Getting to HIV Efficiency and Effectiveness Marelize Görgens The World Bank

To be successful, we need to focus on efficiency and effectiveness simultaneously Local epidemic intelligence HIV transmission dynamics Defining major sources of transmission Program intelligence Proven scalable models Standard Operating Procedures and QA systems Training, support and supervision chains Program implementation Monitoring execution in real time Assessing impact at population effectiveness level Constant tactical and strategic adaptations Program evaluation

Program management analysis, health systems integration studies, program expenditure tracking and cost- effectiveness research to improve the flow, and use of resources and intervention delivery options and mix in order to promote efficient resource management and program implementation Effectiveness evaluation to establish what works, disseminate proven practice and improve program effectiveness Tools to assist countries to project their AIDS costs and to plan for a transition to sustainable financing Strengthen epidemiological intelligence through disease burden analysis, targeted surveillance, integrative synthesis studies and better prioritized strategic planning in order to improve the allocation of scarce AIDS resources, among alternative geographic, target group, disease and intervention priorities Improve : Allocative Efficiency Improve : Implementation Efficiency Improve : Population-level Real World Effectiveness IMPROVING THE EFFICIENCY AND EFFECTIVENESS OF AIDS SPENDING Improve : Sustainability

Program science components identical to World Bank economic components Program science components World Bank economic components Program intelligenceAllocative efficiency Program implementationImplementation efficiency Program evaluationEffectiveness

Program science components identical to World Bank economic components Program science components World Bank economic components Program intelligenceAllocative efficiency Program implementationImplementation efficiency Program evaluationEffectiveness

The case of Lesotho

Lesotho MOT results

Lesotho NASA in 2007/08

Lesotho NASA in 2009/10

Gaps in implementation efficiency Program science components World Bank economic components Program intelligenceAllocative efficiency Program implementationImplementation efficiency Program evaluationEffectiveness

For whom to implement What to implement Where to implement When to implement How to implement – Fast scale-up – Cheaply – Without compromising agreed quality standards “It’s all about implementation”

Less than 30% of people with HIV in Africa know they are HIV positive

Most importantly, we have to get implementation to be most efficiently

Why efficiency? With less money available, it is essential to improve the efficiency of available funding Insufficient data exists on what action to take in order to improve efficiency at the service delivery level Focus on more than service delivery points / level

Cost of treatment per ART patient-year by country US Dollars ARVs constitute ~50% of total cost in all LIC/LMICs; ARVs and personnel together constitute over 70% of total cost in all countries *Lab category includes reagents and consumables only in all countries except SA ** Simple average costs are typically higher than median costs. Averages will be weighted by sampling frame in the next phase of analysis. Simple average and median cost of treatment per ART patient-year by country US Dollar CountryARVsPersonnelLabs*OtherTotal Cost MeanMedianMeanMedianMeanMedianMeanMedianMeanMedian Malawi $66$63 $29$22 $5$1 $36$32 $136$117 Ethiopia $103$101 $28$22 $16$15 $39$35 $186$184 Rwanda $114$112 $67$56 $15$16 $37$30 $232$210 Zambia $155 $73$46 $13 $37$30 $278$250 RSA $181$179 $334$284 $102 $65$56 $682$615 Source: CHAI, 2012

What is an efficient HIV program? Lowest unit cost for a given context Through geographic, temporal and sub-population targeting Using the most streamlined service delivery methods, processes and mechanisms In ways that are integrated and linked when it makes programmatic sense Defined quality standards Enabling institutional and organisational context – Rules of the game is understood – Champions – Fastest – Real time data for decision making

Program science components identical to World Bank economic components Program science components World Bank economic components Program intelligenceAllocative efficiency Program implementationImplementation efficiency Program evaluationEffectiveness

Realities regarding population-level effectiveness To which are we attributing the changes we’re seeing to? Real world evaluations of programmes that are: – Complex – Combined – Integrated

Beyond efficacy to population- level effectiveness Combination HIV prevention …. – What is it? – ‘combination of biomedical, behavioural and structural interventions’ …. – But what does this mean? – How do you know whether (or the extent to which) it is in existence?

Combination prevention definitional challenges: showing how programs and science need to work together  When has ‘combination prevention’ been achieved?  All prevention services in prevention strategy?  Some prevention services in prevention strategy?  If so, which ones? (Probably best decided later)  How best to measure when combination prevention is in place (or the extent to which it is in place) 1.Presence of implementation at district level? 2.Coverage of implementation at district level? 3.Service integration at service delivery points? 4.Provision of combined services for users? 5.User experience of temporal access to prevention services? 6.‘Dose’ of combination prevention provision? Or some combination of measurement?

World Bank Country-level Support To Support HIV Efficiency and Effectiveness

Strategic Partnerships in Program Science at country level Led by country program managers Supported by: – World Bank – US Government – Gates Foundation – DFID – Academic partners – UN partners

Country Efforts: HIV efficiency and effectiveness Nigeria, Kenya, South Africa, Swaziland Uganda, Zambia, Brazil Burkina Faso, Cameroon, Cote d’Ivoire Ukraine, China Indonesia, Malaysia, Philippines Thailand, Viet Nam

Challenges and insights after years of concerted effort Challenges Communication the concept in the context of existing efforts Multiple communication layers, levels and levers Working in countries with mature HIV responses: Asia / Africa contrasts Challenges of not funding implementation Coordination – nitty gritty of getting it right Insights Program Efficiency – doing more for less – not incorporated in to program science principles Stand behind the government; make them strong It all starts with strategy Intervene opportunistically Implementation within the context of World Bank operations In-country coordination: ongoing engagement

Program Science From To In conclusion: what it is all about Bringing program and science together Program Science