What Determines HIV Prevention Costs at Scale? Evidence from the Avahan Programme in India

Abstract

Expanding essential health services through non‐government organisations (NGOs) is a central strategy for achieving universal health coverage in many low‐income and middle‐income countries. Human immunodeficiency virus (HIV) prevention services for key populations are commonly delivered through NGOs and have been demonstrated to be cost‐effective and of substantial global public health importance. However, funding for HIV prevention remains scarce, and there are growing calls internationally to improve the efficiency of HIV prevention programmes as a key strategy to reach global HIV targets. To date, there is limited evidence on the determinants of costs of HIV prevention delivered through NGOs; and thus, policymakers have little guidance in how best to design programmes that are both effective and efficient. We collected economic costs from the Indian Avahan initiative, the largest HIV prevention project conducted globally, during the first 4 years of its implementation. We use a fixed‐effect panel estimator and a random‐intercept model to investigate the determinants of average cost. We find that programme design choices such as NGO scale, the extent of community involvement, the way in which support is offered to NGOs and how clinical services are organised substantially impact average cost in a grant‐based payment setting. © 2016 The Authors. Health Economics published by John Wiley & Sons Ltd.

Influence of supply-side factors on voluntary medical male circumcision costs in Kenya, Rwanda, South Africa, and Zambia

“…Our finding on the association between scale and VMMC unit cost was consistent with prior studies assessing this relationship [ 10 , 13 , 14 ], as well as earlier work appraising the relationship between scale and other HIV prevention interventions [ 20 – 23 , 25 ], and HIV treatment [ 25 – 28 ]. As volume of VMMC clients expands in a facility, reductions in cost per VMMC client are likely as fixed costs are distributed among more clients and staff time is employed more fully.…”

Large-scale delivery of seasonal malaria chemoprevention to children under 10 in Senegal: an economic analysis

“…Our findings of substantial economies of scale represent an important contribution to a very limited evidence base on cost variation in health service delivery in low- and middle-income countries, particularly at the primary health care and community level and outside the HIV field ( Brooker et al 2008 ; Fiedler et al 2014 ; Siapka et al 2014 ). Consistent with previous studies of HIV prevention in India ( Guinness et al 2007 ; Lépine et al 2015 ; Lépine et al 2016 ) and of school-based albendazole distribution in Uganda ( Brooker et al 2008 ), we found that average costs exhibited an L-shape, and found no evidence in our sample of a point at which average costs would begin to increase, generating the U-shape predicted in economic theory. While our statistical analysis remains descriptive and was limited by the small number of data points and possibly by the trial context and other factors, the 46 health facilities we analysed constitute a relatively large dataset in the context of health facility costings.…”

Foreword: Health Economic Evaluations in Low‐ and Middle‐income Countries: Methodological Issues and Challenges for Priority Setting

“…They examine a non‐governmental public health programme to prevent HIV using data on 138 non‐governmental organisations over 4 years in India. Their findings of substantial economies of scale and a number of other determinants of unit costs support the case for using cost functions when conducting economic evaluations of interventions that need to be scaled up (Lépine et al ., ).…”