Developing a Methodology for Cost-Benefit Analysis of GFATM

www.hivtools.lshtm.ac.uk

Developing a Methodology for Cost-Benefit Analysis of

GFATM

Lilani Kumaranayake, Charlotte Watts

and Philip Carriere


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?


Purposes of Analysis

Develop a pilot methodology to estimate cost and benefits of HIV/AIDs programming for Global Fund


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


Methodological Development


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


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


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





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


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


Conceptual framework

Downstream Programming

Intn1

Intn3

Intn2

Intn4

Intn5

ImpactDALYs

Upstream Programming

ImpactDALYs

ImpactDALYs

ImpactDALYs

ImpactDALYs

ImpactDALYs

Valuation of DALY benefits


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


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


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


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


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


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.


Our first Guesstimate of CBA


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.


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


Constraints and Limitations


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


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


Next Steps

Continue to collect more detailed grant and intervention level data by country

Anticipating more comprehensive data from GFATM

Developing a Methodology for Cost-Benefit Analysis of GFATM

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