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Ahmed N, Ong JJ, McGee K, d'Elbée M, Johnson C, Cambiano V, Hatzold K, Corbett EL, Terris-Prestholt F, Maheswaran H. Costs of HIV testing services in sub-Saharan Africa: a systematic literature review. BMC Infect Dis 2024; 22:980. [PMID: 39192180 PMCID: PMC11348535 DOI: 10.1186/s12879-024-09770-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/19/2024] [Indexed: 08/29/2024] Open
Abstract
OBJECTIVE To review HIV testing services (HTS) costs in sub-Saharan Africa. DESIGN A systematic literature review of studies published from January 2006 to October 2020. METHODS We searched ten electronic databases for studies that reported estimates for cost per person tested ($pptested) and cost per HIV-positive person identified ($ppositive) in sub-Saharan Africa. We explored variations in incremental cost estimates by testing modality (health facility-based, home-based, mobile-service, self-testing, campaign-style, and stand-alone), by primary or secondary/index HTS, and by population (general population, people living with HIV, antenatal care male partner, antenatal care/postnatal women and key populations). All costs are presented in 2019US$. RESULTS Sixty-five studies reported 167 cost estimates. Most reported only $pptested (90%), while (10%) reported the $ppositive. Costs were highly skewed. The lowest mean $pptested was self-testing at $12.75 (median = $11.50); primary testing at $16.63 (median = $10.68); in the general population, $14.06 (median = $10.13). The highest costs were in campaign-style at $27.64 (median = $26.70), secondary/index testing at $27.52 (median = $15.85), and antenatal male partner at $47.94 (median = $55.19). Incremental $ppositive was lowest for home-based at $297.09 (median = $246.75); primary testing $352.31 (median = $157.03); in the general population, $262.89 (median: $140.13). CONCLUSION While many studies reported the incremental costs of different HIV testing modalities, few presented full costs. Although the $pptested estimates varied widely, the costs for stand-alone, health facility, home-based, and mobile services were comparable, while substantially higher for campaign-style HTS and the lowest for HIV self-testing. Our review informs policymakers of the affordability of various HTS to ensure universal access to HIV testing.
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Affiliation(s)
- Nurilign Ahmed
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Jason J Ong
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Central Clinical School, Monash University, Melbourne, Australia
| | - Kathleen McGee
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Marc d'Elbée
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Cheryl Johnson
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | | | - Karin Hatzold
- Population Services International, Cape Town, South Africa
| | - Elizabeth L Corbett
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
- United Nations Joint Programme on HIV AIDS, Geneva, Switzerland
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d'Elbée M, Terris-Prestholt F, Briggs A, Griffiths UK, Larmarange J, Medley GF, Gomez GB. Estimating health care costs at scale in low- and middle-income countries: Mathematical notations and frameworks for the application of cost functions. HEALTH ECONOMICS 2023; 32:2216-2233. [PMID: 37332114 DOI: 10.1002/hec.4722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 04/13/2023] [Accepted: 05/12/2023] [Indexed: 06/20/2023]
Abstract
Appropriate costing and economic modeling are major factors for the successful scale-up of health interventions. Various cost functions are currently being used to estimate costs of health interventions at scale in low- and middle-income countries (LMICs) potentially resulting in disparate cost projections. The aim of this study is to gain understanding of current methods used and provide guidance to inform the use of cost functions that is fit for purpose. We reviewed seven databases covering the economic and global health literature to identify studies reporting a quantitative analysis of costs informing the projected scale-up of a health intervention in LMICs between 2003 and 2019. Of the 8725 articles identified, 40 met the inclusion criteria. We classified studies according to the type of cost functions applied-accounting or econometric-and described the intended use of cost projections. Based on these findings, we developed new mathematical notations and cost function frameworks for the analysis of healthcare costs at scale in LMICs setting. These notations estimate variable returns to scale in cost projection methods, which is currently ignored in most studies. The frameworks help to balance simplicity versus accuracy and increase the overall transparency in reporting of methods.
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Affiliation(s)
- Marc d'Elbée
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- University of Bordeaux, National Institute for Health and Medical Research (INSERM) UMR 1219, Research Institute for Sustainable Development (IRD) EMR 271, Bordeaux Population Health Centre, Bordeaux, France
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Fern Terris-Prestholt
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Andrew Briggs
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ulla Kou Griffiths
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- Health Section, Program Group, UNICEF, New York, New York, USA
| | - Joseph Larmarange
- Ceped UMR 196, Université Paris Cité, Research Institute for Sustainable Development (IRD), Inserm, Paris, France
| | - Graham Francis Medley
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriella Beatriz Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
- IAVI, New York, New York, USA
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Njeuhmeli E, Tchuenche M, Opuni M, Stegman P, Hamilton M, Forsythe S, Nhaduco F, Zita F, Gaspar N, Come J. The voluntary medical male circumcision Site Capacity and Productivity Assessment Tool (SCPT): An innovative visual management tool to optimize site service delivery. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000126. [PMID: 36962141 PMCID: PMC10022027 DOI: 10.1371/journal.pgph.0000126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/31/2021] [Indexed: 11/17/2022]
Abstract
Given constrained funding for HIV, achieving global goals on VMMC scale-up requires that providers improve service delivery operations and use labor and capital inputs as efficiently as possible to produce as many quality VMMCs as feasible. The Voluntary Medical Male Circumcision Site Capacity and Productivity Assessment Tool (SCPT) is an electronic visual management tool developed to help VMMC service providers to understand and improve their site's performance. The SCPT allows VMMC providers to: 1) track the most important human resources and capital inputs to VMMC service delivery, 2) strategically plan site capacity and targets, and 3) monitor key site-level VMMC service delivery performance indicators. To illustrate a real-world application of the SCPT, we present selected data from two provinces in Mozambique-Manica and Tete, where the SCPT was piloted We looked at the data prior to the introduction of SCPT (October 2014 to August 2016), and during the period when the tool began to be utilized (September 2016 to September 2017). The tool was implemented as part of a broader VMMC site optimization strategy that VMMC implementers in Mozambique put in place to maximize programmatic impact. Routine program data for Manica and Tete from October 2014 to September 2017 showcase the turnaround of the VMMC program that accompanied the implementation of the SCPT together with the other components of the VMMC site optimizatio strategy. From October 2016, there was a dramatic increase in the number of VMMCs performed. The number of fixed service delivery sites providing VMMC services was expanded, and each fixed site extended service delivery by performing VMMCs in outreach sites. Alignment between site targets and the number of VMMCs performed improved from October 2016. Utilization rates stabilized between October 2016 and September 2017, with VMMCs performed closely tracking VMMC site capacity in most sites. The SCPT is designed to address the need for site level data for programmatic decision-making during site planning, implementation, monitoring and evaluation. Deployment of the SCPT can help VMMC providers monitor the performance of VMMC service delivery sites and improve their performance. We recommend use of the customized version of this tool and model to the need of other programs.
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Affiliation(s)
- Emmanuel Njeuhmeli
- Rollins School of Public Health, Emory University School of Public Health, Atlanta, GA United States of America
| | | | | | - Peter Stegman
- Avenir Health, Glastonbury, CT, United States of America
| | - Matt Hamilton
- Avenir Health, Glastonbury, CT, United States of America
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Pineda-Antunez C, Contreras-Loya D, Rodriguez-Atristain A, Opuni M, Bautista-Arredondo S. Characterizing health care provider knowledge: Evidence from HIV services in Kenya, Rwanda, South Africa, and Zambia. PLoS One 2021; 16:e0260571. [PMID: 34855816 PMCID: PMC8638969 DOI: 10.1371/journal.pone.0260571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 11/12/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Identifying approaches to improve levels of health care provider knowledge in resource-poor settings is critical. We assessed level of provider knowledge for HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), and voluntary medical male circumcision (VMMC). We also explored the association between HTC, PMTCT, and VMMC provider knowledge and provider and facility characteristics. METHODS We used data collected in 2012 and 2013. Vignettes were administered to physicians, nurses, and counselors in facilities in Kenya (66), Rwanda (67), South Africa (57), and Zambia (58). The analytic sample consisted of providers of HTC (755), PMTCT (709), and VMMC (332). HTC, PMTCT, and VMMC provider knowledge scores were constructed using item response theory (IRT). We used GLM regressions to examine associations between provider knowledge and provider and facility characteristics focusing on average patient load, provider years in position, provider working in another facility, senior staff in facility, program age, proportion of intervention exclusive staff, person-days of training in facility, and management score. We estimated three models: Model 1 estimated standard errors without clustering, Model 2 estimated robust standard errors, and Model 3 estimated standard errors clustering by facility. RESULTS The mean knowledge score was 36 for all three interventions. In Model 1, we found that provider knowledge scores were higher among providers in facilities with senior staff and among providers in facilities with higher proportions of intervention exclusive staff. We also found negative relationships between the outcome and provider years in position, average program age, provider working in another facility, person-days of training, and management score. In Model 3, only the coefficients for provider years in position, average program age, and management score remained statistically significant at conventional levels. CONCLUSIONS HTC, PMTCT, and VMMC provider knowledge was low in Kenya, Rwanda, South Africa, and Zambia. Our study suggests that unobservable organizational factors may facilitate communication, learning, and knowledge. On the one hand, our study shows that the presence of senior staff and staff dedication may enable knowledge acquisition. On the other hand, our study provides a note of caution on the potential knowledge depreciation correlated with the time staff spend in a position and program age.
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Affiliation(s)
- Carlos Pineda-Antunez
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | - David Contreras-Loya
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Alejandra Rodriguez-Atristain
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
| | | | - Sergio Bautista-Arredondo
- National Institute of Public Health (INSP), Division of Health Economics and Health Systems Innovations, Cuernavaca, Mexico
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DeStigter K, Pool KL, Leslie A, Hussain S, Tan BS, Donoso-Bach L, Andronikou S. Optimizing integrated imaging service delivery by tier in low-resource health systems. Insights Imaging 2021; 12:129. [PMID: 34529166 PMCID: PMC8444174 DOI: 10.1186/s13244-021-01073-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 08/11/2021] [Indexed: 12/16/2022] Open
Abstract
Access to imaging diagnostics has been shown to result in accurate treatment, management, and optimal outcomes. Particularly in low-income and low-middle-income countries (LICs, LMICs), access is limited due to a lack of adequate resources. To achieve Sustainable Development Goal (SDG) 3, access to imaging services is critical at every tier of the health system. Optimizing imaging services in low-resource settings is best accomplished by prescriptive, integrated, and coordinated tiered service delivery that takes contextual factors into consideration. To our knowledge, this is the first recommendation for optimized, specific imaging care delivery by tier. A model for tier-based essential imaging services informs and guides policymakers as they set priorities and make budgetary decisions. In this paper, we recommend a framework for tiered imaging services essential to reduce the global burden of disease and attain universal health coverage (UHC). A lack of access to basic imaging services, even at the lowest tier of the health system, can no longer be justified by cost. Worldwide, affordable modalities of modern ultrasound and X-ray are becoming an accessible mainstay for the investigation of common conditions such as pregnancy, pneumonia, and fractures, and are safely performed and interpreted by qualified professionals. Finally, given the vast gap in access to imaging resources between LMICs and high-income countries (HICs), a scale-up of tiered imaging services in low-resource settings has the potential to reduce health disparities between, and within countries. As the access to appropriately integrated imaging services improves, UHC may be achieved.
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Affiliation(s)
- Kristen DeStigter
- Department of Radiology, Larner College of Medicine, University of Vermont, 111 Colchester Avenue Main Campus, McClure, Level 1, Burlington, VT, 05401, USA
| | - Kara-Lee Pool
- RAD-AID International, 8004 Ellingson Drive, Chevy Chase, MD, 20815, USA.
| | - Abimbola Leslie
- Department of Radiology, Larner College of Medicine, University of Vermont, 111 Colchester Avenue Main Campus, McClure, Level 1, Burlington, VT, 05401, USA
| | - Sarwat Hussain
- Department of Radiology, University of Massachusetts, 55 North Lake Ave, Worcester, MA, 01655, USA
| | - Bien Soo Tan
- Department of Vascular and Interventional Radiology, Singapore General Hospital, Outram Rd, Singapore, 169608, Singapore
| | - Lluis Donoso-Bach
- Department of Medical Imaging, Hospital Clínic of Barcelona, University of Barcelona, C. de Villarroel, 170, 08036, Barcelona, Spain
| | - Savvas Andronikou
- Department of Pediatric Radiology, The Children's Hospital of Philadelphia and the Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
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Mangenah C, Mavhu W, Garcia DC, Gavi C, Mleya P, Chiwawa P, Chidawanyika S, Ncube G, Xaba S, Mugurungi O, Taruberekera N, Madidi N, Fielding KL, Johnson C, Hatzold K, Terris-Prestholt F, Cowan FM, Bautista-Arredondo S. Relative efficiency of demand creation strategies to increase voluntary medical male circumcision uptake: a study conducted as part of a randomised controlled trial in Zimbabwe. BMJ Glob Health 2021; 6:bmjgh-2021-004983. [PMID: 34275870 PMCID: PMC8287601 DOI: 10.1136/bmjgh-2021-004983] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/01/2021] [Accepted: 05/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Supply and demand-side factors continue to undermine voluntary medical male circumcision (VMMC) uptake. We assessed relative economic costs of four VMMC demand creation/service-delivery modalities as part of a randomised controlled trial in Zimbabwe. METHODS Interpersonal communication agents were trained and incentivised to generate VMMC demand across five districts using four demand creation modalities (standard demand creation (SDC), demand creation plus offer of HIV self-testing (HIVST), human-centred design (HCD)-informed approach, HCD-informed demand creation approach plus offer of HIVST). Annual provider financial expenditure analysis and activity-based-costing including time-and-motion analysis across 15 purposively selected sites accounted for financial expenditures and donated inputs from other programmes and funders. Sites represented three models of VMMC service-delivery: static (fixed) model offering VMMC continuously to walk-in clients at district hospitals and serving as a district hub for integrated mobile and outreach services, (2) integrated (mobile) modelwhere staff move from the district static (fixed) site with their commodities to supplement existing services or to recently capacitated health facilities, intermittently and (3) mobile/outreach model offering VMMC through mobile clinic services in more remote sites. RESULTS Total programme cost was $752 585 including VMMC service-delivery costs and average cost per client reached and cost per circumcision were $58 and $174, respectively. Highest costs per client reached were in the HCD arm-$68 and lowest costs in standard demand creation ($52) and HIVST ($55) arms, respectively. Highest cost per client circumcised was observed in the arm where HIVST and HCD were combined ($226) and the lowest in the HCD alone arm ($160). Across the three VMMC service-delivery models, unit cost was lowest in static (fixed) model ($54) and highest in integrated mobile model ($63). Overall, economies of scale were evident with unit costs lower in sites with higher numbers of clients reached and circumcised. CONCLUSIONS There was high variability in unit costs across arms and sites suggesting opportunities for cost reductions. Highest costs were observed in the HCD+HIVST arm when combined with an integrated service-delivery setting. Mobilisation programmes that intensively target higher conversion rates as exhibited in the SDC and HCD arms provide greater scope for efficiency by spreading costs. TRIAL REGISTRATION NUMBER PACTR201804003064160.
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Affiliation(s)
- Collin Mangenah
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe .,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Webster Mavhu
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Diego Cerecero Garcia
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
| | - Chiedza Gavi
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Polite Mleya
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | - Progress Chiwawa
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe
| | | | | | | | | | | | | | - Katherine L Fielding
- Faculty of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Karin Hatzold
- Population Services International, Washington, District of Columbia, USA
| | - Fern Terris-Prestholt
- Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Frances M Cowan
- Centre for Sexual Health and HIV/AIDS Research Zimbabwe, Harare, Zimbabwe,Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, Instituto Nacional de Salud Publica, Cuernavaca, Mexico
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Bautista-Arredondo S, Pineda-Antunez C, Cerecero-Garcia D, Cameron DB, Alexander L, Chiwevu C, Forsythe S, Tchuenche M, Dow WH, Kahn J, Gomez GB, Vassall A, Bollinger LA, Levin C. Moving away from the "unit cost". Predicting country-specific average cost curves of VMMC services accounting for variations in service delivery platforms in sub-Saharan Africa. PLoS One 2021; 16:e0249076. [PMID: 33886576 PMCID: PMC8062035 DOI: 10.1371/journal.pone.0249076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/10/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND One critical element to optimize funding decisions involves the cost and efficiency implications of implementing alternative program components and configurations. Program planners, policy makers and funders alike are in need of relevant, strategic data and analyses to help them plan and implement effective and efficient programs. Contrary to widely accepted conceptions in both policy and academic arenas, average costs per service (so-called "unit costs") vary considerably across implementation settings and facilities. The objective of this work is twofold: 1) to estimate the variation of VMMC unit costs across service delivery platforms (SDP) in Sub-Saharan countries, and 2) to develop and validate a strategy to extrapolate unit costs to settings for which no data exists. METHODS We identified high-quality VMMC cost studies through a literature review. Authors were contacted to request the facility-level datasets (primary data) underlying their results. We standardized the disparate datasets into an aggregated database which included 228 facilities in eight countries. We estimated multivariate models to assess the correlation between VMMC unit costs and scale, while simultaneously accounting for the influence of the SDP (which we defined as all possible combinations of type of facility, ownership, urbanicity, and country), on the unit cost variation. We defined SDP as any combination of such four characteristics. Finally, we extrapolated VMMC unit costs for all SDPs in 13 countries, including those not contained in our dataset. RESULTS The average unit cost was 73 USD (IQR: 28.3, 100.7). South Africa showed the highest within-country cost variation, as well as the highest mean unit cost (135 USD). Uganda and Namibia had minimal within-country cost variation, and Uganda had the lowest mean VMMC unit cost (22 USD). Our results showed evidence consistent with economies of scale. Private ownership and Hospitals were significant determinants of higher unit costs. By identifying key cost drivers, including country- and facility-level characteristics, as well as the effects of scale we developed econometric models to estimate unit cost curves for VMMC services in a variety of clinical and geographical settings. CONCLUSION While our study did not produce new empirical data, our results did increase by a tenfold the availability of unit costs estimates for 128 SDPs in 14 priority countries for VMMC. It is to our knowledge, the most comprehensive analysis of VMMC unit costs to date. Furthermore, we provide a proof of concept of the ability to generate predictive cost estimates for settings where empirical data does not exist.
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Affiliation(s)
| | - Carlos Pineda-Antunez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Diego Cerecero-Garcia
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Drew B. Cameron
- University of California Berkeley, Berkeley, CA, United States of America
| | - Lily Alexander
- Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Chris Chiwevu
- Independent Consultant, Fairfax, VA, United States of America
| | | | | | - William H. Dow
- University of California Berkeley, Berkeley, CA, United States of America
| | - James Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, United States of America
| | - Gabriela B. Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Carol Levin
- University of California Berkeley, Berkeley, CA, United States of America
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Minnery M, Mathabela N, Shubber Z, Mabuza K, Gorgens M, Cheikh N, Wilson DP, Kelly SL. Opportunities for improved HIV prevention and treatment through budget optimization in Eswatini. PLoS One 2020; 15:e0235664. [PMID: 32701968 PMCID: PMC7377429 DOI: 10.1371/journal.pone.0235664] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 06/20/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Eswatini achieved a 44% decrease in new HIV infections from 2014 to 2019 through substantial scale-up of testing and treatment. However, it still has one of the highest rates of HIV incidence in the world, with 14 infections per 1,000 adults 15-49 years estimated for 2017. The Government of Eswatini has called for an 85% reduction in new infections by 2023 over 2017 levels. To make further progress towards this target and to achieve maximum health gains, this study aims to model optimized investments of available HIV resources. METHODS The Optima HIV model was applied to estimate the impact of efficiency strategies to accelerate prevention of HIV infections and HIV-related deaths. We estimated the number of infections and deaths that could be prevented by optimizing HIV investments. We optimize across HIV programs, then across service delivery modalities for voluntary medical male circumcision (VMMC), HIV testing, and antiretroviral refill, as well as switching to a lower cost antiretroviral regimen. FINDINGS Under an optimized budget, prioritising HIV testing for the general population followed by key preventative interventions may result in approximately 1,000 more new infections (2% more) being averted by 2023. More infections could be averted with further optimization between service delivery modalities across the HIV cascade. Scaling-up index and self-testing could lead to 100,000 more people getting tested for HIV (25% more tests) with the same budget. By prioritizing Fast-Track, community-based, and facility-based antiretroviral refill options, an estimated 30,000 more people could receive treatment, 17% more than baseline or US$5.5 million could be saved, 4% of the total budget. Finally, switching non-pregnant HIV-positive adults to a Dolutegravir-based antiretroviral therapy regimen and concentrating delivery of VMMC to existing fixed facilities over mobile clinics, US$4.5 million (7% of total budget) and US$6.6 million (10% of total budget) could be saved, respectively. SIGNIFICANCE With a relatively short five-year timeframe, even under a substantially increased and optimized budget, Eswatini is unlikely to reach their ambitious national prevention target by 2023. However, by optimizing investment of the same budget towards highly cost-effective VMMC, testing, and treatment modalities, further reductions in HIV incidence and cost savings could be realized.
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Affiliation(s)
| | - Nokwazi Mathabela
- Independent, formerly National Emergency Response Council on HIV/AIDS, Mbabane, Eswatini
| | - Zara Shubber
- World Bank Group, Washington, DC, United States of America
| | - Khanya Mabuza
- National Emergency Response Council on HIV/AIDS, Mbabane, Eswatini
| | | | - Nejma Cheikh
- World Bank Group, Washington, DC, United States of America
| | - David P. Wilson
- Burnet Institute, Melbourne, Australia
- Kirby Institute, University of New South Wales, Sydney, Australia
- University of Maryland, Baltimore, Maryland, United States of America
- Monash University, Melbourne, Australia
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Integrating Economic Evaluation and Implementation Science to Advance the Global HIV Response. J Acquir Immune Defic Syndr 2020; 82 Suppl 3:S314-S321. [PMID: 31764269 DOI: 10.1097/qai.0000000000002219] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Numerous cost-effectiveness analyses have indicated good value for money from a wide array of interventions for treatment and prevention of HIV/AIDS. There is limited evidence, however, regarding how cost-effectiveness information contributes to better decision-making around investment and action in the global HIV response. METHODS We review challenges for economic evaluation relevant to the global HIV response and consider how the practice of cost-effectiveness analysis could integrate approaches and insights from implementation science to enhance the impact and efficiency of HIV investments. RESULTS In light of signals that cost-effectiveness analyses may be vulnerable to systematic bias toward overly optimistic conclusions, we emphasize two priorities for advancing the field of economic evaluation in HIV/AIDS and more broadly in global health: (1) systematic reevaluation of the cost-effectiveness literature with reference to ex-post empirical evidence on costs and effects in real-world programs and (2) development and adoption of good-practice guidelines for incorporating implementation and delivery aspects into economic evaluations. Toward the latter aim, we propose an integrative approach that focuses on comparative evaluation of strategies, which specify both technologies/interventions as well as the delivery platforms, complementary interventions, and actions needed to increase coverage, quality, and uptake of those technologies/interventions. Specific recommendations draw on several existing implementation science models that provide systematic frameworks for understanding implementation barriers and enablers, designing and choosing specific implementation and policy actions, and evaluating outcomes. DISCUSSION These preliminary steps aimed at bridging the divide between economic evaluation and implementation science can help to advance the practice of economic evaluation toward a science of comparative strategy evaluation.
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Marais L, Toefy Y, Thompsen S, Diwan V, Skinner D, Mofolo N, Lenka M, Cloete J. Targeting for male medical circumcision: profiles from two South African cities. AIDS Care 2020; 33:448-452. [PMID: 32070119 DOI: 10.1080/09540121.2020.1728215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Male circumcision is considered by some to be an acceptable global approach to reduce HIV infections. Consequently, many governments in sub-Saharan Africa run voluntary male circumcision programmes. South Africa also provides male circumcision for free at state clinics and hospitals. Very little is known about the men who use this service. This study uses data from Cape Town, a sample of 1194 in 2016, and from Mangaung, a sample of 277 in 2017 and 2018, to fill this gap. The study finds that age targeting is inadequate, risk targeting is absent, and religious and cultural factors have a negative effect on the cost-efficiency of the service in the long run.
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Affiliation(s)
- Lochner Marais
- Centre for Development Support, University of the Free State, Bloemfontein, South Africa
| | - Yoesrie Toefy
- Research on Health and Society Unit, Stellenboach University, Cape Town, South Africa
| | - Sarah Thompsen
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Vinod Diwan
- Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Donald Skinner
- Research on Health and Society Unit, Stellenboach University, Cape Town, South Africa.,Social Aspects of Public Health, Human Sciences Research Council, Cape Town, South Africa
| | - Nathaniel Mofolo
- School of Clinical Medicine, University of the Free State, Bloemfontein, South Africa
| | - Molefi Lenka
- Centre for Development Support, University of the Free State, Bloemfontein, South Africa
| | - Jan Cloete
- Centre for Development Support, University of the Free State, Bloemfontein, South Africa
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11
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Cerecero-García D, Pineda-Antunez C, Alexander L, Cameron D, Martinez-Silva G, Obure CD, Marseille E, Vu L, Kahn JG, Vassall A, Gomez G, Bollinger L, Levin C, Bautista-Arredondo S. A meta-analysis approach for estimating average unit costs for ART using pooled facility-level primary data from African countries. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:297-305. [PMID: 31779577 DOI: 10.2989/16085906.2019.1688362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: To estimate facility-level average cost for ART services and explore unit cost variations using pooled facility-level cost estimates from four HIV empirical cost studies conducted in five African countries .Methods: Through a literature search we identified studies reporting facility-level costs for ART programmes. We requested the underlying data and standardised the disparate data sources to make them comparable. Subsequently, we estimated the annual cost per patient served and assessed the cost variation among facilities and other service delivery characteristics using descriptive statistics and meta-analysis. All costs were converted to 2017 US dollars ($). Results: We obtained and standardised data from four studies across five African countries and 139 facilities. The weighted average cost per patient on ART was $251 (95% CI: 193-308). On average, 46% of the mean unit cost correspond to antiretroviral (ARVs) costs, 31% to personnel costs, 20% other recurrent costs, and 2% to capital costs. We observed a lot of variation in unit cost and scale levels between countries. We also observed a negative relationship between ART unit cost and the number of patients served in a year.Conclusion: Our approach allowed us to explore unit cost variation across contexts by pooling ART costs from multiple sources. Our research provides an example of how to estimate costs based on heterogeneous sources reconciling methodological differences across studies and contributes by giving an example on how to estimate costs based on heterogeneous sources of data. Also, our study provides additional information on costs for funders, policy-makers, and decision-makers in the process of designing or scaling-up HIV interventions.
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Affiliation(s)
| | | | - Lily Alexander
- HIV AIDS TB Research Consortium CISIDAT, Cuernavaca, Mexico
| | - Drew Cameron
- Health Policy, University of California Berkeley, Berkeley, USA
| | | | | | - Elliot Marseille
- Center for Global Surgical Studies, University of California San Francisco, San Francisco, USA
| | - Lung Vu
- Population Council, Washington, USA
| | - James G Kahn
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, USA
| | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, UK
| | - Gabriela Gomez
- London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
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12
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Pineda-Antunez C, Martinez-Silva G, Cerecero-Garcia D, Alexander L, Cameron DB, Chiwevu C, Dandona L, Obure CD, Forsythe S, Nguyen VT, Settumba S, Tchuenche M, Van Minh H, Kahn JG, Gomez G, Sweeney S, Vassall A, Bollinger L, Levin C, Bautista-Arredondo S. Meta-analysis of average costs of HIV testing and counselling and voluntary medical male circumcision across thirteen countries. AJAR-AFRICAN JOURNAL OF AIDS RESEARCH 2020; 18:341-349. [PMID: 31779565 DOI: 10.2989/16085906.2019.1679850] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: Explore facility-level average costs per client of HIV testing and counselling (HTC) and voluntary medical male circumcision (VMMC) services in 13 countries.Methods: Through a literature search we identified studies that reported facility-level costs of HTC or VMMC programmes. We requested the primary data from authors and standardised the disparate data sources to make them comparable. We then conducted descriptive statistics and a meta-analysis to assess the cost variation among facilities. All costs were converted to 2017 US dollars ($).Results: We gathered data from 14 studies across 13 countries and 772 facilities (552 HTC, 220 VMMC). The weighted average unit cost per client served was $15 (95% CI 12, 18) for HTC and $59 (95% CI 45, 74) for VMMC. On average, 38% of the mean unit cost for HTC corresponded to recurrent costs, 56% to personnel costs, and 6% to capital costs. For VMMC, 41% of the average unit cost corresponded to recurrent costs, 55% to personnel costs, and 4% to capital costs. We observed unit cost variation within and between countries, and lower costs in higher scale categories in all interventions.
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Affiliation(s)
- Carlos Pineda-Antunez
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Gisela Martinez-Silva
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Diego Cerecero-Garcia
- Center for Health Systems Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Lily Alexander
- Department of Global Health, University of Washington, Seattle, USA
| | - Drew B Cameron
- Health Policy and Management, University of California Berkeley, Berkeley, USA
| | - Chris Chiwevu
- Center for Population Health Sciences, Hanoi University of Public Health, Hanoi, Vietnam
| | - Lalit Dandona
- Public Health Foundation of India, Gurugram, National Capital Region, India
| | - Carol Dayo Obure
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Stella Settumba
- The Kirby Institute, University of New South Wales, Sydney, Australia
| | | | - Hoang Van Minh
- Center for Population Health Sciences, Hanoi University of Public Health, Hanoi, Vietnam
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, California, USA
| | - Gabriela Gomez
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Sedona Sweeney
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Carol Levin
- Department of Global Health, University of Washington, Seattle, USA
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13
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Salas-Ortiz A, La Hera-Fuentes G, Nance N, Sosa-Rubí SG, Bautista-Arredondo S. The relationship between management practices and the efficiency and quality of voluntary medical male circumcision services in four African countries. PLoS One 2019; 14:e0222180. [PMID: 31581192 PMCID: PMC6776351 DOI: 10.1371/journal.pone.0222180] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/23/2019] [Indexed: 01/01/2023] Open
Abstract
Introduction Given constrained funding for Human Immunodeficiency Virus (HIV) programs across Sub-Saharan Africa, delivering services efficiently is paramount. Voluntary medical male circumcision (VMMC) is a key intervention that can substantially reduce heterosexual transmission—the primary mode of transmission across the continent. There is limited research, however, on what factors may contribute to the efficient and high-quality execution of such programs. Methods We analyzed a multi-country, multi-stage random sample of 108 health facilities providing VMMC services in sub-Saharan Africa in 2012 and 2013. The survey collected information on inputs, outputs, process quality and management practices from facilities providing VMMC services. We analyzed the relationship between management practices, quality (measured through provider vignettes) and efficiency (estimated through data envelopment analysis) using Generalized Linear Models and Mixed-effects Models. Applying multivariate regression models, we assessed the relationship between management indices and efficiency and quality of VMMC services. Results Across countries, both efficiency and quality varied widely. After adjusting for type of facility, country and scale, performance-base funding was negatively correlated with efficiency -0.156 (p < 0.05). In our analysis, we did not find any significant relationships between quality and management practices. Conclusions No significant relationship was found between process quality and management practices across 108 VMMC facilities. This study is the first to analyze the potential relationships between management and service quality and efficiency among a sample of VMMC health facilities in sub-Saharan Africa and can potentially inform policy-relevant hypotheses to later test through prospective experimental studies.
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Affiliation(s)
- Andrea Salas-Ortiz
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of York, York, United Kingdom
| | - Gina La Hera-Fuentes
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- University of Newcastle, Newcastle, Australia
| | - Nerissa Nance
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sandra G. Sosa-Rubí
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
| | - Sergio Bautista-Arredondo
- Division of Health Economics and Health Systems Innovations, National Institute of Public Health (INSP), Cuernavaca, Mexico
- School of Public Health, University of California, Berkeley, California, United States of America
- * E-mail:
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14
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Dent J, Gaspar N, Njeuhmeli E, Kripke K. Age targeting and scale-up of voluntary medical male circumcision in Mozambique. PLoS One 2019; 14:e0211958. [PMID: 30794561 PMCID: PMC6386365 DOI: 10.1371/journal.pone.0211958] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/24/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The voluntary medical male circumcision (VMMC) program in Mozambique aimed to increase male circumcision (MC) coverage to 80 percent among males ages 10 to 49 by 2018. Given the difficulty in attracting adult men over age 20 for circumcision, Mozambique became interested in assessing its age-targeting strategy and progress at the provincial level to inform program planning. METHODS We examined the impact and cost-effectiveness of circumcising different age groups of men using the Decision Makers' Program Planning Toolkit, Version 2.1 (DMPPT 2). We also applied the model to assess the scale-up efforts through the end of September 2017 and project their impact on HIV incidence through 2030. The DMPPT 2 is a compartmental Excel-based model that analyzes the effects of age at circumcision on program impact and cost-effectiveness. The model tracks changes in age-specific MC coverage due to VMMC program circumcisions. Baseline MC prevalence was based on data from the 2011 Demographic and Health Survey. The DMPPT 2 was populated with HIV incidence projections from Spectrum/Goals under an assumption that Mozambique would reach its national targets for HIV treatment and prevention by 2022. RESULTS We estimate the VMMC program increased MC coverage among males ages 10 to 49 from 27 percent in 2009 to 48 percent by end of September 2017. Coverage increased primarily in males ages 10 to 29. VMMCs conducted in the national program through the end of September 2017 are projected to avert 67,076 HIV infections from 2010 to 2030. Scaling up circumcisions in males ages 20 to 29 will have the most immediate impact on HIV incidence, while the greatest impact over a 15-year period is obtained by circumcising males ages 15 to 24 in the majority of priority provinces. Circumcising 80 percent of males ages 10 to 29 can achieve 77 percent of the impact through 2030 compared with circumcising 80 percent of males ages 10 to 49. CONCLUSION The VMMC program in Mozambique has made great strides in increasing MC coverage, particularly for males ages 10 to 29. Scaling up and maintaining MC coverage in this age group offers an attainable and cost-effective target for VMMC in Mozambique.
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Affiliation(s)
- Juan Dent
- The Palladium Group, Washington DC, United States of America
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