Allocative Efficiency and
Sustaining the National
HIV/AIDS Response
Dr. Shiyan Chao
The World Bank
The Caribbean Regional Meeting on Strategic HIV
Investment and Sustainable Financing
Kingston, Jamaica
May 29-30, 2013
Outline
1
• Changing in the global HIV financing
2
• The Role of the World Bank
3
• Economic Analysis of National AIDS Programs
4
• Approaches and Methodologies
5
• Discussion of issues
Changing in Global HIV Financing
IHP+
Gates
Foundation
Cha gi g of the World Ba k s ‘oles
Since the movement for HIV treatment created multiple
streams of vertical funding—led the World Ba k s MAP
and followed by PEPFAR and the Global Fund—there has
been increasing realization that a more general approach
to health systems strengthening is needed to support any
achievement of vertical targets.
The World Ba k s role i HIV o trol la ds ape is ha gi g:
• From HIV/AIDS Investment to Health System
Strengthening
• From investment lending to Non-lending Technical
Assistance
• From Bank alone investing to leveraging partnerships
4
The World Bank Financing HIV in the Caribbean
SVG
US$7M
SKN
US$4.05
ACTIVE
Project
T&T
US$20M
Barbados II
US$35M
STL
US$6.4M
US$156.86
Million
PANCAP
US$9M
Jamaica II
US$10M
Barbados
US$15.15
Jamaica I
US$10.6M
Guyana
US$10M
Grenada
US$
4.66M
Dominican
Republic
US$25M
CLOSED
Project
5
Economic Analysis of National AIDS
Programs
Completed:
– Jamaica: Financial Sustainability Study
– Colombia: Evidence-based Implementation Efficiency
Analysis
On-going
– Argentina: Using Result-based financing to improve
efficiency of National HIV/AIDS Program
– Brazil: Impact Evaluation of the National AIDS Program
– Dominica Republic: Efficiency analysis of the HIV/AIDS
National Response
– Mexico: Efficiency analysis of the National AIDS
Program
– Peru: Allocative efficiency of the National HIV/AIDS
Response
Concept of Efficiency
There are TWO main concepts of efficiency: allocative and
technical
Allocative efficiency: An allocative efficient position is achieved
when it is not possible to increase the overall benefits by
reallocating resources between programs.
Technical efficiency: A technically efficient position is achieved
when the maximum possible improvement in outcome is
obtained from a set of resource inputs.
Allocative efficiency is about whether to do something, or how
much of it to do, rather than how to do it.
Technical efficiency deals with how to do it.
7/22/2013
Approach and Methodology
Allocative
Efficiency
Strengthen
epidemiological
intelligence through
i. analysis of disease
burden and risk
factors.
ii. Integrative synthesis
studies
iii. Analysis of resources
allocation based on
evidence from (i)
and (ii)
Technical
Efficiency
i. Health system
integration analysis
ii. Management
analysis
iii. Cost-effectiveness
analysis
iv. Intervention delivery
options
Impact
Evaluation
Rigorously measures
the impact of a project
has on beneficiaries
through
i. Randomization.
ii. Instrumental Variable
•
iii. Regression
Discontinuity
iv. Difference -indifference
v. Propensity Score
Marching
vi. Pipeline Comparison
Allocative Efficiency
• The concept of allocative efficiency takes health
interventions (including services, drugs, and other
activities to improve health) as inputs and the health of
the population as outputs and outcomes (WHO, 2003).
• The concept of allocative efficiency takes into account not
only the productive efficiency with which healthcare
resources are used to produce health outcomes, but also
the efficiency with which these outcomes are distributed
among the community.
• The ter allo ative effi ie
refers to the a i izatio
of health outcomes with the least costly mix of health
interventions.
7/22/2013
Focus on Allocative Efficiency
• The goal is to allocate the scarce AIDS resources
more effectively, to ensure resources target
those at highest risk of transmitting HIV and
geographic areas of high transmission, with
proven, cost-effective interventions aligned to
epidemic context and focus resources and
interventions on epidemic priorities.
• Other areas: HIV service delivery efficiency,
institutional efficiency, transactional and
administrative efficiency, and information
efficiency, as well as HIV funding sustainability.
7/22/2013
Why Efficiency
• Lack of economic growth
• Limited fiscal space
• Need to reconcile growing demand for
services with available resources.
• Need to get the best value for money
12
The Pursuit of Allocative Efficiency
• Concept of allocative efficiency is not new
and relatively simple, but it is difficult to
achieve: failure rate is high in the public
sector. WHY
– Increase information requirement (data on costs)
– Increase transaction cost (need to measure
results)
– Increase political conflict (redistribution and say
No to some programs)
13
Issues with measuring Efficiency
• limited evidence on the cost-effectiveness of key HIV/AIDS
services, in part, due to the difficulty of obtaining accurate
epidemiological and cost data.
• limited evidence to support further scale-up and sustainability of
integration of voluntary counseling and testing (VCT) or IEC
campaign.
• Lack of systematic analyses of facility-level ART costs as well as of
effectiveness of risk-factor interventions in reducing HIV/AIDS
vulnerability.
• Little is known on how integration of HIV services impacts
effectiveness
14
The Path to Allocative Efficiency
Know your epidemics
Know your Objectives/goals
Know your
Strategy/resources
Know your results/impact
▪
▪
Who are the drivers of the epidemic
What are the risk factors
▪ What do you want to achieve by
when?
▪
▪
▪
▪
How to best achieve your goals?
What are the priorities ?
What are resources available?
What are the trade-offs?
▪ What are the outputs, outcomes
▪
and results?
What are the short-term and long
–term impact?
The World
Bank
1
5
15
[email protected]
www.worldbank.org/lachealth