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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 Sustaining HIV Services: HAPSAT estimates of resource needs under alternative policy scenarios September 15, 2009 Gilbert Kombe, MD, Arin Dutta, PhD, Elaine Baruwa, PhD, Stephen Resch, PhD

2 2 Outline Introduction to Health Systems 20/20 Why another HIV costing study? Introduction to HAPSAT HAPSAT compared to other costing models HAPSAT experience in Zambia, Ethiopia, Cote dIvoire Nigeria Next steps

3 3 Health Systems 20/20 USAID global project working to strengthen the six pillars of the health system: Health financing, governance, human resources, HIS, pharmaceutical/commodities, operations USAID Leader with Associates award, Abt Associates is prime HS 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008

4 4 Costing and HIV Costing of HIV prevention programs began in late 1990s as prevention programs started to scale up UNAIDS published Guidelines for Costing HIV/AIDS Prevention Strategies in 2000 Costing of existing HIV treatment programs (as opposed to cost projections) is more recent but coincides with large scale-up prompted by PEPFAR Achieving the WHO/UNAIDS ART 3 by 5 goal: what will it cost? Guiterrez et al, Lancet 2004 Focus has been on costing vertical HIV programs (BCC, PMTCT, ART) rather than costing a Country HIV Program which is an increasingly integrated suite of HIV programs

5 5 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

6 6 Why another HIV costing tool? Several costing tools exist CDCs PACM Futures SPECTRUM costing module UNAIDS NASA But none answers all of the following for a comprehensive set of HIV services: Where are the potential resource gaps in an uncertain budget environment? What if costs or HIV/AIDS service delivery policies change? What about human resources needed? Labor costs? Beyond 2010? Major changes to eligible populations, e.g., CD4 350 cells/mm 3

7 7 HAPSAT is … More than a new costing study Focus on country ownership For iterative modeling of scale-up scenarios User-friendly tool to be institutionalized with government Provides evidence for decision-making Multiple scenarios – uses 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 Comprehensive and flexible costing approach Incorporates knowledge from previous studies in country Updated with new issues related to HIV/AIDS policy and resources Harmonized with other costing approaches: CDC, Spectrum

8 8 Sustainability analysis What is sustainability analysis? Measures gap between resources needed (financial, human, organizational) and resources available over the relevant time horizon What is more easily quantified: funds, people, equipment What is less easily quantified: well-functioning program management HAPSAT used to conduct sustainability analysis of national HIV programs in Zambia, Nigeria, Ethiopia, and Cote dIvoire 8

9 9 Introduction to HAPSAT HAPSAT based on Microsoft Excel software, models resource requirements/availability over 5-year time horizon 9

10 10 Programmatic areas in HAPSAT TREATMENT CARE PREVENTION MITIGATION SHARED COSTS ART VCT Pre-ART monitoring, OI p&t, home-based care, palliative care Testing & DOTS for TB-HIV co-infection PMTCT Behavior Change Prevention/ABC MARP Outreach, Youth Friendly Services, Mass Media, etc OVC Economic and social support programs for PLWHA Health systems & SI, M&S grouped together as cross-cutting shared costs and overheads

11 11 Policy variables allow flexibility modeling the services received Not ART-Eligible Known HIV Cases ART-Eligible Nothing Pre-ART CareNon-ART Care Nothing ART 1 st Line ART 2nd Line Treatment Failure HCT PMTCT Unknown HIV 11

12 12 Model assumptions: Economic 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

13 13 PEPFAR ART Costing Model (PACM) Developed by CDC/Macro Intl. Recently used in three countries so far; three more ongoing Calculates costs of ART and pre-ART programs over 5-year period Scale-up scenario described in terms of targeted no. patients on Tx. Patients transition monthly between treatment states, for 60 months: Pre-ART vs. ART Adult vs. pediatric 1 st -line vs. 2 nd -line Newly-initiating vs. established New vs. old ARV regimens Narrow focus on ART services, comprehensive costs within that area Recurrent costs = costs per patient-month x no. months on Tx Investment costs calculated separately to take account of program scale-up, timing of investment spending

14 14 Spectrum costing model (Futures) Suite of tools to produce caseloads and cost of ART and OI treatment from demographic, epidemiological, and unit cost data Requires unit costs for: ARVs OI treatment and prophylaxis Service delivery Lab tests Data collection Can use observed care, expert consensus, or norms Draws on Cape Town Tx model for many model assumptions Intended to be flexible Can rely on existing or newly developed unit costs Can reflect service provision or full program including overheads Can reflect different coverage and cost scenarios Leverages country work developing epidemiological projections

15 15 PACMHAPSATSpectrum Service delivery numbers (persons) EnteredCalculated Tx population outputs (pre-ART, non, 1 st line, 2 nd line, etc.?) Pre-ART, 1 st line, 2 nd line, Adult/Peds, Newly- initiating/ established Pre-ART, non-ART, 1 st line, 2 nd line, PMTCT, Adult/Peds for all Non-ART, 1 st line, 2 nd line, number in need Data collection (costs)Facility-level cost data (top down) Ingredients (bottom-up) Ingredients (bottom-up) Major cost data input categories (e.g., drugs, lab, procurement, services) Recurrent costs: ARVs, OI drugs, staff, lab supplies, utilities Investments: training, equipment, program overheads, infrastructure Recurrent costs: drugs, diagnostics, labor (staff) Overheads: facility and program. Also calculates HRH required ARVs, OI treatment and prophylaxis OutputsSize & distribution of ART Tx cohort Quarterly and annual Tx costs disaggregated by patient type, cost category, funding source. Size of various cohorts for HIV/AIDS program areas: ART, PMTCT, OVC, CSS, pre-ART HRH needed by program area Financial requirements and gap analysis Need for ART, annual costs for ARVs, add. cost for TB, labs, OI treatment and prophylaxis, nutrition, service deliver costs 15

16 16 Harmonization: Compare models, common cost, and policy inputs Total ART costs

17 17 HAPSAT: Advantages and limitations Advantages Gap and HRH 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 in PACM, 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

18 18 HAPSAT: Cote dIvoire (2009) 5 years ( ) 2 original HIV/AIDS program scenarios MAINTAIN level of services based on flat PEPFAR funding SCALE-UP ART & HCT – adding 22.8K ART per yr Scale-up findings suggest that financial gaps appear 2010/11 Capacity building and stakeholder involvement RCI Ministry of Health and Ministry of AIDS trained USG RCI trained Stakeholder meeting to develop HAPSAT scenarios

19 19 HAPSAT Cote dIvoire: Drug regimen reduction scenario Streamline number of 1 st line regimens from 9 to 5 Most D4T patients 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)

20 20 HAPSAT Cote dIvoire: Drug regimen reduction scenario US$ 36 available

21 21 HAPSAT: Zambia (2007) 5 years ( ) 3 HIV/AIDS program scenarios SUSTAIN current level of services MODERATE SCALE-UP of services FULL COVERAGE HAPSAT findings With fall in commodity prices, GOZ ability to increase its contribution is further reduced USG and GFATM accounted for 58% and 20% of total budget respectively High levels of government buy-in, collaboration HAPSAT results used for GFATM Rd 8; other mobilization Laboratory staffing found to be a constraint in scale-up

22 22 Funding Gaps for ART, PMTCT, VCT, TB-HIV, CSS, and prevention in sustain, moderate and full coverage scenarios HAPSAT Zambia: Sample output SUSTAIN MODERATE FULL COVERAGE

23 23 HAPSAT: Ethiopia (2009, in progress) 6 years ( ) 5 scenarios developed in consultation with USG team (USAID, CDC) and WHO in Addis Ababa: Maintain current enrolment rates Maintain GOE 'Universal Coverage 2010 targets 'Universal Coverage' targets for 2010 reached in 2014 Program cascade scenario based on GFATM HCT target Program cascade scenario based on PHCT USG mission requested results by July 31 for COP 2010 Prelim draft report sent 8/10 – 3 weeks from data collection Capacity building and stakeholder involvement PEPFAR partners, NGOs, donors interviewed GOE: FHAPCO, FMOH consultations started

24 24 HAPSAT: Nigeria (2008-9) 2 HIV/AIDS program scenarios, as in report (5/09) 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

25 25 HAPSAT Nigeria: Sample output Cascade Scenario (No queue for ART or C&S if eligible) 25 Programmatic Area 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%)

26 26 HAPSAT Nigeria: Sample output Expected financial resources for HIV program 26 Assume GON wins GFATM Round 9 and World Bank MAP II funds

27 27 HAPSAT Nigeria: Sample output Financial requirements: Cascade scenario 27 Program Area 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

28 28 Next steps Increasing use of findings Have been used for COP planning, to support Global Fund applications and World Bank MAP design Can be used to support PEPFAR Partnership Framework activities and National Strategic Planning (5-year plans, MTEF, etc) Working with countries beyond course of the study Specific analyses Live capacity building (OJT) of government and USG staff

29 29 Next HAPSATs Demand is increasing Complete 5-6 additional countries by December 2009 (to meet COP 2010 deadlines) Starting with Haiti, September 2009 Website General Modeling Tool will be posted HAPSAT Toolkit under construction Methodology paper in progress Meta-analysis paper proposed using 2009 HAPSATs

30 30 General contact Technical contact Website: Thank you For more information…

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