Kathy Doherty l Palladium - May 16 2022
Finding the Right Questions for Hard-to-Solve HIV Issues

Credit: Health Policy Plus

Join the HP+ team at the 24th International AIDS Conference and 12th International AIDS Economic Network Preconference 27th July-2nd August where they will be participating in several panels and discussing how data use and innovative approaches can help tackle hard-to-solve HIV issues.

The good news is that HIV has become more of a manageable chronic condition. The less-good news is that global donor funds for HIV programs are expected to flatten while national health budgets have become more burdened due to COVID-19. These facts pose a problem for low- and middle-income countries called upon to mobilise domestic funding for HIV.

But they also pose an opportunity for a somewhat unique method of data collection to do its job.

As donor funds decrease, countries must find resources to fund HIV programs and health planners and governments need to understand costs so they can allocate resources effectively and find potential savings. “Activity-based costing is fundamentally about resource needs and money spent, but it also provides all sorts of useful data that allow administrators to ask the right questions,” says Bryant Lee, a senior technical advisor in health financing for the Health Policy Plus (HP+) project.

“We’re still in the process of figuring out where this may lead, but the idea is to use these data and analytics to solve the problems that will lead to more sustainable HIV programs.”

Activity-based costing and management (ABC/M) is a PEPFAR (U.S. President’s Emergency Plan for AIDS Response) and USAID initiative and HP+ its primary collaborator. An important component is the use of time-driven activity-based costing, a method developed by Harvard Business School professors. Unlike traditional costing studies, this method more accurately pinpoints variations in service delivery by directly observing patients and the resources they consume during their hospital or clinic visit. Process maps of the visit visually depict specifics of the “where, what, when, who, and how long” of the care pathway.

“Time-driven activity-based costing also applies a standard metric called the capacity cost rate, which allows for easy comparison and interesting analysis across many different variables,” Lee says.

Improving Resource Allocation at all Levels

Another key differentiator of the ABC/M approach is that it examines costs at several levels of the health system: above-site, facility, community, and client levels, providing a fuller and more granular picture of the total costs of a disease program. “By looking at these layers, we can see and compare the proportion of where the money is spent and hopefully draw some conclusions on what PEPFAR is getting out of its investments,” explains Lee. “Cost/benefit analysis can then suggest where to best apply scarce resources.”

PEPFAR’s impetus to invest in this approach in their priority countries aligns with its goal to move HIV response more to the local level from the global or donor levels where most investments originate. “We always partner with local research firms, so they have the capacity to take over implementing this approach in the future,” Lee says.

The method is somewhat new—it has been deployed in Tanzania and Uganda and is in process in Kenya and Mozambique. “We’re learning from what has been done and trying to improve things as we go,” says Lee. For example, the approach at the community level was different from the facility level so the plan is to tweak the community method to allow for better comparison.

According to Lee, it has also resulted in some surprising findings. “I don’t think people realised that facility-level costs for service delivery were such a small proportion. Now we see there are opportunities to improve the care given in health clinics without a huge investment.”

A country developing strategies for mobilising domestic resources for HIV programs needs current information on costs, financing, service utilisation, and performance of different patterns of service delivery. It needs a cost analysis that reflects the swift pace of changes to HIV care and patient characteristics and that routinely yields useful data for constant decision making.

A country needs to know it’s asking the right questions and this method is built for that.

“What is driving variation in the way care is delivered,” Lee asks, “and how can we improve efficiency in the care process? How do we optimise the HIV program’s human resources for health? What policies can reduce barriers for poorer clients and increase accessibility? What investments at the above-site level make the most impact?”

For example, the ABC/M method shows that a large cost for HIV clients is transport to reach a clinic and the time spent away from work during the visit— resulting in significant economic burdens for many seeking care. This data could lead health planners to examine ways to better reach HIV clients where they are. Or, researchers may learn that the ideal flow of patient care is not happening at a clinic, and data may reveal where there are opportunities to relieve bottlenecks for more efficient clinical care resulting in patients spending less time waiting for services.

These are examples of what can be done with the data gathered through this method. Each country will have different questions based on the method applied in their context. PEPFAR believes its investment in testing this method will pay off for countries that decide to use it.

Health Policy Plus is funded by the U.S. Agency for International Development and the U.S. President’s Emergency Plan for AIDS Response and is implemented by Palladium. For more information, contact info@thepalladiumgrou.com