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Assessing technical efficiency of HIV prevention interventions in three sub-Saharan countries.
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Assessing technical efficiency of HIV prevention interventions in three sub-Saharan countries S Bautista-Arredondo, SG Sosa-Rubí, D Contreras-Loya, M Opuni, A Kwan, C Chaumont, J Condo, N Martinson, J Coetzee, F Masiye, S Nsanzimana, J Wang'ombe, K Dzekedzeke, O Galarraga, and R Wamai on behalf of the ORPHEA study team July · 2014
Motivation • Need for implementing HIV programs with higher efficiency • Maximizing value for money • Lack of data on updated performance in the region • Previously published evidence suggested enormous heterogeneity in HIV prevention costs and potential waste (PANCEA, 2002) • Need to understand: • Current levels of efficiency • Determinants of more efficient performance
Information needs for optimizing HIV programs • Allocation among interventions • Effectiveness data • Allocation among populations/groups • Epidemiological and behavioraldata • Allocation among health inputs • Performance data (M&E) • Determinants of efficiency • Interventions to improve efficiency • Which incentives work better and are more cost-effective? • How can M&E systems and changing in management practices can facilitate more efficient results
Aims • Research question • Which characteristics predict the most efficient performance in the delivery of HIV services? • Objectives • Measure and explain efficiency: • To estimate the total costs and the average cost per output, at the facility level • To estimate levels and determinants of efficiency • Provide recommendations HTC HIV testing and counseling PMTCT Prevention of Mother-to-child Transmission
Key hypotheses • Heterogeneity of unit costs • High variability on average cost per service across facilities • Possible to identify the role of determinants and constraints • Modifiable characteristics that predict higher efficiency • Environment in which facilities operate and make decisions - Not possible to modify through interventions • Overlap between economics and management • Looking at performance at the facility level: potential for improving efficiency
Measuring Efficiency • Four HIV prevention interventions: HTC, PMTC, MC, FSW • Four African Countries:Kenya, Zambia, South Africa, Rwanda • Outputs: all services produced in the previous fiscal year • Inputs: staff, essential recurrent inputs and services, capital, training and supervision • Managerial and environmental characteristics: describing the environment and constraints in which production decisions are made • Identify constraints and determinants
Determinants of efficiency and constraints to more efficient performance • Constraints from the firm’s perspective in the short term • Country/Location • Urban vs. rural setting • Funding sources • Facility type / Ownership • HIV/AIDS prevalence • Size of demand • Supply of services (utilities) • Determinants, can be adjusted at the facility-level • Structure and governance • Training and staff composition • Management • Accountability • Incentives • Sanctions
Microeconomic approach • Micro-costing • One-year retrospective data collection • Effort to measure staff’s time allocation (Time-motion) • Measurement of quality using exit interviews, clinical vignettes and the cascade approach • Data collection at different levels: • National-level information • Salaries • Prices of supplies (HIV test kits, ART) • Facility-level information • Staff roster • Drugs and supplies • Utilities • Equipment and buildings • District-level information • Training • Supervision
Measuring quality • Process quality using clinical vignettes and exit interviews • Try to capture quality of the program through the outcome measures using a “cascade” approach • Reflect definition of “comprehensive” prevention packages • Reflect hierarchy or sense of “effective” coverage • Assumption: higher quality of services can be captured by higher success of programs in achieving effective coverage • Example: PMTCT
Estimating efficiency • Estimation of total annual input costs – at the facility level • Estimation of unit average cost per services along the HIV prevention services cascade • Correlation of unit average cost vs. scale of production, controlling for quality • Estimation of cost functions using a translog specification • Include determinants and constraints of efficiency in a joint equations system • Technical efficiency analysis using DEA or other methodology
Results Kenya, Rwanda and Zambia
HTC Staff Composition PMTCT Staff Composition PMTCT HTC
ORPHEA: Policy Implications • Assessing the determinants of efficiency • Weak evidence of economies of scale in the first stage, much stronger in the second stage • Supervision seems to have an important role increasing efficiency • Incentives and complex governing structures increase costs • Our results suggest that quality of services is not the most important predictor of efficiency • Three promising approaches • Measuring performance at the clinical level and revealing disparities • Fairly simple management training and interventions • Looking into the production function of services: staff compositions
Acknowledgements • The ORPHEA study is supported by the Bill and Melinda Gates Foundation. • We gratefully acknowledge the collaboration of our academic partners in Kenya, Rwanda, South Africa, Zambia and the United States.