Abt Associates Inc. In collaboration with: I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane Universitys School of Public Health Sustainability Analysis of HIV/AIDS Programs Elaine Baruwa, PhD, Itamar Katz, PhD Abt Associates Inc. December 9, 2010

2 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 Health Systems 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008

HAPSAT Context circa 2008 In 2007/08 HAPSAT was developed to estimate gaps between countrys available human and financial resources, and what is needed to implement HIV programs at the national level Donor support for HIV programs was still ramping up Priority was scale-up across the board from donors to countries to programs

HAPSAT Plus circa 2010 In 2010, paradigm has changed significantly and donor support is referred to as constant but likely to fall soon Priority is sustainability, particularly at country and program level HAPSAT has been adapted to address concerns of current context and key players

5 HAPSAT is … Sustainability study/tool Focuses on country ownership Provides evidence for decision-making Analyzes multiple scenarios based on stakeholder inputs Comprehensive and flexible costing approach Harmonized with other costing approaches: CDC, Spectrum

6 Sustainability Analysis What is sustainability analysis? Measures gap between resources needed (financial, human, organizational) and resources available over the relevant time horizon HAPSAT did this well as did many other tools such as the SPECTRUM model and the PEPFAR costing model, but now countries want to know more What can be done to address the gap? 6

HAPSAT Experience Each of these countries is unique: context, level of program development, priorities Haiti Nigeria Zambia Vietnam Ethiopia Guyana Kenya DR Congo Southern Sudan Sierra Leone

8 HAPSAT Tool HAPSAT was focused on the tool, based on MS Excel software, which models resource requirements/ availability over 5-year time horizon 8

HAPSAT Methodology Global models must become flexible to meet country contexts and needs Global Picture: Funding growth has ceased, leading to gaps between countrys policies (e.g. universal coverage) and their ability to implement their policies HAPSAT: Fully identified financing gaps across the HIV program, (ART, prevention, program costs, etc.) Identified human resources gaps Limited country specificity Limited incorporation of country priorities Country Picture: Financial capacity is limited Human resources are limited Other limiting factors in play? Other unexplored mitigating factors

HAPSAT Methodology Identified sustainability issues lead to Factor analysis leads to Identified solutions HAPSAT Plus Sustainability Analysis Increasing country specificity Increasing focus on country priorities Identifying and addressing inefficiencies Identifying new opportunities Global models/models must become flexible to meet country contexts and needs

HAPSAT Methodology Steps STEP 1 Stakeholder Engagement workshop STEP 2 Results to Policy workshop Design action plans STEP 3 Engage HIV program and stakeholders Adapt HAPSAT to country context Refine data collection and analysis

12 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 OVC Economic and social support programs for PLWHA Health systems & SI, M&S grouped together as cross-cutting shared costs and overheads

Examples of HAPSAT Recommendations Efficiency Sustainability Health systems strengthening Community systems strengthening Target setting

Efficiency: Billboard vs. Radio for HIV Awareness in Southern Sudan Radio is the major information source for southern Sudanese Billboards may be of limited use in a country with low literacy levels, potentially useful in urban areas Annual cost Annual output Exposures per year Cost per exposure Radio ads and talkshows US$ 94,000 1,712 spots34 millionUS$ BillboardsUS$ 2.8 M 32 billboards (64 spots) 54 millionUS$ 0.05

US$ 9.5 M for new equipment and training of staff to provide ART and care services to additional 536 satellite sites Need for additional 295 new nursing and 144 new pharmacy full-time-equivalent staff Source: Maina, Glandon, et al., 2010 Number of additional patients that can be served at satellite sites Increase in coverage Reduced attrition Reduced out-of- pocket costs Sustainability: Decentralization of ART Services in Kenya

Community Systems Strengthening: Care and Support in Southern Sudan Activity Annual unit costContextual factors Microfinance for PLWH$400 Costly activity, partially because of high default rate Livelihood support/income generating activities (IGA) for PLWH$230 Medium-cost activity HBC through facility- based counselors$120 Community members as care- givers will strengthen the community HBC through community primary care givers$70

Health Systems Strengthening: FTE of Medical Doctors Required for pre- ART & ART Calculating FTE medical doctors required for delivering pre-ART and ART Three patients per hour (18 per day) 44 working weeks per year ART patients visits on average 6 times a year Visits evenly distributed during the working hours Need to integrate of ART clinics with less than 600 pre-ART and ART patients

Target Setting Universal access Past performance Human resources capacity Funding availability PMTCT Treatment, Sierra Leone

19 Next HAPSATs Institutionalization ISED, Senegal Model finalization and interface creation Current HAPSATs Sierra Leone

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