How much can we gain from improved efficiency? An examination of performance of national HIV/AIDS programs and its determinants in low- and middle-income countries

We used data envelopment analysis (DEA) to evaluate efficiency of national HIV/AIDS programs in transforming funding into services and implemented a Tobit model to identify determinants of the efficiency in 68 low- and middle-income countries. We considered the change from the lowest quartile to the average value of a variable a "notable" increase.Overall, the average efficiency in implementing HIV/AIDS programs was moderate (49.8%). Program efficiency varied enormously among countries with means by quartile of efficiency of 13.0%, 36.4%, 54.4% and 96.5%. A country's governance, financing mechanisms, and economic and demographic characteristics influence the program efficiency. For example, if countries achieved a notable increase in "voice and accountability" (e.g., greater participation of civil society in policy making), the efficiency of their HIV/AIDS programs would increase by 40.8%. For countries in the lowest quartile of per capita gross national income (GNI), a notable increase in per capita GNI would increase the efficiency of AIDS programs by 45.0%.There may be substantial opportunity for improving the efficiency of AIDS services, by providing more services with existing resources. Actions beyond the health sector could be important factors affecting HIV/AIDS service delivery.Since the beginning of the epidemic of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS), almost 60 million people have been infected with HIV and 25 million people have died of HIV-related causes [1]. Despite the billions of dollars spent on this disease, a gap persists between resource needs and resources available for HIV/AIDS control and treatment [2,3]. The economic downturn since 2008 exacerbates the inadequacy of resources for combating the worldwide HIV/AIDS pandemic [4]. These resource constraints amplify the need to improve the efficiency of HIV/AIDS programs [5].Efficiency studies conducted at the organizational level (e.g., health centers) show a