Summary of the Work of the HIV Economics Reference Group s Technical Working Group on Allocative Efficiency

Transcription

1 Summary of the Work of the HIV Economics Reference Group s Technical Working Group on Allocative Efficiency Are we Spending on the Right Places, on the Right Things and For the Right People? Marelize Gorgens, The World Bank

2 Overview A. Context & Rationale B. Introduction: Work of the HIV Allocative Efficiency and Program Effectiveness Technical Working Group C. ERG TWG Work Products: 1. Inventory of Allocative Efficiency (AE) Models 2. Fit-for-purpose review of AE Models (partnership with HIV Modelling Consortium) 3. Case Study: Use of Optima Allocative Efficiency tool in changing resource allocations in Sudan 4. Case Study: Incorporating HIV benefits into UHC scheme 5. Concept Paper: Use of HIV allocative efficiency modelling tools in UHC benefits package determination

3 A: Context and Rationale

4 HIV Financing Triple Challenge the triple squeeze Flatlined international financing Other development challenges Uncertainties in future domestic financing for health

5 # of countries Risk of Debt Distress: SSA LIC-DSA Countries HIGH MODERATE LOW Source: DSA database, IMF / WB analysis 2016

6 Solvency: 37 DSA countries Debt-to-GDP (%) Debt-to-Revenue (%) th percentile Median 75th percentile 25th percentile Median 75th percentile 6 Source: DSA database

7 WB/IMF Overview: Debt Relief and Debt Burdens in Africa Africa s debt situation has worsened significantly since about 2013 Drivers have been both internal and external Quality of economic governance Inconsistency between political and technical levels of government Commodity price declines Market lending more significant than new bilateral lending There is now a great deal of heterogeneity across African countries Economic and debt management are more challenging and at a higher premium Debt landscape is more complex Buffers are diminished International policy responses will need to evolve to reflect: New financing approaches to scale up financing Reduced policy leverage Future shocks Improving Allocative Efficiency is Important BUT, there are challenges

8 Key challenges with regards to allocative efficiency analyses Different methods and approaches Lack of guidance and inventory of tools with advantages and disadvantages Current allocative efficiency tools do not address geographic and subpopulation targeting How to recognize, incorporate and show uncertainty Time-varying allocation changes over program period Time horizon: many HIV prevention benefits kick in after the program period Should one use maintenance funding for analyses for longer time horizons, or, assume zero funding base?

9 Key challenges with regards to allocative efficiency Assumptions about relationships between costs, outcomes and impact Individual level efficacy vs population level, real life effectiveness Coordination of allocative efficiency TA to countries Allocative efficiency and technical efficiency inter-play Service integration makes HIV AE analyses less meaningful Beyond recommendations: applying the optimized allocations do they make a difference? HOW to move to new allocations Policy, strategy, programming, implementation, procurement and contractual implications

10 B: Allocative Efficiency and Program Effectiveness ERG Technical Working Group: Overview

11 AEPE TWG Scope of Work 1. Map allocative efficiency studies and HIV effectiveness studies undertaken or planned, and the tools used to conduct them 2. Align mathematical models for allocative efficiency, including options for optimization approaches, in generalized and concentrated epidemics TWG Work product 1: Inventory of HIV AE Tools TWG Work product 2: Fit-for-purpose assessment of main AE tools TWG work product 3: Case study real life impact of AE process 3. Develop principles for econometric modelling as part of HIV-related mathematical modelling efforts TWG work product 4: Case study -- HIV service integration into UHC TWG work product 5: Concept paper on using HIV allocative efficiency models in UHC benefits package determination 4. Implementation briefs for complex issues in HIV program effectiveness assessments

12 C:AEPE ERG TWG Work Products: TWG Work product 1: Inventory of HIV AE Tools

13 AE Inventory Purpose Provide users with a single entry point for obtaining an overview on existing tools, models and approaches on HIV allocative efficiency tools Enable users to compare the different approaches for allocative efficiency analyses and select suitable tools for generating the strategic information they require 13

14 Criteria for Inclusion in the AE Inventory 1. Applied to HIV modeling to answer one or more of policy questions in the past 5 years 2. Used to make HIV allocative efficiency decisions OR have a potential to be used for country level decision making 3. Reviewed externally either by global technical working group, peer-reviewed journal, or HIV modeling consortium 4. Available for assistance/contact point 14

15 Intended Target Audience HIV programme experts in their advisory role to policy makers and funding institutions who can make use of the analysis in their decision making Modellers and other researchers, who are provided with an overview about on-going work in the wider research and programming community Funding institutions and country-level managers, to whom the inventory serves as a menu for choosing tools and understanding key features of different tools for different types of analyses 15

16 Classification of the Models/Tools 16

17 Of 32 existing tools and models reviewed, 20 models/tools were included in the current AE inventory 17

18 Models included in the Inventory 18

19 Structure of the Inventory Inventory of HIV Allocative Efficiency Tools

20 C:AEPE ERG TWG Work Products: TWG Work product 2: Fit-for-purpose assessment of main AE tools Partnership with

21 Models included in the Fit-for-Purpose Review 21

22 Review Process Convened meeting in July 2014 Main stakeholders and HIV modelling consortium members involved Report produced after meeting

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25 C:AEPE ERG TWG Work Products: TWG work product 3: Case study real life impact of AE process (Sudan) Partnership with

26 Sudan

27 Sudan: Where was the money going?

28 Sudan: What did the analysis recommend? Same $ but reduce incidence by 37% by 2020

29 Sudan: How did budgets actually change?

30 C:AEPE ERG TWG Work Products: TWG work product 4: Case study -- HIV service integration into UHC Partnership with Government of Indonesia

31 HIV UHC Integration in Indonesia: Conceptual Framework HIV Allocative Efficiency Analysis HIV-UHC Integration HIV Financial Sustainability Investment Case by UNAIDS (AEM/Goals Model) Coverage Estimating Funding Gap Optimisation of allocations (Optima extension; use same epi inputs) Benefit Package + Premium Calculation Programmatic and Financial Sustainability Country s HIV Transition Plan Payment Methods Performance and M&E

32 4 Areas of Analysis: HIV-UHC Integration From Allocative Efficiency analysis 1. Determine Coverage Specific target population groups (key affected populations for HIV services): determine size and distribution, current insurance coverage, and health service utilization patterns 2. BBP + Premium Calculation 3. Payment Methods 4. Performance Measurement BBP: Positive list of which HIV services to be in BBP provider network (types of health facility/providers, patient flow, referral mechanism). HTA needed to expand the BBP and drug formulary (EDL). HIV services outside BBP (like mass communication or condom distribution) will be publicly financed. Cost and Premium Calculation : Marginal cost, utilization of services, geographical risk adjustment (for concentrated or mixed epidemics) Finding the most appropriate provider payment mechanisms to ensure access and continuity of HIV services: provides incentives for outreach, referral and follow up of treatment and care, payment is adequately covered unit cost and total cost of HIV service Indicators to measure the three dimensions of health insurance coverage: population covered (breadth), comprehensiveness of benefits (depth), and adequacy of financial protection (heighth)

33 Illustration: Cost Calculation of HIV Services for Opportunistic Infection Cost calculation 1 : Probability data across JKN members (123.5 millions) Cost Projection (PMPM) in Rupiah CBGS Inpatient CBGs Outpatient CBGs GDP per capita (2013): $3475 Exchange rate: RP = 1 USD Current JKN premium: RP PMPM Cost calculation 2 : Probability data among at risk population (1.58 millions) Cost Projection (PMPM) in Rupiah CBGS 3, , , , , ,923.8 Inpatient CBGs 3, , , , , ,629.0 Outpatient CBGs (Data sources: BPJS BOA Data; CBGs Claims 2014) Important notes : 1. Probability data: Nominator comes from Case Base Group (CBG) claim cases and corrected with Incurred but Not Reported (IBNR) with Chain Ladder (GLM-reserving, sensitivity analysis using BootChain Ladder and MachChain Ladder method. Denominator #1 JKN members; and #2 Population at risks (MOH Data) 2. Per Member Per Month (PMPM) calculation multiplication average CBGs with the probability to 2016 projection CBGs is corrected with correction assumptions 7.5% (2016) and 7.5% (2018) 3. This will be calculated for all HIV services; but data availability is limited

34 C:AEPE ERG TWG Work Products: TWG work product 5: Concept paper on using HIV allocative efficiency models in UHC benefits package determination Partnership with

35 For more information about the work of the HIV ERG and its Technical Working Groups, please visit: