Assessing the costs and effects of anti-retroviral

therapy task-shifting from physicians to other

health professionals in Ethiopia Benjamin Johns MPA PhD1, Elias Asfaw MSc2, Wendy Wong BS1,

Abebe Bekele MSc2, Thomas Minior3 MPH MD, Amha Kebede PhD MSc2,

John Palen MPH PhD1

The 3rd Structural Drivers Conference

The Cullinan Hotel,

Cape Town, South Africa

5 – 6 December 2013

Presentation Outline

Introduction

Objective of the study

Methods and Model

oCost-effectiveness analysis and uncertainty

analysis

oDecision Tree Framework

Results

Discussion

Conclusion and Recommendation

Acknowledgment

Introduction An estimated 6.6 million people in low and

middle-income countries (LMICs) received

antiretroviral treatment (ART) in

2010.(UNAIDS, 2011)

In Ethiopia, there is increased number of

sites offering ART services and the ability of

existing sites to handle more patients.

These successes point to two related trends

in the provision of ART: 1) decentralization

and

2) task shifting of services.

(UNAIDS, 2011)

Trend in Number of People Living with AIDS who Accessed Chronic

HIV Care and ART (EFY, 1998 - 2004)

Source: FMOH health and health indicator report, 2011/12

Introduction

0

500

1000

2004/5 2010/11

3

743

No of Health facilities providing ART service

0

100000

200000

300000

2004/5 2010/11

8276

247805

Number of people accessing ART services

Since the introduction of ART in Ethiopia

in 2003, the delivery model has shifted

from a hospital-based program run by

physicians to a decentralized program

including delivery at the health center level.

(Koethe JR et al, 2010)

Thus, the scale and scope of tasks

shifted varies according to site,

NPCs at some sites delivering

almost all ART services and at other

sites delivering services limited to

routine monitoring and follow-up.

Objective of the study

To compare the probability that patients will be actively on ART

after two years and the costs of ART delivery across categories

of task shifting.

Two categories compared are

(1) Minimal and moderate task shifting and

(2) Maximal task shifting.

To examine the costs and effects of ART delivery at hospitals

and health centers.

To evaluate the effects, costs, and cost-effectiveness of

different degrees of antiretroviral therapy task shifting from

physician to other health professionals in Ethiopia.

Method

A stratified random sample of health networks

across four regions of Ethiopia:

1. Addis Ababa

2. Amhara,

3. Benishangul Gumuz, and

4. Oromia.

The regions were selected based on

important variables for obtaining a

representative sample (i.e. density of doctors,

density of ART patient load per facility by

region, and whether there would be facilities

with doctors administering ART).

Method…

Additional information's were collected from ART coordinators at:

Federal Ministry of Health,

Federal HIV/AIDS prevention and control office (FHPACO), and

Regional Health Bureaus

A health network was included, if regional staff reported that a

physician was involved in ART care at the hospital, the remaining

health networks were sampled at random.

Method…

Health facilities within each sampled network were selected.

o For each health network, we selected : the hospital and 2 or 3 health

centers, out of an average of 5.7 (range 2-15) health centers per network

were selected for each health network

Randomly sampled 50 patient records from those in the eligible time frame

The eligible time frame for the analysis include only patients starting from

January 2008 to June 2010, so as to ensure two year follow-up.

A change in ART guidelines was made in 2007

Decision Tree

Decision

Task Shifting Model 1

(Lower degree of

task shifting)

Patient active after 3 months

Patient active after 1 year

Patient active after 2 years

Cost = 1st year cost + 2nd year

costs

Outcome = 1

Patient not active after 2 years

Outcome = 0

Cost = 1st year costs + 2nd year

costs * (12*0.5)/12

Patient not active after 1

year

Cost = 1st year costs *

(12*0.5)/12

Outcome = 0

Patient not

active after 3 months

Cost = 1st year cost * (3*0.5)/12 months

Outcome = 0

Task Shifting Model 2

(Higher degree of

task shifting)

Patient active after 3 months

Patient active after 1 year

Patient active after 2 years

Cost = 1st year cost + 2nd year costs

Outcome = 1

Patient not active after 2 years

Outcome = 0

Cost = 1st year costs + 2nd year costs *

(12*0.5)/12

Patient not active after 1

year

Cost = 1st year costs * (12*0.5)/12

Outcome = 0

Patient not active after 3 months

Cost = 1st year cost *

(3*0.5)/12 months

Outcome = 0

Method…

The cost metrics of interest are the cost per patient per year for the first and second year of ART.

All costs are presented in 2011 US dollars, using a currency conversion rate of 15.997 Birr per

dollar and health sector inflation rates when necessary. (IMF, 2011; CSA, 2012)

All cost incurred in the second year of patient treatment are discounted using a 3%

discounting rate, and the same rate is used to calculate the annual equivalent cost. (Murray

CJ et al, 2000)

A decision-tree framework to assess the incremental costs and effect of maximal versus minimal

or moderate task shifting.

This model includes three time points (3 months, 1 year, and 2 years) after the initiation of ART,

and we calculate the risk-adjusted probability and conditional probability that a patient was still

active at each time point

Assumption: that the discontinuing patients die or become inactive half way through the

time period (on average)

Ethical clearance

This study received ethical review and approval from the:

o Scientific and Ethical Review Office of the Ethiopian Health and Nutrition

Research Institute and

o Institutional Review Board of Abt Associates.

o All patients interviewed were given oral informed consent before being

interviewed

Result

The sample comprised 21 hospitals and 57 health centers with 3,575 patient records

where outcome information was obtained.

Approximately 30% (1,090) of patients were receiving care at hospitals and 70%

(2,485)at health centers.

o 633 patient exit interviews.

No facilities where physicians handled all aspects of ART delivery, and only three

facilities where only physicians were solely responsible for initiating ART

o Forty-seven (60%) of facilities visited were classified as having either minimal or

moderate task-shifting.

Result…

At three months after initiation, 93% of patients were still actively on ART, with 94%

active at facilities with minimal or moderate task shifting and 90% at facilities with

maximal task shifting (p<0.05)

Over 90% of patients were still active one year after initiation, and over 88% of patients

were still active two years after initiation, with no statistically significant differences

between comparison groups.

The cost for ART was about $206 per patient per year for ART, with no statistically

significant differences between categories.

Combining the costs and effect estimates shows that maximal task shifting costs $36

(95% CI: -$40 to $111) more over 2 years per patient than minimal or moderate task-

shifting, but results in 0.4% (95% CI: -0.9% to 0.2%) fewer patients remaining active at

the end of two years

Result…

Comparison

Adjusted cost

over 2 years

per patient

starting ART

(risk adjusted)

Difference in

risk-adjusted

costs (95% CI*)

Proportion

still active

after 2 years

Difference in

risk-adjusted

effects (95% CI)

Cost-

effectiveness

ratio

Facilities with

minimal or

moderate task

shifting

(baseline)

$369

$36

(-40 to 111)

0.928

-0.004

(-0.009 to 0.002)

Not calculated:

Maximal task

shifting is

more costly,

less effective Facilities with

maximal task

shifting $404 0.926

Result…

There remains no statistically significant difference between the task shifting

categories after using regression to control for facility characteristics for

either outcomes or costs.

o The regressions show that facilities integrating ART care with other non-

HIV services, facilities referring patients out for further care, and facilities

with physicians on staff are associated with a lower treatment success

probability (p<0.05)

Having more patients is initially associated with better treatment success

probabilities, but this effect is attenuated with larger patient loads.

Result…

The results of regression analysis

attenuate the findings from the

unadjusted comparison, with

about 64% of bootstrapped pairs

having a better outcome, and 42%

of bootstrapped pairs showing

lower costs, for maximal task

shifting

-.0

2

0

.02

.04

.06

.08

Incre

men

tal pe

rcen

tage

active o

f m

axim

al ta

sk s

hifting

-600 -400 -200 0 200Incremental cost of maximal task shifting (US$)

Annex 5: Results of uncertainty analysis on incremental costs

and effects after regression adjustment

Result…

While previous studies suggest a cost difference between not task shifting and task

shifting models of delivery (Mdege ND et al, 2012); we did not find differences in costs

between degrees of task shifting.

o Incremental changes in the degree of task shifting do not greatly affect physician

time.

o Labor costs are less than 8% of estimated total costs, so the potential cost

savings may not be substantive enough to impact the total costs of ART.

Our study estimates two year retention rates (88%); and a 24-month retrospective

cohort study of ART patients starting ART from 2003 to 2006 in Ethiopia reported

retention of 76% at health centers and 67% at hospitals.

(Assefa Y et al, 2009)

Strength and Limitation

Strength:

Data reported here include a large number

of facilities and reflect implementation of

ART programs under routine, rather than

research, circumstances

To our knowledge, the first study to examine

the degrees of task shifting, especially

related to tasks beyond NPC ART initiation

Limitation:

Given that the study used observational data,

the results may reflect some selection bias

Some data, such as patients’ age, weight,

height, and sex, were not routinely available in

clinical records, limiting the depth of the

analysis

Conclusion and Recommendation

Shifting the handling both severe drug reactions

and antiretroviral drug regimen changes from

physicians to other clinical officers is not

associated with a significant change the 2 year

treatment success rate or the costs of ART care.

As an observational study, these results are

tentative, and more research is needed in

determining the optimal means of task shifting.

Acknowledgment

GOD, GOD, GOD

United States Agency for International Development (USAID) for

their financial support through Health Systems 20/20

Federal Ministry of Health (FMOH)

Federal HIV/AIDS Prevention and Control Office (FHAPCO)

Addis Ababa City Administration Health Bureau

Amhara Regional Health Bureau

Oromia Regional Health Bureau, and the

BenishangulGumuz Regional Health Bureau

References.docx

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