Health Economics Studies

Following success demonstrated with the HIV Self-Testing Africa Initiative, HIV self-testing (HIVST) is being added to national HIV testing strategies in Southern Africa. An analysis of the costs of scaling up HIVST is needed to inform national plans, but there is a dearth of evidence on methods for forecasting costs at scale from pilot projects. Econometric cost functions (ECFs) apply statistical inference to predict costs; however, we often do not have the luxury of collecting large amounts of location-specific data. We fit an ECF to identify key drivers of costs, then use a simpler model to guide cost projections at scale. We estimated the full economic costs of community-based HIVST distribution in 92 locales across Malawi, Zambia, Zimbabwe, South Africa and Lesotho between June 2016 and June 2019. We fitted a cost function with determinants related to scale, locales organisational and environmental characteristics, target populations, and per capita Growth Domestic Product (GDP). We used models differing in data intensity to predict costs at scale. We compared predicted estimates with scale-up costs in Lesotho observed over a 2-year period.

The scale of distribution, type of community-based intervention, percentage of kits distributed to men, distance from implementer’s warehouse and per capita GDP predicted average costs per HIVST kit distributed. Our model simplification approach showed that a parsimonious model could predict costs without losing accuracy. Overall, ECF showed a good predictive capacity, that is, forecast costs were close to observed costs. However, at larger scale, variations of programme efficiency over time (number of kits distributed per agent monthly) could potentially influence cost predictions. Our empirical cost function can inform community-based HIVST scale-up in Southern African countries. Our findings suggest that a parsimonious ECF can be used to forecast costs at scale in the context of financial planning and budgeting.

 

Full details of the analysis can be found in the published manuscript below: d’Elbée M, Gomez GB, Sande LA, et al Modelling costs of community-based HIV self-testing programmes in Southern Africa at scale: an econometric cost function analysis across five countries BMJ Global Health 2021;6:e005554. https://gh.bmj.com/content/6/Suppl_4/e005554 doi:10.1136/ bmjgh-2021-005554

 

The HIV Self-Testing Africa-Initiative distributed HIV self-test (HIVST) kits using unincentivized HIV testing counsellors across 31 public facilities in Malawi, South Africa, Zambia and Zimbabwe. HIVST was distributed either through secondary (partner’s use) distribution alone or primary (own use) and secondary distribution approaches. We evaluated the costs of adding HIVST to existing HIV testing from the providers’ perspective in the 31 public health facilities across the four countries between 2018 and 2019. We combined expenditure analysis and bottom-up costing approaches. We also carried out time-and-motion studies on the counsellors to estimate the human resource costs of introducing and demonstrating how to use HIVST for primary and secondary use.

 

A total of 41?720 kits were distributed during the analysis period, ranging from 1254 in Zimbabwe to 27?678 in Zambia. The cost per kit distributed through the primary distribution approach was $4.27 in Zambia and $9.24 in Zimbabwe. The cost per kit distributed through the secondary distribution approach ranged from $6.46 in Zambia to $13.42 in South Africa, with a wider variation in the average cost at facility-level. From the time-and-motion observations, the counsellors spent between 20% and 44% of the observed workday on HIVST. Overall, personnel and test kit costs were the main cost drivers. The average costs of distributing HIVST kits were comparable across the four countries in our analysis despite wide cost variability within countries. We recommend context-specific exploration of potential efficiency gains from these facility-level cost variations and demand creation activities to ensure continued affordability at scale.

 

Full details of the analysis can be found in the published manuscript below: Sande LA, Matsimela K, Mwenge L, et al Costs of integrating HIV self-testing in public health facilities in Malawi, South Africa, Zambia and Zimbabwe BMJ Global Health 2021;6:e005191. https://gh.bmj.com/content/6/Suppl_4/e005191 doi:10.1136/ bmjgh-2021-005191

Funding Source: UNITAID

 

Funding Period: DATE

 

Funded by Unitaid (STAR Initiative), sub-agreement number 4214-CeSHHAR the parent trial compared community-led distribution of HIVST kits with an established community-based HIV self-testing (HIVST) model in rural Zimbabwe using a cluster-randomised trial. The full provider’s costs of delivering both intervention arms observed over the full implementation period were analysed. The analysis combined financial expenditure analysis and bottom-up costing methods, with actual expenses allocated top–down, in a stepwise fashion to study arms, activity, and distribution sites using established allocation factors which include M&E data. We include above service level costs and direct cost of service provision including training, self-test distribution and support and supervision. The economic costing supplemented the financial analysis with bottom–up costing to value donated goods or services, including valuing community in-kind contributions. Valuation of distributor time in the paid distributor model applied the value of the stipend (US$50 per distributor), in the community-led model we costed both the direct financial and economic (in-kind) contribution of the headman unit. We present total and unit cost per kit distributed. As the literature has shown that programme costs change over time, we recognise that the paid distributor arm was an established model, while the community-led model is new. To put this in context we compare our costs with the costs of the paid distributor model in 2016/2017 when it was new. All costs are presented in 2020 US$.

Total distribution costs were calculated as US$231, 212 and US$285, 065 for paid distributor and community-led programmes. Human resources were the largest cost category in both model arms at 39% and 46%, followed by HIVST kits which contributed 37% and 23%, respectively. Vehicle costs were 6% and 8% of total costs, respectively. The cost per HIVST kit distributed was US$6.29 and US$10.25 for the paid distributor arms and community-led arms, respectively. When the paid distributor model was first introduced in 2016/17, the cost per HIVST kit distributed was $14.52. Across sites the cost per HIVST kit distributed ranged from US$5.49 to U$9.52 in the paid distributor arm and US$6.14 to US$33.11 in the community-led model arm. Unit costs were generally lower at sites with larger numbers of self-test kits distributed, suggesting a spreading of fixed costs across variable numbers of kits (ie, economies of scale).

Full details of the analysis can be found in the published trial manuscript: Sibanda EL, Mangenah C, Neuman M, et al. Comparison of community-led distribution of HIV self-tests kits with distribution by paid distributors: a cluster randomised trial in rural Zimbabwean communities.  https://gh.bmj.com/content/6/Suppl_4/e005000 doi:10.1136/ bmjgh-2021-005000

 

Funding Source: Welcome Trust

 

Funding Period: April 2019 – March 2024

 

Implemented by a consortium comprising researchers from CeSHHAR Zimbabwe, LSTM, LSHTM, UCL, AHRI, MLW and the National AIDS Council of Zimbabwe the AMETHIST Trial involves development, implementation and evaluation of an intervention scaling up an integrated model of peer-led microplanning supported by self-help-groups for FSW to deepen understanding of how to optimise implementation in the 22 AMETHIST trial sites (11 intervention and 11 control). To inform cost effectiveness modelling, an economic costing study, combining top-down financial expenditure analysis and bottom-up approaches is exploring annual costs of the intervention (including intervention development, initial training and start-up, capital and recurrent costs) from the provider perspective. Site level activity-based-costing has involved (1) observing service provision and other intervention activities, (2) recording site characteristics, services offered, and staff types and numbers involved, (3) conducting time and motion analysis on client facing staff to help allocate human resource costs, (4) mapping and measuring FSW clinic spaces (5) recording equipment and vehicles used, (6) extracting actual drug & other supplies use from pharmacy stock cards, and (7) extracting data from vehicle log books and schedules to help allocate vehicle use, fuel & running expenses. These activities (in combination with M&E data) inform allocation of costs to specific sites, services and tasks.

 

 

In addition to estimating total economic cost, average cost per client reached and per service this costing study is assessing variation (total costs, cost profiles and unit costs) by service delivery sites and over time due to programme learning effects and as staff got more efficient at their roles over the 2-year trial period. Using results from both the economic costing study and trial effectiveness data cost-effectiveness modelling will infer the reduction in DALYs incurred in the whole adult population, taking into account the potential reduction in direct and indirect HIV acquisition and transmission occurring as a result of transactional sex due to the reduction in the proportion of sex workers who are either infectious or at risk of acquisition. Parallel cost analysis explores likely transferability, impact, and cost-effectiveness in very different sex work and programmatic contexts in Malawi and South Africa to generate evidence to inform health policy across Africa.

 

 

Funding Source: UNITAID through PSI Zimbabwe

Funding Period: September 2015 – July 2019

We explored the economic costs of providing facility HIV testing services across three southern African countries with high HIV burden. Primary costing studies were undertaken in 54 health facilities providing HIV testing services (HTS) in Malawi (n=15), Zambia (n=10) and Zimbabwe (n=29). Routinely collected monitoring and evaluation data for the health facilities were extracted to estimate the costs per individual tested and costs per HIV-positive individual identified as well as key cost drivers.  In sensitivity analysis we explored how robust results remained when key cost drivers were varied.

Funding Source: UNITAID through PSI Zimbabwe

Funding period: September 2015 – July 2019

Programme expenditures, supplemented by on-site observation and M&E data were used to estimate full economic total and unit costs per HIVST kit distributed by site during early implementation of the STAR HIVST distribution intervention in Malawi (n=11), Zambia (n=16) and Zimbabwe (n=44).  Inputs were categorised into start-up, capital and recurrent costs. Kit price was modelled using the current prices to account for observed price reductions. Sensitivity and scenario analyses assessed the impact of key parameters on unit costs.

Funding Source: Children’s Investment Fund Foundation (CIFF)

Funding Period: March 2017 – June 2019

Between January-May 2018 technical efficiency analysis was conducted in 20 purposefully selected health facilities providing PMTCT services in Zimbabwe. In each health facility, in-depth technical efficiency surveys were conducted through time and motion studies and clinical vignettes to assess service quality from the health care providers perspective. A facility costing tool was administered together with a patient exit tool that assessed service quality from the patients perspective as well as patient costs. The study also assessed variability in costs by site. A follow up survey will be conducted in 2019.

Funding Source: NIH K award (Sue Napierela)

Funding Period: January to September 2018

Data collection has begun (starting May 2018) on the Health economics in HIV prevention among young high risk women (YWSS) study. The overall goal of this research is to inform identification of the most cost-effective, efficient, and user-preferred package of services to increase engagement of YWSS in HIV services and reduce HIV transmission.  Aim 1 of this study is to estimate the costs and cost-effectiveness of the DREAMS intervention for YWSS in Zimbabwe. Aim 2 is to explore preferred attributes around intervention components and service delivery.

 

Using a combination of facility costing instruments, time and motion observation of clinic staff, and client exit interviews the study will determine client costs and time involved in attending clinic services. Costs of the DREAMS intervention, overall and per client served will be assessed and then combined with output data from the DREAMS IE to estimate the cost-effectiveness of DREAMS on HIV incidence and other secondary outcomes compared to the usual care sites. Incremental cost-effectiveness ratios (ICERs) will be calculated as [Difference in Net Cost] / [Difference in Health Outcome] by exposure to the overall intervention and its components.

Funding Source: ViiV Healthcare’s Positive Action for Adolescents Programme

Funding Period: February 2016 to March 2019

A within trial cost-effectiveness analysis of a community-based programme to improve adherence and retention in care among children and adolescents living with HIV in Zimbabwe will be conducted for the Enhanced Zvandiri Care (EZC) versus Standard of Care. This analysis will combine top down costing, where actual expenses data from project accounts (budgets and expenditure records) are collated and allocated in a step wise fashion to final cost centers and bottom up costing where each ingredient (input) or resource component is quantified and assigned a market related price. A quality of life (QALY) measure EQ-5D will be combined with a visual analogue scale (VAS) to estimate QALYs gained for the purposes of cost-effectiveness analysis.

Funding Source: USAID and PEPFAR through the OPTIONS Consortium

Funding Period: October 2015 to December 2020

A study is planned to cost initiation and retention of women on oral PrEP under different service delivery models in Zimbabwe. The aim of this costing project is to provide the MoHCC, implementers and development partners, including donors, with costing insights to inform introduction and scale up of oral PrEP. Specific objectives are to assess the annual total and unit cost of providing oral PrEP for AGYW and FSWs by service delivery model. The sites costed will represent four PSI/Z DREAMS sites, two PSI/Z Social Franchise Clinics, and one public health facility. Data collection and analysis is planned for July to December 2018.

Funding Source: Bill & Melinda Gates Foundation through PSI Zimbabwe

Funding Period: January 2017 to January 2019

Beginning June 2018 data collection will start under the VMMC catchup and sustainability phases involving cost, cost-effectiveness and technical efficiency analysis. Detailed costing and cost effectiveness analysis of community-based VMMC mobilization will be accompanied by technical efficiency analysis involving assessment of VMMC service quality from both the client and provider perspectives, patient costs and time and motion analysis.

Funding Source: UNITAID through PSI Zimbabwe

Funding Period: September 2015 – July 2019

Adopting the provider’s perspective and beginning September 2018 detailed costing will be conducted of all resources used in distribution of HIV self-testing services and supporting linkage in both distribution models. Both direct costs associated with intervention implementation, including resources required to attain and distribute HIVST kits; and indirect costs associated with supervision and administration will be included in the costing.

 

Costing will specifically account for inputs such as start-up (prior to implementation), stakeholder sensitisation and training, capital costs such as buildings, vehicles and equipment and recurrent costs such as human resources, supplies, building and vehicle operation and maintenance costs and waste management. Time and motion analysis will be employed to value both the direct financial and economic (in-kind) contribution of the community including opportunity cost of time expended on HIVST distribution activities by the community.

Community based distributors time will be valued based on their earnings/ allowances on the programme. If shown to be effective on the primary and secondary outcomes an incremental cost effectiveness analysis (ICER) will be conducted to compare the cost and outcomes of the alternative distribution approaches.