Pr Jean-Paul MOATTIUniversity of Aix-Marseille 2 (France)INSERM/IRD Research Unit 912 SE4SEconomic & Social Sciences, Health Systems &

Societies

HIV and health expenditures surveys : the

need for data at individuals’ level

THE CONTEXT

Health economic literature = strong inefficiencies in health systems (in general and exacerbated in developing countries)

Heterogeneity in unit costs for delivering HIV services (beyond economies of scale & scope)

International and domestic funding bodies asking for information about « value for money »

Scale and Average Unit Cost of VCT programs in 5 countries

1

10

100

1,000

1 10 100 1,000 10,000 100,000

Annual clients receiving VCTMexico Uganda Russia India South Africa

US

$ A

vera

ge U

nit C

osts

Source: Preliminary analysis of PANCEA data. Unpublished data. 2006

THE CONTEXT

Health economic literature = strong inefficiencies in health systems (in general and exacerbated in developing countries)

Heterogeneity in unit costs for delivering HIV services (beyond economies of scale & scope)

International and domestic funding bodies asking for information about « value for money »

THE METHODOLOGICAL TRADE-OFF

THREE EXAMPLES OF THE USE OF INDIVIDUAL DATA

ARV source prices (Brazil) (Meiners et al., Vienna Conference, THAE0205- Thursday 22nd)

EVAL-ANRS survey among HIV+ patients in health care centers (Cameroon) (Boyer et al., AIDS 2010, 24: S5-S15)

Micro-simulation of DHS data for macro-economic impact estimation of alternative scenarios (Cameroon, Swaziland, Tanzania) (UNAIDS, 2010)

Data and methods (Brazil)Data and methods (Brazil)

Object: adult ARV transactions (2009 USD)

Analysed period: 1996 - 2009

Data: transaction, drug and market characteristics

Source: Dept of STD, AIDS and VH, MoH

5/13

Coverage and mean ARV expenditures Coverage and mean ARV expenditures (Brazil)(Brazil)

N=607

6/13

Results

PYD according to supply type (Brazil)PYD according to supply type (Brazil)

7/13

Results

CAMEROON: the EVAL – ANRS 12 116 research project

Cross-sectional and multicentre study (Sept., 2006 to Apr.,

2007)

- 3151 HIV infected adults interviewed in 27 HIV services at the 3

levels of the healthcare delivery (Central; Provincial; District)

- Random sample

- Face-to-face interview and anonymous questionnaires

- Medical information card and blood sample (CD4 cell counts)

- Response rate: 91%

- 97 physicians in the same 27 HIV services

- All-inclusive

- Anonymously self-reported questionnaires

- Data on characteristics of healthcare services

- Data on decentralization policy

Direct out-of-pocket costs related to HIV infection (by month – median) (n=2412 ART-treated pts)

CAMEROON

Yde & Dla

Prov. District

Health expenditures (exp.)* (in FCFA X 103)

- TOTAL (exp. >0 : 98%)

- ART (exp.>0 : 88%)

- Transportation (exp. >0 : 85%)

- Consultations (exp. > 0 : 33%)

- Other drugs (exp. >0 : 20%)

8,6

3,0

1,0

2,0

5,0

6,6

3,0

1,2

1,0

5,0

5,8

3,0

2,0

1,0

1,5

Proportion of expenditures in household income by quintiles- 1st quintile

- 5th quintile

27,2%

3,5%

9,0%

2,3%

16,0%

2,0%

- Catastrophic Health Expenditures (≥ 20% households’ resources) : 44%

CAMEROON EVAL ANRS SurveyFactors associated with the risk of catastrophic health exp.* (n=2412)

Coeff p

Monthly income by equivalent adult (1st quintile = ref.)- 2nd quintile- 3rd quintile- 4th quintile- 5th quintile

-1.1

-1.8

-2.4

-3.0

***

***

***

***

Wealth index -1.3 ***

Free access to ART (interaction term) : - Constant

- Free access: provincial level

- Free access: district level

-1.3

-0.1

-0.9

***

NS

**

Transportation length to the hospital < 1 hour -1.1 ***

Consultation with a private doctor outside the reference hospital 0.4 **

Consultation with a traditional healer: constant

- variance of random effect

0.7

0.7

**

**

Decentralization: - central level (ref.)- Provincial level - District level

-0,6

- 0,6

***

*

* Adjustment variables: gender, age, matrimonial status, area of residence, CD4 at initiation, time since HIV diagnosis, nb of perceived symptoms / technologic level of the medical centre

Ventelou(1,2), Arrighi(1,2), Afridi(1,2), Greener(3), Lamontagne(3), Moatti(2)

Contact Author:

(1) CNRS GREQAM / INSERM Unit 912 and PACA Regional Center for Disease Control(2) INSERM Unit 912 and PACA Regional Center for Disease Control(3) UNAIDS

Estimates of alternative scenarios of scaling-up of ART treatment in an agent-based

microsimulation model

CAMEROUN– 2004 Cameroon Demographic and Health Survey (EDSC

III)– Large dataset : 35,000 individuals sampled– Numerous data on socio-economics and perception of

AIDS– 10,900 Adults aged15-49 are retained

– Linked with a HIV Blood Test Record-– 9,551 tests were performed

– Results in a Sample of 8,186 HIV+ and HIV- individuals– 46.2% Men ; 53.8% Women (weighted)– HIV Prevalence = 7.5% (weighted)– Every Individual represents xxx

Agents in the database are:HIVnegative / HIVpositive / HIVpositive+needing ART The proportion of PLWHIV needing ART has been obtained from WHO data (not given in the

dataset) - differentiated across age classes and genders, for taking into account a probable longer date of infection among the oldest. We randomly assign agents to the HIV+TN status

4 Status: Future states = obtained by artificial“ageing”(Markov)

CBA: Aid Freeze vs. Universal Access- Universal Access dominates Aid Freeze

only on the long-run

- Gains are lower(GDP per capita...)

Ad-Hoc Technical Advisory Group on Costing HIV/AIDS Interventions

(WHO, GFATM, PEPFAR)- June 2010

“WHO and partners should go forward with two levels of program-level ART costing:

a routine data collection across a few basic cost categories at national level; and secondly a more detailed exercise to guide countries in

producing reliable cost figures for comparative analysis”

Recommendations

Need of Multi-country/multi-sites surveys with individual data on HIV expenditures

Need of an Operational Research pooled

mechanism