1. Cost of HIV/AIDS Adult and Pediatric Clinical Care and Treatment in Ghana Felix Asante, Jim Rosen, Futures Group/HPI August 4, 2010 Accra

2. Purpose and objectives of study Purpose To estimate the unit costs of providing HIV/ AIDS care and treatment to clients in Ghana Objectives Feed into costing of the HIV/AIDS National Strategic Plan (2011-2015) Feed into other planning and proposal writing that requires unit cost data 2

3. Study timeline Design: February – April 2010 Field work: April – May 2010 Data entry and analysis: May – July 2010 Presentation of preliminary results: June 2010 Dissemination: August 2010 3

4. Study focus-what are we costing? Clinical care and treatment for adults and children, including: –Pre-antiretroviral therapy –Antiretroviral therapy –Opportunistic infection care and treatment –Nutritional support Criteria for inclusion of interventions: –Services are focused on care and treatment of people infected with HIV –Services are provided in a clinical setting –Services are already being widely provided in the clinical setting (i.e. this a study of ongoing, not planned programs) 4

5. What we are not costing Orphans and Vulnerable Children (OVC) care Counseling and testing for people who are not yet in an ART program Prevention of mother-to-child-transmission Home-based care 5

6. Study questions 1. How much does it cost the national program in Ghana to provide clinical care and treatment for one adult or one child for one year? 2. What are normative versus actual unit costs? 3. How do unit costs vary under different drug regimens? 4. How might unit costs vary between low and high-prevalence areas of the country? 5. How might unit costs vary according the level of care facility? 6. How might unit costs vary according to whether the site is public, private for-profit, or mission? 7. How might unit costs vary as the program scales up? 8. What are the projected total costs nationally over the next five years, taking into account demographic and epidemiological data? 6

7. Costing approach Unit cost: the cost of caring for one client for one year Mostly bottom-up costing Some top-down calculations Facility levelsite visits, interviews Centralinterviews, desk review 7

8. Sample Purposive sample of 15 of the 138 ART sites (end of 2009), reflecting the following criteria: –Level of hospital (from highest to lowest): teaching (2), regional (4), or district hospital (9) –Ownership: government owned, mission, or private for-profit –Location within the country: three agro-ecological zones: savannah, forest, and coastal –HIV prevalence in catchment area: a range of low to high, within the Ghana context 8

9. Study sites T T R R R R D D D D D D D D D Key: T = Teaching hospital; R = Regional hospital; D = District hospital Source for map of prevalence data: WHO and UNAIDS 2008 9

10. Types of costs: direct Staff time in caring for clients Drugs to prevent and treat opportunistic infections ARV drugs Medical consumables and supplies used for clinic visits Laboratory testing Medical equipment Vehicles used directly for client care Physical infrastructure used for client care 10

11. Types of costs: indirect costs directly associated with the program at the facility level Administrative staff time Supervision from regional or central level Office equipment Vehicles used for program administration Physical infrastructure for administering the program Transport costs for administration Public utilities (electricity, water, etc.) Maintenance and repair Staff training Other administrative costs (office supplies, legal costs, audit) 11

12. Types of costs: indirect costs for general program support General program support from the national ART program General program support from national health authorities 12

13. Costs not included Costs to program clients such as client time, transport, meals, out-of-pocket payments, user fees for services or drugs, etc. Costs incurred by local communities (other than volunteer time directly associated with service provision) Program negative externalities (such that they exist) Technical assistance or administrative costs incurred by external donor agencies 13

14. Valuing the inputs Assigned an economic cost, when feasible Valued in local currency, Ghanaian Cedis, and in $U.S. where appropriate (1.42 cedis per $US) Prices adjusted to reflect current (2010) levels 14

15. Data collection, processing, and analysis Developed standard questionnaire Pretested at one site Data collectors trained Questionnaire applied in 15 sites from April 26 to May 21 Central level price data collected Development of Ghana-specific data analysis template Data entered and cleaned Analysis carried out by facility and combined 15

16. Study limitations Sample not representative Sample too small to carry out statistical significance test Quality and completeness of facility data not uniform The diversity of sites Resource use based on estimates, not observation Difficulties in collecting and interpreting facility-level data on OI drugs and laboratory testing 16

17. RESULTS 17

18. Unit cost of HIV clinical care 18

19. Unit cost by facility 19 T = Teaching R = Regional D = District

20. Variation in unit cost 20

21. Unit cost for pediatric clients 21

22. Distribution of costs 22

23. Direct costs 23

24. Direct costs: Antiretroviral drugs 24

25. Direct costs: Laboratory testing 25

26. Indirect costs 26

27. Fixed and variable costs 27

28. Current and capital costs 28

29. Costs by type of input 29

30. Scale effects on unit cost Expansion at existing sites likely to reduce unit cost Expansion through establishment of new clinical care sites likely to increase unit cost 30

31. Discussion: The cost of one year of adult care (illustrative comparison with other recent studies) 31

32. Discussion: Major cost elements Major contributors to direct cost: –ARV drugs –laboratory testing Major indirect costs: –national program support –training 32

33. Discussion: Unit cost differences by major facility characteristic Greatest variation was by level of facility: –teaching and regional lower unit cost versus district Less variation seen by ownership, geographic area, and prevalence zone 33

34. Discussion: Scale up costs Expansion at existing sites will likely lower costs Expansion through establishment of new sites will likely increase increase Overall effect on unit costs will depend on the expansion strategy chosen 34

35. Conclusions Further refinement and analysis by local stakeholders will enhance the impact of the study Suggested analyses –Efficiency in resource use (staff, lab, equipment, etc.) –Impact of different scale-up approaches –Change in ARV drug regimens –Impact analysis through models such as GOALS 35