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

2. 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 targets
Source: UNAIDS 2014, PEPFAR WAD 2014

3. 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

4. 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
*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

5. 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

6. 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

7. 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

8. 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

9. 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
Non test kit costs include direct and indirect costs.
N=20
KEMSA 2012 prices - The price of USD for the Rapid diagnostic test kits is for a Pack of 100 tests.
The exchange rate for ARV items: 1usd=kshs and for the contraceptives the exchange rate was 1usd=ksh (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

10. 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)
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

11. 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

12. 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

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