Modelling, Country Grouping, Impact and Cost
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Transcript Modelling, Country Grouping, Impact and Cost
Modelling the cost and the impact of the
TB Global Plan
Country groups, Post 2015 Targets Strategy, TIME, Costing
Carel Pretorius
29 October 2014
Stop TB Partnership, TB MAC, Futures Institute, WHO Global TB
Program, UNAIDS Reference Group, Gates Foundation, USAID
Acknowledgments
Stop TB Partnership
TB Modeling and Analysis Consortium (TB MAC)
WHO Global TB Program (GTB)
UNAIDS Reference Group for HIV Estimates and
Projection
Bill and Melinda Gates Foundation
USAID
Overview
Give overview of the three-phased approach to modeling
TB Global Plan
Phase 1: Country classification/groups
Phase 2: Produce global TB impact estimates in relation to
Post 2015 Targets framework and Global Plan
intervention packages
Phase 3: Cost country TB plans and produce global price
tag of TB Global Plan
1. Country groups and classification
Overview: Country groups
Data collection and resulting multivariate dataset
Countries can be clustered/grouped/classified in many ways:
be clear about purpose
Hierarchical clustering based on being above or below
thresholds of key variables
K-means clustering and principles components analysis (PCA)
Comments and recommendations
Country groups: Data sources
GTB: TB burden, notification, treatment outcomes, MDR
burden, treatment outcomes
World Development Indictors (WDI): measures of
wealth, health access and coverage
Millennium Development Goals (MDG): measures of
development such as coverage of child vaccinations
UnPop: Population data including population size and TFR
UNDP: Human development indices
FFP: Fragile state indices
UNAIDS: HIV data including ART coverage and PMTCT
coverage
WHO Health Systems data, focusing on Health Financing
Country groups: Data collection
Developed routines to run through the large datasets,
such as WDI and MDG databases, and list the number of
countries with data for each indicator.
Focused on key indicators from the subset of ‘wellrepresented’ indicators that are thought to be relevant to
TB.
Additionally incorporated several variables recommended
by Secretariat (particularly for HS and fragile state
indices).
Performed initial PCA to identify co-linear variables and
reduce list further.
Finalized list at 17 variables available for 120 countries.
Country groups: Hierarchical classification
Each country clustering/grouping/classification should
serve a clearly defined purpose.
One approach is communicated in “Post-2015 Global TB
Strategy and targets: process and vision”: pre-elimination,
concentrated or endemic TB, with high HIV and high
MDR.
Generalized this approach to classify countries as falling
above or below threshold using average values of variables.
The 16 permutations of four variables is a convenient
classification method and allows countries to easily
identify their situation and recommended strategy.
Country groups: K-means clustering
PCA analysis is used to transform the dataset into new
variables, which are independent and successively
accounts for most variance in the original dataset.
Thus, PC 1 explains most of the variance, PC 2 second
most, and so on.
Multivariate dataset is then re-projected into the space
spanned by the PCs.
K-means clustering performed on transformed data.
Country groups: PCA
Country groups: PCA
Country groups: K-means clustering
Statistical method to find a specified number of clusters (i.e. K) so
that the sum, over all clusters, of the within-cluster sums of pointto-cluster-centroid distances is minimized.
We performed K-means clustering on the PCA transformed
dataset, experimenting with the number of clusters K.
K=6 to 9 works well in terms of generating meaningful groups.
More than 9, but depending on variables included, give clusters
that are outliers rather than meaningful clusters in terms of the
analysis.
Country groups: K-means, k=9
Group
TBinc
TBnoti
TBincHP
TBmort
TBmortHN
ALL
TBmortHP
TBm
dr
NEWS
Pts
CDR
1
118.4
88.7
4.2
15.8
15.0
536.9
3.9
86.5
71.9
2
42.9
35.2
5.9
4.6
4.0
215.4
2.8
85.5
83.1
3
18.3
16.1
3.0
1.5
1.4
38.7
1.4
74.0
87.2
4
296.9
172.0
14.4
65.6
49.9
1,843.0
2.9
80.1
56.2
5
87.4
68.7
6.7
10.6
9.6
582.0
29.1
65.4
79.5
6
138.4
92.3
21.0
25.7
17.3
711.5
2.7
82.4
63.4
7
974.4
559.7
66.0
267.9
67.8
1,546.2
4.9
77.5
59.6
8
17.2
14.1
10.3
1.9
1.6
48.7
1.7
64.5
80.2
9
221.9
146.8
29.9
42.6
28.1
1,161.3
1.9
87.0
67.6
Country groups: K-means, k=9
Group
Imun
ARTcov
GNIperca
HDI
p
HExpGD
P
FS
GovVsTot
al
PerCapHe
alth
1
91.6
17.1
8,362.5
0.67
78.2
5.4
7.8
341.4
2
95.9
36.2
15,116.9
0.74
68.5
7.1
12.7
886.7
3
94.7
61.2
38,825.3
0.89
30.7
9.5
15.4
3,725.1
4
73.0
23.1
3,666.4
0.50
95.6
4.8
8.3
125.3
5
91.0
14.7
15,448.6
0.76
66.7
6.3
10.4
819.6
6
83.2
38.1
3,931.2
0.51
86.2
6.0
10.4
181.9
7
82.0
38.1
7,326.9
0.58
75.6
9.3
14.9
568.8
8
94.3
35.2
19,442.7
0.80
47.5
7.7
15.6
1,650.0
9
86.8
34.8
1,171.3
0.43
91.0
12.6
17.9
133.4
Comments and recommendations
The 120 countries in the MV dataset represent > 95% of
world population. The list of 17 variables is the most
representative we could find.
But we can still add specific variables for specific sub-groups,
e.g. to highlight a TB-related Health Systems issue for a group
of countries.
Country groups should allow countries to identify their TB
context and recommended strategies in terms of the most
important variables for their context.
In particular, should maximally inform a corresponding set of
‘Targets’ strategies for each group.
2. Targets framework and GP
intervention packages
Overview: Targets Framework
TIME care and control cascade
Targets Framework
Adaptation of Targets Framework to country groups
Example: Application of Targets Framework to South Africa
TB investment case
Comments and recommendations
Intervention packages: TIME parameters
Diagnostic sensitivity
Relative diagnosis for smear negative cases
Diagnostic rate as probability per year of being
detected
Diagnostic rate for HIV-negative and HIV-positive cases
Linkage to care
Probability of being linked to care once diagnosed
Treatment success
For HIV-negative
For HIV-positive not on ART
For HIV-positive on ART
Intervention packages: Targets Framework
Increase access to high quality TB services
Improve high quality TB services-post diagnosis
Xpert replaces completely or partially smear as first
laboratory test in high quality TB services
Active Case Finding in general population
Active Case Finding in general population and Preventative
Therapy
Continuous IPT for all HIV positive population
Combination of all
Global Plan <-> Targets <-> TIME
To relate the Post 2015 Targets framework to TIME we
have to quantify and make an assessment of:
Access to care
Current diagnostic algorithm
Relative rate of diagnosis in high and service quality of care
Linkage to and quality of subsequent care
So that we can adjust in TIME baseline models
Detection rate, linkage to care and treatment outcomes
To relate the GP to the Post 2015 Targets framework we
have to relate country groups to Targets scenarios:
Assess and quantify variables in terms of how well they measure
access to and quality of care
Focus on group classification variables related to treatment cascade as
a function of quality of care
Targets applied to South Africa IC
TB Targets applied to South Africa IC
TB Targets and most aggressive HIV IC scenario still lead to 0.2%
incidence (200 per 100,000)
ART at 95% coverage, CD4 eligibility at 500
TB diagnostics currently predominantly based on Xpert - thus not
much diagnostic gain from rolling out Xpert
Linkage to care and treatment success to be > 85%
ACF to be 25% of general population
IPT coverage for HIV+ cases to be 85%
Global Impact of GP: country models
TIME Estimates first estimates TB ‘risk of disease’ for HIV
negative cases
F(HIV-negative)(t) = I- (t)/ P(t)
Then formulates risk of disease for HIV-positive CD4 categories:
F(c) = F(HIV-negative)∙p(1)∙p(2)dc where c is a CD4 category and
dc a unit of 100 CD4 decline relative to CD4 500 category
Use TIME Impact to update F, and produce incidence trends using
the same CD4-incidence relationship determined by p(1) and p(2)
Can then produce TB incidence and mortality trends for each
country by modifying official projections via modified F
Can impose ‘realistic’ and ‘advocacy’ version of global HIV
strategy and its impact will be reflected in TB-HIV split.
Prioritization to high risk groups
There is a general limitation in TIME in that risk groups
are not directly modeled.
Consequences include:
No risk groups means no movement between them
The risk groups have differential impact mon transmission
which is crudely presented by ‘average’ approach.
We make the assumptions that risk groups have the same
average risk for TB and progression of TB, since the will have
the same internal (to TIME) risk structure in terms of age,
CD4, HIV and ART status.
Have to decide how severe this limitation is, and how to frame
an approximation as either an upper or lower bound to true
expected impact of targeting to high risk groups.
PT prioritization to high risk groups
HIV or high-risk of HIV
Intravenous drug users known to be HIV-negative
Had close contacts with newly diagnosed and TST negative
children had close contact with newly diagnosed case
Recent converters based on TST criteria
Persons with abnormal chest radiographs showing old TB
Persons with special medical conditions
In addition, perhaps prioritized by age:
Previously low-served population, e.g. low access to care
Residents of facilities for long-term care, e.g., correctional
institutions
ACF prioritization to high risk groups
Could apply similar considerations to PT prioritization,
namely calculate average coverage and effects of ACF and
apply to special populations such as:
HIV or high-risk of HIV
Intravenous drug users known to be HIV-negative
Previously low-served and currently marginalized
population, e.g. low access to care
Correctional institutions
Comments and recommendations
Targets is a well-developed framework for developing GP
Intervention Packages
For each group need to quantify levels of access and quality
of care,
which is then related to TIME parameters
Impact will be estimated for one representative country for
each group through direct TIME Impact modeling.
Impact will be ‘transferred’ to projections for TB burden
within the TIME Estimates model
to obtain country-specific estimates of
Result is a direct impact on the global TB incidence trend
currently produced by GTB
3. Costing the Global Plan
Overview: Costing Global Plan
Discuss different approaches to costing the plan as well as the triangulation of
different approaches:
‘Top-down’ approach based on GTB budget reports
‘Bottom-up’ approach based on One Health/TIME TB costing
Literature reviews of unit costs of key cost inputs, focusing on key and perhaps
all of the high burden countries
Operational insights, e.g. Xpert rollout coordinated/funded by USAID
Have to take a normative approach to costing program support structures
Can produce a cost estimate at country level, based on GTB notification trends
Costing Global Plan: Basic approach
Discuss utility of different costing data sources, in particular GTB and
GF budget estimates
A top-down approach based on extrapolating these estimates using
projected notification trends should provide a reasonable benchmark for
a global TB price tag of the TB GP
Can supplement with a process of collecting country-specific cost data
Can apply costing platform to country-specific impact projections
Costing Global Plan: Country data
Two options
A- Supplement current cost estimates with adjustments based on
country visits or consultations
B- Develop a costing workbook that countries are asked to fill out, in
a process that will be supported with webinars and such
In each case we can apply PPP corrections to obtain estimates for
countries with no direct estimates from countries with direct ones
Costing Global Plan: Cost template
We have prepared a template with the following structure
Epidemiology – notification and its breakdown by case type
Unit costs – sheets for diagnosis, treatment and patient support
Program support - a normative program support costing
approach
Total cost - a sheet calculating total cost of the TB program
Cost template – country support
Countries can be trained on the layout of the cost template
and provided with instructions on how to fill it out
Countries can be support online
The 22 high burden countries should receive special attention
The templates will be validated and serve as the baseline cost,
and then be modified with TIME notification projections
applied to the country workbook
Comments and recommendations
A decision must be made if a country approach should be followed
– regional costing also possible
We suggest the use of multiple approaches which allows for
triangulation
The global price tag should be based on aggregating country-
specific cost projections
A cost-workbook approach is only feasible if WHO and GF take
leading role in dissemination, collection and validation
The end
Thank you