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Developing a Methodology for Cost-Benefit Analysis of
GFATM
Lilani Kumaranayake, Charlotte Watts
and Philip Carriere
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Background
Huge international investments in HIV/TB & Malaria
Increasing questions about value for money Is it possible to estimate the cost-benefits of
specific global initiatives?
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Purposes of Analysis
Develop a pilot methodology to estimate cost and benefits of HIV/AIDs programming for Global Fund
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Challenges
Limited data available from Global fund currently data available by disease area (HIV) and
grant basis No details as of yet on intervention types (although
currently working on it)
Current analysis based on country and grant information from GFATM and examination of country programming from individual countries where details available
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Methodological Development
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Methods 1 - Literature Reviewed
Evidence of intervention impact Cost-effectiveness Summaries of priorities for HIV/AIDS
programmes in different epidemic settings
Results: As of yet we have almost no data on cost-benefit of HIV/AIDS interventions,
Cost-effectiveness data available across some interventions, by region
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Methods 2
What can we do with available evidence to think about global fund programming?
Estimate Health Impact associated with expenditures (DALYs or HIV infections averted)
Health Benefits associated with expenditures (2008 Constant $)
Results expressed in present value terms (3%)e.g. discounting future costs and benefits
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CE Data Used for Analysis Intervention Africa Generalized
High Epidemic
Africa Generalized
Low Epidemic Asia and other regions -
Concentrated Epidemic
Cost per HIV infection averted
Cost per Daly Averted
Cost per HIV infection averted
Cost per Daly Averted
Cost per HIV infection averted
Cost per Daly Averted
Mass Media £46 £2 £46 £2 £243 £14 Peer education for sex workers
£54 £3 £54 £3 £41 £2
Condom Social Marketing £60 £3 £60 £3 £60 £3 Youth education £6,229 £350 £6,229 £350 £6,730 £399 Harm Reduction £273 £14 Voluntary Counselling and Testing
£209 £11 £209 £11 £152 £8
Prevention of mother to child transmission
£667 £27 £667 £27 £5,664 £244
Treatment of STIs (general population)
£258 £17 £258 £17 £353 £21
Reduction of stigma and discrimination*
£209 £11 £209 £11 £209 £11
Cotrimoxazole prophylaxis £5 £5 £5 Support for PLHA £63 £63 £63 Home-based care £63 £63 £63 Palliative care £63 £63 £63 Antiretroviral Treatment (first-line drugs, monitoring)
£27,431 £469 £27,431 £469 £17,162 £449
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Nature of Programming
Upstream support planning, improved financing, enabling
environments, typically do not result in direct contact with
population groups or specific programmes of activities involving them.
Downstream Support to direct programme activities with
populations
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Conceptual framework
Downstream Programming
Intn1
Intn3
Intn2
Intn4
Intn5
ImpactDALYs
Upstream Programming
ImpactDALYs
ImpactDALYs
ImpactDALYs
ImpactDALYs
ImpactDALYs
Valuation of DALY benefits
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Methods 3 – Regional Analysis
Impact and cost-effectiveness vary by stage of HIV/AIDS epidemic
Analysis uses UNAIDS classification Concentrated Epidemic (Asia, Americas,
Europe) Generalised Low Level Epidemic (some
Africa) Generalised High Level Epidemic
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Methods 4 – Programmes and Interventions
Hard to assess how programming translates into intervention-specific expenditure
For analysis, develop attribution weighting Directness category used to reflect
relationship between programming and different forms of HIV/AIDS intervention
Relative classification 9 = directly related, 3=fairly related, 1=less directly related
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Programme Weighting by Intervention – example PMTCT
Mass Media
Sex worker interventions
Condom provision
Youth education
Harm Reduction
VCT PMTCT
0.7 0 0 0.7 0 7.9 78.9
STI Treatment
Reduction of Stigma
Prophylaxis
PLHA support
Home based care
Palliative Care
ART
0.7 0.7 0.7 0.7 0.7 0.7 0.7
Most directly related
Fairly direct Less direct
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Methods 5 - Valuing Upstream and Downstream Investments Not all investment will immediately translate
into intervention activity and short-term impact
Multipliers for expenditure Upstream 0.25 Downstream 0.75
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Methods 6 – Calculation Steps
Estimate upstream and downstream expenditure by grant and region
Use weightings to estimate expenditure by programme and intervention activity
Use multipliers to estimate proportion of expenditure by programme and intervention resulting in short-term impact
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Calculation Steps continued
Use intervention CE data to estimate impact in DALYs gained
Use cost-of-illness approach to value impact gains $6000 for life-time treatment cost, which is the
average value of life-time costs obtained from two recently published cost-effectiveness studies
Thus, using the ratio of 22 DALYs per one HIV infection averted, we can compute the value of a DALY gained as $264.
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Our first Guesstimate of CBA
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Results – Committed Funds – the potential
It was estimated that the present value of DALYs gained was 2,958,000
estimated cost-effectiveness of HIV/AIDS portfolio $181 per DALY gained.
Cost-benefit terms: Net present Value: $2,009,120 Benefit-Cost Ratio: $ 1.34
Results were robust to changes in key assumptions related to discount rates and methods of monetising benefits.
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Results – Disbursements - Actual
To-date only 28% of committed funds have been disbursed Continuing to obtain data which gives us a
better breakdown of programming for disbursed funds
Disbursement profile suggests that perhaps only a third of these benefits have currently been accrued
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Constraints and Limitations
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Calculations Make Many Assumptions Speculative analysis Upstream benefits result only from downstream
activities Downstream activities related to interventions with
CE data Limited number of interventions considered Impact is health-related (DALYs), does not value other
aspects Assume interventions like sustainable livelihoods
translate into DALY benefits (NO evidence) Assume distribution of interventions across
programming
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Limitations Continued
Assume multipliers for upstream/downstream (NO evidence)
Assume valuation of DALYs into benefits by cost-of-illness (preventing costs of treating)Does not consider other aspects of valuation
Larger uncertainty about multilateral analysisConstrained by level of data available
Using CE approach means that prevention has greater impact
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Next Steps
Continue to collect more detailed grant and intervention level data by country
Anticipating more comprehensive data from GFATM