Academic journal article Bulletin of the World Health Organization

Is There Scope for Cost Savings and Efficiency Gains in HIV Services? A Systematic Review of the Evidence from Low- and Middle-Income countries/Est-Il Possible De Faire Des Economies et D'obtenir Des Gains En Termes D'efficacite Dans Les Services Anti-VIH? Un Examen Systematique Des Elements De Preuve Dans Les Pays a Revenu Faible et Intermediaire

Academic journal article Bulletin of the World Health Organization

Is There Scope for Cost Savings and Efficiency Gains in HIV Services? A Systematic Review of the Evidence from Low- and Middle-Income countries/Est-Il Possible De Faire Des Economies et D'obtenir Des Gains En Termes D'efficacite Dans Les Services Anti-VIH? Un Examen Systematique Des Elements De Preuve Dans Les Pays a Revenu Faible et Intermediaire

Article excerpt

?Hay margen para el ahorro de costes y el aumento de la eficacia en los servicios de VIH? Un examen sistematico de la evidencia de paises con ingresos bajos y medios

Introduction

To reach the Millennium Development Goals for human immunodeficiency virus (HIV) infection (1) and the targets of the Political Declaration on HIV and Acquired Immunodeficiency Syndrome (AIDS), (2) many low- and middle-income countries still need to scale up essential HIV services. Given the scarce financial resources available and competing donor priorities, methods to improve efficiency in the delivery of HIV services are gaining increased global attention. (3-6)

In general, an "efficient" HIV service cannot be improved without the further use of existing resources and cannot be maintained at its current level with fewer resources. The word "efficiency" has several dimensions when applied to HIV services. For example, economic theory distinguishes between efficiency from improving social welfare--the "allocative" efficiency that is often assessed in the health sector in terms of cost-effectiveness--and a more contained definition of efficiency that examines how best to use resources to provide individual services--the "technical" efficiency that is commonly assessed in terms of the unit costs of a service. Two potential areas for improving technical efficiency are service scale and service scope. "Economies of scale" are the reductions in the unit cost of a service that might be achieved when the volume of that service's provision is increased, whereas "economies of scope" are the reductions in the unit cost of a service that might be observed when that service is provided jointly with other services. (3,4,7-12)

There have been several recent reviews of the data available on the costs and cost-effectiveness of HIV interventions. (3,4,7-13) Most of these reviews were focused on allocative efficiency. (3,4,7,9,12) The results of the few previous studies on the technical efficiency of HIV services indicate not only that there is considerable variation--between service providers and between settings--in the unit costs of providing similar HIV services, but also that there is, in general, much scope for improving the technical efficiency of HIV services. (7,9,14) However, these reviews are outdated or were only partial in their coverage of possible interventions.

Given the current interest of policy-makers in reducing the costs of HIV services, there is now an urgent need to update and synthesize the data on the technical efficiency of HIV services. We therefore present here a systematic literature review of the costs of the six basic programmatic activities of the Strategic Investment Framework of the Joint United Nations Programme on HIV/AIDS (UNAIDS): antiretroviral therapy (ART) and counselling and testing; "key-population" programmes--that is, programmes that target groups of individuals who are at particularly high risk of HIV infection; condom distribution and social marketing; voluntary medical male circumcision; programmes to eliminate HIV infections among children and to keep their mothers alive; and programmes of behaviour-change communications targeted at young adults and the general population. (15)

Methods

Search strategy and selection criteria

We conducted a systematic review of the peer-reviewed and "grey" literature on HIV services in low- and middle-income countries by following the search and analysis process recommended in the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. (16) The PubMed and Eldis databases and the Cochrane library were searched, using AIDS, HIV, acquired immunodeficiency syndrome, cost, cost analysis, efficiency, economies of scale and economies of scope as the search terms. Searches were limited to English-language articles published between January 1990 and October 2013. Manual searches of the web sites of key organizations were also carried out to identify grey literature and minimize the risk of publication bias (Fig. …

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