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
THE ORPHEA
PROJECT
Aims
• Research question
– Which characteristics predict the most efficient
performance in the delivery of HIV services?
HTC
• Objectives
HIV testing and counseling
PMTCT
Prevention of Mother-to-child
Transmission
– 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
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
METHODS
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
Determinants of efficiency and constraints to
more efficient performance
Constraints from the firm’s
perspective in the short term
Determinants, can be adjusted at
the facility-level
-
-
Country/Location
Urban vs. rural setting
Funding sources
Facility type / Ownership
HIV/AIDS prevalence
Size of demand
Supply of services (utilities)
Structure and governance
Training and staff composition
Management
Accountability
Incentives
Sanctions
Determinants of Efficiency
&
Environmental Constraints
Inputs & costs
(1) Districtlevel
questionnaire
(Obtaining relevant
information from
other sources is
necessary)
(2) Facility Process Mapping
component
(3) Facility
questionnaire
Intervention
specific
questionnaires
(5) HTC
(6) PMTCT
(7) ART
(8) FSW
(9) Time motion component
Quality
(10) Client exit interviews
(11) Vignettes
Outputs for each intervention:
• HTC
• PMTCT
(4) Health facility records
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
District-level information
National-level information
-
-
-
Staff roster
Drugs and supplies
Utilities
Equipment and buildings
Training
Supervision
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: PMTCT
Pregnant 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
RESULTS
Kenya, Rwanda and Zambia
Unit cost breakdown
HTC Staff Composition
HTC
PMTCT Staff Composition
PMTCT
Cost per client across the service cascade
HTC
PMTCT
Average cost vs scale for two stages in the cascade
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
Acknowledgements
-
The ORPHEA study is supported by the Bill and Melinda Gates
Foundation.
We gratefully acknowledge the collaboration of our academic partners
in Kenya, Rwanda, South Africa, Zambia and the United States.