Leveraging existing program data for routine efficiency measurement in Zambia.

Rationale: As donor contributions for HIV/AIDS stagnate globally, national governments must seek ways to improve use of existing resources through interventions to drive efficiency at the facility level.  But program managers lack routine information on unit expenditures at points of care, and higher-level planners are unable to assess resource use in the health system.  Thus, managers cannot measure current levels of technical efficiency, and are unable to evaluate effectiveness of interventions to increase technical efficiency. Phased Implementation of REMS: FHI 360 developed the Routine Efficiency Monitoring System (REMS)-a relational database leveraging existing budget, expenditure and output data to produce quarterly site-level estimates of unit expenditure per service.  Along with the Government of the Republic of Zambia (GRZ) and implementation partner Avencion, we configured REMS to measure technical efficiency of Ministry of Health resources used to deliver HIV/AIDS services in 326 facilities in 17 high-priority districts in Copperbelt and Central Provinces.  REMS allocation algorithms were developed through facility assessments, and key informant interviews with MoH staff.  Existing IFMIS and DHIS-2 data streams provide recurring flows of expenditure and output data needed to estimate service-specific unit expenditures.  Trained users access REMS output through user-friendly dashboards delivered through a web-based application.  REMS as a Solution: District health managers use REMS to identify "outlier" facilities to test performance improvement interventions.  Provincial and national planners are using REMS to seek savings and ensure that resources are directed to geographic and programmatic areas with highest need.  REMS can support reimbursement for social health insurance and provide time-series data on facility-level costs for modeling. Conclusions and Next Steps:  REMS gives managers and planners substantially-improved data on how programs transform resources into services.  The GRZ is seeking funding to expand REMS nationally, covering all major disease areas.  Improved technical efficiency supports the goal of a sustainable HIV/AIDS response.

Expanding Access to a New, More Affordable Levonorgestrel Intrauterine System in Kenya: Service Delivery Costs Compared With Other Contraceptive Methods and Perspectives of Key Opinion Leaders.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective forms of contraception and offers important non-contraceptive health benefits. However, it is not widely available in developing countries, largely due to the high price of existing products. Medicines360 plans to introduce its new, more affordable LNG IUS in Kenya. The public-sector transfer price will vary by volume between US$12 to US$16 per unit; for an order of 100,000 units, the public-sector transfer price will be approximately US$15 per unit. METHODS: We calculated the direct service delivery cost per couple-years of protection (CYP) of various family planning methods. The model includes the costs of contraceptive commodities, consumable supplies, instruments per client visit, and direct labor for counseling, insertion, removal, and resupply, if required. The model does not include costs of demand creation or training. We conducted interviews with key opinion leaders in Kenya to identify considerations for scale-up of a new LNG IUS, including strategies to overcome barriers that have contributed to low uptake of the copper intrauterine device. RESULTS: The direct service delivery cost of Medicines360's LNG IUS per CYP compares favorably with other contraceptive methods commonly procured for public-sector distribution in Kenya. The cost is slightly lower than that of the 3-month contraceptive injectable, which is currently the most popular method in Kenya. Almost all key opinion leaders agreed that introducing a more affordable LNG IUS could increase demand and uptake of the method. They thought that women seeking the product's non-contraceptive health benefits would be a key market segment, and most agreed that the reduced menstrual bleeding associated with the method would likely be viewed as an advantage. The key opinion leaders indicated that myths and misconceptions among providers and clients about IUDs must be addressed, and that demand creation and provider training should be prioritized. CONCLUSION: Introducing a new, more affordable LNG IUS product could help expand choice for women in Kenya and increase use of long-acting reversible contraception. Further evaluation is needed to identify the full costs required for introduction-including the cost of demand creation-as well as research among potential and actual LNG IUS users, their partners, and health care providers to help inform scale-up of the method.

Integrating family planning promotion into the work of environmental volunteers: a population, health and environment initiative in Kenya.

Voluntary use of family planning is instrumental to the health and social well-being of women, families and communities.Although contraceptive use in Sub-Saharan Africa is increasing, unmet need for family planning remains high. Even within countries that have achieved increases in contraceptive prevalence, use remains low among some population subgroups. Contraceptive prevalence is generally lower in rural areas than in cities, and is consistently lower among women in the lowest wealth quintile than among those in the highest. Achieving progress in health and social indicators, such as those captured by the Millennium Development Goals, depends on expanding family planning services to poor, remote rural areas in Africa.

Comparing direct costs of facility-based Shang Ring provision versus a standard surgical technique for voluntary medical male circumcision in Zambia.

BACKGROUND: Rapid scale-up of voluntary medical male circumcision (VMMC) is needed to realize potential reductions in HIV incidence in sub-Saharan Africa. New disposable VMMC devices such as the Shang Ring may offer several advantages over standard surgery, including lower costs. METHODS: We compared direct costs of the Shang Ring and dorsal slit techniques for delivery of VMMC in the context of a randomized-controlled trial carried out in Zambia in 2011. Information on direct costs of clinician time, disposable supplies, and reusable medical instruments were collected by study staff. RESULTS: During the trial, the direct cost of 1 VMMC procedure using the Shang Ring device was US $18.21, whereas the direct cost of using dorsal slit was US $17.67. Higher costs of clinician time related to dorsal slit VMMC were offset by higher costs of disposable supplies with the Shang Ring approach. DISCUSSION: Although direct costs were roughly equivalent during this small-scale trial, with the increased demand from scaling up VMMC, a Shang Ring team could provide services at a substantially lower average total cost due to the potential for more intensive use of staff and other fixed resources.

Building on safety, feasibility, and acceptability: the impact and cost of community health worker provision of injectable contraception.

BACKGROUND: A critical shortage of doctors, nurses, and midwives in many sub-Saharan African countries inhibits efforts to expand access to family planning services, especially in rural areas. One way to fill this gap is for community health workers (CHWs) to provide injectable contraceptives, an intervention for which there is growing evidence and international support. In 2009, with approval from the Government of Zambia (GoZ), FHI 360 collaborated with ChildFund Zambia to design and implement such an intervention as part of its existing CHW family planning program. METHODS: The safety of CHW provision of injectable DMPA (depot medroxyprogesterone acetate) was measured by client reports and by a 21-item structured observation checklist. Feasibility and acceptability were measured by interviews with CHWs and a subset of DMPA clients. The impact of adding DMPA to pill and condom provision was assessed by family planning uptake among the clients of trained CHWs from February 2010 to February 2011. Costs were documented using spreadsheets over the period November 2009 to February 2011. RESULTS: Scores were high on all measures of safety, feasibility, and acceptability. Couple-years of protection (CYP, protection from pregnancy for 1 year) was provided to 51 condom clients, 391 pill clients, and 2,206 DMPA clients. Of the 1,739 clients new to family planning, 85% chose injectable DMPA, while 13% chose pills and 2% chose condoms. Continuation rates were also high, at 63% after 1 year as compared with 47% for pill users. Incremental costs per couple-year were US$21.24 if 50% of users continue with CHW-provided DMPA. CONCLUSION: The study affirms that the provision of injectable contraceptives by CHWs is safe, acceptable, and feasible in the Zambian context, with very high rates of uptake in hard-to-reach areas. High continuation rates among clients mean that costs of the intervention can be low when added to an existing community-based distribution program-a finding that is relevant to program replication (now underway in Zambia).

The promise of affordable implants: is cost recovery possible in Kenya?

BACKGROUND: Contraceptive implants are one of the most effective methods of family planning but remain underutilized due to their relatively high upfront cost. The increasing availability of a low-cost implant may reduce financial barriers and increase uptake of implants. The commodity cost of Sino-implant (II) is approximately 60% less than two other widely available implants, and a direct service delivery cost of approximately US$12 makes it one of the most cost-effective methods available. This study was conducted to assess whether implant clients in Kenya are paying as much or more than the direct service delivery cost of Sino-implant (II). STUDY DESIGN: A study was conducted in 22 facilities throughout Kenya, including public (n=8), private for-profit (n=6) and private not-for-profit facilities (n=8). Interviews were conducted with a convenience sample of 293 current and returning implant clients after at least 6 months of product use. RESULTS: The median price for implant insertion paid by clients in the public, private for-profit and private not-for-profit sectors was US$1.30, US$13.30 and US$20.00, respectively. CONCLUSION: Patient fees in both private sectors allow for 100% recovery of the direct cost of providing Sino-implant (II). Currently in Kenya, all sectors can receive donated commodities free of charge; Sino-implant (II) has the potential to reduce reliance on donor-supplied implants and thereby improve contraceptive security.

Costs of HIV/AIDS outpatient services delivered through Zambian public health facilities.

OBJECTIVE: To present evidence on unit and total costs of outpatient HIV/AIDS services in ZPCT-supported facilities in Zambia; specifically, to measure unit costs of selected outpatient HIV/AIDS services, and to estimate total annual costs of antiretroviral therapy (ART) and prevention of mother-to-child transmission (PMTCT) in Zambia. METHODS: Cost data from 2008 were collected in 12 ZPCT-supported facilities (hospitals and health centres) in four provinces. Costs of all resources used to produce ART, PMTCT and CT visits were included, using the perspective of the provider. All shared costs were distributed to clinic visits using appropriate allocation variables. Estimates of annual costs of HIV/AIDS services were made using ZPCT and Ministry of Health data on numbers of persons receiving services in 2009. RESULTS: Unit costs of visits were driven by costs of drugs, laboratory tests and clinical labour, while variability in visit costs across facilities was explained mainly by differences in utilization. First-year costs of ART per client ranged from US$278 to US$523 depending on drug regimen and facility type; costs of a complete course of antenatal care (ANC) including PMTCT were approximately US$114. Annual costs of ART provided in ZPCT-supported facilities were estimated at US$14.7-$40.1 million depending on regimen, and annual costs of antenatal care including PMTCT were estimated at US$16 million. In Zambia as a whole, the respective estimates were US$41.0-114.2 million for ART and US$57.7 million for ANC including PMTCT. CONCLUSIONS: Consistent with the literature, total costs of services were dominated by drugs, laboratory tests and clinical labour. For each visit type, variability across facilities in total costs and cost components suggests that some potential exists to reduce costs through greater harmonization of care protocols and more intensive use of fixed resources. Improving facility-level information on the costs of resources used to produce services should be emphasized as an element of health systems strengthening.

Predicting impact of price increases on demand for reproductive health services: can it be done well?

OBJECTIVE: To assess criterion validity of a survey that uses contingent valuation to elicit estimates of client willingness-to-pay (WTP) higher prices for family planning and reproductive health services in three developing countries. METHODS: Criterion validity was assessed at the individual client level and at the aggregate service level. Individual-level validity was assessed using a longitudinal approach in which we compared what women said they would do with their actual utilization behavior following a price increase. Aggregate-level validity was assessed using predictions derived from cross-sectional surveys and comparing these with actual utilization data. Phi coefficients and correlation statistics were calculated for individual and aggregate-level analyses, respectively. RESULTS: None of the three individual-level cohorts exhibited statistically significant relationships between predicted and actual WTP. Approximately 70% of clients returned for follow-up care after the price increase, regardless of their responses on the WTP survey. For the aggregate analysis the correlation coefficient between predicted and actual percentage change in demand was not significant. Many clinics experienced higher demand after prices increased, suggestive of shifting demand curves. CONCLUSIONS: A validated technique for predicting utilization subsequent to a price increase would be highly useful for program managers. Our individual and aggregate-level results cast doubt on the usefulness of WTP surveys for this purpose.

The impact of price changes on demand for family planning and reproductive health services in Ecuador.

Donor funding for family planning and reproductive health (FP/RH) has declined in Latin America over the past decade, obliging providers to consider other financing mechanisms, including cost recovery through user fees. Pricing decisions are often difficult for providers, who fear that increased fees will cripple demand and create barriers to access for poor clients. Providers need information on how changes in price can affect utilization of services, and how to resolve trade-offs between generating income and serving poor clients. This paper reports on an experiment that measured the impact of higher client fees on utilization, revenue and client socioeconomic characteristics at 15 clinics operated by CEMOPLAF, an Ecuadoran not-for-profit FP/RH agency. The study improves on previous research by comparing effects of different price levels on demand for services. We conclude that demand was inelastic for three of CEMOPLAF's four main FP/RH services, and we found no evidence that the price increases had a disproportionate impact on utilization by poorer clients. The study therefore provided CEMOPLAF managers with knowledge that price increases at the levels tested would help to achieve sustainability goals (by increasing locally generated income) without undermining CEMOPLAF's social mission.