Economic analysis of ART task shifting in limited resource setting using econometric

model: Ethiopia Case StudyElias Asfaw, Naod Mekonnen, Benjamin Johns, Wendy Wong, Abebe

Bekele, Yibeltale Assefa, John Palen, Amha Kebede, Shara Domin

13th Annual International Conference on Health Economics, Management and Policy 23-26 June 2014,

Athens, Greece

Table of Content

Background ~ ART task shifting Antiretroviral treatment program Objective of the study Methods Econometric model Results

Descriptive Analysis Econometric Model Analysis

Conclusion and future research direction

Background-ART Task shifting Sub-Saharan Africa is facing a crisis in human

health resources. Need to be scaled up by as much as 140% to

attain international health development targets (Kinfu et al, 2009).

The burden of HIV/AIDS has led to task shifting Task shifting- the name now given to a process of

delegation whereby tasks are moved, where appropriate, to less specialized health workers.

(WHO, 2007)

ART Task shifting ~ Ethiopia In Ethiopia, the ART delivery model has shifted

from a physician-led hospital based program to decentralized service delivery at health centers by the nurses and health officers.

2004/2005 2010/20110

100200300400500600700800

3

743

ART providing health facility

2004/2005 2010/20110

50000

100000

150000

200000

250000

8276

247805Antiretroviral service users

Source: FHAPCO ART performance report

ART Task shifting ~ Ethiopia However, there is scanty information available

concerning the cost differences associated with task shifting and decentralization and

The determinants of any possible cost differences.

The length of visit and type of the health professional providing the services affects the magnitude of cost difference.

Study Objective The research focuses on the relationship

between:

The length of a visit and the labor cost of visit with The explanatory variables:

1. Type of health profession type (doctors, health officers and nurses),

2. Type of health facilities (hospitals, health centers) and

3. Specific purpose of the visit (initiation, follow-up).

Method A stratified random sample of health facilities

across four regions of Ethiopia (Addis Ababa, Amhara, Benishangul Gumuz, and Oromia) is included in this study.

The unit of randomization was the health network, consisting of one hospital and its associated health centers.

The cost of resources used to deliver ART was collected from the health facilities and the Federal Ministry of Health.

Method… Data were collected on the number of staff working in

the ART clinic, how much time they spend in the ART clinic, how much time they work overall, and staff salaries.

Using a time motion study and task checklist, staff roles and time spent in ART care was assessed.

The labor cost spent for the visit was calculated and estimated through multiplying the length of the visit with average salary of a particular cadre of worker per minute. All costs are presented in 2011 Ethiopian Birr.

Econometric Model…

Econometric Model:Though there were many determinant variables

contributing to ART program success, this study emphasizes on the above mentioned 3 determinant variables.

An ordinary least square (OLS) model was applied with the following equations:

Econometric Model…Where:

• YLi= the length of visit,, = Cost of visit, • D2i= 1 if the professional is Nurse; 0 otherwise: • D3i= 1 if the professional Health officer; 0 otherwise:• D4i=1 if the facility is Hospital; 0 if facility is Health

Centre, and• D5i =1 if the type of patient seen at that particular

visit is initiation; 0 if the type of patient seen at that particular visit is follow-up.

Econometric Model…Log transformation of the dependent variable and using generalized linear models.

o For symmetric distribution of the variables, low skewness value and low kurtosis value

Cost of visit Log of cost of visit Length of visit Log of visitNumber of observation

665 665 665 665

Mean 1.72 0.35 8.42 1.95

Median (p50) 1.42 0.35 7.00 1.94

SD 1.14 0.61 5.67 0.61

Skewness 2.34 -0.04 2.35 -0.41

Kurtosis 15.1 2.81 14.86 2.80

Econometric Model…

Considering the above factors, ordinary least square (OLS) regression was applied to the log transformed dependent variable To estimate the difference among health professional types,

type of health facility and type of visit.

Both models were tested for proper functional form, outliers, residual normality, homoskedasticity, and multicollinearity.

YLi/…..4.3

Ethical Clearance…

The study approval in:

– the scientific and ethical review office (SERO) of the Ethiopian Public Health Institute and

– Institutional Review Board of Abt Associates, USA

FindingA total of 79 health facilities covered during the survey.

Time motion studies and task checklists were conducted with 665 patients.

Descriptive Analysis o The majority of patients (77%) saw nurses, while 19.6%

and 3.5% were treated by health officers and doctors. o 62% of the patients visited a health center, while the

remainder (38 percent) attended a hospitalo More than 60% of the patients were examined were

categorized as WHO stage 1 or II

Finding…

Length of Visit:• The average minutes spent by the a patient for ART

services was 8.46 minutes (range 1 to 60 minutes)per visit.• The average time spent with patients was similar at

health centers (8.3 minutes) and hospital (8.9 minutes).• The length of a visit with a doctor and senior a nurse

was almost similar, with each average spent 8.7 minutes. – Health officers spent average 7.6 minutes with a

patient

Finding…

Cost of Visit:o The overall mean cost per visit was 2 ETB, with the

range of 0 to 12 ETB (less than 0.5 USD). o The variation can be attributed to two factors

1. the amount of salary paid and 2. the amount of time spent during the visit.

The highest visit cost was recorded when a patient visited a physician/doctor (3.02 ETB), while visits with a nurse had the lowest cost (1.90 ETB).

Finding…

Cost of Visit:o The labor cost per visit further varies with the types

of the services provided: initiation, follow-up and referral. – The highest cost was for patient on initiation (2.32 ETB), – the lowest was for patients with continuing/ follow-up

visits (1.95 ETB). o The cost of a visit at hospitals averaged 2.04 ETB,

which is slightly higher than the average visit cost at health centers (1.91 birr).

Finding… 1) Result of model for the log of cost per visit

Variables Coef. Std. Err. P>t

Professional 0.15 0.08 0.02*

Facility 0.01 0.05 0.83

Type of visit -0.01 0.20 0.97

Constant 0.35 0.41 0.39

R2 for the above model was found to be 0.02, showing the model does explains little of the variation in the cost per visit.

The insignificant result from the Cook-Weisburg test indicates no heteroskadasticy.

Finding…

2) Result of model for the log of cost per visit• The second model was estimated using the log of length of visit

as the dependent variable. The coefficients of the second model are very similar to first model on the labor cost per visit.

Variables Coef. Std. Err. P>t

Professional

0.15 0.08 0.07

Type of visit

-0.01 0.20 0.97

Facility

0.01 0.05 0.83

Constant 1.94 0.41 0.00

Finding…The interpretation of the above two models follow the approaches suggested by Halvorson and Palmquist (2008).

The median length of visit for doctors (D=1) is found to be higher than that of nurses and health officers by 16 percent when controlling for health facility type and type of visit (P<0.05) The median cost per visit in hospitals (D=1) to be 1 percent higher than that of health centers (p-value = 0.97).The length of visit for a follow up/ continuing visit (D=1) would be 1 percent lower than that of an initiation visit (p-value = 0.83).

Finding…

Similar results were obtained using the length of visit as the dependent variable

The model suggests again that the median length of a visit for doctors (D=1) is longer than that of nurses and health officers by about 16 percent (p value < 0.05)

The results also indicates minimal differences in the length of visit in hospitals (D=1) than in health centers by type of visit

Policy Implication from the finding

The study indicated a 16 percent lower length of visit and labor cost per visit for ART patients treated by nurses and health officers as compared to physicians. o These findings support the principles underlying task

shifting (Huicho et al, 2008)o The study strongly supports the recent momentum of

task shifting initiation by WHO (2007)

Unlike the variable on the health professionals types, there was no statistically difference detected on the other variables, which suggests that efficiency gains are due, in fact, to task shifting.

Policy Implication from the finding…

Similar studies also indicated task-shifting as a cost-effective measure to maximize health workforce output (Babigumira, Castelnuovo et al. 2009), but should not be offset by cost attributed to compromised quality of care (Zachariah et al, 2009)

The small estimated visit cost could attribute to the lower amount of salary payment at the public health facilities in Ethiopia and huge flow of ART patients due to economic of scale.

Future research recommendation and limitation of the study…

Future research Limitation of the studyo Further research on other

determinant variables such as • quality of care should

be analyzed in order to show their cost difference.

o The impact of ART task shifting remains an important research question.

Due to limited availability of data only 3 determinant variables considered in our model

The models were limited to supply-side independent variables, without recognizing other variables (socio demographic, quality of care)

The cost analysis emphasized only the labor visit cost

Acknowledgment