Access, Bottlenecks, Costs, and Equity (ABCE):

1. Access, Bottlenecks, Costs, and Equity (ABCE):
Understanding the costs of and constraints to
health service delivery in Uganda
On behalf of the ABCE research team
Institute for Health Metrics and Evaluation | Infectious Diseases Research Collaboration
January 2015

2. Overview
• Overview of the ABCE project in Uganda
• Key findings
o Facility capacity and service provision
o Non-HIV patient perspectives
o Efficiency and costs of care
o A focus on HIV: service provision and
patient characteristics
o Results from the Viral Load Pilot Study
• Using ABCE work and findings for
policymaking
• Conclusions

3. Overview of the ABCE project in Uganda

4. Overview of the ABCE project in Uganda
ABCE study design and implementation
• Collaboration between IDRC and IHME
• Primary data collection took place in two phases:
o April – October 2012
o April – August 2013
• Four main data-collection mechanisms:
o ABCE Facility Survey
o Clinical chart extractions of HIV-positive patients on ART
o Patient Exit Interview Survey
o Biological samples for the Viral Load Pilot Study

5. Overview of the ABCE project in Uganda
ABCE Facility Survey
• Primary data collection from a
nationally representative sample of
247 facilities
• Collected data on a full range of
indicators
o Inputs, finances, outputs, supply-side
constraints and bottlenecks, indicators
for HIV care
• Randomly sampled a full range of
facility types
o National and regional referral
hospitals, district hospitals, health
centers, clinics, drug stores or
pharmacies, and DHTs

6. Overview of the ABCE project in Uganda
Clinical chart extraction
• Extracted data on HIV-positive patients currently enrolled in ART
• Chart data included patient demographic information, ART initiation
characteristics (e.g., CD4 cell count, WHO stage, drug regimen,
referral points), and patient outcomes

7. Overview of the ABCE project in Uganda
Patient Exit Interview Survey
• Over 3,900 structured interviews
were conducted with patients
after they exited facilities from
the ABCE sample.
• Interviewees include patients
who sought HIV care and those
who presented at facilities for
non-HIV services.
• Questions included reasons for
the facility visit, satisfaction with
services, expenses paid
associated with the facility visit,
and HIV-specific indicators.

8. Overview of the ABCE project in Uganda
Viral Load Pilot Study
• Included 15 facilities within the
ABCE sample.
• Compared measures of patient viral
load (VL) assessed by plasma and
dried blood spots (DBS).
• Also collected concurrent measures
of CD4 cell counts.
• Collected data from patients who
had been on ART between 6 and 60
months from 15 facilities in the ABCE
sample.

9. Key findings from the ABCE project in Uganda
Facility capacity and service provision

10. Facility capacity and service provision
Availability of health services in 2012
• Relatively high availability of key services across platforms,
especially among public or NGO-owned facilities.
o 94% had a formal immunization program
o 85% offered antenatal care (ANC)
o 83% provided family planning options
o 72% had HIV/AIDS care
o 93% stocked ACTs for treating malaria
• Other services remained fairly scarce, particularly at lower levels
of care.
o e.g., emergency services were available at 73% of district hospitals, 42%
of health center IVs, and 28% of health center IIIs

12. Facility capacity and service provision
Gaps in reported and functional capacity for care, 2012
• Many facilities reported providing a given service, but then lacked
the full capacity to provide that service (e.g., lacking functional
equipment or stocking out of medications).
Service
Facilities reporting
capacity
Facilities with
functional capacity
Antenatal care 78% 13%
General surgery
services
24% 5%

13. Facility capacity and service provision
Gaps in reported and functional capacity for ANC
• Sulfadoxine/pyrimethamine (SP) was widely available across platforms
for IPTp.
• Outside of hospitals, few facilities had the capacity to perform important
tests for ANC (e.g., Rh factor, blood glucose).
• Less than 20% of health centers had ultrasound.
• District hospitals had the smallest discrepancy in reported and functional
capacity (100% reported providing ANC, 73% were fully equipped to
provide ANC).
• Health center IVs and health center IIIs had the widest discrepancy (96%
reported providing ANC, less than 5% were fully equipped).

14. Facility capacity and service provision
Gaps in reported and functional capacity for ANC, 2012

15. Facility capacity and service provision
Availability of and deficiencies in physical capital
• Power supply
o All hospitals were connected to the energy grid, whereas 30% of health
center IIIs and 66% of health center IIs lacked access to the energy grid.
o Just over 50% of facilities that had access to the energy grid also had a
generator.
• Water and sanitation
o Nearly all hospitals had piped water and sewer infrastructure (flush
toilets).
o The majority of health centers had at least a covered pit latrine and an
improved water source; however, it was less than the 2010 MOH target.
• Transportation and communication
o The majority of primary care facilities lacked emergency transportation
and did not have access to a facility-based phone.

16. Facility capacity and service provision
Availability of and deficiencies in physical capital, 2012

17. Facility capacity and service provision
Availability of equipment across platforms
• Individual types of equipment
o Hospitals had a greater availability of most functional equipment than
primary care facilities.
o Relatively basic equipment, such as glucometers and ultrasound, was
generally available among 20% of health centers.
• Full stocks of medical equipment for levels of care
o Applied the WHO Service Availability and Readiness Assessment (SARA)
survey standards for a subset of equipment and their availability.
o Hospitals generally had a higher availability of equipment
recommended for their level of care than primary care facilities.

18. Facility capacity and service provision
Availability of recommended equipment for level of care, 2012
Based on a subset of items from the WHO SARA survey

19. Facility capacity and service provision
Availability of pharmaceuticals across platforms
• Based on the 2012 Essential Medicines List (EML), most facilities
had at least 50% of the pharmaceuticals recommended for their
level of care.
• Stocking of EML pharmaceuticals ranged within platforms,
especially health center IIIs and health center IIs.
• Most commonly missing pharmaceuticals:
o Key contraceptive medications
o Opiate pain medications
o Medications to treat NCDs

20. Facility capacity and service provision
Availability of recommended pharmaceuticals for level of care, 2012
Based on the 2012 EML list

21. Facility capacity and service provision
Capacity for disease-specific case management
• Assessed the proportion of medical equipment, tests, and
pharmaceuticals available to manage a subset of conditions that cause
large disease burden in Uganda.
• Identified diseases based on the Global Burden of Disease 2010 study
(GBD 2010):
o Infectious diseases: lower respiratory infections (LRIs), HIV/AIDS, malaria,
meningitis
o Non-communicable diseases (NCDs) and injuries: diabetes, injuries,
ischemic heart disease
• Facilities had the greatest capacity to diagnose and treat LRIs, HIV/AIDS,
and malaria, but this capacity declined with levels of care.
• Facilities were least equipped to manage NCDs, especially among health
centers.

22. Facility capacity and service provision
Capacity for disease-specific case management, 2012

23. Facility capacity and service provision
Vaccine storage temperature for immunization services
• Of the facilities that routinely stored vaccines, 8% had refrigerators
operating outside of the optimal range (2°C to 8°C).
• A greater proportion of facilities had storage temperatures below
the optimal range (5%) than above (3%).
• Health center IIs had the greatest proportion of storage
temperatures below 2°C or above 8°C (14%).
• All health center IIIs and health center IIs with improper
temperature readings lacked functional electricity.

24. Facility capacity for service provision
Vaccine storage temperature for immunization services, 2012

25. Facility capacity and service provision
Capacity to test for and treat malaria
• 93% of all facilities, including pharmacies, stocked artemisinin-
combination therapies (ACTs) at the time of facility visit.
• 91% of publicly owned facilities had either rapid diagnostic tests
(RDTs) or a microscope to test for malaria.
• All referral and district hospitals had the concurrent availability of
ACTs and RDTs; 95% of health center IVs and 85% of health center
IIIs had both.
• Demonstrates a successful uptake of Uganda’s policy for
parasitological confirmation of malaria in the public sector.
• Private and NGO-owned facilities showed a lower availability of malaria
testing than their public equivalents.

26. Facility capacity for service provision
Capacity to test for and treat malaria, 2012

27. Facility capacity and service provision
Human resources for health
• Nurses accounted for the largest proportion of staff personnel
across platforms, ranging from 33% at private hospitals to 57% at
district hospitals.
• On average, 71% of personnel were considered skilled medical
staff.
• Seven facilities – one district hospital and six health center IIIs –
achieved the staffing goals outlined by the HSSP II.
• There was no direct relationship between facility staffing and
urbanicity; however, far fewer rural health center IVs met the
staffing goal for nurses.

28. Facility capacity and service provision
Human resources for health: district hospitals, 2012

29. Facility capacity and service provision
Human resources for health: health center IVs, 2012

30. Facility capacity and service provision
Outputs, 2007-2011
• Outpatient visits remained relatively stable over time across facilities.
o The clear exception was referral hospitals, at which an average 11% annual
gain in outpatient visits occurred between 2007 and 2011.
• Inpatient visits were fairly consistent between 2007 and 2011.
o Referral hospitals were the exception, with average inpatient visits
increasing 4% annually during this time.
• ART visits rapidly rose at a subset of platforms from 2007 to 2011.
o There was a 115% increase across all facilities.
o Largely driven by referral hospitals, recording an average of 64,620 ART
visits in 2011.
o Health center IVs and health center IIIs also had a large rise, but their
relative patient volumes were much smaller than other platforms.

31. Facility capacity and service provision
Outputs: average outpatient visits, by platform, 2007-2011

32. Facility capacity and service provision
Outputs: average inpatient visits, by platform, 2007-2011

33. Facility capacity and service provision
Outputs: average ART visits, by platform, 2007-2011

34. Key findings from the ABCE project in Uganda
Non-HIV patient perspectives

35. Non-HIV patient perspectives
Patient reports of expenses associated with facility visit
• As part of the Patient Exit Interview Survey, patients who did not
seek HIV services reported the types of expenses they had in
association with the facility visit.
• Ugandan policies abolished user fees for health centers and
general wings of public hospitals in 2001.
• Based on the ABCE sample, very few patients (3%) reported any
medical expenses associated with visits to public facilities.
o By contrast, 82% of patients seeking care at private facilities had
medical expenses.

36. Non-HIV patient perspectives
Patient reports of expenses associated with facility visit, 2012

37. Non-HIV patient perspectives
Levels of patient medical expenses
• Of patients who had medical expenses at public facilities, 75%
spent less than 10,000 Ushs ($4).
• By contrast, many patients spent at least 20,000 Ushs ($8) in
medical expenses at private facilities.

38. Non-HIV patient perspectives
Levels of patient medical expenses, by facility, 2012

39. Non-HIV patient perspectives
Patient wait times at facilities
• Just over half of patients reported less than an hour waiting
for care, whereas 49% of patients had to wait at least an hour
before seeing a provider
• At referral hospitals, 40% of patients spent more than two
hours waiting for care. At private hospitals, 45% of patients
received care within 30 minutes.
• Among health centers, a greater proportion of patients
received care within an hour with descending levels of care.

40. Non-HIV patient perspectives
Patient reports of wait times at facilities, by platform, 2012

41. Non-HIV patient perspectives
Patient ratings of facilities
• Overall, patients gave high ratings for care received across
platforms.
• Patients rated staff interactions highly, especially for medical
provider respectfulness.
• Patients generally gave lower ratings to facility
characteristics, particularly for spaciousness and wait time.

42. Non-HIV patient perspectives
Patient overall ratings of facilities, by platform, 2012

43. Non-HIV patient perspectives
Average patient ratings of facility indicators, by platform, 2012

44. Key findings from the ABCE project in Uganda
Efficiency and costs of care

45. Efficiency and costs of care
Estimating efficiency: Data Envelopment Analysis (DEA)
• DEA: quantifies the relationship between a facility’s resources (medical
staff, beds) and its production of services (outpatient visits, inpatient bed-
days, births, and ART visits) relative to comparably sized facilities in the
ABCE sample.
• Efficiency score: a value between 0% and 100%, reflecting the alignment
of facility resources to service production.
o 100% = maximum use of facility resources for output production
• Outpatient equivalent visits (OEV): weighting different outputs in a
standardized way to allow for direct comparisons across facilities.
o Average across facilities:
 Inpatient bed-day = 3.7 outpatient visits
 Birth = 10.5 outpatient visits
 ART visit = 1.7 outpatient visits

46. Efficiency and costs of care
Average production of outputs across facilities
• Across platforms, facilities averaged a total of five outpatient equivalent
visits per medical staff per day, ranging from 4.3 visits at health center IIs
to 7.0 visits at clinics.
• Outpatient visits accounted for the largest proportion of patient visits
experienced per medical staff per day at primary care facilities and
private hospitals.
• Inpatient bed-days accounted for the largest proportion of patient visits
produced per medical staff per day at referral and district hospitals.
• Private hospitals recorded the largest volume of ART visits per medical
staff per day (1.7, as measured in OEV).

47. Efficiency and costs of care
Average production of outputs across facilities, 2011
Note: All visits are in outpatient equivalent visits, with an average of one inpatient bed-day equaling 3.7
outpatient visits; one birth equaling 10.5 outpatient visits; and one ART visit equaling 1.7 outpatient visits.

48. Efficiency and costs of care
Efficiency scores varied across and within platforms
• Across all facilities, the average efficiency score was 31%.
• Over half of facilities had an efficiency score at or less than 30%.
• Average efficiency scores declined in parallel with decreasing levels of
care among public facilities.
• Tremendous range in efficiency scores within platforms:
o At least one facility had an efficiency score of 100% for each platform.
o Multiple facilities had efficiency scores close to 0% for each facility type.
• No consistent relationship between urbanicity and efficiency scores:
o Urban hospitals generally had higher efficiency scores than rural hospitals.
o Rural health centers generally had higher efficiency scores than urban
health centers.

49. Efficiency and costs of care
Efficiency scores across platforms, 2007-2011

50. Efficiency and costs of care
Estimated potential for expanded service production
• We estimated that facilities had substantial potential for increasing
output production, especially among lower levels of care.
• An average of 16 additional visits, measured in OEV, could be
added across facilities, based on observed resources.
• This potential for expanded service production does not reflect
the quality of services delivered; it shows the alignment of facility
resources and output production.

51. Efficiency and costs of care
Estimated potential for expanded service production, 2011

52. Efficiency and costs of care
Cross-country comparison of efficiency
• Uganda showed more potential for expanded service
provision, given observed resources, than Kenya and Zambia.

53. Efficiency and costs of care
Estimating costs of care
• Using information produced through DEA, output-specific
spending by facilities was divided by outputs produced by each
facility.
• All cost data were adjusted for inflation and reported in 2011
Ugandan shillings (Ushs).
o All US dollar estimates were based on the 2011 exchange rate of 2,500
Ushs per $1.

54. Efficiency and costs of care
Average facility cost per visit, across outputs and by platform
• Facility costs per patient visit varied across platforms and by
output type.
• The average facility cost per outpatient visit was generally the
least expensive to produce, and births were the most expensive.
• Private hospitals generally spent the most per patient visit
produced, whereas health center IIIs generally produced patient
visits at the lowest facility cost per output.

55. Efficiency and costs of care
Average facility cost per visit, across outputs and by platform

56. Efficiency and costs of care
Cross-country comparison of output costs
• Ugandan facilities averaged the least expensive production cost
per outpatient visit and ART visit (excluding the cost of ARVs).

57. Key findings from the ABCE project in Uganda
A focus on HIV: service provision and patient characteristics

58. HIV service provision and patient characteristics
ART regimen at initiation, 2008-2012
• From 2008 to 2012, there was a rapid transition away from d4T-
based ART regimens toward those with a TDF backbone for ART
initiates.
• In 2008, 9% of ART patients initiated on TDF. In 2012, 59% did.
• TDF prescription rates varied across facilities, from 2% to 85% in
2011 and 2012.
o Health centers generally had a slightly lower proportion of ART patients
initiating on TDF-based regimens than hospitals in 2011 and 2012.

59. HIV service provision and patient characteristics
ART regimen at initiation, 2008-2012

60. HIV service provision and patient characteristics
ART regimen at initiation, by facility, 2011-2012

61. HIV service provision and patient characteristics
Patient clinical characteristics at ART initiation: WHO staging
• There was a steady shift toward ART initiation at earlier stages of
disease progression between 2008 and 2012.
• In 2008, 51% of patients initiated at WHO stage 1 or 2. In 2012,
72% began treatment at the same stages.
• There was substantial heterogeneity in ART initiation by WHO
stage across facilities in 2011 and 2012.
o In general, hospitals saw a greater proportion of ART patients starting
therapy at WHO stage 1 than health centers.

62. HIV service provision and patient characteristics
WHO stage at initiation, 2008-2012

63. HIV service provision and patient characteristics
WHO stage at initiation, by facility, 2008-2012

64. HIV service provision and patient characteristics
Patient clinical characteristics at ART initiation: CD4 cell count
• A greater proportion of ART patients began therapy at higher CD4
cell counts in 2012 than in 2008.
o In 2008, 35% of patients initiated at a CD4 cell count of 200 cells/mm3
or higher. In 2012, 54% of patients initiated at this level of CD4.
• Median CD4 cell count increased 62%, from 139 cells/mm3 in 2008
to 225 cells/mm3 in 2012.
• A substantial portion of ART patients still began therapy once they
were symptomatic.
o About 20% of patients initiated ART with a CD4 cell count less than 50
cells/mm3 from 2008 to 2012.

65. HIV service provision and patient characteristics
CD4 cell count at initiation, 2008-2012

66. HIV service provision and patient characteristics
Facility availability of patient clinical information
• Testing rates have remained stable over time, indicating that
record-keeping has increased in parallel with rising ART patient
volumes.
• In 2012, a portion of ART initiates still did not receive key tests.
o 17% lacked a CD4 cell count
o 10% were not assigned a WHO stage
o 6% did not have a weight measurement
o 81% did not have a height measurement
• Follow-up measures were relatively infrequent, especially in
comparison with Ugandan guidelines.

67. HIV service provision and patient characteristics
Facility availability of patient clinical information

68. HIV service provision and patient characteristics
ART patient reports of expenses associated with visit, 2012
• As part of the Patient Exit Interview Survey, patients who sought
HIV services reported the types of expenses they had in
association with their facility visits.
• Ugandan national policy stipulated that ART care should be free at
public facilities in 2003.
• Based on the ABCE sample, very few ART patients (< 2%) reported
any medical expenses associated with visits to public facilities.
o By contrast, 45% of ART patients seeking care at private facilities had
medical expenses.
• More than 50% of ART patients experienced some kind of
transportation expense, especially at private hospitals (64%).

69. HIV service provision and patient characteristics
ART patient reports of expenses associated with visit, 2012

70. ART patient perspectives
ART patient reports of wait times at facilities
• Overall, ART patients reported relatively long wait times at
facilities and often spent more time waiting than non-HIV
patients at similar facilities.
• This was consistently found across platforms:
o Health center IIIs
 54% of ART patients waited more than two hours
 25% of non-HIV patients waited more than two hours
o Private hospitals
 41% of ART patients received care within one hour
 70% of non-HIV patients received care within one hour

71. ART patient perspectives
ART wait times at facilities, by platform, 2012

72. ART patient perspectives
ART patient ratings of facilities
• Overall, ART patients gave high ratings for care received across
platforms.
o Nearly 70% of ART patients gave at least a rating of 8 out of a possible 10.
• ART patients generally gave higher ratings, across facility
indicators, than non-HIV patients – except for wait time.
• Like non-HIV patients, ART patients rated staff interactions highly,
especially for medical provider respectfulness.
• ART patients gave fairly high ratings of facility cleanliness and
privacy, but rated wait time very poorly – especially at health
center IIIs.

73. ART patient perspectives
ART patient overall ratings of facilities, by platform, 2012

74. ART patient perspectives
Average ART patient ratings of facility indicators, by platform, 2012

75. HIV service provision and patient characteristics
Efficiency scores for facilities providing ART
• Across facilities with ART, the average efficiency score was 49%.
• ART facilities typically had higher levels of efficiency, compared to
all facilities in the ABCE sample.
• Potential to expand ART patient volumes, especially among health
center IVs.

76. HIV service provision and patient characteristics
Efficiency scores for facilities providing ART

77. HIV service provision and patient characteristics
Estimated potential for increased ART visits given resources
• We estimated that many facilities had potential for increasing
annual ART visits.
• Given observed facility resources, we estimated that an average of
6,367 additional ART visits could be added, per facility, each year.
• This gain represents a 55% increase in ART visits from the average
annual ART visits observed in 2011 (11,632 ART visits).

78. HIV service provision and patient characteristics
Estimated potential for increased ART visits given resources

79. HIV service provision and patient characteristics
Cross-country comparison of ART efficiency
• Uganda showed potential for expanded ART provision, given
observed resources, but at a lesser magnitude than Kenya
and Zambia.

80. HIV service provision and patient characteristics
Projected facility ART costs: analytical approach
• Four streams of data were used to project ART costs
1. Average facility cost per ART visit, excluding ARVs, based on the ABCE
sample
2. Average number of annual visits observed for new and established ART
patients in 2011, as extracted from clinical charts
3. The ARV regimens of ART patients in 2011 extracted from clinical charts
4. The ceiling ARV prices for 2011 published by the Clinton Health Access
Initiative (CHAI)
• Analytical steps for projecting ART costs
1. Visit costs: multiplied average facility cost per ART visit, excluding ARVs, by
the average number of annual visits observed for new and established ART
patients in 2011.
2. Total costs: using the relative proportion of TDF-, d4T-, and AZT-based
regimens observed for patients, applied the ceiling price for each ARV, and
added projected ARV costs to estimated visit costs.

81. HIV service provision and patient characteristics
Projected facility ART costs, 2011
• ARVs accounted for a large portion of projected annual facility
costs for ART, but varied across patient types and platforms.
o New patients
 ARVs accounted for 47% of total projected ART costs to private hospitals
 ARVs accounted for 78% of total projected ART costs at health center IVs
o Established patients
 ARVs accounted for 53% of total projected ART costs to private hospitals
 ARVs accounted for 82% of total projected ART costs at health center IIIs
• Facility costs for ARVs may be viewed as more stable over time,
whereas visit costs associated with ART services are likely to be
lower for established patients.
o Substantial implications for longer-term ART care and funding sources

82. HIV service provision and patient characteristics
Projected facility costs for ART, 2011

83. HIV service provision and patient characteristics
Cross-country comparison of ART costs
• Ugandan facilities had ART costs comparable to those in Kenya, but
much lower than those in Zambia.
• ARVs accounted for 72% of annual facility costs in Uganda, which was
far more than Kenya (69%) and Zambia (60%).

84. Key findings from the ABCE project in Uganda
A focus on HIV: results from the Viral Load Pilot Study

85. Results from the Viral Load Pilot Study
Patient viral load suppression across facilities
• The vast majority of ART patients (87%) showed successful viral
load suppression (< 1,000 copies VL).
• All facilities in the Viral Load Pilot Study had viral suppression rates
exceeding 75%, but these ranged from 76% to 96%.
• We did not find a significant correlation between average rates of
viral load suppression and facility-level retention rates.

86. Results from the Viral Load Pilot Study
Patient viral load suppression across facilities, 2013

87. Results from the Viral Load Pilot Study
Patient viral load suppression and current CD4 cell count
• Rates of viral load suppression were highly correlated with the
concurrent measure of CD4, but not to CD4 measures at ART
initiation.
• CD4 cell counts did not ideally predict viral load suppression.
o 27% of ART patients had a CD4 cell count less than 100 cells/mm3 but a
viral load less than 1,000 copies.
o 6% of ART patients had a CD4 cell count of at least 350 cells/mm3 but
had a viral load exceeding 1,000 copies.
• CD4 cell count is a better measure of patient outcomes than solely
clinical measures, but its use for assessing treatment response is
inferior to using measures of viral load.

88. Results from the Viral Load Pilot Study
Patient viral load suppression by CD4 cell count, 2013

89. Results from the Viral Load Pilot Study
Using DBS to measure viral load
• Overall, DBS samples underestimated viral load for ART
patients.
• The DBS assay used was not sensitive enough to detect
treatment failure at the patient level.
• Further assay development and testing is needed before
DBS is a viable substitute for plasma under routine
conditions.

90. Using ABCE work and findings for policymaking

91. Using ABCE for policymaking
Identifying health system progress and challenges
• Provides policymakers with the evidence to pinpoint areas of
success and for improvement as linked to national goals and
priorities
• Enables direct comparisons across facility types and
ownership, allowing policymakers to contrast facility capacity
in the public sector with that of the private sector
• Supports the timely use of data to inform policy dialogues
o e.g., considering whether DBS is a viable substitute for plasma

92. Using ABCE for policymaking
ABCE Uganda policy report
http://www.healthdata.org/dcpn/uganda

93. Conclusions

94. Conclusions
Facility capacity for service provision
• High availability of a subset of services reflects how Uganda has
expanded service availability throughout the country.
o Immunization, family planning, ANC, concurrent availability of malaria diagnostics
and treatment.
• Substantial gaps in reported capacity and full capacity to provide services
found across all levels of care.
o This was particularly pronounced among primary care facilities and for the
management of NCDs.
• Many more facilities had improved infrastructure, especially electricity
and piped water, than what was found in past studies.
• Facilities had a moderately high availability of recommended equipment
and pharmaceuticals, but stocks varied greatly within facility types
• Over 70% of facility employees were skilled medical staff. Urban facilities
generally had higher levels of skilled medical personnel than rural
facilities.

95. Conclusions
Facility production of health services
• Average patient volumes generally remained stable over time,
with ART visits as the clear exception at most facilities.
• Shortages in human resources and facility overcrowding have been
viewed as widespread; in the ABCE sample, most facilities
averaged fewer than six visits per medical staff per day.
• Given observed facility resources, service production could be
potentially increased by an additional 16 outpatient equivalent
visits per day, on average, per facility
• Annual ART visits could potentially increase as well, but by a more
moderate magnitude (a 55% gain).

96. Conclusions
Facility costs of care
• Average facility cost per patient visit differed substantially across
platforms and types of visits.
• In comparison with a subset of other countries in the ABCE
sample, average facility costs in Uganda were low per ART visit
and per outpatient visit.
• On average, ARVs accounted for a large proportion of ART facility
costs, but how much varied based on patient status (new or
established).
o Projected ART facility costs, including ARVs, were generally lower in
Uganda in comparison with Kenya and Zambia, but ARVs contributed to a
larger portion of overall annual costs in Uganda (72%) than the other two
countries (69% and 60%, respectively).

97. Conclusions
Patient perspectives
• Among public facilities, very few patients reported any medical
expenses associated with their facility visit.
o This reflects Uganda’s prioritization of removing cost barriers to health
services.
• In general, a large portion of patients spent more time waiting at
facilities to receive care than the time they spent traveling to the
facility.
o Given average staffing observed across facilities and patients seen per
medical staff per day, it is unlikely that inadequate human resources are the
main driver of these long wait times.
• Patients gave high ratings of facilities, especially ART patients.
o Staff interactions were regularly rated higher than facility characteristics
o Patients gave fairly low ratings of wait time, particularly ART patients.

98. Conclusions
Facility-based provision of ART services
• A rapid shift away from d4T-based ART regimens and toward TDF
occurred throughout Uganda – a significant success.
• Steady progress took place for initiating ART patients at earlier
stages of disease, for both WHO staging and CD4 cell counts.
• However, a portion of patients still began treatment after becoming
symptomatic in 2012.
• Gradual improvements were made in collecting ART patient
clinical data, but too few did not receive key measures and tests
at initiation and during follow-up visits.
o Greater investment in ART patient record-keeping and data collection
ought to be considered.

99. Conclusions
Measures of viral load
• Among ART patients in the Viral Load Pilot Study, the vast
majority showed successful viral load (VL) suppression.
• CD4 cell count measures did not consistently reflect VL
suppression among ART patients, indicating that CD4 is an
inferior indicator to VL for monitoring response to treatment.
• Currently available DBS assays are not sensitive enough to detect
treatment failure, under routine conditions, at the patient level.
o Plasma-based measures of VL should remain the optimal way to assess
patient responsiveness to ART until further DBS assay development and
testing occur.

100. Conclusions
Priority considerations for future work
• Updated analyses across indicators to assess progress and identify areas
that may require more investment.
• Targeting a broader set of facilities to capture a clearer picture of levels
and trends in facility performance.
• Linking estimates of efficiency to quality of the services produced at
facilities, as well as other factors.
o e.g., expediency with which patients receive care, demand for increased services
• Updated analyses for ART patient characteristics at initiation, to
determine more recent uptake of new eligibility guidelines.
• Generating estimates of cost-effectiveness based on facility delivery of
services and costs of production, and linking to ongoing work on
estimating trends in health outcomes and disease burden.

101. Thank you
http://www.healthdata.org/dcpn/uganda