Improving health facility efficiency could markedly expand HIV treatment

Health facilities in Kenya, Uganda, and Zambia could extend life-sustaining antiretroviral therapy (ART) to hundreds of thousands of people living with HIV if facilities improved the efficiency of service delivery. This is one of the main findings from a paper published today in BMC Medicine, co-authored by the Institute for Health Metrics and Evaluation (IHME) and collaborators from Action Africa Help-International (AAH-I) in Kenya, the Infectious Diseases Research Collaboration (IDRC) in Uganda, and the University of Zambia in Zambia.

The global scale-up of ART to treat HIV is one of world's greatest success stories in health, transforming the diagnosis of HIV from an early death sentence to a controllable, chronic condition. Access to ART has rapidly increased over the past 15 years largely due to the escalation of funding for HIV/AIDS, particularly in sub-Saharan Africa.

The World Health Organization (WHO) recently recommended that all people living with HIV start ART, which establishes millions more people as eligible for treatment at a time when funding for HIV has plateaued. With constrained resources and ever-increasing demand, expanding ART services depends on the efficiency with which facilities use their resources.

"Improving efficiency can support major gains in expanding ART to people who need treatment, especially when funding is limited," says IHME Assistant Professor Abraham Flaxman, senior author of the study. "Now we, as a global health community, need to figure out how."

In this study, researchers measured the efficiency of facilities, including those providing ART services, in Kenya, Uganda, and Zambia. Researchers analyzed how efficiently health services were produced and predicted how many more ART patient visits facilities could accommodate, given their resources, if they increased efficiency.

The results of the study showed that if facilities improved their efficiency to 80%, there could be a 33% increase in ART visits in Kenya, 62% in Uganda, and 33% in Zambia. This means that increases in efficiency could support facilities seeing almost 460,000 new ART patients across all three countries.

Key findings from the study include:

• Most health facilities in Kenya, Uganda, and Zambia scored relatively low in terms of efficiency – indicating that facilities could produce more services and accommodate more patients given their resources.
• No one facility characteristic (like number of beds or health care providers) was consistently associated with better efficiency; this suggests that other factors, such as facility management practices, are more closely linked to improved efficiency.
• If analyzed health facilities providing ART increased their efficiency levels to at least 80%, ART visits could increase 33% in Kenya and Zambia, and 62% in Uganda.
• Health facilities in Kenya, Uganda, and Zambia – and likely throughout sub-Saharan Africa – have the opportunity to expand ART services if they improve efficiency of health facilities.

This paper is based on research from the Disease Control Priorities Network (DCPN) project, a multi-country study that assesses drivers of health system performance and costs of care. Funded by the Bill & Melinda Gates Foundation, the DCPN project began in 2011, with Kenya, Uganda, and Zambia as three of the countries initially involved in the study.