Pr Jean-Paul MOATTI University of Aix-Marseille 2 (France) INSERM/IRD Research Unit 912 SE4S Economic & Social Sciences, Health Systems & Societies HIV and health expenditures surveys : the need for data at individuals’ level
Jan 12, 2016
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 Unpublished data. 2006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