HIV This Week

Souteyrand YP, Collard V, Moatti JP, Grubb I, Guerma T. Free care at the point of service delivery: a key component for reaching universal access to HIV/AIDS treatment in developing countries. AIDS. 2008 Jul;22 Suppl 1:S161-8.

User fees are a common feature of health system financing in low and middle-income countries. In the context of universal access to HIV treatment and care, the advantages of user fees for funding at country and local level should be balanced with their clinical and public health impact. Souteyrand et al reviewed the literature on user fees and the impact of user fees on HIV service delivery. Empirical evidence gathered since the 1980s shows that sustainability, efficiency and equity challenges faced by health systems have persisted with and have often been exacerbated by the introduction of user fees. The evidence on HIV suggests that free care at the point of service fosters uptake and helps to extend access for the poorest users. User fees are currently the main barrier to adherence to antiretroviral therapy. Their abolition is associated with better virological results and increased survival. Such abolition should be carried out in parallel with the implementation of financing mechanisms, such as prepayment and risk pooling, which are able to gather funds from the sectors of the population who are able to pay for healthcare and to promote equity towards the poorest. WHO has included free access to HIV treatment at the point of service delivery as a component of its public health approach for reaching universal access. Implementation of free HIV care should, however, be linked to efforts to strengthen healthcare systems, ensure long-term sustainability of funding and monitor equity of access to care.

Editors’ note: Financial barriers cannot be allowed to provoke non-adherence and compromise first-line treatment regimens. In March 2005, countries were advised to adopt a policy of free access to HIV treatment at the point of service delivery, following a WHO/UNAIDS/World Bank consultation. Abolition of user fees and introduction or strengthening of more equitable funding mechanisms can create positive spillover that increases access and strengthens health care infrastructure as a whole.

The number of people in the world living with HIV is increasing as HIV-related mortality has declined but the annual number of people newly infected with HIV has not. The international response to contain the HIV pandemic, meanwhile, has grown. Since 2006, an international commitment to scale up prevention, treatment, care and support services in middle and lower-income countries by 2010 has been part of the Universal Access programme, which itself plays an important part in achieving the Millennium Development Goals by 2015. Apart from providing technical support, donor countries and agencies have substantially increased their funding to enable countries to scale up HIV services. Many countries have been developing their HIV monitoring and evaluation systems to generate the strategic information required to track their response and ensure the best use of the new funds. Financial information is an important aspect of the strategic information required for scaling up existing services as well as assessing the effect of new ones. It involves two components: tracking the money available and spent on HIV at all levels, through budget tracking, national health accounts and national AIDS spending assessments, and estimating the cost and efficiency of HIV services. The cost of service provision should be monitored over time, whereas evaluations of the cost-effectiveness of services are required periodically; both should be part of any country’s HIV monitoring and evaluation system. This paper provides country examples of the complementary relationship between monitoring the cost of HIV services and evaluating their cost-effectiveness. It also summarizes global initiatives that enable countries to develop their own HIV monitoring and evaluation systems and to generate relevant, robust and up-to-date strategic information.

Editors’ note: If you have been lost in the jargon, this paper sorts out the differences between effectiveness (outcome or impact of programmes or services), efficiency (resources require to achieve a certain outcome or impact), equity (who benefits from programmes or services), and acceptability (both to users and providers of services and in terms of improvements in the quality of life that programmes achieve). These criteria are supported by other pieces of strategic information that underpin a plan of action for programmes or services, such as direct and indirect costs and HIV incidence/prevalence. Topping this off with a robust monitoring and evaluation system, similar to those that many countries are now developing, can enhance country responses.