Optimal decentralization of early infant diagnosis of HIV in resource-limited settings
By Sarang Deo, Milind Sohoni
Manufacturing and Service Operations Management | April 2015
DOI
doi.org/10.1287/msom.2014.0512
Citation
Deo, Sarang., Sohoni, Milind. Optimal decentralization of early infant diagnosis of HIV in resource-limited settings Manufacturing and Service Operations Management doi.org/10.1287/msom.2014.0512.
Copyright
Manufacturing and Service Operations Management, 2015
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Abstract
Unavailability of appropriate diagnostic capability is a major constraint in scaling up HIV early infant diagnosis (EID) programs in resource-limited countries. Due to the complexity of the existing diagnostic technology, most EID networks are highly centralized with a few laboratories serving a large number of health facilities. This leads to long diagnostic delays and consequent failure of patients to collect results in a timely manner. Several point-of-care (POC) devices that provide rapid diagnosis within the health facilities are being developed to mitigate these drawbacks of the centralized EID networks. We argue that the decision of which facilities should receive the POC device (the placement plan) is critical to maximizing their public health impact in the presence of tight budget constraints. To formalize this argument, we develop an operational queueing network submodel that quantifies the impact of POC placement decision on the diagnostic delay and link it to a patient behavior submodel that quantifies the impact of diagnostic delay on the likelihood of result collection. We embed these two submodels within an optimization model that maximizes the number of patients receiving results, which has the structure of a nonlinear, nonseparable knapsack problem and is not amenable to exact analysis. Hence, we adopt a two-pronged solution approach. First, we approximate the patient behavior submodel with a piecewise linear relationship between the average diagnostic delay at a health facility and the fraction of results collected at that facility. We also approximate the operational dynamics using extant results on queueing networks with batched service and superposition of arrival streams. In addition, we use auxiliary variables and constraints to linearize the approximate formulation and use it to derive an ``optimal'' placement solution. Second, we develop a computational model by combining a detailed discrete event simulation of the exact operational dynamics with a Monte Carlo simulation of the exact patient behavior. We calibrate the computational model with data from the EID program in an East African country and evaluate the impact of the optimal allocation described above and two thumb rules that have practical appeal. We find that the optimal allocation can result in up to 30% more patients collecting their results compared to the thumb rules. A thumb rule that allocates POC devices to highest volume health facilities performs well if the accuracy of the POC device is sufficiently high and if patients are not very sensitive to delay. In contrast, a thumb rule of allocating POC devices to minimize average diagnostic delay in the network performs well if patients are very sensitive to delay. Finally, we show that the effectiveness of POC devices is much higher than other conventional interventions such as increased laboratory capacity, reduced transportation delay, and more regularized transport that are aimed at improving the laboratory network operations.

Sarang Deo is a Professor of Operations Management at the Indian School of Business (ISB), where he also serves as the Deputy Dean for Faculty and Research and as the Executive Director of the Max Institute of Healthcare Management (MIHM).

His primary area of research is health care delivery systems. He is interested in investigating the impact of operations decisions on population-level health outcomes. Some of the healthcare contexts that he has studied include the influenza vaccine supply chain and the phenomenon of ambulance diversion in the US, HIV early infant diagnosis networks in sub-Saharan Africa, and formal and informal pathways for tuberculosis (TB) diagnosis in India. He regularly collaborates with international public health funding and implementation agencies such as Bill & Melinda Gates Foundation (BMGF), Clinton Health Access Initiative (CHAI), and PATH for his research. He currently serves as a member of the WHO Strategic and Technical Advisory Group on TB (STAG-TB).

Prior to joining ISB, Professor Deo was an Assistant Professor at the Kellogg School of Management. He holds a PhD from UCLA Anderson School of Management, an MBA from Indian Institute of Management (IIM) Ahmedabad, and a B Tech from the Indian Institute of Technology (IIT) Bombay. Before entering academia, he worked with Accenture as a management consultant.

Sarang Deo
Sarang Deo