Costs of Scaling HIV Programme Activities to a National Level in Sub-Saharan Africa: Methods and Estimates

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Home >  Documents > Costs of Scaling HIV Programme Activities to a National Level in Sub-Saharan Africa: Methods and Estimates

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I. SUMMARY

HIV/AIDS continues to have a devastating impact in Sub-Saharan Africa (SSA). Close to 71% of people with HIV/AIDS live in SSA (UNAIDS, 2000a). Life expectancy at birth in Southern Africa, which climbed from 44 years in the early 1950s to 59 years in the early 1990s, is expected to drop back to 40 years sometime between 2005 and 2010, mainly attributed to the result of AIDS. However, while there are strong HIV/AIDS interventions across Africa, few are implemented at a national scale. Yet the experiences of countries such as Uganda and Senegal, which have been successful in mitigating the epidemic, suggest the importance of a national and co-ordinated response. Thus, a key priority in addressing the HIV/AIDS crisis in SSA is rapid expansion of activities.

The aim of the approach followed in this document is to provide a method to present estimates of the cost of scaling-up HIV/AIDS interventions to various levels of coverage. While providing guidance on the relative resource requirements of different HIV/AIDS interventions, the report does not provide explicit guidance on priority-setting and resource allocation among programmes. To do this, one needs also to consider the likely impact and cost-effectiveness of these activities, which are not considered here. The process of choosing which activities to scale up and at which levels depends on several factors, and the analysis of costs is only a component of this process.

This document develops and discusses a resource determination model (RDM) designed to estimate how much it would cost to scale-up different HIV prevention and care strategies to a national level in Sub-Saharan Africa. The model combines cost-studies with detailed information on sexual behavior, condom availability, HIV prevalence and other epidemiological, demographic and health systems. The model yields estimates of the costs of scaling-up ten different HIV prevention and eight care strategies for 37 countries in Sub-Saharan Africa.

What is scaling-up?

Scaling-up is defined in the document as an expansion in the coverage of existing HIV/AIDS interventions as well as an expansion in the type of HIV/AIDS programmes that are in place. This has the following implications when considering the cost of scaling-up interventions:

• Scaling-up is a relative concept. It refers to increasing the coverage of target groups by specific HIV/AIDS interventions from one level to another. For example, scaling-up the prevention of mother to child transmission of HIV/AIDS (MTCT) means increasing the coverage among pregnant women attending antenatal care. It does not imply that all the population of pregnant women will be covered.

• There are limits to scaling-up activities given existing capacity and infrastructure. The concept of coverage that underlies the cost estimates presented in this document does not assume additional investment in underlying infrastructure. As a result, the estimated costs of scaling-up HIV/AIDS activities must be discussed with reference to the increase in coverage that is assumed to take place between now and 2005.

Priority-setting

The process of priority-setting entails a strategic planning process. It will depend on factors such as the stage and characteristics of the epidemic, the cost-effectiveness of particular interventions in a setting, and the level of resources, support and implementation capacity that are available within a country.

This report provides estimates of resources, but priority-setting also needs consideration of the impact or effectiveness of the interventions for each setting. Just as information on costs is limited, information on impact and cost-effectiveness is even scarcer. While it is difficult to estimate the impact of prevention strategies, nevertheless, one can start to compare comparable outputs between interventions (e.g. the number of condoms distributed and used). Gathering information on this level of intervention outcome is essential for more refinement within the priority-setting and resource allocation process.

Regardless of the stage of the epidemic, there is still a need to sustain HIV prevention efforts, even though care needs are becoming more substantial. Ultimately, limiting the transmission of HIV is the long-term solution to mitigating the epidemic. There may be different prevention priorities at different stages of the epidemic. A small sub-set of interventions may be identified as priorities for scaling up and resource mobilization. As the epidemic becomes more generalized, HIV incidence becomes increasingly concentrated amongst youth. Thus, interventions for students or out-of school youth become increasingly more important. Resource considerations in such a situation can help determine how best to reach different sections of the youth population (e.g. how can we reach the greatest number in the cheapest manner) or designing a package of key/essential services.

Given the need to intervene, priority-setting also has to consider which activities can be rapidly scaled-up. The task ahead is complex. In the short term, effective activities that can be scaled-up quickly need to be identified. For rapid scaling-up, the potential to use the existing infrastructure to achieve widespread coverage must be maximized. For example, with current enrolment rates a quarter of the youths aged 12-16 years could potentially be reached each year through interventions based on secondary schooling. However, an additional 10% could be reached if prevention activities were also undertaken in the last year of primary school (Watts and Kumaranayake, 1999).

As HIV prevalence rises, there will be increasing costs associated with the higher burden of care that is needed. Thus, there will be greater tensions in allocating scarce resources between prevention and care interventions. This is particularly the case in much of SSA where the HIV epidemic is already generalized.

Finally, the substantial potential to use private-sector and informal networks must also not be overlooked. Already in some countries, condoms are transported to rural areas through food-and-beverage distribution systems. More generally, the widespread involvement of different organizations and networks (such as workplaces, unions and religious and community networks) could help to increase the access of different social and geographical groups to specific activities.

The agenda ahead

There is a patchwork of mostly the small-scale, prevention and care activities being implemented across SSA by public-sector and private profit and non-profit organizations. There is little experience of replication and expansion, so strategic and creative thinking is needed. Overall, intensified action is needed to scale-up effectively and reduce the burden of HIV/AIDS in the following areas:

• Substantial resources need to be mobilized. The estimates developed in this report suggest that if one were to scale-up a wide range of HIV/AIDS interventions, the annual cost would be $US1.5-2.3 billion. Providing antiretroviral therapy (HAART) would add another $US1.5-2.4 billion depending on the prices at which drugs could be available. These estimates are based on relatively conservative estimates likely coverage that can be achieved by 2005. Despite the devastating impact of HIV in SSA, resources to address HIV/AIDS have been limited compared with those for other priority areas. In 1998, external spending on HIV/AIDS was about $US165 million, less than a third of the $650 million spend on childhood immunization programmes (UNICEF, 1999). There is therefore a need to increase resource mobilization and strengthen partnerships to achieve feasible levels of increased coverage.

• Acting early is essential. There is a substantial body of evidence which shows the importance of acting early to prevent the spread of the epidemic (World Bank 1997a, UNAIDS, 1999a). The choice is either to pay a small price now or a much larger price latter on. But few countries can afford the latter. In the case of a typical Sub-Saharan African country with a per capita income of $US300, HIV/AIDS interventions would amount to about 1.3% of GDP when the HIV prevalence rate is less than 5%. But the cost of prevention, care and treatment (including antiretroviral therapy) would represent 10% of GDP once the prevalence rate has reached 30% (even taking into account the recent price reductions and assuming that only 10% of the target group would have access). By contrast, countries that invest early on in prevention activities would be able to afford the cost of antiretroviral therapy because the total number of AIDS cases would be fewer. In addition to these financial costs, one would need to take into account the broader costs imposed by the HIV epidemic in terms of the loss of young adults in their most productive years (Whiteside and Stover 1997; Stover and Bollinger, 1999).

• Additional investment in health infrastructure may be needed to compensate for the deterioration of existing levels of infrastructure and human capital caused by the HIV/AIDS epidemic. Critical on the care side, is the ability of current health system infrastructure to cope with the growing burden that HIV/AIDS imposes. For example, it has been estimated that a country with a stable 5% HIV prevalence can expect that each year between 0.5 and 1% of its health care providers will die from AIDS. In contrast, a country with a 30% prevalence would lose 3-7% of health workers to the epidemic each year (World Bank, 1997a). About 50-70% of medical beds in large hospitals are taken by patients with HIV-related illnesses. This suggests the need for complementary actions to sustain and expand current levels of infrastructure. In addition, the education sector is also likely to be seriously affected. A recent survey in Malawi found that the rate of HIV infection among school-teachers was 30% (UNICEF, 1999). This will seriously compromise the ability and sustainability of prevention efforts within schools, where trained teachers have a critical role.

• Specific interventions may be needed for countries that are classified as having very low programme strength. In some cases, the increase in coverage that can be achieved with the existing infrastructure may be too low. Without additional investment, it may not be feasible to contain the epidemic. In addition, many of these countries face disruptions due to conflict situations. Thus, a real question is how to implement activities when there are constraints that are more than limited infrastructure. This has been outside of the current analysis, but is crucial to consider in the implementation of policy.

• Key gaps in information need to be addressed. Knowledge is lacking about the relative quality, efficiency and cost-effectiveness of various interventions as their implementation is scaled-up. It is clear that we cannot wait for better information before implementation, given the need to act quickly. However during implementation, key gaps in information need to be addressed. Thus it is crucial to document the costs, cost-effectiveness and operational learning so that experiences can be shared and successes quickly replicated.

It is our hope that better resource determination will lead to resource mobilization and to hastened action for HIV prevention and care for people living with HIV/AIDS.

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3-7 December 2000, Addis Ababa, Ethiopia

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