ART Resource Requirements and Potential Efficiency Gains in Tanzania

Transcription

1 ART Resource Requirements and Potential Efficiency Gains in Tanzania July 15, 2016 Steven Forsythe, Bryant Lee, Arin Dutta and Catherine Barker

2 Executive Summary The weighted average site-level cost of ART in Tanzania is estimated to be approximately $279 per adult and $307 per child treated, per year. The costs of achieving NACP targets are projected to rise from $238 million in 2015 to $451 million by This represents a 91% increase in treatment costs. With the most efficient service delivery model, NACP s targets could be achieved while, reducing the resource requirements to $359 million by 2020.

3 As the treatment eligibility criteria has changed, the number of people eligible for treatment has increased dramatically 1,600,000 1,400,000 1,200, : Adult CD4- based eligibility raised from 350 to 500 cells/mm 3 and children 0-14, pregnant PLHIV start ART regardless of CD4 1,000, , , CD4- based eligibility raised from 200 to 350 cells/mm 3 400, , Source: Spectrum (2015) file, and the 4 th and 5 th Edition Standard Treatment Guidelines.

4 Purpose of analysis 1. Calculate the cost of site-level ART service delivery to efficiently achieve the NACP targets in Tanzania 2. Assess potential monetary savings associated with delivering treatment services more efficiently

5 Tanzania s Planned Treatment Scale-Up Should Increase Coverage from 57% to 85% of Persons Needing Treatment by ,800,000 1,600,000 1,400,000 1,200,000 1,000,000 49% 57% 905,783 68% 1,072,210 77% 1,210,898 83% 85% 1,294,112 1,321, , , , , , Persons to Receive Tx People Living with HIV Source: National AIDS Control Program targets; Spectrum (2013) estimates of Persons Requiring Treatment in Tanzania.

6 Assumptions Unit Costs and Mark-ups Drug commodity costs are fixed over time period of projection Supply chain costs will be 24.6% of ARV and lab costs The human resource and overhead costs are based on a Tanzaniaspecific facility-based costing study* (2013) Targets Targets for scaling-up ART are as indicated by NACP, with dramatically increased coverage between 2015 and Outcomes and Stable Patients 4% of patients per year will fail first line therapy and will switch to second line therapy 70% of all patients on treatment in a year are stable. * Paxton, Dutta, et al. (2013). Outcome-adjusted ART costing in Tanzania using IQSolutions data. LEAD Project. Tanzania: Dar es Salaam (unpublished)

7 How many ART patients in Tanzania are stable? Who are Stable patients? 5 th Ed. Tanzanian guidelines No definition of stable patient Dichotomy of On ART vs. Treatment failure (VL>1000 copies/ml) OGAC guidance* Stable=undetectable viral load Or based on simple clinical criteria We assumed 70% stable, which may be optimistic for Tanzania (table). We vary this in sensitivity analysis. Study Populations & Findings for Tanzania Ped. & adolescent, 2-19 years. Optimal adherence 80% of pills taken. 70% optimal in 2012 Pediatric cohort started , follow-up Viral suppression. 76% suppressed. New patients enrolled in 2010 in Temeke. Viral suppression at 12 months. Value: 69% females, 45% males First-line patients, DSM in Viral suppression. 41% suppressed after median 16.5 months of ART. Source Nyogea et al Dow et al Mosha et al Mosha et al * OGAC. PEPFAR: Increasing program impact and efficiency through data analysis. Presentation at the World Bank. February Washington, DC

8 Three scenarios for cost analysis 1. Current Practice: This scenario represents existing service delivery practice in Tanzania (as of late 2015) based on data collected from health workers and sites. 2. Tanzanian Guidelines (5 th Edition): This represents the recommended treatment practice in Tanzania, with specific laboratory tests performed and the number of visits planned for new and ongoing ART patients. 3. Efficient Service Delivery (PEPFAR COP 16): This is aligned with the Tanzanian guidelines but improves the efficiency of service delivery based on some PEPFAR guidance. This includes a reduction of laboratory tests, clinical visits, and the use of pharmacy refill visits.

9 ART targets and costs: Three scenarios 1. Current Practice 2. Tanzanian Guidelines (5 th Edition) 3. Efficient Service Delivery (PEPFAR COP 2016) Targeted number receiving ART Eligibility for treatment will remain at current criteria (CD4<500) Numeric annual targets developed by NACP - targets are based on program data on past enrollment & meeting the national coverage goals ARV costs Regimen costs per person per year and percentage of patients receiving each regimen are according to NACP quantification (July 2015)

10 Future laboratory management of new and continuing patients: three scenarios (needs refinement) Annual number of tests per patient 1. Current Practice, all patients 2 & 3. Tanzanian Guidelines / Efficient Service Delivery New* (Stable patients) c Continuing 2020 (Non-stable patients) CD4 2 tests 2 tests 1 test - 2 tests Creatinine** % get 1 a 63% get 1 a 63% get 1 a Clinical chemistry # 2 tests 2 tests 1 test - 1 test Hb** % get 1 b 36% get 1 b 36% get 1 b Hematology 2 tests 2 tests 1 test - 1 test Viral load 0 tests 1 test 1 test 1 test 1 test * Less than 12 months of ART. # Includes AST, ALT, glucose ** Hemoglobin is a part of full hematology. Creatinine clearance is part of a clinical chemistry panel. a. 63% of all 1 st line patients are assumed to be on a TDF-containing regimen in nd line: 55%. Ped. ratios differ. b. 36% of all 1 st line patients are assumed to be on an AZT-containing regimen in nd line: 25%. Ped. ratios differ. c. 70% of all patients are assumed to be stable in 2020 (varied in sensitivity analysis).

11 Facility visits: clinical and refill Assumptions 1. Current Practice* 2. Tanzanian Guidelines (5 th Edition) 3. Efficient Service Delivery (PEPFAR COP 2016) Clinical visits for new clients Clinical visits for stable, continuing clients Clinical visits for non-stable continuing clients 13 visits per year** 12 visits per year 12 visits per year 5 visits per year 3 visits per year 4 visits per year 2 visits per year 12 visits per year 12 visits per year Refill visits (nonclinical) for stable, continuing clients - 8 visits per year 2 visits per year * Visits include ARV pick-up/refills. ** Twice in the first month

12 Changes in ART unit cost over time in Tanzania $800 $700 $600 $500 ARVs Other Drugs Supplies & Overhead $656 $84 $184 $458 $72 Lab Equipment/Training/Supply Chain Human Resources $400 $300 $51 $101 $46 $279 $37 $200 $100 $324 $260 $54 $37 $8 $142 $ Sources: For older unit costs: The Cost of Comprehensive HIV Treatment in Tanzania, Report of a Cost Study of HIV Treatment Programs in Tanzania, (Berruti et al. 2012). Estimates for 2015 unit cost based on this analysis. Note: Total unit costs (in bold) for 2007 and 2008 are median estimates and therefore don t match the sum of each component.

13 Comparison of This Unit Cost Calculations and Berruti et al analysis $300 $250 $279 $37 $200 $150 $100 $50 $189 $35 $10 $1 $20 $95 $55 $37 $8 $142 $0 Berruti et al, 2015 Dutta et al, 2016 ARVs Lab Other Drugs Supply Chain Supplies & Overhead Human Resources Sources: Berruti et al 2015 are based on the unpublished data currently under review. The Dutta et al 2015 estimates are based on this study. In both cases, the estimates are based on stable patients only. Note: Total unit costs (in bold) for 2007 and 2008 are median estimates and therefore don t match the sum of each component.

14 US$ Millions A more efficient delivery of services can make Tanzania s ART program less expensive and more sustainable, predominantly through the reduced need for human resources $500 $450 $400 $350 Current Practice Tanzanian Guidelines Efficient SD Savings of $258 million over with efficient services vs. current practice Efficiency scenarios begin $300 $250 Total site-level costs per year, NACP targets $200 $ Source: National AIDS Control Program targets, HPP analysis

15 US$ Billions Total site-level resources required between 2016 and 2020 under the three different scenarios $2.5 $2.0 $1.5 $2.10 $0.3 $0.4 $0.3 $1.90 $1.83 $0.2 $0.2 $0.3 $0.2 $0.3 $0.3 Human Resources Supplies & Overhead Equipment/Training/Supply Chain Other Drugs $1.0 $0.2 $0.1 $0.1 Lab $0.5 $1.0 $1.0 $1.0 ARVs $0.0 Current Practice Tanzania Guidelines Efficient SD Source: NACP targets for ART. HPP analysis

16 Main components of cost savings between the Current Practice scenario and the Efficient Service Delivery scenario are savings from overhead/supplies (42%) and human resources (30%) 30% 22% Lab Supply Chain 6% Supplies & Overhead Human Resources 42%

17 US$ Millions The benefits of efficiency measures are likely to be significantly reduced if the quality of treatment is not maintained $550 $500 Total site-level costs per year, NACP targets: variation in efficiency scenario based on % stable $450 $400 $350 $300 $250 Compared with 70% stable: with 50% stable, total savings $72 mil. less. With 30% stable, $142 mil. less. 30% 50% 70% 80% $ Current - 70% stable Efficient - 70% stable Efficient - 50% stable Efficient - 30% stable Efficient - 80% stable Source: HPP analysis

18 Summary of Findings The site-level unit cost of providing ART to adults in Tanzania is estimated to be $279 per adult patient per year, rising to $343 per adult patient per year by This unit cost could be reduced if: Client visits could be reduced from once per month to once per 6 months (with quarterly refill visits) for stable patients The major cost savings are likely to be from human resource and shared overhead/supplies costs The total ART costs in Tanzania could be reduced from $451 million in 2020 to as low as $359 million if efficiency service deliver measures could be implemented without adverse effects for adherence and follow-up to clients

19 Thank You! The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A , beginning September 30, The project s HIV activities are supported by the U.S. President s Emergency Plan for AIDS Relief (PEPFAR). It is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute), Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).

20 Child Treatment was Slightly Higher than Adult Treatment $350 $300 $250 $200 $150 $279 $37 $54 $37 $8 $307 $37 $54 $42 $8 $100 $50 $142 $164 $0 Adults Children ARVs Lab Other Drugs Supply Chain Supplies & Overhead Human Resources Sources: HPP analysis based on unit costs from NACP quantification. ARVs reflect weighted avg. costs across regimens and lines.