Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries

Abstract

Background Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries. Methods and findings We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions’ socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs. Conclusions We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

What Interventions are Cost Effective in Reducing Violence Against Women? A Scoping Review

“…There was conflicting evidence of cost effectiveness from two economic and social empowerment programmes implemented in South Africa ([ 26 , 27 ]; Table 1 ). When compared to usual practice in control villages, engaging with low-income women participating in a loans programme in gender and HIV-related training was cost effective in reducing physical and/or sexual IPV during pilot phases, and highly cost effective when scaled up [ 26 ].…”

“…The unit cost to deliver the intervention reduced when the pilot programme was scaled up over two years to reach more women within participating communities (USD$18 per beneficiary). A second gender-transformative intervention that engaged unemployed women and men living in informal settlements in related activities reported a higher unit cost per person (USD$338–$1919) and relative to outcomes measured, a cost-effectiveness ratio that exceeded the Gross Domestic Product (GDP) per capita and opportunity cost threshold applied [ 27 ]. Cost-effectiveness results were more favourable when focusing on women only and from a societal perspective [ 27 ].…”

“…Engaging couples (and individuals) in gender transformative activities was cost effective in preventing cases of physical and/sexual IPV when compared to a brief intervention in Ethiopia (IPV education [ 28 ]) and control comparator in Rwanda [ 27 ]; Table 1 ). A low unit cost to deliver the intervention in Rwanda per person (USD$7) and in Ethiopia per community-level beneficiary (USD$6) were reported.…”

“…Among the three treatment arms of the intervention in Ethiopia (couples, men-only or women-only), the men-only intervention had the most favourable cost-effectiveness results, with the couples’ intervention associated with higher costs and fewer cases of IPV prevented. Whereas the couples’ intervention in Rwanda was cost effective in the local context when compared to a control group as reported in subgroup analysis [ 27 ]. The cost effectiveness of this couples’ programme compared to a gender transformative community mobilisation component subsequently delivered in participating communities is reported below.…”

Assessing the cost-effectiveness of economic strengthening and parenting support for preventing violence against adolescents in South Africa: an economic modelling study using non-randomised data

“…Economic evaluations of violence prevention interventions remain relatively uncommon, particularly in low- and middle-income countries (5–8). Experimental studies are recommended for evaluating cost-effectiveness (9–11).…”