The effects of scale on costs of Targeted HIV Prevention Interventions Among Female and Male Sex workers, MSM, and

Transgenders in India

Abstract No. 10818: Poster Code-A-072-0228-10818)International AIDS Economics Network Symposium

The effects of scale on costs of Targeted HIV Prevention Interventions Among Female and Male Sex workers, MSM, and

Transgenders in India

Abstract No. 10818: Poster Code-A-072-0228-10818)International AIDS Economics Network Symposium

XVII International AIDS Pre-Conference in Mexico City 3-8 August 2008

Chandrashekar S1,4, Kumaranayake L1, Bhaskar Reddy R2, Govindraj Y2, Alary M3

1London School of Hygiene and Tropical Medicine, London, UK;

2Karnataka Health Promotion Trust, Bangalore, India

3Centre Centre hospitalier affilié universitaire de Québec, Canadahospitalier affilié universitaire de Québec, Canada

4 4 St.John’s Research InstituteSt.John’s Research Institute

Objectives Objectives

1. Estimate economic cost of resources used to implement programme

2. To study the cost variation by NGO implementing targeted interventions over a two year period

Overall Costing MethodologyOverall Costing Methodology

Framework of Economic AnalysisFramework of Economic Analysis

Include all 62 districts in 4 Southern States where Avahan has Intervention

activities for a four-year period.

For each SLP:– Some districts will have detailed cost analyses, chosen in

consultation with SLP. Detailed cost analyses undertaken twice.

– Other districts will rely on routinely collected data and data gathered from detailed districts

– Data collection is at level of implementing NGO within district

– Analysis is undertaken by NGO and district for each SLP

Summary of District AnalysisSummary of District AnalysisSLP Number

Districts

Detailed Districts

(Number NGOs)

Number NGOs

TAI-VHS 12 Dharmapuri (2)Madhurai (5)

26

KHPT 16 All 16 (17) 17

Pathfinder 11 Ahmednagar (1)Parbhani (1)

12

FHI 2 Mumbai (5)*Not all NGOs in district chosen, 5

chosen by typology

14

HLFPPT 8 Guntur (1) 10

Alliance 13 Karimnagar (3)Rangareddy (1)

28

All Avahan 62 24 (36) 107

Costing ApproachCosting Approach Provider perspective

– excludes costs of clients using services (e.g. travel time)

Full costing – includes all costs of running program including administration,

infrastructure etc.

Economic cost– Includes value of all items used in implementing services, even if not

paid for or donated– This contrasts to financial costs, which only include expenditures

which are actually paid

Specific Considerations in CostingSpecific Considerations in Costing

By Input: capital versus recurrent items By Activity: training, STI services etc Annualizing capital costs so that costs are spread

over period of project, not just one year Allocating shared resources Donated goods and services Timeframe: start-up versus implementation. Start-

up treated as a capital item. Multi-year Costing: establish base year (2006) and

adjust by inflation

Organizational levels for costingOrganizational levels for costing

District Support

District

NGO most common

level for costing

Our Analysis

SLP LEVEL

NGO

NGONGO

Data SourcesData Sources

Retrospective and prospective Financial records from NGOs and SLPs

Using routine financial and management reporting Process and outcome data from routine reporting Interviews with SLP staff related to district programming Districts in detailed costing – additional data collection

instruments

Specific Data Collection Instruments for Detailed CostingSpecific Data Collection Instruments for Detailed Costing

Records review – designed to review all data that is being routinely reported (financial and

programming).

Key informant interviews with project staff– questionnaires for the field officers and project/district coordinators

Focus group discussion guidelines –– discussions with peer educators

Time-sheets – to collect data regarding allocation between activities undertaken by field

officers and STI doctors

Overall Results Costing 2004-2006Overall Results Costing 2004-2006

Y1 Y2 Y1 Y2Karnataka 16 17 15 16

Maharashtra SLP 1 14 2

Tamil Nadu 24 26 12 12

Maharashtra SLP 2 12 11

Andhra Pradesh SLP 1 10 10 8 8

Andhra Pradesh SLP 2 21 28 9 13Total 71 107 44 62

SLPNGO's Dist's Avahan scale up from

Y1-Y2 consisted addition of 18 districts and 36 NGOs in the 4 implementing states.

Avahan Scale-up

Total District level Economic cost (2004-06) Total District level Economic cost (2004-06)

Y1(2004-05) Y2(2005-06)Karnataka 1,089,422$ 2,757,685$

Maharashtra SLP 1 732,865$

Tamil Nadu 547,298$ 1,534,543$

Maharashtra SLP 2 207,211$

Andhra Pradesh SLP 1 137,291$ 552,266$

Andhra Pradesh SLP 2 214,620$ 964,356$

Total 1,988,630$ 6,748,925$

SLP The total economic costs

have increased by $ 4,760,294(70.5%) from

Y1 to Y2

Total Economic Cost

Analysis by InputAnalysis by Input Main types of inputs: capital and recurrent

– Capital costs: items which last for multiple years– Recurrent costs: Incurred for use of resources that produce benefits

for one year or less, incurred on a continual basis (e.g. salaries, supplies)

Annualisation of capital items– Ensures early years of the programme do not overestimate annual

costs– Makes recurrent and capital costs comparable– Recognises the investment aspect of capital items (benefits are

spread over a number of years)

Main differences between financial and economic costsMain differences between financial and economic costs

Valuation of donated condomsDonated space (taluka offices, government buildings) opportunity of cost of peer education Interviews with Project Co-ordinator & Field Officers gave insights into the extent of donated inputs (free or subsidised space, mobilization of free doctors for outreach camps, joint events with other local groups)

District level Economic Costs By Input :Y 1+ Y 2 (Constant 2006 Rs)

District level Economic Costs By Input :Y 1+ Y 2 (Constant 2006 Rs)

Personal45.2%

Capital Total12.9%

Travel6.3%

Building Operating & Maintanance

5.4%

STI Supplies13.8%

Monitoring and Evaluation

2.2%

Trainings3.1%

Enabling Environment

4.1%

Others0.4%

Condom Promotion

6.7%

Cost Analysis by activityCost Analysis by activity Main categories for activity -Capacity building, outreach, STI services, condom promotion, enabling environment,

Community mobilization, IEC, Planning and co-ordination, Essential AIDS care, Monitoring and evaluation,

Method of allocation – district specific Where costs directly allocable to category (e.g. training, STI, start-

up) put in respective category Personnel time – based on time-sheet analysis Other recurrent items were allocated based on allocation factors

derived from personnel time-sheets; then capital which was non-allocable was based on overall recurrent cost percentages

Time-sheets – had been prospectively collected during Year 1 PC, FO, some ORW were asked to fill in individual time-sheet for 1

week, showing how their time was allocated over activities For peers from peer group FGD and job descriptions General staff time was allocated equally across the activities

District level Economic Costs By Activity :Y 1+ Y 2 (Constant 2006 Rs)

District level Economic Costs By Activity :Y 1+ Y 2 (Constant 2006 Rs)

Peer education 15.5%

STI services31.8%

Condom Promotion

13.9%

Enabling Environment

7.4%

Community Mobilization

5.4%

Monitoring and Evaluation

5.7%

Planning & Coordination

8.3%

Start up activites

4.1%

Others 1.0%

Trainings6.9%

Process Output MeasuresProcess Output Measures

64% of Estimated Key population were registered by end of 2nd Year

04-05. 05-06. 04-05. 05-06. 04-05. 05-06.Karnataka 22709 47654 13479 28845 9756 27674

Maharashtra SLP 1 27990 32186 29643

Tamil Nadu 33900 33900 29651 35797 6102 19866

Maharashtra SLP 2 0 11649 1467 2050

Andhra Pradesh SLP 1 4338 16525 Y3 available Y3 available 998 20063

Andhra Pradesh SLP 2 44292 44292 1390 18247 3177 25373

Total 105239 182010 44520 116542 20033 124669

SLPEstimated Registered Clinic Visits

Average Costs By Scale – Year 1 +Year 2 ( per

Person registered )

Average Costs By Scale – Year 1 +Year 2 ( per

Person registered )

N=85

$-

$100

$200

$300

$400

$500

0 1000 2000 3000 4000 5000 6000 7000

Scale

Ave

rag

e C

ost

Average Costs By Scale – Year 1 +Year2 (Clinic visits)

Average Costs By Scale – Year 1 +Year2 (Clinic visits)

N=98

$-$50

$100$150$200$250

$300$350

0 2000 4000 6000 8000 10000

Scale

Ave

rag

e C

ost

Results continued…..Results continued…..

64% of Estimated Key population were registered by end of 2nd Year (116,542 )

The scale of activity varied from 37-6315 people registered, and 7-8004 people contacted across NGO interventions.

The median cost per person registered was US$36, with a mean cost of US $72 (95 Confidence Interval $55-$87).

Large reductions in the cost per person registered were observed. Costs declined from $427 for low scales of activity to $ 9 for the highest scale of activity. (R2 = .209)

Scale was significantly associated with decreasing average costs (Pearson correlation coefficient -0.457, p=0.001)

Scale explains 21% of the variations in the cost across NGOs

Results continued…..Results continued…..

About 1,24,669 had availed STI Services during the 2 year period

The median cost per person availing STI Services $68.4 (Range $10.54 to $1406)

Scale was significantly associated with decreasing average costs (Pearson correlation coefficient -0.321, p=0.001)

Scale explains 10% of the variations in the cost across NGOs and there was significant reduction in costs as the scale increased (R2 = .103)

ConclusionsConclusions

During rapid scale-up of targeted HIV preventions, a significant reduction in average costs was observed as the scale of activity increased.

Scale effects are important to quantify for planning future resource requirements of large-scale interventions.

AcknowledgementsAcknowledgements

State lead partner staff, NGO staff at district and headquarters, Peer educators and community members

" Support for this study was provided by the Bill & Melinda Gates Foundation through Avahan, its India AIDS Initiative.  The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation and Avahan