This study assesses the unit costs of MAT provision in Georgia from the perspective of the two service providers in-country—the Ministry of Labor, Health, and Social Affairs (MOLHSA) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM). Both MOLHSA and GFATM-funded sites offer MAT in multiple facilities throughout urban and rural Georgia. Treatment protocols and personnel requirements are centrally mandated, thus allowing for little variation per patient characteristics. While service delivery tends to be comparable across MOLHSA and GFATM sites, there is one significant difference—the ministry requires that MAT clients pay for services while GFATM offers free services. The analysis found that a majority of HIV-positive patients are enrolled in the GFATM MAT program. The study compared average unit costs between two years (2009 and 2010) and found a minimal increase. Unit costs increased only slightly at MOLHSA facilities from 229 GEL ($133 ) per month to 236 GEL ($137) per month. At GFATM sites, the monthly per patient cost of MAT rose slightly between 2009 and 2010 from 217 GEL ($126) to 229 GEL ($133). Further, data analysis revealed that GFATM programs are only slightly less expensive than at MOLHSA facilities. An important caveat—unit cost calculations for the MOLHSA sites include patient contributions that amount to 150 GEL ($87) per month for each patient. In the case of both providers, direct costs of MAT provision far exceed indirect costs. Three inputs—personnel, drugs/medical supplies, and utilities—account for a major portion of costs associated with running MAT programs in Georgia. The most significant budget item in both MOLSHA and GFATM programs is the cost of personnel (salaries of clinical and support staff).

1. Costing MAT for HIV
Prevention among
PWIDs in Georgia
1
Veena Menon & Irma Kirtadze 07/20/12

2. Outline
• Background
• Study Design
• Findings
2

3. Background
● One of the first countries to adopt
Christianity, in the early 4th century, remains
strongly Georgian Orthodox
● From 1921 to 1991, the Georgian Soviet
Socialist Republic was one of the 15 soviet
republics of the USSR
● Suffered from civil war and economic crisis
during the 1990s
● Rose Revolution of 2003, at which time the
new government introduced democratic and
economic reforms
● It covers a territory of 69,700 square
kilometers
● Its current population is almost 4.5 million
3

4. Study Goal
Evaluate costs of MAT programs
in Georgia to improve budgeting
and planning related to MAT
programs
4

5. Study Objectives
• Estimate unit costs of MAT
provision for one patient (per
month)
• Optimize current capacity to
include more PWIDs
5

6. Background
MSM MTCT Other
3% 2% 2%
• PWID population
approximately 40,000
• Estimated number of
HIV+ people in
Georgia - 4000 PWID
Hetero- 56%
• Injecting drug use sexual
identified as primary 37%
cause of transmission
Source: AIDS and Clinical Immunology Research Centre
(2011).
6

7. Program Characteristics
GFATM
- Start year 2005
- 5 sites in total
- Free for clients
MAT
providers MOHLSA
- Start year 2008
- 11 sites in total
- 150 GEL/pm/patient
7

8. Program Characteristics (2)
GFATM MAT centers MOLHSA MAT centers GFATM prison centers
8

9. Program Characteristics (3)
• MAT treatment protocol/personnel
centrally-mandated and identical for all
service providers
– Key treatment parameters include
• Daily methadone dosage
• STI testing (HIV, Hepatitis B/C)
• Individual psychotherapy
• Group counseling
9

10. Program Characteristics (4)
• Staffing at MAT sites is regulated by
Georgian law:
– 3 medical doctors
– 1 psychologist
– 1 social worker
– 1 head of department/chief doctor/
coordinator
– 1-3 nurses
– Other support staff (data entry specialist,
consultants, toxicologist, pharmacist and etc.)
10

11. Study Details
• Study design – samples from each provider
– MOHLSA – 7 of 11 sites (sites chosen to ensure
representation from small and large population
centers)
– GFATM – 4 of 5 sites (excluded prison site)
• Study period
– Qualitative data collected on treatment
parameters – March, April and May 2011
– Financial program data – 2009, 2010
11

12. Study Details (2)
• Collected cost and quantity data on:
• Personnel
• Drugs and supplies
• Furniture and equipment
• Land and buildings
• Consumables
• Utilities
12

13. Results
MAT Dosages Across Sites
Below 60 mg Above 60 mg
% of patients within each dose range
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
13

14. Distribution of HIV+ patients
800
1.5%
700
Total Number of Patients
600
1.1%
500
400 12.2%
12.7% 98.5%
300 98.9%
200
87.8%
87.3%
100
0
GF 2009 GF 2010 MOLHSA 2009 MOLHSA 2010
HIV Negative HIV Positive 14

15. Increase in Average # Patients
800
700
600
500
400
300
200
100
0
GF—MAT MOLHSA—MAT
15

16. Unit cost for 1 month treatment
2010 $
GFATM
Average number of PWID in 1
364
month
Unit cost for one month 229 GEL $133
MOHLSA
Average number of PWID in 1
689
month
Unit cost for one month 236 GEL $137
16

17. Cost Drivers
Share of direct and indirect costs in MAT facilities
250
21.1% 20.9%
200 23.2%
24.6%
Unit Cost (GEL)
150
100
78.9% 79.1% 76.8%
75.4%
50
0
MoLHSA 2009 MoLHSA 2010 GF 2009 GF 2010
Direct Costs Indirect Costs 17

18. Key cost drivers
MOLHSA—2010 Drugs and
GFATM—2010
Bank/
medical Rental cost
Drugs and 5% Utilities insurance
Rental cost supplies fees
medical 13%
5% 21% 0.44%
supplies
Utilities
28%
14%
Stationary Bank/ Non
office insurance Stationary medical
supply 0% office supply equipment
0% 1% 5%
Non
medical
Regional equipment
monitoring 2% Regional
0% Salaries of monitoring
clinical & 0.41%
support
Salaries of
staff clinical &
51% support staff
55% 18

19. Economies of Scale
GFATM Shida GFATM
Kartli Batumi
Narcological Narcological MoLHSA MOLHSA
Center Center Division 3 Division 6
Average
patients
per 45 117 18 142
month
Unit cost
291 GEL 161 GEL 702 GEL 122 GEL
patient/
month ($169) ($93) ($407) ($71)
19

20. Potential for Service Expansion
• 1382 maximum PWID capacity at MOLHSA sites
• 500 maximum PWID capacity at GFATM sites
(currently at capacity)
• Modelled 2 scenarios to assess potential for
expanding MAT coverage within existing facilities:
– Scenario A: Increase coverage by 15 percent until
maximum available existing capacity is reached.
– Scenario B: Graduated expansion in MAT coverage over
five years (five, seven, nine, 11 and 13 percent increases)
using existing sites until maximum available capacity is
reached. 20

21. Scenario A – 15% increase
Increase in average #
MOLHSA of patients
2010—11 MAT sites 898
2011—15% increase
1,033
2012—15% increase
1,187
2013—15% increase
1,366
21

22. Scenario A – Decreasing unit costs
1600 1366 450
1400 400
1187
Number of Patients
350
1200 1033
Unit Cost (GEL)
898 300
1000
250
800
235.8 200
600 213.21 193.58 176.5 150
400 100
200 50
0 0
2010 extrapolated 2011 2012 2013
number of patients unit cost
22

23. Scenario A – Share of direct/indirect costs
MOLHSA Direct Indirect
costs (%) costs (%)
2010—11 MAT 79.10 20.90
facilities
2011—15% increase 79.90 20.10
2012—15% increase 80.75 19.25
2013—15% increase 81.64 18.36
23

24. Scenario B – graduated increase
Graduated increase in average
MOLHSA # of patients
2010—11 MAT sites 898
2011—5% increase 943
2012—7% increase 1009
2013—9% increase 1100
2014—11% increase 1221
2015—13% increase 1379
24

25. Scenario B – Decreasing Unit Costs
1600 450
1379.2 400
1400
1220.5
350
Number of Patients
Unit Cost (GEL)
1200 1099.6
1008.8 300
1000 897.9 942.8
250
800
235.8 200
225.6 213.2
600 200.7 189.1 179.4 150
400 100
200 50
0 0
2010 2011 2012 2013 2014 2015
extrapolated
25
Number of Patients Unit cost

26. Scenario B – Share of direct/indirect costs
MOLHSA Direct costs Indirect costs
(%) (%)
2010—11 MAT facilities 79.10
20.90
2011—5% increase 79.47
20.53
2012—7% increase 79.88
20.13
2013—9% increase 80.43
19.57
2014—11% increase 81.11
18.89
2015—13% increase 81.94
18.06
26

27. Limitations
• We were unable to include certain costs in this analysis,
primarily due to lack of data.
• Accurate patient tracking was a challenge in some
MOLHSA methadone facilities, particularly Tbilisi, where
patients may have moved from one MAT site to another.
• Finally, this analysis focused on the costs incurred by
facilities offering MAT services. As such, it does not include
the costs incurred by patients as they sought and received
services or the opportunity costs of time spent travelling to
and seeking services.
27

28. Recommendations
• Specify clear indicators for successful
treatment outcomes.
• Integration/co-location of PWID/HIV services
for better patient follow-up (currently no data
on recidivism)
• Greater autonomy for MAT sites on protocol/
personnel
28

29. Acknowledgements
 USAID funded project HPI costing
• Veena Menon, Kip Beardsley, Stiven Forsythe (Futures
Group) & data collectors team : Natia Topuria, Nino
Balanchivadze, Tea Kordzade (Alternative Georgia),
Lela Sturua (NCDC)
 Staff of participant MAT centers’
 Authors declaring no conflict of interest
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30. Thank you
irma@altgeorgia.ge
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