Costing Health and HIV services in Kenya Dr. Benson Chuma SHOPS Kenya Health Financing Coordinator July 22, 2015

Kenya must increase access to HIV services to achieve an AIDS Free Generation World’s 4th largest population of PLHIV, approximately 1.6 million people Adult Prevalence is 6%, with approximately 100,000 new infections per year Number of PLHIV on ART 744,116, total coverage estimated 41 percent   Although Kenya has made impressive advances in getting PLHIV on ART – third highest number in sub-Saharan Africa; There are still along way to go to achieve epidemic control Will need to drastically increase that number to achieve UNAIDS 90-90-90 targets Source: UNAIDS 2014, PEPFAR WAD 2014

Kenya’s private health sector is a large, dynamic partner 51% 40% 22% 59% Health facilities are private Of all health financing comes from the private sector Total health expenditures in private facilities THE managed by private sector financing agents The private health sector in Kenya (for-profit and not-for-profit) is strong and growing Bullet One The private sector makes up over half of all health facilities (Master facility list, accessed January 2014) and serves as a large employer of healthcare professionals – Largest in some cadres such as doctors, pharmacists Bullet Two The private sector is the largest financing source for health at 39.8 % translating to (93 billion KES; donors are not far behind at 35%. (NHA 2012/2013) Bullet Three 22.2% of THE was spent in private health facilities. Between 2005 to 2010, private sector spending increased from KES 21 to 27 billion shillings Bullet Four Private sector financing agents control 59% of THE Kenya HF is highly donor dependent….private sector provides an alternative option financing/catering for some health needs

Nairobi: Private Health Facilities Nairobi Private health facilities are located in areas with large populations of PLHIV Nairobi: Private Health Facilities Nairobi Understanding where and for what private sector costs are incurred is critical to ensure efficiencies and project scale up of provision of private sector HIV services Talking points: CPrivate providers are active in counties with large populations of PLHIV; Concentration of private providers in urban areas where there are large numbers of PLHIV presents huge opportunity to increase their provision of ART and sustainably make progress toward 90-90-90 *primary barriers to scaling up ART provision were inadequate provider expertise, laboratory capacity, and financing the cost of treatment (Estimating the Untapped Capacity of the Private Sector to Deliver Antiretroviral Therapy in Kenya) Source: eHealth-Kenya, 2015; NASCOP, 2014

Costing data for the private health sector is critical to achieving the expansion of HIV services Costing supports strategic planning and budgeting Costing explains the efficient use of resources Where and what types of services are patients accessing, how much are those services costing? Which facilities are doing more with less, and which facilities are doing less with more? Costing is thus important to support decisions geared towards improved efficiency and sustainability Hence enable use of resources more sustainably

Country wide sampling across different counties, levels and ownership types Collected data from 238 facilities Two data collection efforts: Phase I (Feb – July 2013): Partnered with GIZ to collect data from 238 public and private facilities Phase II (2014): Verified data at 30 private facilities and generated service-specific costs Analysis done using MASH (Management Accounting System for Hospitals) excel tool to generate facility specific costs 238 facilities By ownership 90 public 62 FBO/NGO 86 P4P By level 2 level 6 10 level 5 70 level 4 64 level 3 95 level 2

Overview of our costing approach Inputs: Financial costs: Staff (incl. donated labor) Drugs/clinical supplies (incl. some donated drugs) Indirect costs (e.g. admin, maintenance) Utilization: OP/IP visits and services MASH OUTPUTS Facility specific unit costs: Out patient visit Inpatient bed day Generate service provision costs for: HIV-VCT and ART Family planning Maternity-normal and caesarian section delivery services Gives costing methodology and expected outputs Introduction and emphasis of HIV Outputs Mention challenges in data collection – poor record keeping, lack of HMIS, few facilities do costing exercises Challenges contributed to decision not to include capital costs

OP unit costs varied across different levels and ownership types Highest variability in level 2 and level 4 Level 2 : Dispensary Level 3: Health Centre Level 4: County Referral Hospital

Non-test costs comprised the bulk of HCT visit costs with level 2 and 4 facilities having higher costs Notes: Costs are provided by level of care combining both FBO, NGO and P4P facilities. KEMSA provided 2012 prices of RTKs KES 90.12. Non test kit costs include direct and indirect costs. N=20 KEMSA 2012 prices - The price of USD 108.20 for the Rapid diagnostic test kits is for a Pack of 100 tests. The exchange rate for ARV items: 1usd=kshs 83.2878 and for the contraceptives the exchange rate was 1usd=ksh99.3417 (FY 11/12). Level 2 (1.17) and 4 (1.38) facilities had higher test kits used per visit as compared to Level 3 (0.66) explaining variance in test kit costs Level 2 and 4 facilities had higher double testing rates, 17% and 38% respectively, as compared to Level 3 facilities

ART at private facilities does not necessarily cost more than PEPFAR estimates for LMIC 2014 Report on Costs of Treatment in the President’s Emergency Plan for AIDS Relief (PEPFAR) http://www.pepfar.gov/documents/organization/223163.pdf Some facilities are comparable with ART and Non ARV recurrent costs of 15,779+ 9,763=25, 542 2014 PEPFAR Share of annual ART Costs per patient, by major cost component (Ksh) for LMIC ARVs: KES 15,779 Non-ARV recurrent costs: KES 9,768 Above site costs: KES 9,017 Non-ARV investment costs: KES 1,503 Each bar represents a distinct facility An ART visit includes newly initiated and established clients at a Comprehensive Care Clinic Non drug costs include direct and indirect costs

Drug costs were significant cost drivers in provision of ART care Cost of an ART visit for Sampled Facilities (KES) N=6 Further expounds on the variations seen Differences in ART drug costs due to use of expensive second line regiments An ART visit includes newly initiated and established clients at a Comprehensive Care Clinic Non drug costs include direct and indirect costs Each bar represents a distinct facility

Summary and next steps ART and OP costs varied across facilities, highlighting potential to improve efficiency in private sector Private sector ART costs were not higher than global averages, implying significant potential to leverage existing private sector infrastructure to provide care Study results can be used to: Enable private sector in LMIC countries in benchmarking on costs of providing care efficiently Support decision making on how to sustainably leverage private sector providers to increase access to HIV services Mention on lack of proper record keeping

Benson Chuma Benson_Chuma@shopsproject.com Thank you. Are there any questions?