Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia

Abstract

Few studies have assessed the efficiency and quality of HIV services in low-resource settings or considered the factors that determine both performance dimensions. To provide insights on the performance of outpatient HIV prevention units, we used benchmarking methods to identify best-practices in terms of technical efficiency and process quality and uncover management practices with the potential to improve efficiency and quality. We used data collected in 338 facilities in Kenya, Nigeria, Rwanda, South Africa, and Zambia. Data envelopment analysis (DEA) was used to estimate technical efficiency. Process quality was estimated using data from medical vignettes. We mapped the relationship between efficiency and quality scores and studied the managerial determinants of best performance in terms of both efficiency and quality. We also explored the relationship between management factors and efficiency and quality independently. We found levels of both technical efficiency and process quality to be low, though there was substantial variation across countries. One third of facilities were mapped in the best-performing group with above-median efficiency and above-median quality. Several management practices were associated with best performance in terms of both efficiency and quality. When considering efficiency and quality independently, the patterns of associations between management practices and the two performance dimensions were not necessarily the same. One management characteristic was associated with best performance in terms of efficiency and quality and also positively associated with efficiency and quality independently: number of supervision visits to HIV units.

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Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

ART:

Antiretroviral therapy

DEA:

Data envelopment analysis

DMU:

Decision making unit

HTC:

HIV testing and counseling

ORPHEA:

Optimizing the Response in Prevention HIV Efficiency in Africa

ORPTHEN:

Optimizing the Response in Prevention and Treatment HIV Efficiency in Nigeria

PCA:

Principal components analysis

PMTCT:

Prevention of mother-to-child transmission

SUR:

Seemingly unrelated regression

VRS:

Variable returns to scale

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Acknowledgements

We thank all of the members of the ORPHEA study team. Mexico: Martin Romero-Martínez and Andrea Salas-Ortiz of the National Institute of Public Health, Mexico; Claire Chaumont of Harvard University; Amilcar Azamar-Alonso of McMaster University; Ivan Ochoa-Moreno of University of York; Ada Kwan, Raluca Buzdugan, and Rita Cuckovich of University of California, Berkeley; Alvaro Canales and Victor Canales of Sistemas Integrales, Santiago, Chile. Kenya: Mercy Mugo, Hellen Nyakundi, and Joseph Wang’ombe of University of Nairobi; Omar Galárraga of Brown University;Richard Wamai of Northeastern University. Rwanda: Sabin Nsanzimana, Jean Pierre Ayingoma, Placidie Mugwaneza, and Eric Remera of Rwanda Biomedical Center, Institute of HIV/AIDS, Disease Prevention & Control; Jeanine Condo, Collins Kamanzi, Nathalie Mulindahabi, Angele Musabyimana, and Sabine Musange of National University of Rwanda School of Public Health. South Africa: Neil Martinson, Jenny Coetzee, Charity Dire, Limakatso Lebina, and Sabelo Sekhukuni of the Perinatal HIV Research Unit, University of the Witwatersrand. Zambia: Felix Masiye, Abson Chompolola, Sydney Chauwa, and Bona Chitah of University of Zambia; Kumbutso Dzekedzeke of Dzekdzeke Research & Consultancy.

Funding

This study was conducted with funding from the Bill and Melinda Gates Foundation, Seattle, WA, USA. The funder played no role in the design of the study and collection, analysis, and interpretation of data and in the writing of the manuscript.

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Contributions

SGSR and SBA conceptualized the study. SGSR, MO, DCL, and SBA provided guidance on data analysis and interpretation of results. CCM and GHF contributed to all parts of the analysis and produced the tables and figures. SGSR, MO, and DCL wrote the initial and final drafts of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to David Contreras-Loya.

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The ethical review boards of the following institutions approved the study in Kenya, Rwanda, South Africa, and Zambia: National Institute of Public Health, Mexico; Kenyatta National Hospital and University of Nairobi; Northeastern University; Rwanda Biomedical Center; University of the Witwatersrand; and University of Zambia. The National Institute of Public Health, Mexico, and the Nigerian Institute for Medical Research approved the study in Nigeria.

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The authors declare that they have no competing interests.

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Sosa-Rubí, S.G., Bautista-Arredondo, S., Chivardi-Moreno, C. et al. Efficiency, quality, and management practices in health facilities providing outpatient HIV services in Kenya, Nigeria, Rwanda, South Africa and Zambia. Health Care Manag Sci (2021). https://doi.org/10.1007/s10729-020-09541-1

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Keywords

  • data envelopment analysis
  • HIV testing and counseling
  • prevention of mother-to-child transmission
  • process quality
  • technical efficiency
  • sub-Saharan Africa