Getting to HIV Efficiency and Effectiveness

Marelize GörgensThe World Bank

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

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

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VEN

ESS

OF

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Improve :Sustainability

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

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

The case of Lesotho

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

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%

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%

Gaps in implementation efficiency

Program science components

World Bank economic components

Program intelligence Allocative efficiency

Program implementation Implementation efficiency

Program evaluation Effectiveness

• 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”

“It’s all about implementation”

Less than 30% of people with HIV in Africa know they are HIV positive

Most importantly, we have to get implementation to

be most efficiently

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

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

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

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

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

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?

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?

World Bank Country-level SupportTo Support HIV Efficiency and

Effectiveness

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

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

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

Program

ScienceFrom

To

In conclusion: what it is all aboutBringing program and science together

Program

Science