title: The potential to expand antiretroviral therapy by improving health facility efficiency: evidence from Kenya, Uganda, and Zambia.
abstract: Since 2000, international funding for HIV has supported scaling up antiretroviral therapy (ART) in sub-Saharan Africa. However, such funding has stagnated for years, threatening the sustainability and reach of ART programs amid efforts to achieve universal treatment. Improving health system efficiencies, particularly at the facility level, is an increasingly critical avenue for extending limited resources for ART; nevertheless, the potential impact of increased facility efficiency on ART capacity remains largely unknown. Through the present study, we sought to quantify facility-level technical efficiency across countries, assess potential determinants of efficiency, and predict the potential for additional ART expansion.
  
  
  
  Using nationally-representative facility datasets from Kenya, Uganda and Zambia, and measures adjusting for structural quality, we estimated facility-level technical efficiency using an ensemble approach that combined restricted versions of Data Envelopment Analysis and Stochastic Distance Function. We then conducted a series of bivariate and multivariate regression analyses to evaluate possible determinants of higher or lower technical efficiency. Finally, we predicted the potential for ART expansion across efficiency improvement scenarios, estimating how many additional ART visits could be accommodated if facilities with low efficiency thresholds reached those levels of efficiency.
  
  
  
  In each country, national averages of efficiency fell below 50 % and facility-level efficiency markedly varied. Among facilities providing ART, average efficiency scores spanned from 50 % (95 % uncertainty interval (UI), 48-62 %) in Uganda to 59 % (95 % UI, 53-67 %) in Zambia. Of the facility determinants analyzed, few were consistently associated with higher or lower technical efficiency scores, suggesting that other factors may be more strongly related to facility-level efficiency. Based on observed facility resources and an efficiency improvement scenario where all facilities providing ART reached 80 % efficiency, we predicted a 33 % potential increase in ART visits in Kenya, 62 % in Uganda, and 33 % in Zambia. Given observed resources in facilities offering ART, we estimated that 459,000 new ART patients could be seen if facilities in these countries reached 80 % efficiency, equating to a 40 % increase in new patients.
  
  
  
  Health facilities in Kenya, Uganda, and Zambia could notably expand ART services if the efficiency with which they operate increased. Improving how facility resources are used, and not simply increasing their quantity, has the potential to substantially elevate the impact of global health investments and reduce treatment gaps for people living with HIV.
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Laura
authors.initials: L
authors.lastname: Di Giorgio
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Mark W
authors.initials: MW
authors.lastname: Moses
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Nancy
authors.initials: N
authors.lastname: Fullman
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Wollum
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Ruben O
authors.initials: RO
authors.lastname: Conner
authors.affiliation: Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda.
authors.forename: Jane
authors.initials: J
authors.lastname: Achan
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Tom
authors.initials: T
authors.lastname: Achoki
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Kelsey A
authors.initials: KA
authors.lastname: Bannon
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Roy
authors.initials: R
authors.lastname: Burstein
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Emily
authors.initials: E
authors.lastname: Dansereau
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Brendan
authors.initials: B
authors.lastname: DeCenso
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Kristen
authors.initials: K
authors.lastname: Delwiche
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Herbert C
authors.initials: HC
authors.lastname: Duber
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Emmanuela
authors.initials: E
authors.lastname: Gakidou
authors.affiliation: African Leaders Malaria Alliance, Kampala, Uganda.
authors.forename: Anne
authors.initials: A
authors.lastname: Gasasira
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Annie
authors.initials: A
authors.lastname: Haakenstad
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Hanlon
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.|Infectious Diseases Research Collaboration, Mulago Hospital Complex, Kampala, Uganda.
authors.forename: Gloria
authors.initials: G
authors.lastname: Ikilezi
authors.affiliation: Action Africa Help-International, Nairobi, Kenya.
authors.forename: Caroline
authors.initials: C
authors.lastname: Kisia
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Aubrey J
authors.initials: AJ
authors.lastname: Levine
authors.affiliation: School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.
authors.forename: Mashekwa
authors.initials: M
authors.lastname: Maboshe
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.|School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.
authors.forename: Felix
authors.initials: F
authors.lastname: Masiye
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Samuel H
authors.initials: SH
authors.lastname: Masters
authors.affiliation: School of Humanities and Social Sciences, University of Zambia, Lusaka, Zambia.
authors.forename: Chrispin
authors.initials: C
authors.lastname: Mphuka
authors.affiliation: Afya Resource Associates, Nairobi, Kenya.
authors.forename: Pamela
authors.initials: P
authors.lastname: Njuguna
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: Odeny
authors.affiliation: Bill & Melinda Gates Foundation, Seattle, WA, USA.
authors.forename: Emelda A
authors.initials: EA
authors.lastname: Okiro
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: D Allen
authors.initials: DA
authors.lastname: Roberts
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA.
authors.forename: Christopher J L
authors.initials: CJ
authors.lastname: Murray
authors.affiliation: Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Ave, Suite 600, Seattle, WA, 98121, USA. abie@uw.edu.
authors.forename: Abraham D
authors.initials: AD
authors.lastname: Flaxman
mesh_terms: D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D017598:Efficiency, Organizational; D015658:HIV Infections / Q000188:drug therapy*; D058016:Health Facility Administration; D006742:Hospital Bed Capacity; D006801:Humans; D007630:Kenya; D015999:Multivariate Analysis; D014454:Uganda; D015024:Zambia
chemical_list: D044966:Anti-Retroviral Agents
keywords: Antiretroviral therapy; Efficiency; HIV/AIDS; Sub-Saharan Africa