Browsing by Author "Karengera, Stephen"

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    Scaling up ART in Rwanda: the financial and economic costs
    (2007) Karengera, Stephen; Cleary, Susan
    Rwanda has been rolling-out free antiretroviral treatment (ART) since 2004. This scale up could only be realised through significantly increased funding to the HIV/AIDS sub-account. Funding grew from US$9 million in 2003 to US$43 million in 2004 (UNAIDS, 2006b) and has continued to grow since this time given increased grants from GFATM and PEPFAR. Although international funding has been pivotal in the initiation of ART roll-out in resource poor settings, national programmes must look inwards for long term sustainability. This raises the question of whether the country will be able to sustain this level of funding once these grants cease ot are significantly reduced. This question could be answered to a large extent if one knew the lifetime costs of providing ART in Rwanda and the capacity of the country to raise domestic revenue. Unfortunately the body of evidence on unit and lifetime costs for providing ART in Rwanda is nonexistent. The study aimed to determine the economic costs of scaling up ART in Rwanda. Costing from the provider's perspective was undertaken based on data from 3,310 patients in 3 ART sites. The health care utilisation and cost data obtained, supplemented by appropriate secondary data, were used to estimate the cost perpatient period and lifetime costs. These were then used to model the costs of scaling up and to explore the financial sustainability of ART in Rwanda.
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    Scalling up ART in Rwanda: the financial and economic costs
    (2007) Karengera, Stephen; Cleary, Susan
    Rwanda has been rolling-out free antiretroviral treatment (ART) since 2004. This scale up could only be realised through significantly increased funding to the HIV/AIDS sub-account. Funding grew from US$9 million in 2003 to US$43 million in 2004 (UNAIDS, 2006b) and has continued to grow since this time given increased grants from GFATM and PEPFAR. Although international funding has been pivotal in the initiation of ART roll-out in resource poor settings, national programmes must look inwards for long term sustainability. This raises the question of whether the country will be able to sustain this level of funding once these grants cease or are significantly reduced. This question could be answered to a large extent if one knew the lifetime costs of providing ART in Rwanda and the capacity of the country to raise domestic revenue. Unfortunately the body of evidence on unit and lifetime costs for providing ART in Rwanda is nonexistent. The study aimed to determine the economic costs of scaling up ART in Rwanda. Costing from the provider's perspective was undertaken based on data from 3,310 patients in 3 ART sites. The health care utilisation and cost data obtained, supplemented by appropriate secondary data, were used to estimate the cost per-patient period and lifetime costs. These were then used to model the costs of scaling up and to explore the financial sustainability of ART in Rwanda. Key findings: The modelled costs per-patient period were US$244 for patients during the first six months on the first-line regimen and US$306 annually thereafter. Once firstline had been failed, costs increased to US$792 for the first six months on second-line and were US$1,299 during each annual period thereafter. Costs were US$680 per annum once both treatment regimens had been failed. Lifetime costs were determined to be $4,440 discounted at 3% and US$4,815 undiscounted. This corresponded to an annual average cost of US$741 or US$683 discounted at 3%. The 5-year cumulative costs of rolling-out ART, based on policy targets of initiating 153,014 adults on ART by 2011, were estimated to be US$206 million, or US$192 discounted at 3%. The cumulative total costs for scaling up was US$187 million or US$173 million discounted at 3%. The percentage composition of these costs was 70% ARVs, 12% clinical staff, 9% monitoring laboratory tests and 4% overheads. Over the period annual total costs increased from US$19 million in 2007 to US$62.5 million in 2011, an increase of 328%. Most of this increase was accounted for by increases in the costs of ARVs corresponding to 376%. The study established that 98.6% of ART provider costs were funded from public sources, of which 20% was domestic (central government) revenue and 80% foreign aid. Ceteris paribus, the ratio of domestic to foreign funding would rise to 1 to 5 or 17% to 83% by 2011. The ratio widens to about 2% to 98% when financial costs are considered. The combined commitment of US$243.4 million from Global Fund and PEPFAR is expected to cover nearly all patient specific costs during the scaling up period. The total health care resource envelope allocated to the Ministry of Health from public revenue in the financial year 2006/07 was US$73.5 million, of which 2.3% was from taxes and 97.7% from foreign aid. This is 7.8% of the total government budget (including donor funds). Total budgetary allocations to the Ministry of Health grew from US$50.1 in 2005 to US$73.5 million by 2007, equivalent to an increase of 46.7%. This growth was mainly accounted for by external resources, which grew by 50% while domestic resources fell by 40% during the same period. This finding does not augur well for sustainability of the ART programme in Rwanda. The total number of doctors in the public and the quasi-public sector is 204 and there are 465 unfilled posts (Ministry of Health 2006). The total number of full-time-equivalent (PTE) doctors (OPs) required for scale up was estimated to be 68 in 2007 rising to 164 in 2011. This would consume up to 33% of available physician time in 2007 and 80% in 2011 holding other things constant. A similar number of PTE counsellors would be required over the same period. The number xu of nurses was estimated to be 204 and 491 . in 2007 and 2011 respectively. Considering the human resource deficit in Rwanda and the number required to scale up ART there are serious con˜erns of ART crowding out other services. Although this cost analysis only includes ART provider costs for adult outpatients in public facilities in Rwanda, costs are projected to exceed US$62 million by 2011 if scaling up achieves 130,000 patients in care. At this level of scale, ART funding would need to grow by a rate exceeding 50% annually. It is difficulty to sustain such a level of funding from public revenue alone. Innovative health care financing mechanisms that exclude user fees need to be devised. Given that user-fees paid at the point of treatment have negative equity implications, other innovative financing approaches are needed to improve the financial sustainability of the ART programme.