Repositioning AIDS: The World Bank s Approach to Improved Efficiency and Effectiveness Using HIV Program Science Principles Marelize Gorgens mgorgens@worldbank.org The World Bank s Global HIV/AIDS Program 19 April 2012
WHY? It is a new, less-cushioned day for HIV/AIDS 1. Flatlined / less international funding available without signs (or a history of) concomitant increases in Government spending in HIV/AIDS in countries with high disease burdens
Less international funding for HIV, despite current and expanding resource gaps US $ (billions) 25 20 15 10 Donor Commitments Disbursements Projected need (UNAIDS investment framework projections) Domestic funding Funding gap (?) 5 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2003 2004 2005 2006 2007 2008 2009 2010 Sources: Schwartlander et al (2011). The Lancet 2011; 377:2031-2041 (DOI:10.1016/S0140-6736(11)60702-2; KFF and UNAIDS, 2011
In a context where government financing for health in Africa has not been close to the promised 15% GDP levels, and declining Population X millions Burden of communicable diseases DALYs Total health expenditure $ XX millions Africa 750 38046 Rest of the world 265 345 5,703 4,351, 772 Source, WHO 2008
WHY? It is a new, less-cushioned day for HIV/AIDS 1. Less international funding available without signs (or a history of) concomitant increases in Government spending in HIV/AIDS in countries with high disease burdens 2. No complete certainty of contributions of HIV prevention programmes and sexual behaviour change to the reductions in HIV prevalence
Kenya s changes but have programmes contributed? Percent 50.0 45.0 40.0 35.0 30.0 25.0 20.0 15.0 10.0 5.0 0.0 Percent of Men with 2 or More Partners, Kenya 1993-2008 NA 0.0 23.0 7.3 4.3 (In last 6 months for 1993, in last 12 months for 1998 and 2008) 44.7 38.1 16.4 11.8 32.4 28.9 28.4 20.8 24.9 13.1 12.5 12.3 10.8 9.7 10.2 8.8 15-19 20-24 25-29 30-39 40-49 Age 1993 1998 2003 2008 Source: Kenya DHS and Kenya AIDS Indicator Surveys, 1993, 1998, 2003 and 2008
WHY? It is a new, less-cushioned day for HIV/AIDS 1. Less international funding available without signs (or a history of) concomitant increases in Government spending in HIV/AIDS in countries with high disease burdens 2. No complete certainty of contributions of HIV prevention programmes and sexual behaviour change to the reductions in HIV prevalence 3. Other development priorities and focus areas
Challenges for HIV/AIDS in next decade Be more effective: Laser-like precision in prioritisation of effective programs depending on epidemic context Political challenge of reducing funding on some programs Be more efficient: Achieving better-for-less Diagnosing and addressing hidden inefficiencies Do so in a fiscally-sustainable way
Repositioning AIDS: The World Bank s approach to doing better-with-less through improved effectiveness and efficiency Source: The World Bank, 2011
Being more effective
. Means we need to understand. Where do new HIV infections come from?. What proven, feasible interventions do we have for each major source of new infections? How do we implement, monitor and evaluate the delivery of proven feasible interventions for each major source of new infections?
Means we need to: Know our epidemics Understand the origins of our last 1,000 infections Understanding transmission dynamics And, fundamentally, making sure: money follows the epidemic; interventions follow the evidence; and information improves efficiency of implementation
For this, we need to understand population-level effectiveness Coverage HIV+ve Individual Each square represents the area under study. The divisions are simplified diagrams of how the area is divided during an evaluation. HIV-ve Individual Intervention allocation Area exposures Individual exposures Individual endpoints Area endpoints Allocation area endpoints High intensity intervention High exposure Medium exposure Lower incidence Low incidence Lower incidence Low-intensity/no intervention No exposure Low exposure High incidence Medium incidence Higher incidence Efficacy (I) Effectiveness (A) Impact
WB s work with Governments to improve HIV Program Effectiveness Effectiveness evaluations in various concentrated, mixed and generalised epidemics In India: Targeted HIV prevention programmes have averted 3m out of a potential 5.5m new infections In Swaziland: What is the incremental benefit of behavioural HIV prevention programmes? In Zimbabwe: What are the efficiency and effectiveness gains of investing in the integration of HIV services? In South Africa: What is the cost of averting new infections with a combination HIV prevention approach?
Being more efficient.
means we need to: Focus on implementation Document service delivery processes and streamline them Track linkages and referrals between services being delivered in communities and at health facilities Set up demonstration sites where what we planned, actually works Start with the low hanging fruit address the largest cost drivers and most cumbersome processes Quantify levels and types of (in)efficiency and measure their improvement BUT It is about more than unit costs efficiencies gained through process simplification, targeted integration and heads-on addressing governance challenges
Although efficiency starts with unit costs, it is about more than that $1,000 $900 $800 $700 Unit Costs for Delivering ART $600 $500 Personnel ARVs Labs Other $400 $300 $200 $100 $- Rwanda Malawi Ethiopia Zambia RSA Source: CHAI, 2011
We could even have too much equipment Source: CHAI, 2011
An HIV Programme Is Efficiently Implemented if At each service delivery point, each HIV service output within the programme is provided at the most appropriate unit cost for the context in which the HIV service is being implemented for defined levels of quality An optimal balance between the costs of delivering HIV service outputs at service delivery points and the upstream costs of enabling those services to be developed and the downstream costs of the costs of service recipients accessing and taking up services Each HIV service within the HIV programme is implemented using the most streamlined service delivery models Where feasible and logical, HIV services are integrated and linked, with referrals between different services working optimally Information, supply chain, and human resource systems enable the highest levels of coverage to be achieved in areas where they are needed and when they are needed, without service outages or stockouts of essential commodities Organisational and institutional factors enable efficient service delivery.
HIV Program Efficiency Studies CORE QUESTION: How can we deliver the most HIV services in an integrated way for the least cost, without compromising quality? Four areas of investigation Service delivery efficiency Institutional efficiency Transactional and administrative efficiency Information efficiency
World Bank s work in this area HIV program efficiency studies Zambia Ukraine Lesotho Kenya Nigeria South Africa Linked to effectiveness studies and implementation support so a program science approach in how support is rolled out
Being sustainable.
means we need to Quantify the long term cost savings of specific HIV investments to Ministers of Finance in ways that are familiar to them Understand HIV funding with 15 or 20 year time horizons in mind Need to move beyond effectiveness or even cost effectiveness: Does it work? (effectiveness) Is it the best way to do it? (efficiency and cost effectiveness) What will it mean for our government s resources if we do it? (fiscal space and return on investment studies)
Almost 50% funded externally, with wide range (19% to 98%), in epicentre of epidemic
Projections of fiscal costs of HIV programmes in Swaziland (2010 2030)