Sustainability Analysis of HIV/AIDS Programs

1. Sustainability Analysis of HIV/AIDS Programs Elaine Baruwa, PhD, Itamar Katz, PhD Abt Associates Inc. December 9, 2010

2. Health Systems 20/20 USAID global project working to strengthen the six pillars of the health system: Health financing, governance, human resources, HIS, pharmaceutical/commodities, operations USAID ‘Leader with Associates’ award, Abt Associates is prime Health Systems 20/20 developed the HIV/AIDS Program Sustainability Analysis Tool (HAPSAT) in 2008

3. HAPSAT Context circa 2008 • In 2007/08 HAPSAT was developed to estimate gaps between country’s available human and financial resources, and what is needed to implement HIV programs at the national level • Donor support for HIV programs was still ‘ramping’ up • Priority was ‘scale-up’ across the board from donors to countries to programs

4. HAPSAT Plus circa 2010 • In 2010, paradigm has changed significantly and donor support is referred to as ‘constant’ but likely to ‘fall’ soon • Priority is ‘sustainability’, particularly at country and program level • HAPSAT has been adapted to address concerns of current context and key players

5. HAPSAT is … Sustainability study/tool Focuses on country ownership Provides evidence for decision-making Analyzes multiple scenarios based on stakeholder inputs Comprehensive and flexible costing approach Harmonized with other costing approaches: CDC, Spectrum

6. Sustainability Analysis What is sustainability analysis? Measures gap between resources needed (financial, human, organizational) and resources available over the relevant time horizon HAPSAT did this well as did many other tools such as the SPECTRUM model and the PEPFAR costing model, but now countries want to know more What can be done to address the gap? 6

7. HAPSAT Experience • Each of these countries is unique: context, level of program development, priorities Nigeria Ethiopia Sierra Leone Haiti Kenya Guyana Vietnam Zambia DR Congo Southern Sudan

8. HAPSAT Tool • HAPSAT was focused on the ‘tool’, based on MS Excel software, which models resource requirements/ availability over 5-year time horizon 8

9. HAPSAT Methodology Global models must become flexible to meet country contexts and needs Global Picture: Funding growth has ceased, leading to gaps between country’s policies (e.g. universal coverage) and their ability to implement their policies • HAPSAT: • Fully identified financing gaps across the HIV program, (ART, prevention, program costs, etc.) • Identified human resources gaps • Limited country specificity • Limited incorporation of country priorities • Country Picture: • Financial capacity is limited • Human resources are limited • Other limiting factors in play? • Other unexplored mitigating factors

10. Identified sustainability issues lead to Factor analysis leads toIdentified solutions ▼ HAPSAT Plus Sustainability Analysis▼ • Increasing country specificity • Increasing focus on country priorities • Identifying and addressing inefficiencies • Identifying new opportunities HAPSAT Methodology Global models/models must become flexible to meet country contexts and needs

11. HAPSAT Methodology Steps STEP 1 Engage HIV program and stakeholders STEP 2 Adapt HAPSAT to country context “Stakeholder Engagement” workshop STEP 3 Refine data collection and analysis “Results to Policy” workshop Design action plans

12. Programmatic Areas in HAPSAT TREATMENT CARE PREVENTION MITIGATION SHARED COSTS • ART • VCT • Pre-ART monitoring, OI p&t, home-based care, palliative care • Testing & DOTS for TB-HIV co-infection • PMTCT • Behavior Change Prevention/ABC • OVC • Economic and social support programs for PLWHA • Health systems & SI , M&S grouped together as cross-cutting shared costs and overheads

13. Examples of HAPSAT Recommendations • Efficiency • Sustainability • Health systems strengthening • Community systems strengthening • Target setting

14. Efficiency: Billboard vs. Radio for HIV Awareness in Southern Sudan • Radio is the major information source for southern Sudanese • Billboards may be of limited use in a country with low literacy levels, potentially useful in urban areas

15. Sustainability: Decentralization of ART Services in Kenya Number of additional patients that can be served at satellite sites • US$ 9.5 M for new equipment and training of staff to provide ART and care services to additional 536 satellite sites • Need for additional 295 new nursing and 144 new pharmacy full-time-equivalent staff • Increase in coverage • Reduced attrition • Reduced out-of-pocket costs Source: Maina, Glandon, et al., 2010

16. Community Systems Strengthening: Care and Support in Southern Sudan

17. Health Systems Strengthening: FTE of Medical Doctors Required for pre-ART & ART • Calculating FTE medical doctors required for delivering pre-ART and ART • Three patients per hour (18 per day) • 44 working weeks per year • ART patients visits on average 6 times a year • Visits evenly distributed during the working hours Need to integrate of ART clinics with less than 600 pre-ART and ART patients

18. Target Setting • Universal access • Past performance • Human resources capacity • Funding availability PMTCT Treatment, Sierra Leone

19. Next HAPSATs • Institutionalization • ISED, Senegal • Model finalization and interface creation • Current HAPSATs • Sierra Leone

20. Thank youFor more information… General contact email: John_Osika@abtassoc.com Technical contact email: Itamar_Katz@abtassoc.com Elaine_Baruwa@abtassoc.com Danielle_Altman@abtassoc.com Website: www.healthsystems2020.org