Estimating the Capacity for ART Provision in Tanzania with the Use of Data on Staff Productivity and Patient Losses

BACKGROUND: International targets for access to antiretroviral therapy (ART) have over-estimated the capacity of health systems in low-income countries in Sub-Saharan Africa. The WHO target for number on treatment by end 2005 for Tanzania was 10 times higher than actually achieved. The target of the national Care and Treatment Plan (CTP) was also not reached. We aimed at estimating the capacity for ART provision and created five scenarios for ART production given existing resource limitations. METHODS: A situation analysis including scrutiny of staff factors, such as available data on staff and patient factors including access to ART and patient losses, made us conclude that the lack of clinical staff is the main limiting factor for ART scale-up, assuming that sufficient drugs and supplies are provided by donors. We created a simple formula to estimate the number of patients on ART based on availability and productivity of clinical staff, time needed to initiate vs maintain a patient on ART and patient losses using five different scenarios with varying levels of these parameters. FINDINGS: Our scenario assuming medium productivity (40% higher than that observed in 2002) and medium loss of patients (20% in addition to 15% first-year mortality) coincides with the actual reported number of patients initiated on ART up to 2008, but is considerably below the national CTP target of 90% coverage for 2009, corresponding to 420,000 on ART and 710,000 life-years saved (LY's). Our analysis suggests that a coverage of 40% or 175,000 on treatment and 350,000 LY's saved is more achievable. CONCLUSION: A comparison of our scenario estimations and actual output 2006-2008 indicates that a simple user-friendly dynamic model can estimate the capacity for ART scale-up in resource-poor settings based on identification of a limiting staff factor and information on availability of this staff and patient losses. Thus, it is possible to set more achievable targets

Actual and authorized number of clinicians at different types of health facilities in Tanzania in the fiscal year 2001/2.

*<p>Ministry of Health/Civil Service Department Staffing levels for health facilities/institutions. Dar es Salaam 1999.</p>**<p>Ministry of Health, Census of Human Resources for Health for 2001/2.</p>***<p>Includes one military hospital.</p

Input estimates for productivity and losses and outcomes obtained mid-year 2009 for the five scenarios and the CTP based on the formula.

*<p>includes age-specific mortality of 1%+losses to follow-up and non-adherence+1^st year AIDS mortality.</p>**<p>includes age-specific mortality of 1%+losses to follow-up and non-adherence.</p>***<p>total number of AIDS deaths minus the sum of the number of new patients per year 2004–2009.</p

ART output.

<p>The number of patients on ART in Tanzania according to end of year numbers of WHO's “3 by 5” initiative and mid-year numbers of CTP and five scenarios. Finally the reported number of patients initiated on ART as the thick grey line running up till the end of February 2008.</p

AIDS deaths.

<p>Estimated number of AIDS deaths without ART from 1999 to 2009 and with ART according to the five scenarios and to the CTP from 2004 to 2009.</p

Number of patients in thousands on ART and CD4 monitoring by end of fiscal year in Tanzania; staff requirements and budget for each fiscal year according to the CTP.

*<p>The external input into salary costs.</p

Formula for the calculation of ART output.

<p>Formula for the calculation of ART output.</p