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Assessing technical efficiency of HIV prevention interventions in three sub-Saharan countries. - PowerPoint PPT Presentation
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Assessing technical efficiency of HIV prevention interventions in three sub-Saharan
countries
S Bautista-Arredondo, SG Sosa-Rubí, D Contreras-Loya, M Opuni, A Kwan, C Chaumont, J Condo, N Martinson, J Coetzee, F Masiye, S Nsanzimana, J Wang'ombe,
K Dzekedzeke, O Galarraga, and R Wamai on behalf of the ORPHEA study team
July · 2014
Motivation
- Need for implementing HIV programs with higher efficiency- Maximizing value for money
- Lack of data on updated performance in the region- Previously published evidence suggested enormous
heterogeneity in HIV prevention costs and potential waste (PANCEA, 2002)
- Need to understand:- Current levels of efficiency- Determinants of more efficient performance
Information needs for optimizing HIV programs
- Allocation among interventions- Effectiveness data
- Allocation among populations/groups- Epidemiological and behavioral data
- Allocation among health inputs- Performance data (M&E)- Determinants of efficiency- Interventions to improve efficiency
- Which incentives work better and are more cost-effective?- How can M&E systems and changing in management practices can facilitate
more efficient results
Aims
• Research question– Which characteristics predict the most efficient performance in
the delivery of HIV services?
• Objectives– Measure and explain efficiency:
- To estimate the total costs and the average cost per output, at the facility level
- To estimate levels and determinants of efficiency
– Provide recommendations
HTCHIV testing and counseling
PMTCTPrevention of Mother-to-child
Transmission
Key hypotheses
- Heterogeneity of unit costs- High variability on average cost per service across facilities
- Possible to identify the role of determinants and constraints- Modifiable characteristics that predict higher efficiency - Environment in which facilities operate and make decisions - Not possible to
modify through interventions
- Overlap between economics and management - Looking at performance at the facility level: potential for improving efficiency
Measuring Efficiency
• Four HIV prevention interventions: HTC, PMTC, MC, FSW
• Four African Countries: Kenya, Zambia, South Africa, Rwanda
• Outputs: all services produced in the previous fiscal year
• Inputs: staff, essential recurrent inputs and services, capital, training and
supervision
• Managerial and environmental characteristics: describing the environment
and constraints in which production decisions are made
- Identify constraints and determinants
8
Constraints from the firm’s perspective in the short term
- Country/Location- Urban vs. rural setting- Funding sources- Facility type / Ownership - HIV/AIDS prevalence - Size of demand- Supply of services (utilities)
Determinants, can be adjusted at the facility-level
- Structure and governance- Training and staff composition- Management - Accountability- Incentives- Sanctions
Determinants of efficiency and constraints to more efficient performance
Microeconomic approach
- Micro-costing- One-year retrospective data collection - Effort to measure staff’s time allocation (Time-motion)- Measurement of quality using exit interviews, clinical vignettes
and the cascade approach- Data collection at different levels:Facility-level information
- Staff roster- Drugs and supplies- Utilities- Equipment and buildings
District-level information
- Training - Supervision
National-level information
- Salaries- Prices of supplies (HIV test
kits, ART)
Measuring quality
- Process quality using clinical vignettes and exit interviews
- Try to capture quality of the program through the outcome measures using a
“cascade” approach
- Reflect definition of “comprehensive” prevention packages
- Reflect hierarchy or sense of “effective” coverage
- Assumption: higher quality of services can be captured by higher success of programs in
achieving effective coverage
- Example: PMTCTPregnant women
tested for HIV
Pregnant women tested and positive for
HIV
Pregnant, HIV-positive women linked to ART
Estimating efficiency
- Estimation of total annual input costs – at the facility level
- Estimation of unit average cost per services along the HIV prevention
services cascade
- Correlation of unit average cost vs. scale of production, controlling for
quality
- Estimation of cost functions using a translog specification
- Include determinants and constraints of efficiency in a joint equations system
- Technical efficiency analysis using DEA or other methodology
ORPHEA: Policy Implications
- Assessing the determinants of efficiency- Weak evidence of economies of scale in the first stage, much stronger in
the second stage- Supervision seems to have an important role increasing efficiency- Incentives and complex governing structures increase costs- Our results suggest that quality of services is not the most important
predictor of efficiency
- Three promising approaches- Measuring performance at the clinical level and revealing disparities- Fairly simple management training and interventions- Looking into the production function of services: staff compositions