January 2004, Vol. 10, No. 1

Operations Research 
Enhancing HIV/AIDS Care in South India

As of 2002, nearly 4 million adults in India were infected with HIV, according to UNAIDS. The number of new HIV infections in India is rapidly increasing, and the health care system is experiencing a substantial growth in the demand for services. To address this challenge, the Population Council’s Horizons program began collaborating with the International HIV/AIDS Alliance in September 1999 to examine the experiences of the Y.R. Gaitonde Centre for AIDS Research and Education (YRG CARE), a nongovernmental organization based in Chennai, India. YRG CARE provides a range of successful prevention, care, and support services for people with HIV/AIDS. The organization wanted to expand services in Chennai as well as introduce its style of services to organizations in four other locations in India: Calicut, Chirala, Mysore, and Pondicherry. Horizons employed operations research to facilitate this expansion of services.

In the HIV/AIDS field, operations research applies systematic research techniques to analyze factors that are under the control of program managers, such as improving the quality of services and counseling. An important objective of operations research is to provide managers with the information they need to improve and expand services.

This Horizons study includes components focusing on clients’ quality of life and satisfaction with services, in addition to institutional costs, clients’ willingness to pay for services, and the effect of treatment costs on clients’ budgets. The researchers investigated these issues using client surveys and in-depth interviews, personnel training and assessment, and the development of case studies for each location.

The USAID-funded Horizons research program is implemented by the Population Council in collaboration with the International Center for Research on Women, the International HIV/AIDS Alliance, the Program for Appropriate Technology in Health, Tulane University, Johns Hopkins University, and Family Health International.

Scaling up
Because of its reputation as a source of high-quality, affordable, and confidential care, YRG CARE has attracted clients not only from the Chennai area but from throughout South India, some of whom travel hundreds of miles for services. From its facilities in Chennai, the organization provides voluntary HIV counseling and testing, nutrition counseling, inpatient and outpatient care, and many other services. One of the main goals of the study was to find ways to transfer the clinic’s services and core concept—providing economical, high-quality HIV/AIDS care—to the new locations without necessarily imposing the Chennai managerial structure.

“It’s important to acknowledge that concepts and values rather than rigid organizational structures and models are the critical elements to export to a new environment,” says Chris Castle of Horizons/International HIV/AIDS Alliance.

For example, most of the services available at YRG CARE are provided in-house, with a few services being outsourced. In contrast, some of the scale-up sites, particularly the one in Calicut, found it best to outsource many of their services to trusted collaborators. As partnerships and networking intensified, referrals grew and care options increased.

In Chirala, researchers and collaborators discovered a need to emphasize counseling over other services. A manager there noted, “In Chirala, many testing centers are present, but many do not give counseling. So we want to take counseling as the first priority.”

Willingness-to-pay surveys
Meeting clients’ needs and maintaining quality of care while remaining solvent is one of the toughest issues facing any nonprofit service provider. In order to do this, many organizations must impose or increase service fees. The challenge is to increase fees to an amount that clients are willing and able to pay while ensuring that the poorest clients can continue to access those services. One way of investigating these issues is to conduct a willingness-to-pay survey. Using this method, the researchers found that clients value YRG CARE’s services and show considerable willingness to pay higher fees for services. Client responses indicated that although some could spend less on amenities to meet higher costs, most would seek money from friends or family members.

Another way of increasing sustainability is to more efficiently manage donated money and funds from existing sources. The research suggested that YRG CARE could expand its client base without reducing the quality of its services. Doing this would offset such fixed costs as rent and salaries. The organization could also use revenues gathered from more lucrative services to pay for deficits incurred by other services.

“It is unreasonable to expect that nongovernmental organizations, which serve some of the most disenfranchised members of society, can rely solely on user fees to offset the cost of providing care and support,” explains Rick Homan of Family Health International, a Horizons partner.

Future research efforts on the YRG CARE scale-up are likely to explore strategies for further improving the quality of service provision and for expanding access to antiretroviral therapy.

Sources
Castle, Chris. 2003. Expanding Care and Support in South India: Scaling Up YRG CARE’s Patient-Centered Approach. Washington, DC: Population Council. (PDF)

Castle, Chris. 2003. “YRG CARE base model report: Integrated prevention, care, and support services,” Horizons Project Report. Washington, DC: Population Council. (PDF)

Dadian, Margaret (ed.). 2002. Horizons Report: Care and Support in India—Special Focus on YRG CARE. Washington, DC: Population Council. (full text)

Outside funding
United States Agency for International Development

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See Also

• "AIDS in India: Attacking the epidemic on many fronts," Momentum May 2003 (full text)
• "Investing in AIDS care and support programs: Horizons research shows that small investments pay big dividends" (news release)