Cost of HIV/AIDS Adult and Pediatric Clinical Care and Treatment in Ghana

Felix Asante, Jim Rosen, Futures Group/HPI

August 4, 2010

Accra

Purpose and objectives of study

Purpose• To estimate the unit costs of providing HIV/ AIDS care and

treatment to clients in Ghana

Objectives• Feed into costing of the HIV/AIDS National Strategic Plan

(2011-2015)• Feed into other planning and proposal writing that requires unit

cost data

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Study timeline

• Design: February – April 2010• Field work: April – May 2010• Data entry and analysis: May – July 2010• Presentation of preliminary results: June 2010• Dissemination: August 2010

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Study focus-what are we costing?

• Clinical care and treatment for adults and children, including:– Pre-antiretroviral therapy– Antiretroviral therapy– Opportunistic infection care and treatment– Nutritional support

• Criteria for inclusion of interventions:– Services are focused on care and treatment of people infected with

HIV– Services are provided in a clinical setting– Services are already being widely provided in the clinical setting

(i.e. this a study of ongoing, not planned programs)

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What we are not costing

• Orphans and Vulnerable Children (OVC) care• Counseling and testing for people who are not yet in

an ART program • Prevention of mother-to-child-transmission• Home-based care

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Study questions

1. How much does it cost the national program in Ghana to provide clinical care and treatment for one adult or one child for one year?

2. What are “normative” versus “actual” unit costs? 3. How do unit costs vary under different drug regimens? 4. How might unit costs vary between low and high-prevalence

areas of the country? 5. How might unit costs vary according the level of care facility? 6. How might unit costs vary according to whether the site is public,

private for-profit, or mission? 7. How might unit costs vary as the program scales up? 8. What are the projected total costs nationally over the next five

years, taking into account demographic and epidemiological data?

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Costing approach

• Unit cost: the cost of caring for one client for one year• Mostly bottom-up costing• Some top-down calculations• Facility level—site visits, interviews• Central—interviews, desk review

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Sample

• Purposive sample of 15 of the 138 ART sites (end of 2009), reflecting the following criteria:– Level of hospital (from highest to lowest): teaching (2), regional (4),

or district hospital (9)– Ownership: government owned, mission, or private for-profit– Location within the country: three agro-ecological zones: savannah,

forest, and coastal– HIV prevalence in catchment area: a range of low to high, within the

Ghana context

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Study sites

T

T

R

R

R

R

D

D

D DD

D

DD

D

Key: T = Teaching hospital; R = Regional hospital; D = District hospitalSource for map of prevalence data: WHO and UNAIDS 2008

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Types of costs: direct

• Staff time in caring for clients• Drugs to prevent and treat opportunistic infections• ARV drugs• Medical consumables and supplies used for clinic

visits• Laboratory testing• Medical equipment• Vehicles used directly for client care• Physical infrastructure used for client care

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Types of costs: indirect costs directly associated with the program at the facility level

• Administrative staff time• Supervision from regional or central level• Office equipment• Vehicles used for program administration• Physical infrastructure for administering the program• Transport costs for administration• Public utilities (electricity, water, etc.)• Maintenance and repair• Staff training • Other administrative costs (office supplies, legal

costs, audit) 11

Types of costs: indirect costs for general program support

• General program support from the national ART program

• General program support from national health authorities

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Costs not included

• Costs to program clients such as client time, transport, meals, out-of-pocket payments, user fees for services or drugs, etc.

• Costs incurred by local communities (other than volunteer time directly associated with service provision)

• Program negative externalities (such that they exist) • Technical assistance or administrative costs incurred

by external donor agencies

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Valuing the inputs

• Assigned an economic cost, when feasible• Valued in local currency, Ghanaian Cedis, and in

$U.S. where appropriate (1.42 cedis per $US)• Prices adjusted to reflect current (2010) levels

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Data collection, processing, and analysis

• Developed standard questionnaire • Pretested at one site• Data collectors trained• Questionnaire applied in 15 sites from April 26 to May

21• Central level price data collected• Development of Ghana-specific data analysis

template • Data entered and cleaned• Analysis carried out by facility and combined

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Study limitations

• Sample not representative• Sample too small to carry out statistical significance

test• Quality and completeness of facility data not uniform• The diversity of sites• Resource use based on estimates, not observation• Difficulties in collecting and interpreting facility-level

data on OI drugs and laboratory testing

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RESULTS

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Unit cost of HIV clinical care

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Unit cost by facility

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T = TeachingR = RegionalD = District

Variation in unit cost

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Unit cost for pediatric clients

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Distribution of costs

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Direct costs

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Direct costs: Antiretroviral drugs

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Annual cost% of clients on regimen

Adults1st line 127.63$ 98%2nd line 1,021.18$ 2%Weighted average 142.72$ 100%

Children1st line 185.06$ 93%2nd line 357.45$ 7%Weighted average 197.24$ 100%

Direct costs: Laboratory testing

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Indirect costs

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Fixed and variable costs

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Current and capital costs

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Costs by type of input

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Scale effects on unit cost

• Expansion at existing sites likely to reduce unit cost• Expansion through establishment of new clinical care

sites likely to increase unit cost

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Discussion: The cost of one year of adult care (illustrative comparison with other recent studies)

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Discussion: Major cost elements

• Major contributors to direct cost:– ARV drugs – laboratory testing

• Major indirect costs:– national program support– training

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Discussion: Unit cost differences by major facility characteristic

• Greatest variation was by level of facility: – teaching and regional lower unit cost versus district

• Less variation seen by ownership, geographic area, and prevalence zone

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Discussion: Scale up costs

• Expansion at existing sites will likely lower costs• Expansion through establishment of new sites will

likely increase increase• Overall effect on unit costs will depend on the

expansion strategy chosen

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Conclusions

• Further refinement and analysis by local stakeholders will enhance the impact of the study

• Suggested analyses– Efficiency in resource use (staff, lab, equipment, etc.)– Impact of different scale-up approaches– Change in ARV drug regimens– Impact analysis through models such as GOALS

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