Programmatic implications of a cost study of home-based care programs in South Africa

The HIV/AIDS epidemic has meant that an increasing number of chronically ill people need ongoing assistance with care and support. Programs providing home-based care (HBC) services are a key component of the response to HIV/AIDS. However, few programs are using operations research, including cost studies, to decide what services to provide and how to structure their services. In 2004, the Horizons Program undertook a study of six HBC programs from different South African provinces to provide key information to NGOs, government ministries, donors, and the programs themselves to inform decisions about service delivery. The study analyzed the cost of HBC services, the best use of resources, and how well programs are able to meet the needs of beneficiaries and their families. The sample represents programs that operate in rural areas and informal settlements. This brief focuses on the coverage, organization, volume, and costs of the services and on findings from two of the methods of data collection: financial records and service statistics, and interviews with financial officers, program managers, and caregivers

Reaching truckers in Brazil with non-stigmatizing and effective HIV/STI services

Research with mobile populations has demonstrated that men in the mobile workforce tend to be exposed to greater HIV risk, and have higher sexually transmitted infection (STI) and HIV prevalence, than those in less mobile or non-mobile professions. At the request of the Brazilian Ministry of Health and with support from USAID/Brazil, the Population Council conducted an assessment in Brazilian border areas to determine which populations were most in need of HIV prevention activities. The research revealed the presence of an extremely mobile, international truck driver community with little to no access to HIV prevention, testing, and treatment services. The intervention strategy of placing a health unit inside the customs station and offering HIV/STI-related services with other services to meet the general health needs of truckers was successful for reaching truckers, was acceptable and well received, and promoted some important HIV-related behavior change

Leveraging existing program data for routine efficiency measurement in Zambia [version 2; referees: 2 approved, 1 approved with reservations]

Rationale: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level.  But program managers lack routine information on unit expenditures at points of care, and higher-level planners are unable to assess resource use in the health system.  Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Phased Implementation of REMS: FHI 360 developed the Routine Efficiency Monitoring System (REMS)-a relational database leveraging existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service.  Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces.  REMS allocation algorithms were developed through facility assessments, and key informant interviews with MoH staff.  Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures.  Trained users access REMS output through user-friendly dashboards delivered through a web-based application.  REMS as a Solution: District health managers use REMS to identify “outlier” facilities to test performance improvement interventions.  Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need.  REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling. Conclusions and Next Steps:  REMS gives managers and planners substantially-improved data on how programs transform resources into services.  The GRZ is seeking funding to expand REMS nationally, covering all major disease areas.  Improved technical efficiency supports the goal of a sustainable HIV/AIDS response

Assessing the feasibility, acceptability and cost of introducing postabortion care in health centres and dispensaries in rural Tanzania

The EngenderHealth ACQUIRE Project has been supporting the Tanzanian Ministry of Health (MOH) since early 2005 to decentralize the management of postabortion care (PAC) services to primary healthcare facilities (health centers and dispensaries), with the intention of bringing services closer to women who are unable to access them at district hospitals. Findings from this study were provided to the MOH and ACQUIRE to address issues arising from introduction of the intervention; and in September 2006, to assess the feasibility, cost, and effectiveness of the intervention. Findings show that the intervention appears to have broadened service providers’ range of clinical skills and led to an increase in the number of women accessing family planning services after the evacuation. Facilities are well prepared to provide the PAC services, and few clients were being referred for advanced clinical management for incomplete abortions within 12 weeks of conception. The report concludes that decentralizing PAC services to health centers and dispensaries is feasible and effective, and the approach could be scaled up at a reasonable cost to other lower level facilities in Tanzania

Impact of antiretroviral therapy on household economics: Findings from Mombasa, Kenya

While the clinical impact of receiving antiretroviral therapy (ART) on individuals living with HIV is well documented, less is known about how the receipt of ART affects household economics. This analysis examined the direct and indirect effects of receiving ART on household economics. A direct effect is reduced spending on health services as a result of the improved health status of the household member on ART. The potential indirect effects include increased labor-force participation by the household member on ART, a change in how other household members spend their time (working or in school), and a shift in composition of household expenditures. This brief describes the experiences of a cohort of people living with HIV who were receiving ART through a program coordinated by the Coast Provincial General Hospital in Mombasa, Kenya. A longitudinal study of clients on ART found that perceived health improved, reported incidence of illness and use of health services declined, and labor-force participation increased within 12 months of initiating therapy

How much will it cost to scale up a reproductive health pilot project?

Most service-delivery interventions begin as pilot projects. When a pilot study of an intervention is successful, managers begin to think about scaling up the project to new areas. Cost is a critical factor influencing the extent and pace of scale-up. This brief explains how to adapt and modify cost information obtained from a pilot project to estimate scale-up costs. The brief shows why the costs of a pilot project alone are not sufficient to predict costs of scale-up and gives examples of how costs are influenced by factors like economies and diseconomies of scale, resource substitution, and intervention modification. The aim of this brief is to help managers think critically about the factors that must be considered in estimating the costs of scaling up an effective intervention. The first decision is whether to scale up the pilot project at all. There should be evidence that the pilot project proved successful, and its success should be achieved at reasonable cost

Financial capacity building for NGO sustainability

While demand for family planning and reproductive health services is increasing worldwide, a number of recent trends threaten the financial sustainability of donor-supported NGOs that provide these services. First, the U.S. Agency for International Development has seen its funding for population assistance decline since 1995. A second reason is the growth of government-funded programs that provide these services for low-income clients, which reduced the need for NGOs to focus programs entirely on the poor. Health-sector reform has created opportunities for NGOs via public–private partnerships in some countries, but sustained public-sector support is unlikely given limited economic growth in domestic economies and competition from other health priorities. Faced with these challenges, many NGOs ceased operations, while others struggled to produce health services for which clients or donors are willing to pay. Long-term sustainability of NGOs may require that they become largely financially self-reliant, but few NGOs have the skills to reduce costs and increase income. This brief describes the FRONTIERS program’s Financial Sustainability Capacity Building Initiative (FSCBI). FSCBI’s objective is to build NGO capacity to conduct economics-related operations research to improve financial sustainability

Strengthening financial sustainability through integration of voluntary counseling and testing services with other reproductive health services

In West Bengal, India, the Child in Need Institute (CINI) operated an HIV/AIDS voluntary confidential counseling and testing center and a reproductive health clinic at separate locations. Concerns about lack of service coordination as well as cost and revenue considerations led CINI to integrate the two services. CINI conducted an operations research study to examine the impact of integration on utilization and revenues. The objective of the study was to examine whether integration of services would yield an increase in clients served and improve the financial position of the program. The study found that integrating services was associated with increased provision of services and improved financial sustainability. The study also demonstrated that the capacity of CINI to carry out economic evaluations of their programs was improved as a result of training in economic analysis and operations research

Effect of introducing an \u27afternoon pay clinic\u27 on service utilization and cost recovery (Nepal)

An operations research study was initiated with financial and technical assistance from the FRONTIERS program to examine whether introducing an afternoon clinic at the Chhetrapati Family Welfare Center (CFWC) in Nepal with a substantially higher registration fee could improve cost recovery by adding more to program revenues than to program costs. The study showed, however, that premium pricing of afternoon services generated very little additional demand for services. Even with a premium price, the afternoon clinic could reach its cost recovery goal only if the volume of afternoon clients were to increase significantly. However, client perceptions about the ability of CFWC providers to provide non-family planning services needs to change in order for the utilization of the CFWC afternoon clinic to increase. Among the report’s conclusions is that family planning program sustainability without external support would not be feasible in the near future

A case study of Nairobi City Council\u27s decentralised syphilis screening programme in antenatal clinics

It has long been known that syphilis is one of the more serious sexually transmitted infections (STI), especially during pregnancy when, if untreated, at least 60 percent of infected women will experience an adverse pregnancy outcome. There has been renewed interest in its control and prevention because of its proven link with HIV transmission. In 1992, the Nairobi City Council (NCC) pilot-tested a decentralized approach to syphilis screening and management in a sample of their antenatal clinics. A case study was carried out to assess the effectiveness, readiness, and cost effectiveness of the NCC’s antenatal care program, with a focus on the decentralized syphilis screening and treatment service. This report concludes that decentralization of maternal syphilis screening and management is feasible in a public-sector urban program, and, when implemented properly, leads to more antenatal clients and their partners being screened and treated. However, the NCC clinics are insufficiently prepared to offer good quality antenatal services and to ensure that syphilis screening and treatment are available for all antenatal clients