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Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications.

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Presentation on theme: "Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications."— Presentation transcript:

1 Abt Associates Inc. In collaboration with: Aga Khan Foundation BearingPoint Bitrán y Asociados BRAC University Broad Branch Associates Forum One Communications RTI International Tulane Universitys School of Public Health Training Resources Group An Introduction to the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) April 2010

2 2 Outline Introduction to Health Systems 20/20 HAPSAT for Costing and Gap analysis HAPSAT for Programmatic Sustainability HAPSAT for Resource Generation/Innovative Financing The HAPSAT HAPSAT in action: Nigeria and Cote dIvoire

3 What is sustainability analysis? Sustainability Analysis is the analysis of factors promoting and preventing the ability of a program to provide quality services in the future, based on: Current levels (present utilization) or Higher levels (targets) based on a national scale-up plan

4 4 Health Systems 20/20 Health Systems 20/20 is a USAID funded global project working to strengthen the six pillars of health systems: Financing, governance, human resources, information systems, pharmaceutical/commodities, operations HS 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008 for: Costing and Gap Analysis Programmatic Sustainability Analysis Resource Generation/Innovative Financing

5 5 HAPSAT is … More than a costing study Focuses on country ownership Enables one to create iterative modeling of scale-up scenarios A tool that provides direct evidence for decision-making Creates multiple scenarios using a stakeholder process Compares sustainability – helps with target setting, advocating resource mobilization/rationalization, identifying trade-offs Models expected changes to service policies, budgets, or unit costs A comprehensive and flexible costing approach Incorporates knowledge from previous studies in country Updated with new issues related to HIV/AIDS policy and resources Draws upon the strengths of other costing approaches by harmonizing SPECTRUM and CDC platforms

6 Costing and Gap analysis

7 7 Key principles of costing Economic vs. Financial Costs Economic – financial costs plus value of input not paid for like volunteer time, patient travel costs etc. Financial – what program pays for its inputs Top-down vs. Bottom-up Approach Top-down – use total program expenditures to determine program costs Bottom-up - estimate unit costs of each input and then multiply by number of units delivered or needed in future Capital vs. Recurrent Costs Capital – cost of inputs that last more than a year Recurrent – cost of inputs used in a year and then repurchased HAPSAT: uses financial, bottom-up, and recurrent costs

8 Costing and Gap Analysis HAPSAT can cost multiple scenarios to reduce uncertainty in picking the highest value policy options Different paths/scenarios to scale-up Cost implications of changes to guidelines or service approaches Analyze priorities and trade-offs, help relocate resources Assist data-driven policy decisions Local Ownership of process Generate scenarios/options from consultation, stakeholder process Iterative process-refines scenarios over time Can be harmonized with SPECTRUM tool for epi-assumptions for specific in-country data

9 Programmatic Sustainability

10 Sustaining quality of service requires resources that support amongst other things Clinical outcomes, including drug resistance Access to care for all patients Affordability Safety and infection control in service delivery Patient satisfaction The benefits of horizontal health systems Therefore HAPSAT scenarios analyze the feasibility of policy initiatives that ease constraints Example: Increasing access by decentralization requires an understanding of the costs of that strategy and the cost drivers and then the development of scenarios analysis related to the scale of the strategys implementation

11 Resource Generation & Innovative Financing

12 Resource Generation & Innovative Financing HAPSAT explores creative and feasible financing approaches By using country level approaches driven by consultation with governments and partners, HAPSAT allows for an understanding of scale-up in national plans that require domestic and alternative sources beyond the usual HAPSAT allows for medium-term projections and the analysis of their secondary effects Example: HAPSAT has been used with national governments to explore implementation of special levies with low secondary effects, to gradually increase government HIV/AIDS funding

13 The HAPSAT software

14 14 HAPSAT software To assists in the costing and gap analysis Based on Microsoft Excel software, models resource requirements/availability over 5-year time horizon 14

15 15 Comprehensive HIV/AIDS Program Sustainability Analysis HAPSAT softwares allows the development of scenarios that address a comprehensive HIV/AIDS program and accommodates a wide range of interventions Consequently, HAPSAT software can be used to model more detailed scenarios than traditional costing models that address only ART or prevention costs

16 16 Flexible Scenario Analysis HAPSAT softwares flexibility allows the modeling of many treatment policy scenarios 16 Not ART-Eligible Known HIV Cases ART-Eligible Nothing Pre-ART Care Non-ART Care Nothing ART 1 st Line ART 2nd Line Treatment Failure HCT PMTCT Unknown HIV Example: HAPSAT software is able to model all of the possible outcomes of treating HIV/AIDS positive clientele to give different scenarios of possible costs to national HIV/AIDS plans

17 17 Economic Model Assumptions Constant returns to scale Assumes unit costs are the same, regardless of the number of people on treatment Unit cost of inputs assumed to be constant over time with some exceptions ARVs can have price changes by year Labor cost can be subject to an annual inflation-adjusted salary escalation Costs denominated in US dollars exchange rate for inputs sourced locally (e.g. labor) fixed for time horizon No discounting of downstream costs and benefits

18 18 HAPSAT : Advantages and limitations Advantages Gap and Human Resources for Health analysis Comprehensive view of HIV/AIDS national strategy Stakeholder process leading to cost and scenario input Current limitations Limited modeling of infrastructure/investment cost As with other models, such as PACM and SPECTRUM, implementing partner overhead needs more modeling definition and data Does not produce partner specific sustainability analysis, e.g. PEPFAR More definition required on TB-HIV integration

19 Country Examples

20 Country examples are discussed under three headings: Context Scenario HAPSAT Outputs Detailed country reports are available at

21 21 HAPSAT Nigeria: Context 2 HIV/AIDS program scenarios, in 2009 MAINTAIN current coverage SCALE-UP according to national targets HS 20/20 gap analysis of 3 additional scenarios 1. Program cascade scenario: ART Access for All Known Eligible 2. Moderate scale-up (updated SCMS-GON targets) 3. Universal access by 2014 (80% of need) HAPSAT findings Strong involvement, co-authoring with NACA; high buy-in NACA used results in application for WB MAP2 USG team would like to use as active tool in Partnership Framework discussions and COP planning Proposed Use in National Strategic Framework Policy Process

22 22 HAPSAT Nigeria: Scenario Cascade Scenario (No queue for ART or C&S if eligible) 22 Programmatic Area 20102011201220132014 PMTCT Policy Pregnant Women Screened (Percent of pregnancies) 291,704 (5%) 297,188 (5%) 302,821 (5%) 308,588 (5%) 314,466 (5%) Pregnancies PMTCT-Treated (Percent of Known HIV+ pregnancies) 32,838 (70%) 37,701 (70%) 41,971 (70%) 45,921 (70%) 49,865 (70%) VCT Policy Percent of Population that is tested per year1.0% 1.00% Percent of tested persons who receive results80.0% 80.00% Total HIV Diagnostic Tests1,453,5331,481,7301,510,5921,540,0331,569,953 ART Policy Percent of Known Eligible Started on Treatment 100% Total on ART 523,236598,838668,443735,709805,504 Care & Support Policy: PLWHA Number Receiving CSS in lieu of ART (Percent of Known Eligible not on ART) 91,775 (100%) 103,512 (100%) 115,580 (100%) 127,677 (100%) 140,143 (100%) Number Receiving Pre-ART CSS (Percent of Known Non-Eligible) 375,884 (100%) 429,071 (100%) 478,629 (100%) 527,726 (100%) 580,842 (100%)

23 23 HAPSAT Nigeria: Output Financial requirements: Cascade scenario 23 Program Area 20105-YR Total Prevention $53.0$267.9 PMTCT (Drugs, Lab, Labor) $5.5$30.8 Other $47.5$237.0 Care $81.8$473.4 VCT (Lab, Labor) $12.1$65.5 Palliative Care (Drugs, Lab, Labor) $6.2$40.8 Pre-ART care (Drugs, Lab, Labor) $30.3$198.7 TB-HIV (Drugs, Lab, Labor) $7.1$38.3 OVC $26.0$130.1 Treatment (ART) $270.4$1,802.0 Drugs $148.1$1,007.6 Laboratory Tests $96.3$613.3 Labor $26.0$181.1 Shared Costs Across Program Areas $216.7$1,366.5 Training $19.5$123.2 Facility / Program Overhead $77.9$492.9 Central-Level Costs $119.3$750.4 Grand Total $621.9$3,909.7 Expected Resources $529.1$2,897.1 Predicted Shortfall ('Gap') $92.8$1,012.6

24 24 5 year projection (2009-2013) 2 original HIV/AIDS program scenarios MAINTAIN level of services based on flat PEPFAR funding SCALE-UP ART & HCT – adding 22.8 thousand ART patients per yr 2010-11 Scale-up findings show that financial gaps appear as early as 2010/11 and increase over the 5 year projection Capacity building and stakeholder involvement was required to determine strategies to address financial sustainability Cote dIvoire (RCI) Ministry of Health and Ministry of AIDS trained US Government RCI trained Stakeholder meeting to develop HAPSAT scenarios HAPSAT Cote dIvoire: Context

25 25 HAPSAT Cote dIvoire: Scenario The high number of regimens in use was thought to be inefficient and resulting unnecessary costs Strategy suggested involved reducing these costs HAPSAT modelled a streamlined scenario with a reduced number of regimens (number of 1 st line regimens reduced from 9 to 5 Simultaneous policy switch from D4T regimens also costed (policy implying most D4T patients to be on non-D4T regimens by December 2009 Increase average drug costs of 1 st line regimen US $214 current Up to US $255 (well implemented switch) Up to US $344 (not so well implemented switch)

26 26 US$ 36m available for ART program annually HAPSAT Cote dIvoire: Output

27 27 For more information… General contact Technical contact email: Website:

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