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Agenda

Facility-based Unit Costing for Antiretroviral Treatment in Ethiopia, Malawi, Rwanda , South Africa, and Zambia Preliminary Findings. Agenda. Overview of Methodology Key findings and areas of opportunities Annex slides.

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Agenda

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  1. Facility-based Unit Costing for Antiretroviral Treatment in Ethiopia, Malawi, Rwanda, South Africa, and Zambia Preliminary Findings

  2. Agenda Overview of Methodology Key findings and areas of opportunities Annex slides

  3. The overall objective of the study was to identify opportunities to improve efficiency and effectiveness of HIV treatment spending • CHAI supported the governments of Ethiopia, Malawi, Rwanda, South Africa, and Zambia, to conduct facility-level costing of HIV treatment (ART). The study was conducted at 161 health facilities across the 5 countries. • Study methodology was designed by the study team, refined through field testing and reviewed by a Technical Advisory Group in consultation with an expert group • Data collection was executed during 2011 • The study team has completed a preliminary descriptive analysis. An analysis of the determinants of cost and retention will follow in the coming months Project plan • Through this exercise, we set out to answer the following research questions: • What are typical costs of ARV treatment per patient year in each country? • How do these costs vary across countries, funding streams, administrators, facility types, rural/urban location, and other factors? How do patient outcomes vary? • What are the drivers of this variation in treatment cost across sites? • What lessons can be learnt from this variation to improve the efficiency and effectiveness of treatment at the global, national, and facility level? Objective

  4. The study provides a top-down assessment of ART costs per patient-year in a random sample of sites The study captured actual spend data for the most recently available full year on record (either fiscal or calendar year), which in most countries began in 2010 and began no earlier than mid-2009 Study period The study was conducted at facility level, not at a program, patient or cohort level. It includes all ART related spend at the facility level, but no spend incurred above the facility (e.g., OH, system strengthening) or outside the facility (e.g., community programs), or on inpatient costs Level Top down: starting with total cost at a given facility, allocated costs to ART, and divided by total patient years to arrive at an average cost per patient-year Costing approach Basic complexity and outcome indicators derived from patient chart reviews. The indicators are used to adjust costs and arrive at cost per patient alive and on ART at 12 months Patient outcome indicators

  5. Agenda Overview of Methodology Key findings and areas of opportunities Annex slides

  6. Key findings • Facility-level treatment costs in LICs and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient-year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across the sample. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  7. Facility level costs are lower than expected in LIC/LMIC countries, at an average of $136 in Malawi, $186 in Ethiopia, $232 in Rwanda, and $278 in Zambia. Average cost in RSA is $682 Cost of treatment per ART patient year by country US Dollars Legend Max 3rd Q Median 1st Q Min Avg ** * *RSA cost include updated ARV prices, which were renegotiated by the RSA government in early 2010 and are 53% lower than those observed during the costing period

  8. ARVs constitute ~50% of total cost in all LIC/LMICs; ARVs and personnel together constitute over 70% of total cost in all countries Cost of treatment per ART patient-year by country US Dollars Simple average and median cost of treatment per ART patient-year by country US Dollar *Lab category includes reagents and consumables only in all countries except SA ** Simple average costs are typically higher than median costs. Averages will be weighted by sampling frame in the next phase of analysis.

  9. Key findings • Facility-level treatment costs in LICs and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient-year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across the sample. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  10. Average annual attrition rates for established patients range from 2 – 8%, while retention in the first 12 months of treatment is significantly lower Pending Further Analysis Average attrition (at 12 months) for established patients Percent • Sites in the sample have demonstrated an ability to keep patients alive and on treatment. However, variation is significant for both new and established patients. • Rwanda stands out for their ability to manage both newly initiated patients as well as those receiving long-term care. • Further analysis is required to better understand the observed differences across the sample. Average retention (at 12 months) for new patients Percent * Transferred patients were excluded from analysis, which may reduce retention rates for sites that transfer stable patients, and increase rates for sites that transfer sicker patients. 10

  11. Preliminary analysis shows a strong correlation between CD4 at initiation and new patient retention at 12 months Preliminary pending further analysis Retention rates at 12 months for new patients by CD4 level at initiation Percent, CD4 count • Preliminary analysis of 7,611 patient records suggests a strong correlation between stage of initiation and ability to maintain patients alive and on treatment • This trend appears to support evidence in the literature linking early initiation to better outcomes • However only 27% of patients across the sample initiate at CD4 >200, while 20% initiated with no CD4 test • ~$90ppy is spent on manage pre-ART patients, yet outcomes (e.g, baseline CD4) are sub-optimal. Better understanding of pre-ART program spending and drivers of late initiation should be prioritized % of patients in category 24% 29% 18% 9% 20% * Only 20% of patients in the sample had an available CD4 value at initiation 11

  12. Key findings • Facility level treatment costs in LIC and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient per year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across countries and facilities. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will likely need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  13. Universal access to treatment in LIC/LMIC would only cost an estimated $2B in facility-level costs. Aggressive scale up in LIC/LMICs should be affordable. • The facility-level cost of universal access to treatment in LIC/LMICs will be around ~$2B. Aggressive scale up should be affordable. • This cost estimate does not include a number of important cost elements that will be critical to achieving universal access (community outreach, etc) but we do not expect that those will drive cost. • Work to better understand the non-facility based cost of treatment should be prioritized. Rough estimates of funding required for treatment in LIC/LMICs, USD millions 2 Total Cost $16B $2B $0.8B Current volume = ~3.7M patients (2010 UNAIDS Report) Universal Access= ~10M patients (LIC /LMIC share of 15M HLM target) * Assuming that cost pppy stays constant as countries scale up to achieve universal access

  14. Key findings • Facility level treatment costs in LIC and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient per year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across countries and facilities. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will likely need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  15. Given the low cost of treatment, there do not appear to be significant savings to be gained by optimizing service delivery design in LIC/LMICs. 1. Current non-ARV costs 2. Shift all to 1st quartile 3. Calculate savings Weighted average 1st quartile of facilities by country Average savings per patient - = 5. Savings potential in LIC/LMC portion of 15M target 4. Savings potential in study countries, excl. SA $19 pppy X 10 M patients = $190 M * Weighted by patient load across facilities in the sample. Since smaller facilities have higher costs, weighted is lower than simple average

  16. Key findings • Facility level treatment costs in LIC and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient per year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across countries and facilities. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will likely need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  17. To generate savings, we will need to focus optimization efforts on non-facility treatment and other program costs. Examples of allocative inefficiencies in HIV spending Across interventions BCC accounted for >45% of prevention, and 14% of total GFATM HIV spending to 2009; Far less was spent on PMTCT, and other interventions. Across population groups In two countries, high risk groups account for a large % of new infections but receive <1% of prevention spending Prevention spending at the GFATM % of total prevention % of new cases and prevention funding US Dollars Country 2 Country 1 * See, for example, Effectiveness of HIV prevention strategies in resource-poor countries: tailoring the intervention to the context, Padian et al, AIDS 2006 Sources: JAWP data and CHAI analysis, UNAIDS for prevention spending, GFATM Enhanced Financial Reporting Mechanism

  18. Key findings • Facility level treatment costs in LIC and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient per year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across countries and facilities. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will likely need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  19. In RSA, given higher patient numbers and costs, the opportunity for efficiency gains is substantial Potential size of savings based on non-ARV cost distribution in sample of facilities Potential opportunities include: • Optimizing staffing models across facilities • Rationalizing frequency of visits to balance demand on HRH, travel burden on patients and retention/adherence benefits of clinical visits • Optimizing testing level, especially non-CD4/VL • Increasing the proportion of CD4 tests that that are returned to patients Weighted average: $402 - 1st quartile of facilities: $376 = Average savings: $26 x 2015 patient numbers: 2.93M = Potential savings: $76M Weighted average brought down by low cost, large facilities. Given aggressive scale-up plans in RSA, saving potential might be greater 19

  20. Key findings • Facility level treatment costs in LIC and LMICs are lower than previously understood, ranging from USD 136 - 278 per patient per year. Not unexpectedly, treatment costs are higher in RSA due to higher salaries and more laboratory testing. • Facilities have demonstrated the ability to keep established patients alive and on ART, with some variation across countries and facilities. Average annual attrition rates for established patients range from 2% in Rwanda to 8% in RSA. Retention rates for new patients are lower and appear to be strongly correlated with CD4 at initiation. • The findings from our study, together with data from other sources, may have some interesting implications on the E2 agenda over the next several years: • Aggressive scale up in LIC/LMICs should be affordable. • Given the low cost of treatment, there are not significant savings opportunities at the facility level in LIC/LMICs. • To generate savings, we will likely need to focus optimization efforts on non-facility treatment and other program costs. A continued focus on drug optimization is also required to prevent costs from increasing as patients move from D4T to TDF • Unlike in LIC/LMICs, optimizing service delivery design in RSA (and potentially other MICs) will be necessary to achieve universal access • There are opportunities to improve outcomes without substantially increasing cost. A focus on earlier initiation is likely needed to make significant improvements in patient outcomes.

  21. There are clear opportunities to improve patient outcomes without substantially increasing cost and these should prioritized Increasing uptake of cotrim to 100% will increase costs by $2-$10 pppy Driving earlier initiation through increased testing and improved pre-ART program will help increase retention Average cost pppy of providing cotrimoxazole US Dollar New patient retention at 12 months with baseline CD4 Percent, CD4 count Current spend on cotrimpppy Spend on cotrimpppy at 100% uptake % of patients in category 24% 29% 18% 9% 20%

  22. Universal access to treatment in LIC/LMIC would only cost an estimated $2B in facility-level costs. Aggressive ART scale-up should be affordable. Rough estimates of funding required for treatment in LIC/LMICs, USD millions 2 Total Cost $16B $2B $0.8B 1 Current volume = ~3.7M patients (2010 UNAIDS Report) Universal Access= ~10M patients (LIC /LMIC share of 15M HLM target) 1 Assuming that cost pppy stays constant as countries scale up to achieve universal access 2 Assuming rates found across the sample: pre-ART costs pppy are 50% of ART cost pppy, and number of pre-ART patient years are 25% of ART patients

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