Similar costs and outcomes for differentiated service delivery models for HIV treatment in Uganda.

This cost-outcome study estimated, from the perspective of the service provider, the total annual cost per client on antiretroviral therapy (ART) and total annual cost per client virally suppressed (defined as < 1000 copies/ml at the time of the study) in Uganda in five ART differentiated service delivery models (DSDMs). These included both facility- and community-based models and the standard of care (SOC), known as the facility-based individual management (FBIM) model. The Ministry of Health (MOH) adopted guidelines for DSDMs in 2017 and sought to measure their costs and outcomes, in order to effectively plan for their resourcing, implementation, and scale-up. In Uganda, the standard of care (FBIM) is considered as a DSDM option for clients requiring specialized treatment and support, or for those who select not to join an alternative DSDM. Note that clients on second-line regimes and considered as "established on treatment" can join a suitable DSDM.Using retrospective client record review of a cohort of clients over a two-year period, with bottom-up collection of clients' resource utilization data, top-down collection of above-delivery level and delivery-level providers' fixed operational costs, and local unit costs. Forty-seven DSDMs located at facilities or community-based points in the four regions of Uganda were included in the study, with 653 adults on ART (> 18 years old) enrolled in a DSDM. The study found that retention in care was 98% for the sample as a whole [96-100%], and viral suppression, 91% [86-93%]. The mean cost to the provider (MOH or NGO implementers) was $152 per annum per client treated, ranging from $141 to $166. Differences among the models' costs were largely due to clients' ARV regimens and the proportions of clients on second line regimens. Service delivery costs, excluding ARVs, other medicines and laboratory tests, were modest, ranging from $9.66-16.43 per client per year. We conclude that differentiated ART service delivery in Uganda achieved excellent treatment outcomes at a cost similar to the standard of care. While large budgetary savings might not be immediately realized, the reallocation of "saved" staff time could improve health system efficiency and with their equivalent or better outcomes and large benefits to clients, client-centred differentiated models would nevertheless add great societal value.

Do differentiated service delivery models for HIV treatment in sub-Saharan Africa save money? Synthesis of evidence from field studies conducted in sub-Saharan Africa in 2017-2019.

Introduction: "Differentiated service delivery" (DSD) for antiretroviral therapy (ART) for HIV is rapidly being scaled up throughout sub-Saharan Africa, but only recently have data become available on the costs of DSD models to healthcare providers and to patients. We synthesized recent studies of DSD model costs in five African countries. Methods: The studies included cluster randomized trials in Lesotho, Malawi, Zambia, and Zimbabwe and observational studies in Uganda and Zambia. For 3-5 models per country, studies collected patient-level data on clinical outcomes and provider costs for 12 months. We compared costs of differentiated models to those of conventional care, identified drivers of cost differences, and summarized patient costs of seeking care. Results: The studies described 22 models, including conventional care. Of these, 13 were facility-based and 9 community-based models; 15 were individual and 7 group models. Average provider cost/patient/year ranged from $100 for conventional care in Zambia to $187 for conventional care with 3-month dispensing in Zimbabwe. Most DSD models had comparable costs to conventional care, with a difference in mean annual cost per patient ranging from 11.4% less to 9.2% more, though some models in Zambia cost substantially more. Compared to all other models, models incorporating 6-month dispensing were consistently slightly less expensive to the provider per patient treated. Savings to patients were substantial for most models, with patients' costs roughly halved. Conclusion: In five field studies of the costs of DSD models for HIV treatment, most models within each country had relatively similar costs to one another and to conventional care. 6-month dispensing models were slightly less expensive, and most models provided substantial savings to patients. Limitations of our analysis included differences in costs included in each study. Research is needed to understand the effect of DSD models on the costs of ART programmes as a whole.

Financing intersectoral action for health: a systematic review of co-financing models.

BACKGROUND: Addressing the social and other non-biological determinants of health largely depends on policies and programmes implemented outside the health sector. While there is growing evidence on the effectiveness of interventions that tackle these upstream determinants, the health sector does not typically prioritise them. From a health perspective, they may not be cost-effective because their non-health outcomes tend to be ignored. Non-health sectors may, in turn, undervalue interventions with important co-benefits for population health, given their focus on their own sectoral objectives. The societal value of win-win interventions with impacts on multiple development goals may, therefore, be under-valued and under-resourced, as a result of siloed resource allocation mechanisms. Pooling budgets across sectors could ensure the total multi-sectoral value of these interventions is captured, and sectors' shared goals are achieved more efficiently. Under such a co-financing approach, the cost of interventions with multi-sectoral outcomes would be shared by benefiting sectors, stimulating mutually beneficial cross-sectoral investments. Leveraging funding in other sectors could off-set flat-lining global development assistance for health and optimise public spending. Although there have been experiments with such cross-sectoral co-financing in several settings, there has been limited analysis to examine these models, their performance and their institutional feasibility. AIM: This study aimed to identify and characterise cross-sectoral co-financing models, their operational modalities, effectiveness, and institutional enablers and barriers. METHODS: We conducted a systematic review of peer-reviewed and grey literature, following PRISMA guidelines. Studies were included if data was provided on interventions funded across two or more sectors, or multiple budgets. Extracted data were categorised and qualitatively coded. RESULTS: Of 2751 publications screened, 81 cases of co-financing were identified. Most were from high-income countries (93%), but six innovative models were found in Uganda, Brazil, El Salvador, Mozambique, Zambia, and Kenya that also included non-public and international payers. The highest number of cases involved the health (93%), social care (64%) and education (22%) sectors. Co-financing models were most often implemented with the intention of integrating services across sectors for defined target populations, although models were also found aimed at health promotion activities outside the health sector and cross-sectoral financial rewards. Interventions were either implemented and governed by a single sector or delivered in an integrated manner with cross-sectoral accountability. Resource constraints and political relevance emerged as key enablers of co-financing, while lack of clarity around the roles of different sectoral players and the objectives of the pooling were found to be barriers to success. Although rigorous impact or economic evaluations were scarce, positive process measures were frequently reported with some evidence suggesting co-financing contributed to improved outcomes. CONCLUSION: Co-financing remains in an exploratory phase, with diverse models having been implemented across sectors and settings. By incentivising intersectoral action on structural inequities and barriers to health interventions, such a novel financing mechanism could contribute to more effective engagement of non-health sectors; to efficiency gains in the financing of universal health coverage; and to simultaneously achieving health and other well-being related sustainable development goals.

The investment case for hepatitis B and C in South Africa: adaptation and innovation in policy analysis for disease program scale-up.

Even though WHO has approved global goals for hepatitis elimination, most countries have yet to establish programs for hepatitis B and C, which account for 320 million infections and over a million deaths annually. One reason for this slow response is the paucity of robust, compelling analyses showing that national HBV/HCV programs could have a significant impact on these epidemics and save lives in a cost-effective, affordable manner. In this context, our team used an investment case approach to develop a national hepatitis action plan for South Africa, grounded in a process of intensive engagement of local stakeholders. Costs were estimated for each activity using an ingredients-based, bottom-up costing tool designed by the authors. The health impact and cost-effectiveness of the Action Plan were assessed by simulating its four priority interventions (HBV birth dose vaccination, PMTCT, HBV treatment and HCV treatment) using previously developed models calibrated to South Africa's demographic and epidemic profile. The Action Plan is estimated to require ZAR3.8 billion (US$294 million) over 2017-2021, about 0.5% of projected government health spending. Treatment scale-up over the initial 5-year period would avert 13 000 HBV-related and 7000 HCV-related deaths. If scale up continues beyond 2021 in line with WHO goals, more than 670 000 new infections, 200 000 HBV-related deaths, and 30 000 HCV-related deaths could be averted. The incremental cost-effectiveness of the Action Plan is estimated at $3310 per DALY averted, less than the benchmark of half of per capita GDP. Our analysis suggests that the proposed scale-up can be accommodated within South Africa's fiscal space and represents good use of scarce resources. Discussions are ongoing in South Africa on the allocation of budget to hepatitis. Our work illustrates the value and feasibility of using an investment case approach to assess the costs and relative priority of scaling up HBV/HCV services.

EPIC Studies: Governments Finance, On Average, More Than 50 Percent Of Immunization Expenses, 2010-11.

Governments in resource-poor settings have traditionally relied on external donor support for immunization. Under the Global Vaccine Action Plan, adopted in 2014, countries have committed to mobilizing additional domestic resources for immunization. Data gaps make it difficult to map how well countries have done in spending government resources on immunization to demonstrate greater ownership of programs. This article presents findings of an innovative approach for financial mapping of routine immunization applied in Benin, Ghana, Honduras, Moldova, Uganda, and Zambia. This approach uses modified System of Health Accounts coding to evaluate data collected from national and subnational levels and from donor agencies. We found that government sources accounted for 27-95 percent of routine immunization financing in 2011, with countries that have higher gross national product per capita better able to finance requirements. Most financing is channeled through government agencies and used at the primary care level. Sustainable immunization programs will depend upon whether governments have the fiscal space to allocate additional resources. Ongoing robust analysis of routine immunization should be instituted within the context of total health expenditure tracking.

Cost analysis of routine immunisation in Zambia.

BACKGROUND: This study aimed to inform planning and funding by providing updated, detailed information on total and unit costs of routine immunisation (RI) in Zambia, a GAVI-eligible lower middle-income country with a population of 13 million. METHODS: The exercise was part of a multi-country study on costs and financing of routine immunisation (EPIC) that utilized a common, ingredients-based approach to costing. Data on inputs, prices and outputs were collected in a stratified, random sample of 51 facilities in nine districts between December 2012 and March 2013 using a pre-tested questionnaire. Shared inputs were allocated to RI costs on the basis of tracing factors developed for the study. A comprehensive set of costs were analysed to obtain total and unit costs, at facility and above-facility levels. RESULTS: The total annual economic cost of RI was $38.16 million, equivalent to approximately 10% of government health spending. Government contributed 83% of finances. Labour accounted for the lion's share (49%) of total costs followed by vaccines (16%) and travel allowances (12%). Analysis of specific activity costs showed that outreach and facility-based services accounted for half of total economic costs. Costs for managing the program at district, provincial and national levels (above-facility costs) represented 24% of total costs. Average unit costs were $7.18 per dose, $59.32 per infant and $65.89 per DPT3 immunised child, with markedly higher unit costs in rural facilities. Analyses suggest that greater efficiency is associated with higher utilisation levels and urban facility type. CONCLUSIONS: Total and unit costs, and government's contribution, were considerably higher than previous Zambian estimates and international benchmarks. These findings have substantial implications for planners, efficiency improvement and sustainable financing, particularly as new vaccines are introduced. Variations in immunisation costs at facility level warrant further statistical analyses.

Mapping financial flows for immunisation in Uganda 2009/10 and 2010/11: New insights for methodologies and policy.

BACKGROUND: The Global Vaccine Action Plan highlights the need for immunisation programmes to have sustainable access to predictable funding. A good understanding of current and future funding needs, commitments, and gaps is required to enhance planning, improve resource allocation and mobilisation, and to avoid funding bottlenecks, as well as to ensure that co-funding arrangements are appropriate. This study aimed to map the resource envelope and flows for immunisation in Uganda in 2009/10 and 2010/11. METHODS: To assess costs and financing of immunisation, the study applied a common methodology as part of the multi-country Expanded Program on Immunisation Costing (EPIC) study (Brenzel et al., 2015). The financial mapping developed a customised extension of the System of Health Accounts (SHA) codes to explore immunisation financing in detail. Data were collected from government and external sources. The mapping was able to assess financing more comprehensively than many studies, and the simultaneous costing of routine immunisation collected detailed data about human resources costs. RESULTS: The Ugandan government contributed 56% and 42% of routine immunisation funds in 2009/10 and 2010/11, respectively, higher than previously estimated, and managed up to 90% of funds. Direct delivery of services used 93% of the immunisation financial resources in 2010/11, while the above service delivery costs were small (7%). Vaccines and supplies (41%) and salaries (38%) absorbed most funding. There were differences in the key cost categories between actual resource flows and the estimates from the comprehensive multi-year plan (cMYP). CONCLUSIONS: Results highlight that governments and partners need to improve systems to routinely track immunisation financing flows for enhanced accountability, performance, and sustainability. The modified SHA coding allowed financing to be mapped to specific immunisation activities, and could be used for standardised, resource tracking compatible with National Health Accounts (NHA). Recommendations are made for refining routine resource mapping approaches.

Financing the response to HIV in low-income and middle-income countries.

OBJECTIVES: To describe levels of national HIV spending and examine programmatic allocations according to the type of epidemic and country income. METHODS: Cross-sectional analysis of HIV expenditures from 50 low-income and middle-income countries. Sources of information included country reports of domestic spending by programmatic activity and HIV services. These HIV spending categories were cross tabulated by source of financing, stratified by type of HIV epidemic and income level of the country and reported in international dollars (I$). RESULTS: Fifty low-income and middle-income countries spent US $ 2.6 billion (I$ 5.8 billion) on HIV in 2006; 87% of the funding among the 17 low-income countries came from international donors. Average per capita spending was I$ 2.1 and positively correlated with Gross National Income. Per capita spending was I$ 1.5 in 9 countries with low-level HIV epidemics, I$ 1.6 in 27 countries with concentrated HIV epidemics and I$ 9.5 in 14 countries with generalized HIV epidemics. On average, spending on care and treatment represented 50% of AIDS spending across all countries. The treatment-to-prevention spending ratio was 1.5:1, 3:1, and 2:1 in countries with low-level, concentrated and generalized epidemics, respectively. Spending on prevention represented 21% of total AIDS spending. However, expenditures addressing most-at-risk populations represented less than 1% in countries with generalized epidemics and 7% in those with low-level or concentrated epidemics. CONCLUSIONS: The most striking finding is the mismatch between the types of HIV epidemics and the allocation of resources. The current global economic recession will force countries to rethink national strategies, especially in low-income countries with high aid dependency. Mapping HIV expenditures provides crucial guidance for reallocation of resources and supports evidence-based decisions. Now more than ever, countries need to know and act on their epidemics and give priority to the most effective programmatic services.

A case study of the South Puget Intertribal Planning Agency's comprehensive cancer control planning and community mobilization process.

BACKGROUND: The high rates of cancer among American Indians and Alaska Natives are of growing concern. CONTEXT: In response to high cancer rates, national, state, and tribal organizations have worked to assess knowledge, attitudes, beliefs, and screening practices related to cancer in American Indian and Alaska Native communities and to increase awareness and use of cancer screening. The National Comprehensive Cancer Control Program (NCCCP) of the Centers for Disease Control and Prevention is one such effort. NCCCP's comprehensive cancer control (CCC) planning process provides a new approach to planning and implementing cancer control programs. The CCC process and components for American Indians and Alaska Natives are not yet fully understood because this is a fairly new approach for these communities. Therefore, the purpose of our case study was to describe the CCC process and its outcomes and successes as applied to these communities and to identify key components and lessons learned from the South Puget Intertribal Planning Agency's (SPIPA's) CCC planning and community mobilization process. METHODS: We used interviews, document reviews, and observations to collect data on SPIPA's CCC planning and community mobilization process. CONSEQUENCES: We identified the key components of SPIPA's CCC as funding and hiring key staff, partnering with outside organizations, developing a project management plan and a core planning team, creating community cancer orientations, conducting community cancer surveys, developing a community advisory committee, ongoing training and engaging of the community advisory committee, and supporting the leadership of the communities involved. INTERPRETATION: The CCC planning process is a practicable model, even for groups with little experience or few resources. The principles identified in this case study can be applied to the cancer control planning process for other tribes.

A nursing model of community organization for change.

Community health nursing has the potential to reach beyond the individual and create interventions that affect the community as a whole. The Nursing Model of Community Organization for Change presented in this article describes the relationships among the concepts of empowerment, partnership, participation, cultural responsiveness, and community competence within a community organizing context. These concepts are implemented through the use of the Nursing Model of Community Organization for Change, which consists of four phases: assessment/reassessment, planning/design, implementation, and evaluation/dissemination. This nursing model provides a theoretical framework for community health professionals when creating community health interventions in partnership with community members.