By Annie Harrison, Rabb MS’21
UNAIDS estimates 38.4 million people around the world are living with HIV as of 2021. Over 25 million are in sub-Saharan Africa.
Yet the percentage of people who have access to antiretroviral therapy in sub-Saharan Africa is less than populations in Western and Central Europe and North America.
Heller researchers are supporting a new United States President’s Emergency Plan for AIDS Relief (PEPFAR)-led, multicountry initiative, that aims to systematically track funding and cost of HIV services in sub-Saharan Africa with a view to improve quality of care and efficiency, and optimize the patient experience in treatment centers.
Known as activity-based costing and management, this effort will generate detailed information on the cost of providing various HIV services, and also track the patient experience at service points on a consistent and regular basis.
Several global health institutions, including the Office of the Global AIDS Coordinator (OGAC) and Health Diplomacy at the United States Department of State; Global Fund to Fight AIDS, Tuberculosis and Malaria; Joint United Nations Programme on HIV/AIDS (UNAIDS); United States Agency for International Development (USAID) and other U.S. agencies, banded together in 2020 to make the new initiative a reality.
Building a global coalition
In the Bulletin of the World Health Organization (WHO), Allyala Krishna Nandakumar, director of the Institute for Global Health and Development of the Schneider Institutes for Health Policy and Research at Heller, and co-authors write that the project will help countries better understand how HIV resources are being allocated.
The initiative recognizes that country governments and global institutions need to optimize investments, especially at a time when governments are taking on increased fiscal and functional responsibility for the delivery of services. The initiative aims to provide detailed information about where current investments are directed and help shape what the HIV response should look like in the future.
“As a global coalition, the initiative will empower institutions to gather patient-level information on HIV resource allocation and then share findings through a learning collaborative model,” Nandakumar says.
Targeting communities in need
A multicountry effort of this scale requires a lot of coordination.
At the national level, a steering committee made up of key stakeholders is established in each country to oversee and guide the work. A local academic or research institution is then selected to carry out the country-level activities and work closely with implementing partners.
At the international level, a global coordination committee and global technical working group have been established to both coordinate work across institutions and provide guidance on technical issues.
The effort is currently underway in Kenya, Mozambique, Namibia, Uganda, United Republic of Tanzania, and Zambia, with plans to expand beyond sub-Saharan Africa.
Dr. Ntuli A. Kapologwe, director of Health, Social Welfare and Nutrition Services at the President’s Office Regional Administration and Local Government in Tanzania, says the project will improve how countries in sub-Saharan Africa distribute resources. With more than 6,000 primary health care facilities across Tanzania, for example, he says the initiative will help the country send resources where they are needed most.
“Activity-based costing and management will help in the targeted resource allocation at the primary health care level by using a process map that allows us to know exactly where the cost-effective investment should be directed,” he says.
Collecting and analyzing patient-level data
The approach to activity-based costing and management is simple: Measure the costs of all resources used to care for patients with HIV as they move through the health care system, and use time as a unit of measurement when determining the cost of resources. Researchers then use the observations across all patients to estimate recommendations.
Nandakumar explains that this approach has two advantages over alternative frameworks.
First, health clinics and hospitals collect data at the patient level by directly observing and measuring interactions and movements through the health care system.
Second, the approach reveals departures from protocols, including the degree of variation in resources allocated to different patients. This is essential to program evaluation because it allows policymakers to analyze patient-level information in order to determine predictors for why some patients receive more resources than others.
“The initiative will allow participating institutions to assess how much of their investments actually reach health care facilities, as well as quantify the impact of the finances on facility-level resources and out-of-pocket spending,” Nandakumar says. “The international reach of the initiative will also allow institutions to bring together country leaders to compare and assess alternative HIV care delivery models and inform future investments.”
Optimizing program performance
Once patient-level data are collected and analyzed, local committees disseminate reports and other information to relevant organizations, including participating health clinics and hospitals.
“The project will provide accurate and actionable information on what it actually costs to diagnose and treat infectious diseases in low- to medium-income countries,” says Robert Kaplan, senior fellow and Marvin Bower Professor of Leadership Development, emeritus, at Harvard Business School.
Kaplan adds that this information will promote accountability to external funders, such as the PEPFAR, the Global Fund, and USAID. These data enable funders to collaborate better with ministries of health in low- and middle-income countries.
“These ministries will now be able to right-size their budgets and resources for hospitals, clinics, and villages to deliver effective and efficient diagnoses and treatments for HIV and TB,” he says.
While activity-based costing and management has been used in high-income countries primarily for cost reduction, this new approach in low-resource settings is likely to reveal situations where greater resources are needed. Whether trimming or expanding resources, the authors conclude, a main emphasis of the initiative is to strengthen the return on investment for services and optimize program performance.
“Activity-based costing and management provides health care administrators clear information to both improve quality and reduce costs,” says Michael E. Ruffner, deputy coordinator with the Office of the Global AIDS Coordinator and Health Diplomacy. “The data generated will also help the PEPFAR program integrate services into national systems and maintain the HIV gains built over the last 20 years.”