Research

Donald S. Shepard
Funder:  Abbot Global Diagnostics

Rwanda has recently initiated a new model of providing essential primary health care services within a 30-minute walk of all Rwandans' homes: Second Generation Health Posts (SGHPs). These health posts bring accessible, affordable, and enhanced quality health services to rural communities in Rwanda and improve patient outcomes and quality of life, while decreasing the risks of complications from delays in obtaining care.

This study aims to quantify the costs of SGHPs from both the societal and healthcare sector perspectives.  The intervention costs include the cost of building and equipping the SCHPs, which will be provided by global healthcare company Abbott.  As SGHPs are expected to increase the number of patients being treated, the operational costs will be obtained by assembling monthly operational costs from the newly established SGHPs to assess the costs of serving these patients.  Other costs related to seeking care, such as travel costs and productivity loss for both patients and their caretakers, will be based on interviews.

The study will also estimate the benefits of the SGHPs.  The expected health outcomes (number of deaths averted) cannot be observed directly due to limited sample size.  Instead, we will estimate the benefits indirectly, based on the effectiveness of each service, such as prenatal care or facility-based delivery.

We will also examine the financial sustainability of SGHPs to their operators who must cover their expenses by billing Rwanda’s national insurance system.  We will present a cost-effectiveness analysis and recommendations for scale-up.  An incremental cost-effectiveness ratio in terms of cost per quality-adjusted life year (QALY) gained will be estimated for determining the cost-effectiveness of the program.  Additionally, we will examine the affordability of scale up to the Rwanda national insurance system.

Diana Bowser
Funder:  Global Fund

In collaboration with Pharos Global Health Advisors, this Global Fund project aims to identify integration opportunities for Haiti’s HIV, TB, and malaria response programs. Currently these programs largely operate in silos that lead to inefficiencies which are both costly and potentially detrimental to patient care. Given a global decline in donor financing, Prof. Bowser's work in identifying these integration opportunities and recommending actions to mobilize them are paramount to informing both the Haitian government and the Global Fund’s response. Ultimately, it is hoped the resulting efficiency gains will not only help the response to the three diseases become more sustainable, but also improve the quality of care at the patient level.

Gary Gaumer, Diana Bowser
Funder: Office of the U.S. Global AIDS Coordinator and Health Diplomacy

Since its inception, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR)’s program has been instrumental in funding HIV/AIDS programs in many countries and has played a critical role in responding to the global HIV/AIDS epidemic. The Office of the U.S. Global AIDS Coordinator and Health Diplomacy (OGAC) has recognized the importance of accelerating treatment as a key to stemming and winning the war against HIV/AIDS. With constrained budgets and increasing performance targets, PEPFAR has increasingly turned its attention to ways in which to increase the efficiency of resource use. Since there is limited data to help drive efficiency improvements of HIV/AIDS service delivery and inform PEPFAR programming and national HIV/AIDS spending, OGAC funded the establishment of an Analytics Hub to conduct economic analysis and create the evidence needed to inform decisions around programmatic investments as well as inform dialogue with countries on sustaining the response in the future.

 The Analytics Hub at the Heller School is analyzing DHS data on HV prevalence and wealth inequality measures. Specifically, the team is examining the data using the technique of Inverse Probability Weighting (IPW). The use of IPW in the analysis accounts for possible selection bias in original sampling by using lower weights for oversampled individuals, depicting a closer estimation of prevalence of HIV seropositivity across socio-demographic groups. The literature suggests a pattern of prevalence with wealth, but analyses using IPW suggest there is not such a consistent association.

The researchers will also begin work on a new research question focusing on the geographic alignment of PEPFAR program support with prevalence rates, and levels of inequality in wealth.

Additionally, the Analytics Hub will be part of an effort to support a multi-country effort to put in place a system that will provide regular information of the cost of HIV/AIDS activities. This effort will use the approach of activity-based costing, and the Brandeis team will play a central role in providing technical support to implement and analyze this costing method globally.

Over US$20 billion is spent globally on HIV prevention and treatment annually, funded by country ministries, bilateral, and multilateral investments. However, tracking the actual expenditure of these resources at healthcare facilities is challenging.

In early 2020, several global health organizations, including the Global Fund, UNAIDS, the United States Agency for International Development, and the Office of the Global AIDS Coordinator at the United States Department of State, launched a new multicountry initiative. This initiative, known as activity-based costing and management (ABC/M), aims to track resource allocation and funding for HIV services throughout sub-Saharan Africa by directly observing the resource consumption patterns of individual patients as they move through healthcare facilities.

ABC/M effort emphasizes country ownership. The mentioned global health organizations engage with country governments to secure approval and establish local Steering Committees for guidance. The Analytics Hub serves as the ABC/M Secretariat, producing structured datasets, creating process maps, and supporting reports and academic publications. Currently being implemented in five African countries—Kenya, Mozambique, Namibia, Uganda, and Tanzania—with Uganda and Tanzania as the earliest adopters, ABC/M highlights the need for country governments and global institutions to align and optimize their investments in the HIV response, especially as country governments gradually take on greater fiscal responsibility for service delivery.

The comprehensive research conducted in Tanzania and Uganda represented the first studies utilizing ABC/M and provided insights into how HIV services are managed in both countries. The study focused on five key HIV services: antiretroviral therapy (ART), HIV testing and counseling (HTC), prevention of mother-to-child transmission (PMTCT), voluntary male medical circumcision (VMMC), and pre-exposure prophylaxis (PrEP). The research involved direct observation and interviews at 31 facilities in Uganda and 22 in Tanzania, covering 1,119 adult patients in Uganda and 886 in Tanzania. ABC/M was used to track the time and resources consumed for each service, allowing for detailed cost calculations.

The study's findings shed light on the current state of HIV service delivery in Uganda and Tanzania. In Uganda, costs ranged from $8.18 per visit for HTC to $43.43 for ART for clients with suppressed HIV. In Tanzania, costs ranged from $3.67 per visit for HTC to $28.00 for VMMC. Consumables were the primary cost drivers, accounting for more than 60% of expenditures in both countries. Furthermore, both patient and facility characteristics influenced the costs and resource allocation. Patient characteristics such as age, household assets, and comorbidities affected the time spent with providers and the cost of visits. Additionally, facility characteristics like type, region, and funding source impacted costs.

The analysis revealed variations in resource allocation, suggesting both equitable and inequitable practices. Older and sicker patients received more resources, indicating vertical equity. However, wealthier individuals and those at PEPFAR-funded facilities received more attention, highlighting areas where equity could be improved. These findings underscore the importance of considering both patient and facility factors in managing and allocating resources for HIV services.

The insights from this study provide valuable information for policymakers and healthcare providers to optimize HIV service delivery. The data collected through ABC/M can help improve the efficiency and equity of HIV services, ultimately enhancing health outcomes for people living with HIV in Uganda and Tanzania. Future research endeavors aim to extend this methodology to examine other countries.

The United States President’s Emergency Plan for AIDS Relief (PEPFAR) has been recognized for saving millions of lives and altering the course of the global HIV epidemic. Authorized in 2003 to combat the global impact of HIV, PEPFAR represents the largest commitment by any country to address a single disease. It has provided support to over 100 countries, helping them to mitigate the HIV epidemic.

Comprehensive studies conducted by the Institute for Global Health and Development and by the Kaiser Family Foundation (KFF) demonstrate PEPFAR’s broader impact beyond its primary goal of combating HIV/AIDS on various health and socio-economic outcomes in low- and middle-income countries (LMICs). Using a rigorous methodology, we evaluate the impacts of PEPFAR across 157 LMICs, including 90 PEPFAR recipient countries, from 1990 to 2018. Employing difference-in-differences (DID) estimators, we compare the baseline period before 2004, when PEPFAR began, to the period after.

The first study examines seven maternal and child health (MCH) indicators, including child and maternal mortality rates, vaccination rates for diphtheria, whooping cough, tetanus, measles, and HepB3, and the prevalence of anemia among women of childbearing age. The second study assesses PEPFAR's impact on all-cause mortality (ACM) rates over 15 years, comparing PEPFAR recipient countries with those that did not receive significant funding. The third study analyzes five key economic and educational indicators: GDP per capita growth rate, the share of girls and boys out of school, and female and male employment rates, contrasting these with 67 countries that received minimal or no PEPFAR funding.

The findings reveal significant positive effects of PEPFAR on MCH outcomes. PEPFAR recipient countries exhibited substantial improvements in childhood immunization rates, reductions in child and maternal mortality rates, and decreased prevalence of anemia among women in countries receiving high levels of PEPFAR funding. Importantly, there was no evidence of "crowding out" or negative spillovers on non-HIV health sectors, reinforcing the effectiveness of PEPFAR.

Furthermore, PEPFAR's presence is associated with a significant reduction in ACM rates. Across different model specifications, PEPFAR is attributed with a 10-21% decline in ACM rates from 2004 to 2018. The impact is more pronounced in countries with higher intensities of PEPFAR aid and those involved in the Country Operational Planning (COP) process, showing reductions in ACM rates of 15-25% and 17-27%, respectively. The average impact of PEPFAR across all recipient countries shows a 7.6% reduction in ACM in the first five years (2004-2008), a 5.5% reduction in the second five years (2009-2013), and a 4.7% reduction in the third five years (2014-2018).

Finally, PEPFAR is associated with significant increases in GDP per capita growth rates and improvements in educational outcomes, specifically reductions in the number of girls and boys out of school. These impacts are most pronounced in countries with higher levels of PEPFAR funding and those involved in the Country Operational Planning (COP) process. However, the analysis reveals mixed results for employment rates, with some models suggesting reductions in male and female employment. However, these findings are influenced by trends in comparison group countries rather than by the direct programmatic impacts of PEPFAR.

The combined findings of all three studies underscore the extensive positive spillover effects of PEPFAR on economic growth, educational attainment, maternal and child health, and all-cause mortality in LMICs. These benefits extend beyond PEPFAR’s primary objective of combating HIV/AIDS, highlighting its broader impact on overall health and development outcomes. The robust evidence supports the continuation and potential expansion of PEPFAR’s efforts to sustain and enhance its positive impacts on global health.