1. PEPFAR Technical Assistance Support for Health Financing in the Caribbean 1 Laurel Hatt, MPH, PhD Project Director, Health Systems 20/20 Caribbean Project Abt Associates Inc. November 2013

2. HIV, health systems strengthening, and financial sustainability Financial sustainability of HIV programs is linked with overall health system financial sustainability Need for health system financial planning: Cost escalation? Rising out-of-pocket spending? Increasing prevalence of NCDs? Global recession? Decreased tax revenues? Need for HIV program sustainability planning, given decline in external funding: What public and private domestic resources can be leveraged? 2

3. Leveraging USG resources for health systems strengthening PEPFAR II has emphasized health systems strengthening to improve financial sustainability U.S.-Caribbean PEPFAR Partnership Framework aims to increase HIV program sustainability by: Supporting health system and health financing reforms Strengthening and expanding partnerships among public and private entities 3

4. U.S.-Caribbean PEPFAR Partnership Framework 6 U.S.G. Agencies: CDC, Dept. of Defense, Peace Corps, HRSA, State Department, USAID 11 countries: Antigua & Barbuda Dominica Grenada St. Kitts & Nevis Saint Lucia St. Vincent & the Grenadines 4 Bahamas Barbados Jamaica Suriname Trinidad & Tobago

5. USAID-funded projects working on sustainability in the Caribbean Health Systems 20/20 Caribbean Strengthening Health Outcomes through the Private Sector (SHOPS) Health Policy Project MEASURE Evaluation Caribbean HIV/AIDS Alliance (CHAA) 5

6. Information needs for financial sustainability planning QuestionApproachExample How much have public and private entities spent on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much have public and private entities spent on HIV and AIDS? NHA subaccounts for HIV and AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 6

7. Information needs for financial sustainability planning QuestionApproachExample How much have public and private entities spent on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much have public and private entities spent on HIV and AIDS? NHA subaccounts for HIV and AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 7

8. NHA quantifies health spending and tracks every health dollar from the original source through the funds manager, to the provider, and finally to the type of health service where it is spent Financing Source Funds Managers Providers Functions Focus example: NHA & HIV Subaccounts

9. Focus example: NHA with HIV Subaccounts in the OECS NHA health spending information is urgently needed to: Understand current health care use and spending patterns for evidence-based planning Design national health insurance schemes Plan for reduced donor HIV funding 9 How much are governments spending on HIV programs? How much for prevention vs. treatment? How dependent are countries on external funds for HIV programs? How much are PLHIV spending “out-of-pocket” on HIV care?

10. Focus example: NHA with HIV Subaccounts in the OECS HS20/20 collaboration with UWI-HEU: growing regional capacity to conduct future rounds of NHA St. Kitts & Nevis and Dominica are the first in the OECS to collect NHA data and HIV Subaccounts

11. Information needs for financial sustainability planning QuestionApproachExample How much are public and private entities spending on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much are public and private entities spending on HIV/AIDS? NHA subaccounts for HIV/AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 11

12. Costing studies in Antigua & Barbuda, Grenada, and St. Lucia Estimated unit costs of Health center services including VCT Outpatient services at hospitals including care for PLHIV Inpatient services including care for PLHIV Collaboration has built capacity of MOHs, National AIDS Programs, and hospital staff 12

13. Annual outpatient care costs for PLHIV: Selected findings 13 ServiceCost per patient (EC$) Direct costs of VCT per client tested and counseled$98 Cost of full set of laboratory tests for patient newly diagnosed with HIV $952 Cost per year for PLHIV not yet receiving ART*$732 Of which lab tests account for:$584 Cost per year for PLHIV on ART*$4,477 Of which ARV drugs account for:$3,262 *Does not include drugs/care for opportunistic infections.

14. Annual outpatient care costs for PLHIV: Selected findings 14 ServiceCost per patient (EC$) Direct costs of VCT per client tested and counseled$98 Cost of full set of laboratory tests for patient newly diagnosed with HIV $952 Cost per year for PLHIV not yet receiving ART*$732 Of which lab tests account for:$584 Cost per year for PLHIV on ART*$4,477 Of which ARV drugs account for:$3,262 *Does not include drugs/care for opportunistic infections.

15. Cost per outpatient visit at hospitals: Selected findings Clinic or UnitTotal cost per visit (EC$) Medicines & supplies SalariesOther, overhead, admin. Country 1: STI clinic$35648%39%13% Hospital outpatient unit$2828%81%12% Country 2: STI clinic$46750%39%11% Hospital outpatient unit$16911%80%9% 15

16. Cost per outpatient visit at hospitals: Selected findings Clinic or UnitTotal cost per visit (EC$) Medicines & supplies SalariesOther, overhead, admin. Country 1: STI clinic$35648%39%13% Hospital outpatient unit$2828%81%12% Country 2: STI clinic$46750%39%11% Hospital outpatient unit$16911%80%9% 16 Drug costs include the costs of ARVs -- currently subsidized by the Global Fund. Country 2  ARV drugs equivalent to 17% of the total value of all drugs and supplies procured by Central Medical Stores

17. Inpatient care at hospitals: Selected HIV-relevant findings Cost per inpatient stay (EC$) Average length of stay (days) 17

18. Inpatient care at hospitals: Selected HIV-relevant findings ABC Number of PLHIV admissions 648219 PLHIV as % of all admissions 1.0%1.5%0.2% PLHIV bed-days as % of all bed-days 2.8%4.5%0.5% PLHIV costs as % of all recurrent hospital costs 1.5%2.5%0.3% Total costs for PLHIV admissions EC $0.6 millionEC $1.2 millionEC $0.09 million 18

19. Inpatient care at hospitals: Selected HIV-relevant findings ABC Number of PLHIV admissions 648219 PLHIV as % of all admissions 1.0%1.5%0.2% PLHIV bed-days as % of all bed-days 2.8%4.5%0.5% PLHIV costs as % of all recurrent costs 1.5%2.5%0.3% Total costs for PLHIV admissions EC $0.6 millionEC $1.2 millionEC $0.09 million 19

20. Information needs for financial sustainability planning QuestionApproachExample How much are public and private entities spending on health overall? Is spending allocated to the “right” things? National Health Accounts (NHA) St. Kitts & Nevis, Dominica How much are public and private entities spending on HIV/AIDS? NHA subaccounts for HIV/AIDS St. Kitts & Nevis, Dominica What do HIV prevention and treatment services currently cost? Costing studies (unit cost estimation) Antigua, Grenada What resources will be needed to support HIV programs adequately in the future? Financial projections and gap analysis (such as HAPSAT) Guyana 20

21. Focus example: HAPSAT HIV/AIDS Program Sustainability Analysis Tool Flexible, user-friendly software for quantifying the financial and human resources required for a set of HIV program scenarios Gap analysis: Assess current funding resources Assess financial and human resources required to maintain and scale-up HIV services Planning resource generation/innovative financing 21

22. HAPSAT in Guyana Stakeholders’ top priority for HIV program: Shortage of HRH HAPSAT analysis quantified HRH needs Result: Gaps are relatively small if current health workers can be utilized more efficiently Stakeholders’ decisions: Establish appointment system Adjust clinic hours to better fit client needs Review number of HIV counselors 22

23. Options for increasing financial sustainability of HIV programs (1) Resource mobilization Experiment with innovative taxes (“sin” taxes, airline levies) Increase public sector allocations to health Increase the proportion of health budgets allocated to HIV Leverage additional resources from private sources Incentivize enrollment in private health insurance plans and mandate that HIV benefits be included Prioritization Reallocate budgets to more cost-effective services (e.g. investments in prevention programs to reduce long-term health costs) Contract with private providers when it is more efficient 23

24. Options for increasing financial sustainability of HIV programs (2) Increase efficiency of health programs -- stretch health budgets further Service integration (one-stop shopping) Primary care model for routine services Provider payment mechanisms to incentivize cost-efficient service provision Better quality assurance to make best use of health resources 24

25. Thank you! Laurel Hatt, Project Director, Health Systems 20/20 Caribbean project Laurel_Hatt@abtassoc.com Lisa Tarantino, Senior Associate, Health Systems 20/20 Caribbean and SHOPS project Lisa_Tarantino@abtassoc.com Rene Brathwaite, USAID HIV Officer rbrathwaite@usaid.gov William Conn, PEPFAR Regional Coordinator wconn@usaid.gov 25