Focusing on Efficiency in the AIDS Fight

The context today is very different. We are already spending record amounts of money and treating record numbers of patients. But the needs are increasing rapidly while the funds available for treatment have all but flatlined. The fight needs to focus on deploying our limited resources more efficiently.
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When the United Nations prioritized the fight against HIV in the 2001 Millennium Development Goals (MDGs), a lack of affordable treatment options meant we could only scale up prevention, treating less than 1% of patients living with the disease. Fifteen years later, more than 15 million patients are receiving treatment, and we have hopes of ending the epidemic by 2030.

The enormous gains achieved over the past decade and a half were largely made possible by an unprecedented financial mobilization around HIV, focusing on one simple target: increasing the number of people receiving treatment.

The context today is very different. We are already spending record amounts of money and treating record numbers of patients. But the needs are increasing rapidly while the funds available for treatment have all but flatlined. The fight needs to focus on deploying our limited resources more efficiently.

At one time, HIV meant certain death. No longer. The more successful the treatment--that is, the longer it keeps patients alive--the greater the absolute number of patients requiring treatment. With the population of Africa, where the vast majority of HIV cases occur, expected to more than double by 2050, the challenge of maintaining these 15 million patients on treatment and providing treatment to the rest of people living with HIV (an estimated 35 million) becomes that much greater.

Meanwhile, contributions to the global fight against HIV are slowing due to competing funding priorities, from climate change to Ebola and other health issues.

From 2000 to 2014, the United States--the single largest contributor to such efforts--raised annual funding for global health from US $1.6 billion to $8.4 billion. For fiscal year 2016, the administration's budget request is roughly flat, and this trend is not likely to stop. Of the eight MDGs set in 2001, one was specifically dedicated to fighting TB, HIV and malaria; of the 17 Sustainable Development Goals set in 2015 to replace the MDGs, only one is health-related, and it's dedicated to "health" in general. Funding increases from African governments may fill some of the void but are not likely to be sufficient.

Competition means that countries and donors need to become smarter and more effective with resource allocation. Disease fighters must learn how to increase productivity and stretch their dollars to deliver services to a growing client base without parallel increases in resources.

Sound familiar? For those of us in the private sector, there is a strong parallel with the challenges corporations face when competition increases and the economy slows down. We can learn much from those that survive and thrive.

During the economic boom in the '60s, most companies focused solely on growth. This continued until the economic crisis in the '70s intensified competition, demanding a shift in strategy from "growth" to "efficiency."

The fight against HIV is at a similar juncture. Until now, most global development organizations focused on treating more patients (i.e. growth), rejecting efficiency as a business term ill-suited for the social sector. Heightened competition for stagnant resources means the only way to continue to grow--and save more lives by doing so--is by using resources more efficiently. Corporations learned that the focus needs to shift to operational effectiveness. We now need to translate this into the operations of African health centers.

As part of a recent project, my colleagues and I reviewed the performance of health centers in Africa. Despite operating with the same resources and same constraints, some centers achieved better outcomes than others. We further investigated the performance of 45 health facilities in Kenya, Senegal, and Uganda that were achieving higher results than average to determine what they were doing differently. Our goal was to identify efficiency-boosting measures that could be replicated at other facilities. The effort was not in vain.

One strategy we observed is differentiation--that is, tailoring services and delivery models to customers. In this case, patients. Some facilities tailored their HIV drug delivery systems to the needs and constraints of their patients, leveraging community distribution of drugs for stable patients (a patient-friendly distribution method in which all the drugs required by beneficiaries in a given community are delivered to a central location for easy pickup, sparing beneficiaries a trip to the center). This alone reduced the per-patient cost of HIV treatment by 20 percent. If deployed across Africa, this could reduce total spending by the countries with the heaviest HIV disease burdens by almost $750 million annually, without any treatment reductions.

Another way in which facilities differentiated among patients was to lengthen the time between appointments for the most-stable patients from the usual one-to-two months to three months. This too, if broadly adopted, could reduce costs by another 20 percent and save an additional $700 million per year--without impacting patient care. The combined savings from these two measures alone would enable an additional 3.8M HIV patients to be treated without increasing current budgets.

The efficiency strategies employed by Africa's top-performing health centers are not widely used today. If broadly adopted, hundreds of millions of dollars could be saved each year, money that could finance treatment for millions of additional patients.

HIV fighters will need to switch to continuous efficiency improvement as corporations do. Only by thinking, organizing, and using resources differently can the global health community end the epidemic.

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Mathieu Lamiaux is a Paris-based senior partner of The Boston Consulting Group (BCG) with more than 15 years' experience working with governments, international institutions, NGOs, and private-sector organizations to improve access to care in emerging economies and develop more efficient and effective health systems. He currently leads the firm's Health Care practice in Western Europe, South America, and Africa.

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