getting to hiv efficiency and effectiveness marelize görgens the world bank
TRANSCRIPT
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Getting to HIV Efficiency and Effectiveness
Marelize GörgensThe World Bank
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To be successful, we need to focus on efficiency and effectiveness simultaneously
• Local epidemic intelligence• HIV transmission dynamics• Defining major sources of transmission
Programintelligence
• Proven scalable models• Standard Operating Procedures and QA systems• Training, support and supervision chainsProgram
implementation
• Monitoring execution in real time• Assessing impact at population effectiveness level• Constant tactical and strategic adaptations
Program evaluation
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Program management analysis, health systems integration studies, program expenditure tracking and cost-effectiveness research to improve the flow, and use of resources and intervention delivery options and mix in order to promote efficient resource management and program implementation
Effectiveness evaluation to establish what works,
disseminate proven practice and improve program effectiveness
Tools to assist countries to project their AIDS costs and to plan for a
transition to sustainable financing
Strengthen epidemiological intelligence through disease
burden analysis, targeted surveillance, integrative
synthesis studies and better prioritized strategic planning in order to improve the allocation of scarce AIDS resources, among
alternative geographic, target group, disease and intervention
priorities
Improve :Allocative Efficiency
Improve :Implementation Efficiency
Improve :Population-levelReal World EffectivenessIM
PRO
VIN
G T
HE
EFFI
CIEN
CY A
ND
EFF
ECTI
VEN
ESS
OF
AID
S SP
END
ING
Improve :Sustainability
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Program science components identical to World Bank economic components
Program science components
World Bank economic components
Program intelligence Allocative efficiency
Program implementation Implementation efficiency
Program evaluation Effectiveness
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Program science components identical to World Bank economic components
Program science components
World Bank economic components
Program intelligence Allocative efficiency
Program implementation Implementation efficiency
Program evaluation Effectiveness
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The case of Lesotho
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Lesotho MOT results
0%
20%
40%
60%
80%
100%H
IV i
ncid
en
ce
Blood transfusions 0.00 0.00 0.00 0.00
Medical injections 0.07 0.04 0.07 0.04
No risk 0.00 0.00 0.00 0.00
Low-risk heterosexual 60.45 61.80 34.61 35.15
P artners MP 15.07 15.27 27.37 27.65
Multiple partnerships (MP ) 15.55 16.49 29.43 31.04
Female partners of MSM 0.50 0.52 0.48 0.50
MSM 5.56 3.02 5.34 2.89
P artners of SW clients 1.76 1.75 1.70 1.68
SW Clients 0.57 0.62 0.55 0.59
Sex workers 0.46 0.49 0.44 0.47
P artners IDU 0.00 0.00 0.00 0.00
Injecting Drug Use (IDU) 0.00 0.00 0.00 0.00
DHS Multiple partners, default TP
DHS Multiple partners, doubling TP
CIET Multiple partners, default TP
CIET Multiple partners, doubling TP
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Lesotho NASA in 2007/08
Risk reduction for Vulnerable & accessible
1%
Prevention - Youth4%
Prevention in Workplace
10%
Blood Safety1%
Prevention not disagreggated by
Intervention3%
Prevention Activities n.e.c1%
BCC4%
VCT17%
PMTCT41%
STIs5% Condom Social
Marketing5%
Community Mobilization
8%
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Lesotho NASA in 2009/10
Male Circumcision2%
PMTCT26%
VCT44%
Female Condoms2%
Sex worker's programmes
1%
Prevention not disagreggated by
Intervention7%
BCC3% Community
Mobilization2%
Risk reduction for Vulnerable & accessible
1%Prevention - Youth1%
Prevention in Workplace
2%
Prevention Activities n.e.c1%
STIs5%
Blood Safety1%
Condom Social Marketing
2%
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Gaps in implementation efficiency
Program science components
World Bank economic components
Program intelligence Allocative efficiency
Program implementation Implementation efficiency
Program evaluation Effectiveness
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• For whom to implement• What to implement• Where to implement• When to implement• How to implement
– Fast scale-up– Cheaply– Without compromising agreed quality standards
“It’s all about implementation”
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“It’s all about implementation”
Less than 30% of people with HIV in Africa know they are HIV positive
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Most importantly, we have to get implementation to
be most efficiently
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Why efficiency?
• With less money available, it is essential to improve the efficiency of available funding
• Insufficient data exists on what action to take in order to improve efficiency at the service delivery level
• Focus on more than service delivery points / level
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Cost of treatment per ART patient-year by countryUS Dollars
ARVs constitute ~50% of total cost in all LIC/LMICs; ARVs and personnel together constitute over 70% of total cost in all countries
*Lab category includes reagents and consumables only in all countries except SA** Simple average costs are typically higher than median costs. Averages will be weighted by sampling frame in the next phase of analysis.
Simple average and median cost of treatment per ART patient-year by countryUS DollarCountry ARVs Personnel Labs* Other Total Cost
Mean Median Mean Median Mean Median Mean Median Mean MedianMalawi $66 $63 $29 $22 $5 $1 $36 $32 $136 $117Ethiopia $103 $101 $28 $22 $16 $15 $39 $35 $186 $184Rwanda $114 $112 $67 $56 $15 $16 $37 $30 $232 $210Zambia $155 $155 $73 $46 $13 $13 $37 $30 $278 $250RSA $181 $179 $334 $284 $102 $102 $65 $56 $682 $615
Malawi Ethiopia Rwanda Zambia RSA$0
$100
$200
$300
$400
$500
$600
$700
$800
$900Personnel ARVs Labs Other
Source: CHAI, 2012
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What is an efficient HIV program?
• Lowest unit cost for a given context• Through geographic, temporal and sub-population targeting• Using the most streamlined service delivery methods,
processes and mechanisms• In ways that are integrated and linked when it makes
programmatic sense• Defined quality standards• Enabling institutional and organisational context
– Rules of the game is understood– Champions– Fastest– Real time data for decision making
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Program science components identical to World Bank economic components
Program science components
World Bank economic components
Program intelligence Allocative efficiency
Program implementation Implementation efficiency
Program evaluation Effectiveness
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Realities regarding population-level effectiveness
• To which are we attributing the changes we’re seeing to?
• Real world evaluations of programmes that are:– Complex– Combined– Integrated
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Beyond efficacy to population-level effectiveness
• Combination HIV prevention ….– What is it?– ‘combination of biomedical, behavioural and
structural interventions’ …. – But what does this mean?– How do you know whether (or the extent to
which) it is in existence?
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Combination prevention definitional challenges:
showing how programs and science need to work together
When has ‘combination prevention’ been achieved? All prevention services in prevention strategy? Some prevention services in prevention strategy?
If so, which ones? (Probably best decided later)
How best to measure when combination prevention is in place (or the extent to which it is in place)
1. Presence of implementation at district level?2. Coverage of implementation at district level?3. Service integration at service delivery points?4. Provision of combined services for users?5. User experience of temporal access to prevention services?6. ‘Dose’ of combination prevention provision?
Or some combination of measurement?
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World Bank Country-level SupportTo Support HIV Efficiency and
Effectiveness
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Strategic Partnerships in Program Science at country level
• Led by country program managers• Supported by:
– World Bank– US Government– Gates Foundation– DFID– Academic partners– UN partners
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Country Efforts: HIV efficiency and effectiveness
• Nigeria, Kenya, South Africa, Swaziland• Uganda, Zambia, Brazil• Burkina Faso, Cameroon, Cote d’Ivoire• Ukraine, China• Indonesia, Malaysia, Philippines• Thailand, Viet Nam
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Challenges and insights after years of concerted effort
Challenges• Communication the concept in
the context of existing efforts• Multiple communication
layers, levels and levers• Working in countries with
mature HIV responses: Asia / Africa contrasts
• Challenges of not funding implementation
• Coordination – nitty gritty of getting it right
Insights• Program Efficiency – doing more
for less – not incorporated in to program science principles
• Stand behind the government; make them strong
• It all starts with strategy• Intervene opportunistically• Implementation within the
context of World Bank operations
• In-country coordination: ongoing engagement
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Program
ScienceFrom
To
In conclusion: what it is all aboutBringing program and science together
Program
Science