The effects of scale on the costs of targeted HIV prevention interventions among female and male sex workers, men who have sex with men and transgenders in India

BACKGROUND: The India AIDS Initiative (Avahan) project is involved in rapid scale-up of HIV-prevention interventions in high-risk populations. This study examines the cost variation of 107 non-governmental organisations (NGOs) implementing targeted interventions, over the start up (defined as period from project inception until services to the key population commenced) and first 2 years of intervention. METHODS: The Avahan interventions for female and male sex workers and their clients, in 62 districts of four southern states were costed for the financial years 2004/2005 and 2005/2006 using standard costing techniques. Data sources include financial and economic costs from the lead implementing partners (LPs) and subcontracted local implementing NGOs retrospectively and prospectively collected from a provider perspective. Ingredients and step-down allocation processes were used. Outcomes were measured using routinely collected project data. The average costs were estimated and a regression analysis carried out to explore causes of cost variation. Costs were calculated in US$2006. RESULTS: The total number of registered people was 134,391 at the end of 2 years, and 124,669 had used STI services during that period. The median average cost of Avahan programme for this period was$76 per person registered with the project. Sixty-one per cent of the cost variation could be explained by scale (positive association), number of NGOs per district (negative), number of LPs in the state (negative) and project maturity (positive) (p<0.0001). CONCLUSIONS: During rapid scale-up in the initial phase of the Avahan programme, a significant reduction in average costs was observed. As full scale-up had not yet been achieved, the average cost at scale is yet to be realised and the extent of the impact of scale on costs yet to be captured. Scale effects are important to quantify for planning resource requirements of large-scale interventions. The average cost after 2 years is within the range of global scale-up costs estimates and other studies in India

Comparative health systems research in a context of HIV/AIDS: lessons from a multi-country study in South Africa, Tanzania and Zambia

Comparative, multi-country research has been underutilised as a means to inform health system development. South-south collaboration has been particularly poor, even though there have been clearly identified benefits of such endeavours. This commentary argues that in a context of HIV/AIDS, the need for regional learning has become even greater. This is because of the regional nature of the problem and the unique challenges that it creates for health systems. We draw on the experience of doing comparative research in South Africa, Tanzania and Zambia, to demonstrate that it can be useful for determining preconditions for the success of health care reforms, for affirming common issues faced by countries in the region, and for developing research capacity. Furthermore, these benefits can be derived by all countries participating in such research, irrespective of differences in capacity or socio-economic development

Is there scope for cost savings and efficiency gains in HIV services? A systematic review of the evidence from low- and middle-income countries.

OBJECTIVE: To synthesize the data available--on costs, efficiency and economies of scale and scope--for the six basic programmes of the UNAIDS Strategic Investment Framework, to inform those planning the scale-up of human immunodeficiency virus (HIV) services in low- and middle-income countries. METHODS: The relevant peer-reviewed and "grey" literature from low- and middle-income countries was systematically reviewed. Search and analysis followed Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. FINDINGS: Of the 82 empirical costing and efficiency studies identified, nine provided data on economies of scale. Scale explained much of the variation in the costs of several HIV services, particularly those of targeted HIV prevention for key populations and HIV testing and treatment. There is some evidence of economies of scope from integrating HIV counselling and testing services with several other services. Cost efficiency may also be improved by reducing input prices, task shifting and improving client adherence. CONCLUSION: HIV programmes need to optimize the scale of service provision to achieve efficiency. Interventions that may enhance the potential for economies of scale include intensifying demand-creation activities, reducing the costs for service users, expanding existing programmes rather than creating new structures, and reducing attrition of existing service users. Models for integrated service delivery--which is, potentially, more efficient than the implementation of stand-alone services--should be investigated further. Further experimental evidence is required to understand how to best achieve efficiency gains in HIV programmes and assess the cost-effectiveness of each service-delivery model

Pilfering for survival: how health workers use access to drugs as a coping strategy

BACKGROUND: Coping strategies have, in some countries, become so prevalent that it has been widely assumed that the very notion of civil services ethos has completely – and possibly irreversibly – disappeared. This paper describes the importance and the nature of pilfering of drugs by health staff in Mozambique and Cape Verde, as perceived by health professionals from these countries. Their opinions provide pointers as to how to tackle these problems. METHODS: This study is based on a self-administered questionnaire addressed to a convenience sample of health workers in Mozambique and in Cape Verde. RESULTS: The study confirms that misuse of access to pharmaceuticals has become a key element in the coping strategies health personnel develop to deal with difficult living conditions. Different professional groups (mis)use their privileged access in different ways, but doctors diversify most. The study identifies the reasons given for misusing access to drugs, shows how the problem is perceived by the health workers, and discusses the implications for finding solutions to the problem. Our findings reflect, from the health workers themselves, a conflict between their self image of what it means to be an honest civil servant who wants to do a decent job, and the brute facts of life that make them betray that image. The manifest unease that this provokes is an important observation as such. CONCLUSION: Our findings suggest that, even in the difficult circumstances observed in many countries, behaviours that depart from traditional civil servant deontology have not been interiorised as a norm. This ambiguity indicates that interventions to mitigate the erosion of proper conduct would be welcome. The time to act is now, before small-scale individual coping grows into large-scale, well-organized crime

HIV prevention costs and program scale: data from the PANCEA project in five low and middle-income countries

<p>Abstract</p> <p>Background</p> <p>Economic theory and limited empirical data suggest that costs per unit of HIV prevention program output (unit costs) will initially decrease as small programs expand. Unit costs may then reach a nadir and start to increase if expansion continues beyond the economically optimal size. Information on the relationship between scale and unit costs is critical to project the cost of global HIV prevention efforts and to allocate prevention resources efficiently.</p> <p>Methods</p> <p>The "Prevent AIDS: Network for Cost-Effectiveness Analysis" (PANCEA) project collected 2003 and 2004 cost and output data from 206 HIV prevention programs of six types in five countries. The association between scale and efficiency for each intervention type was examined for each country. Our team characterized the direction, shape, and strength of this association by fitting bivariate regression lines to scatter plots of output levels and unit costs. We chose the regression forms with the highest explanatory power (R²).</p> <p>Results</p> <p>Efficiency increased with scale, across all countries and interventions. This association varied within intervention and within country, in terms of the range in scale and efficiency, the best fitting regression form, and the slope of the regression. The fraction of variation in efficiency explained by scale ranged from 26% – 96%. Doubling in scale resulted in reductions in unit costs averaging 34.2% (ranging from 2.4% to 58.0%). Two regression trends, in India, suggested an inflection point beyond which unit costs increased.</p> <p>Conclusion</p> <p>Unit costs decrease with scale across a wide range of service types and volumes. These country and intervention-specific findings can inform projections of the global cost of scaling up HIV prevention efforts.</p

Resource flows and levels of spending for the response to HIV and AIDS in Belarus

<p>Abstract</p> <p>Background</p> <p>Belarus has a focused HIV epidemic concentrated among injecting drug users, female sex workers and men who have sex with men. However, until 2008, Belarus had no way of evaluating HIV spending priorities. In 2008, Belarus committed to undertaking a comprehensive National AIDS Spending Assessment (NASA) in order to analyze HIV spending priorities. NASA was used to 'follow the money' from the funding sources to agents and providers, and eventually to beneficiary populations.</p> <p>Findings</p> <p>Belarus spent the majority of its funding on prevention, diagnosis and treatment of sexually transmitted infections and on securing the blood supply. International donors and NGOs working within Belarus spent the majority of their funding on preventative activities for high risk groups while Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) solely funded antiretroviral treatment.</p> <p>Conclusions</p> <p>The data and experience obtained through conducting NASA will help build capacity for future resource tracking activities for HIV and other health priorities. This experience established the foundation for enhanced and future consistent quality-reporting of National Health Accounts. Monitoring the flow of resources for Belarus' HIV response provides valuable strategic information that can improve operations and planning as well as mobilize greater resources. NASA offers Belarusian policy makers an overview of HIV activities that merit their priority attention. In addition, the findings from Belarus are particularly relevant for the rest of the Commonwealth of Independent States due to their similar epidemiological profiles and centrally planned systems. The Belarusian government faces future challenges, especially in increasing public investments in HIV prevention for female sex workers and their clients, men who have sex with men, and among intravenous drug users.</p

Costs Associated with Low Birth Weight in a Rural Area of Southern Mozambique

BACKGROUND: Low Birth Weight (LBW) is prevalent in low-income countries. Even though the economic evaluation of interventions to reduce this burden is essential to guide health policies, data on costs associated with LBW are scarce. This study aims to estimate the costs to the health system and to the household and the Disability Adjusted Life Years (DALYs) arising from infant deaths associated with LBW in Southern Mozambique. METHODS AND FINDINGS: Costs incurred by the households were collected through exit surveys. Health system costs were gathered from data obtained onsite and from published information. DALYs due to death of LBW babies were based on local estimates of prevalence of LBW (12%), very low birth weight (VLBW) (1%) and of case fatality rates compared to non-LBW weight babies [for LBW (12%) and VLBW (80%)]. Costs associated with LBW excess morbidity were calculated on the incremental number of hospital admissions in LBW babies compared to non-LBW weight babies. Direct and indirect household costs for routine health care were 24.12 US$(CI 95$ (CI 95% 6.33; 10.72). Of the 3,322 live births that occurred in one year in the study area, health system costs associated to LBW (routine health care and excess morbidity) and DALYs were 169,957.61 US$ (CI 95% 144,900.00; 195,500.00) and 2,746.06, respectively. CONCLUSIONS: This first cost evaluation of LBW in a low-income country shows that reducing the prevalence of LBW would translate into important cost savings to the health system and the household. These results are of relevance for similar settings and should serve to promote interventions aimed at improving maternal care

Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review

A systematic review conducted by Sanjay Basu and colleagues reevaluates the evidence relating to comparative performance of public versus private sector healthcare delivery in low- and middle-income countries

Improvements in access to malaria treatment in Tanzania after switch to artemisinin combination therapy and the introduction of accredited drug dispensing outlets - a provider perspective

BACKGROUND\ud \ud To improve access to treatment in the private retail sector a new class of outlets known as accredited drug dispensing outlets (ADDO) was created in Tanzania. Tanzania changed its first-line treatment for malaria from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (ALu) in 2007. Subsidized ALu was made available in both health facilities and ADDOs. The effect of these interventions on access to malaria treatment was studied in rural Tanzania.\ud \ud METHODS\ud \ud The study was carried out in the villages of Kilombero and Ulanga Demographic Surveillance System (DSS) and in Ifakara town. Data collection consisted of: 1) yearly censuses of shops selling drugs; 2) collection of monthly data on availability of anti-malarials in public health facilities; and 3) retail audits to measure anti-malarial sales volumes in all public, mission and private outlets. The data were complemented with DSS population data.\ud \ud RESULTS\ud \ud Between 2004 and 2008 access to malaria treatment greatly improved and the number of anti-malarial treatment doses dispensed increased by 78%. Particular improvements were observed in the availability (from 0.24 shops per 1,000 people in 2004 to 0.39 in 2008) and accessibility (from 71% of households within 5 km of a shop in 2004 to 87% in 2008) of drug shops. Despite no improvements in affordability this resulted in an increase of the market share from 49% of anti-malarial sales 2005 to 59% in 2008. The change of treatment policy from SP to ALu led to severe stock-outs of SP in health facilities in the months leading up to the introduction of ALu (only 40% months in stock), but these were compensated by the wide availability of SP in shops. After the introduction of ALu stock levels of the drug were relatively high in public health facilities (over 80% months in stock), but the drug could only be found in 30% of drug shops and in no general shops. This resulted in a low overall utilization of the drug (19% of all anti-malarial sales)\ud \ud CONCLUSIONS\ud \ud The public health and private retail sector are important complementary sources of treatment in rural Tanzania. Ensuring the availability of ALu in the private retail sector is important for its successful uptake

Modelling the impact and cost-effectiveness of the HIV intervention programme amongst commercial sex workers in Ahmedabad, Gujarat, India.

BACKGROUND: Ahmedabad is an industrial city in Gujarat, India. In 2003, the HIV prevalence among commercial sex workers (CSWs) in Ahmedabad reached 13.0%. In response, the Jyoti Sangh HIV prevention programme for CSWs was initiated, which involves outreach, peer education, condom distribution, and free STD clinics. Two surveys were performed among CSWs in 1999 and 2003. This study estimates the cost-effectiveness of the Jyoti Sangh HIV prevention programme. METHODS: A dynamic mathematical model was used with survey and intervention-specific data from Ahmedabad to estimate the HIV impact of the Jyoti Sangh project for the 51 months between the two CSW surveys. Uncertainty analysis was used to obtain different model fits to the HIV/STI epidemiological data, producing a range for the HIV impact of the project. Financial and economic costs of the intervention were estimated from the providers perspective for the same time period. The cost per HIV-infection averted was estimated. RESULTS: Over 51 months, projections suggest that the intervention averted 624 and 5,131 HIV cases among the CSWs and their clients, respectively. This equates to a 54% and 51% decrease in the HIV infections that would have occurred among the CSWs and clients without the intervention. In the absence of intervention, the model predicts that the HIV prevalence amongst the CSWs in 2003 would have been 26%, almost twice that with the intervention. Cost per HIV infection averted, excluding and including peer educator economic costs, was USD 59 and USD 98 respectively. CONCLUSION: This study demonstrated that targeted CSW interventions in India can be cost-effective, and highlights the importance of replicating this effort in other similar settings.Published versio