Technical efficiency and its relation to health providers' competence and scale of production of HTC services in Africa: A multi-country cost and quality of care study

Introduction: Staff costs comprise the largest share of average facility costs to provide HIV prevention services. Evidence has shown that greater scale of production reduces average costs of these interventions. Little is known about the optimal combination of staff and quality that predict technical efficiency, as to increase value-for-money of HIV spending.

Methods: A cost analysis was implemented at 92 facilities offering HTC in Kenya, Zambia, Rwanda and South Africa in 2011-2012. Staff costs were allocated to interventions using time-motion data. Standardized vignettes were administered to score technical proficiency. We estimated average staff cost by dividing total prorated staff costs by the number of HTC clients in each facility. We created quantiles of operation scale and quality, to analyze its tradeoff and explore costs efficiency of HTC delivery.

Results: Mean staff costs per client tested were 18.8 USD (IQR: 0.5;18.1), with heterogeneity by facility type. Independent of health providers' competence score, operation scale negatively correlated with average costs: Moving from the first quartile of scale towards the upper quartile yielded a 90% reduction in staff costs. Among the subset of facilities in the uppermost quartile of scale, we found a mean difference in staff costs between the lower and upper quartiles of providers’ competence of 1.2 USD.

Conclusions: These results demonstrate the need to understand the mechanisms that curb efficiency in the provision of HIV prevention interventions. We provide evidence of the possibility to achieve higher quality of care without escalating the budget, provided that service utilization is increased.