals but door-to-door models are more cost effective for early detection. • Botswana has multiple service delivery modes for HTC within the contexts of facility based delivery, community delivery and mobile services. HPI Costing TO is trying to assess the cost of HTC per infected person eligible for early treatment • Botswana is a test case to learn from and develop a set of tools and methodology to apply in different country contexts (e.g. both concentrated and generalized epidemics)

7. 3. Transitional Financing • HIV and AIDS programs are among the GoB’s most expensive and successful social protection investment • GoB finances the majority of the HIV program and donor funding as a share of all resources is expected to decline in the near future • Government of Botswana needs to explore approaches to increasing fiscal space for HIV (and health overall), despite shrinking revenues from sources such as diamonds • The ART, OVC and PMTCT programs are the three most expensive programs in the national response to HIV and AIDS: are there opportunities to increase program efficiency? • Transitional financing analysis in Botswana can identify approaches to increasing sustainability of funding

8. Contributions of Costing Task Order • Promote efficiency by: • Modeling impact of changes in HIV treatment regimens/ service delivery • Increasing availability of data to inform program and policy decision-making • Increase sustainability of resources by: • supporting countries in estimating their resource needs and generating resources in order to achieve the stated targets • identifying ways to increase program efficiency and promote domestic resource generation • Support resource allocation decision-making by: • Providing decisionmakers with country-specific data to facilitate strategic planning • Developing new intervention-specific costing and modeling tools (MC, early treatment as prevention, MARPs, GBV, MAT, combination prevention)

9. Contributions of Costing Task Order • Build country ownership and capacity by: • Increasing cadre of individuals who can provide support/ conduct analyses • Increasing ability of counterparts to use information for decision-making • Encourage information sharing by: • Developing and disseminating costing tools and protocols and capacity building approaches that are replicable and contribute to best practices • Disseminating cost information through a number of sources, including the unit cost database and the International AIDS and Economics Network (IAEN).

10. Conclusion The HPI Costing Task Order supports countries and partners by enhancing existing capacity and providing tools and analysis aimed at promoting greater resource allocation and technical efficiencies and feeding lessons learned and best practices back into global concerns around HIV and AIDS program sustainability.

11. For more information on the HPI Costing Task Order please visit our website http://www.healthpolicyinitiative.com/costing