HIV/AIDS PROGRAM COSTING TOOLS

Transcription

1 HIV/AIDS PROGRAM COSTING TOOLS Concepts and Methods Used under the USAID Health Policy Initiative, Costing Task Order AUGUST 2013 This publication was produced for review by the U.S. Agency for International Development (USAID). It was prepared by Alexander Paxton and Nadia Carvalho of the Health Policy Initiative, Costing Task Order.

2 Suggested citation: Paxton A, Carvalho N HIV/AIDS Program Costing Tools: Concepts and Methods Used under the USAID Health Policy Initiative, Costing Task Order. Washington, DC: Futures Group, Health Policy Initiative, Costing Task Order. The USAID Health Policy Initiative, Costing Task Order, is funded by the U.S. Agency for International Development under Contract No. GPO-I , beginning July 1, The Costing Task Order is implemented by Futures Group, in collaboration with Futures Institute and the Centre for Development and Population Activities (CEDPA), now part of Plan International USA.

3 HIV/AIDS PROGRAM COSTING TOOLS Concepts and Methods Used under the USAID Health Policy Initiative, Costing Task Order AUGUST 2013 The views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the U.S. Government.

4 TABLE OF CONTENTS Acknowledgments Acronyms and Abbreviations iv v Introduction 1 Economic Evaluation and Cost Analysis 3 HIV Costing and Modeling Tools Used by the USAID Health Policy Initiative, Costing Task Order 8 Overview of HIV/AIDS Program Costing Tools and Models 8 AIDS Impact Model for Business (AIM-B) 11 Antiretroviral Therapy Unit Cost Spreadsheet (ART) 12 Decision-Makers Program Planning Tool (DMPPT) 14 Gender Based Violence Program Cost Calculator (GBV) 17 Goals Model 19 HTC Service Delivery Costing Model (HSDC) 21 Key Populations Costing Workbook 23 Medication-assisted Therapy Costing Worksheet (MAT) 25 PMTCT and Pediatric ART Costing Tools (PMTCT/Peds) 27 Resource Needs Model (RNM) 29 Annex A: Cost Categories 31 Annex B: Other Costing Tools 32 References 33 iii

5 ACKNOWLEDGMENTS The authors would like to thank the developers and researchers who have put in tremendous effort creating, tweaking, and piloting the products presented in this document. Thanks to Steven Forsythe (Futures Institute), Sarah Alkenbrack (Futures Group), Margaret Reeves (Futures Group), Alexandra Scott (Futures Group), Peter Stegman (Futures Institute), Veena Menon (Futures Group), Katherine Kripke (Futures Institute), Rachel Sanders (Futures Institute), Biyi Adesina (Futures Institute), Joni Waldron (Futures Group), and Anita Datar (Futures Group). iv

6 ACRONYMS AND ABBREVIATIONS AIDS AIM-B AMC ART ARV CBA CEA CUA DALY DMPPT GBV HIV HSDC HTC HYE MAT MC MDG PEPFAR PMTCT PWID QALY UNAIDS USAID VMMC WHO acquired immune-deficiency syndrome AIDS Impact Model for Business adult male circumcision antiretroviral therapy antiretroviral cost-benefit analysis cost-effectiveness analysis cost-utility analysis disability-adjusted life year Decision-Makers Program Planning Tool gender-based violence human immune-deficiency virus HTC Service Delivery Costing Model HIV testing and counseling healthy years equivalent medication-assisted therapy male circumcision Millennium Development Goal U.S. President s Emergency Plan for AIDS Relief prevention of mother-to-child transmission (of HIV) persons who inject drugs quality adjusted life year Joint UN Programme on HIV/AIDS U.S. Agency for International Development voluntary medical male circumcision World Health Organization v

7 INTRODUCTION Over the past two decades, unprecedented resources and global commitment have facilitated great progress in the fight against HIV and AIDS. To sustain this kind of significant progress, the governments and bi- and multi-lateral donors leading the response need to find innovative ways to do more with less. Resources must be carefully allocated to make the biggest impact in the most efficient way possible. To make informed resource allocation decisions, policymakers require data on the costs and impacts of specific interventions. Such data can help decisionmakers understand the impact of investments on outcomes such as new infections, prevalence, deaths, and numbers of orphans. The USAID Health Policy Initiative, Costing Task Order was tasked with developing new tools and methodologies to address questions related to the costs and impacts of HIV programs, while generating new data that would inform decisions around budgeting, resource allocation, and strategic planning. HIV/AIDS Program Costing Tools shares with the reader some of the costing tools and approaches developed and applied by the USAID Health Policy Initiative, Costing Task Order. The project has used these tools to generate and analyze cost and impact data to inform HIV policymakers around the world as they develop strategies for sustainable solutions and make critical resource allocation decisions. HIV program costing tools included in this guide: AIDS Impact Model for Business (AIM-B) Antiretroviral Therapy Unit Cost Spreadsheet (ART) Decision-Makers Program Planning Tool for Male Circumcision (DMPPT) Gender-Based Violence Program Cost Calculator (GBV) Goals Model HIV Testing and Counseling Service Delivery Costing Model (HSDC) Key Populations Costing Workbook Medication-assisted Therapy Costing Worksheet (MAT) Orphans and Vulnerable Children (OVC) Costing Tools PMTCT and Pediatric ART Costing Tools (PMTCT/Peds) Resource Needs Model (RNM) All tools were developed or used by the USAID Health Policy Initiative, Costing Task Order. The guide first describes why, in the current context of reduced funding for global health, and increasing need, economic evaluations play a more critical role than ever in informing health policy decisions. Next, the guide provides some common concepts and terminology related to economic evaluation. Finally, the guide presents the overall costing approach used by the USAID Health Policy Initiative, Costing Task Order and presents each of the costing tools developed and used under the project. All of the tools included in this guide are available online at The online tools can be manipulated to fit environmental and situational needs; however, care should be taken since this can lead to program changes that may produce unrealistic or erroneous outputs. Once a user alters a tool to fit his or her needs, he or she is solely responsible for the results produced by the altered model. 1

8 Financial pressures facing HIV programs To this end, money for AIDS must work better for people: programmes should be cost effective, more efficient in service delivery and unit costs reduced. What Countries Need: Investments Needed for 2010 Targets, UNAIDS. p. 14 Thanks to a coordinated global response, the overall growth of the HIV/AIDS epidemic is stabilizing (UNAIDS, 2010). Over the last two decades, domestic and international donors have stepped up and made crucial investments to slow the spread of HIV and improve the lives of people living with AIDS. Despite progress, these exciting achievements are very fragile, and the need is as great as ever for continued and collaborative investment in the HIV response. The recent economic crisis has halted and reversed the growth of funds for HIV from multi-lateral and bi-lateral donors, who still provide the lion s share of HIV funding in many countries. In addition, changes to eligibility requirements for countries to receive funding from the multi-lateral Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) has further limited resources available for countries looking for external assistance. Under the banner of shared responsibility, international donors are placing greater emphasis on building country capacity and ownership of health activities. The United States President s Emergency Program for AIDS Relief (PEPFAR) and the Global Fund are encouraging greater financial contributions from partner countries. At the same time, the recent global economic crisis has directly impacted national and local responses to HIV and AIDS. Decreased government revenue has led to reduced domestic public spending on AIDS, and crucial medical commodities (e.g., antiretroviral drugs, testing kits, and laboratory equipment) cost more to import due to unfavorable shifts in exchange rates (UNAIDS, 2009). As a result of reduced resources from both domestic and international sources, countries will have difficulty reaching targets set in national health agendas and universal access goals. The global economic context described above, along with the continued need to expand and improve HIV programs, has forced donors, policymakers and implementers to rethink how resources are allocated and how services are financed. In order to have the greatest impact in averting new HIV infections and preventing AIDS-related deaths, it is essential that policymakers and program planners make optimal use of available resources. Financial investments in HIV care and prevention need to be both efficient and effective. To this end, policymakers have placed new emphasis on evaluating the efficiency of HIV programs and services. These efforts require timely and accurate data on the cost and cost-effectiveness of programs and services. Economic evaluation provides the tools to help understand the costs and impacts of HIV/AIDS programs and provide valuable information for strategic, policy and operational planning. 2

9 ECONOMIC EVALUATION AND COST ANALYSIS What is economic evaluation? We can bring down costs so investments can reach more people. This means doing it better knowing what to do, directing resources in the right direction and not wasting them, bringing down prices and containing costs. State of the AIDS Response, 2010, UNAIDS. p. 29 We must have the courage to measure the varying costs and effectiveness of our programmes. Only by revealing best practices can we emulate them. Only by revealing inefficiencies can we correct them. Stefano Bertozzi, Together We Will End AIDS, UNAIDS. p. 83 Economic evaluation (EE) is a set of research techniques that systematically and objectively collect and calculate the costs and outcomes of health interventions. Broadly speaking, it answers questions like: What results have I achieved (or will I achieve) for my investment? and What would a new or expanded program cost? It can help identify which investments will yield the best results in terms of reaching more people with services, or better target services to reach the right populations and make the greatest impact. Policymakers draw on the results of economic evaluations to help make difficult decisions about balancing the costs and benefits of specific HIV interventions. Sound economic analyses help countries allocate scarce resources, set HIV- and AIDS-related priorities and targets, and reduce spending inefficiency. EE can help countries to scale up their HIV and AIDS programs to achieve results in support of national strategic plans or international goals. To be relevant and useful, EE must be founded on reliable data about program costs. Therefore, cost analysis is the essential first step in the evaluation process. While costing alone does not account for health or financial outcomes, it yields useful information about the performance of a program. HIV costing tools designed to guide users through the data collection process and automate the extensive calculations involved can greatly simplify costing analyses. How does cost analysis improve decision-making? There are several ways in which policymakers and program planners can use information obtained from HIV costing exercises for informed policy decisions (Forsythe, 2006): Planning and budgeting A cost analysis provides financial information on costs and expenditures. This allows program planners to determine, plan and budget for the amount of resources required for current and future HIV programs and services. This information can help planners to prepare budgets and strategic plans, and to compare actual expenditures to budgets. It also allows policymakers and implementers to use timely and accurate data for strategic planning in developing national and sub-national HIV plans with aligned budgets and realistic targets. 3

10 Sustainability Costing exercises can help program planners to ensure that interventions are sustainable by helping them estimate and plan for the costs of programs over time (Forsythe, 2006). Data from cost analyses help program planners determine the amount of resources needed to sustain a particular program or service and can serve as evidence to mobilize additional resources. Economic evaluation A cost analysis is the common essential component of all types of economic evaluations of HIV/AIDS interventions, which determine the efficiency of programs and guide the allocation of health resources by policy priorities (Forsythe, 2006). By analyzing the unit costs identified as critical inputs for service delivery, the planner can identify cost drivers (aspects of the program that require the most resources), which can help identify potential cost savings through increased efficiencies in the future. This information can help program planners understand whether it is prudent to continue a program or service, and/or cost-effective ways to expand the program or service. Table 1. Costing and modeling tools can generate data to answer the following questions: Planning & Budgeting Sustainability Economic Evaluation What is the cost of providing VCT to one person? What is the cost of providing outreach for one person for one year? What will it cost to implement the national HIV/AIDS strategy? What is the gap between the current resources available and the levels required? How much more funding will be needed to sustain the program for future populations? What is the cost per unit of health outcomes (e.g., HIV infection averted) produced from the program/service? Based on the resources required, is it worthwhile to implement the program/service? How much money could be saved in treatment costs by investing in prevention? 4

11 Types of Economic Evaluation There are four main types of economic evaluations: 1) cost analysis, 2) cost-effectiveness analysis, 3) cost-utility analysis, and 4) cost-benefit analysis. Each method includes explicit measurements of inputs (costs) and outcomes (benefits), but they differ in the way in which the health outcomes are valued. Choosing the appropriate analytical tool depends on three main criteria (Haycox and Noble, 2003; Forsythe, 2003; Forsythe, 2006). 1) The context in which the analysis is being undertaken 2) The focus of the economic evaluation 3) The nature of the outcome that arises from the competing HIV interventions. Table 2 describes the different policy-related questions that can be answered using the different types of HIV economic evaluations, and Table 3 summarizes their structure. Table 2. Examples of policy questions that can be answered with economic evaluations Cost Analysis Cost-Effectiveness Analysis Cost-Utility Analysis Cost-Benefit Analysis What are we currently spending on HIV care in this country? How much funding is needed to expand the program to more people? Which of two HIV programs results in the greatest number of infections averted? Which program has lower costs per infection averted? Which of two programs results in the greatest gains in life and quality of life? Which program has lower costs per QALY gained or DALY averted? 5 What are the financial consequences of implementing or not implementing this program? How does this program compare to other financial choices I could make? Cost analysis Cost analysis is an economic evaluation technique that involves the systematic collection and assessment of program costs. While it may seem at first that costing a program would be as simple as adding up all the bills, HIV interventions are usually performed in complex community-based or health care environments with many different types of expenditures and sources of funding. In addition, HIV responses can (and usually should) differ from one population to another. This reality necessitates that comprehensive data be collected from all sources and analyzed in order to obtain an accurate estimate of total HIV program costs in a given context. The simplest form of economic evaluation cost analysis involves determining the costs of interventions, allowing program planners to calculate budgetary requirements and determine whether an intervention is affordable, and to understand the current and future cost requirements of a program. The results of a cost analysis are often expressed as a total program cost and/or a unit cost (cost-per-patient or cost-per-encounter, for example). Cost analysis is the basis for other economic evaluations, and the technique is consistent for each evaluation type. Cost analyses can also help program planners to understand how funds are spent and to predict how the costs of a program or service might change over time. When done systematically, they account for all (or nearly all) types of program costs within the scope of analysis. Cost information can also be used to estimate the efficiency or cost-effectiveness of resources being used by combining information on the cost of the service, with outcome measures to obtain cost-effectiveness ratios

12 and other measures of efficiency (Beck et al., 2008). However, it is important to note that cost analyses do not address the effectiveness of an intervention or its value for money. If you interested in learning more about the type of costs examined, Appendix A provides an introduction to some general categories. The basic steps in a cost analysis are (CDC, nd): Step 1: Define the problem, including why it is important, the aspects of the problem to be explained, and questions that need to be answered. Step 2: Define the interventions, comparisons, target population, delivery site, personnel, etc. Step 3: Define the audience (i.e., who will be using the results of the cost analysis, and how will they be used?). Step 4: Define the study perspective (i.e., which costs are relevant and should be included in the cost analysis?). Step 5: Define the time frame, ensuring it is long enough to capture the full extent of the program costs and of side effects. Step 6: Determine the analytic horizon, ensuring that it is long enough to capture the full costs and effects of the program, and short enough that the future costs and benefits are not uncertain. Step 7: Determine the format: retrospective analysis (conducted with the intervention is in place or has been carried out); prospective analysis (costs are tracked as they are incurred); or models (costs are based on estimated values from other studies). HIV programs can differ dramatically depending on the nature of the intervention. In general, however, most programs have common cost types, including staff salaries, rent or building costs, utilities, drugs, medical supplies, transportation, and equipment. Between different types of HIV programs these costs may vary considerably as a proportion of the total. For example, the cost of antiretroviral treatment (ART) programs tends to be driven most by the cost of medications and lab tests. On the other hand, voluntary counseling and testing (VCT) programs are driven primarily by staff salaries and overhead. While cost analyses are useful alone, they are often combined with measures of outcome to estimate the health, social, or financial impact of the intervention. This extra step allows policymakers to evaluate the effects of the resources spent and make informed decisions about the most efficient ways to achieve HIV goals. Depending on the policy question and the chosen measure of outcome, these higher-level methods of economic evaluation are known alternatively as cost-effectiveness analysis (CEA), cost-utility analysis (CUA), or cost-benefit analysis (CBA). Luckily for policymakers and researchers, software programs exist to assist in the economic evaluation of current programs and to model the costs and benefits of future programs. Cost-Effectiveness Analysis (CEA) Used for health care planning, CEA can be used to evaluate HIV interventions by comparing the net monetary costs of an intervention with a measure of health impact or outcome (e.g., patients treated or infections averted). It allows policymakers and program managers to make informed decisions about resource allocation, by allowing them to examine alternative ways to achieve their objectives, so they can choose the method that uses the available resources most effectively and efficiently. The weakness of CEA is that it provides only a financial snapshot and does not account for the true impact of an intervention on a person s health and quality of life. 6

13 Cost-Utility Analysis (CUA) CUA is used to compare health interventions relative to a person s quality of life, measured in quality-adjusted life years (QALYs) saved, disability-adjusted life years (DALYs) averted, or healthy years equivalent (HYE). Since CUA takes into account changes in quality of life and mortality in one measure, it is a more comprehensive way to show the effectiveness of the intervention. CUA is also a useful tool for policymakers because it allows them to rank different interventions to show the comparative impacts of alternative investments (Forsythe, 2006). However, CUA requires information about people s quality of life under different outcomes, which may be unreliable or difficult to obtain. Cost-Benefit Analysis (CBA) CBA measures the economic benefits of an HIV intervention but differs from CEA and CUA in that both costs and benefits are represented as monetary values. Through CBA, any intervention can be evaluated on its own worth, and programs with different objectives can be compared, even across other (non-health) sectors. CBAs are rarely used in health care because health outcomes are difficult to express in monetary terms. Table 3. Structure of Economic Evaluations Method Outcome Measured Applications Cost Analysis: for determining costs and cost projections Cost- Effectiveness Analysis: to compare interventions with similar output Cost-Utility Analysis: to compare interventions according to impact on quality of life Intervention costs Cost per program outcome (infections averted, patients successfully treated, etc.) Intervention outcome measured on mortality (quantity of life) and morbidity (quality of life) - Evaluating budgetary requirements - Describing current and future funding needs - Evaluating interventions by combining project costs and outcomes - Comparing interventions with similar goals - Examining intervention outcomes in the context of quality of life - Comparing interventions that deal with different diseases Challenges - Does not address quality or effectiveness of intervention - Health services can have different outputs - Hard to measure effectiveness of prevention programs - Can underestimate the value of a particular service - Requires comparing the results to a league table of health interventions that may not be available - Can underestimate the value of a particular service - Might not reflect society s opinion of the value of lives saved 7

14 Cost-Benefit Analysis: to determine a program s financial costs and benefits Costs and benefits measured in money; financial value of costs and benefits compared - Evaluating interventions without comparing to others - Comparing programs with different objectives Sources: Haycox and Noble, 2003; Forsythe, 2002; Forsythe, Difficult to assign monetary value to changes in a person s health HIV COSTING AND MODELING TOOLS USED BY THE USAID HEALTH POLICY INITIATIVE, COSTING TASK ORDER The USAID Health Policy Initiative, Costing Task Order works with policymakers and program managers to develop new tools, approaches, and analyses to help them more accurately predict the cost and impact of their HIV programs and other public health responses. The Health Policy Initiative, Costing Task Order used and developed several costing tools for specific HIV interventions, which can help policymakers and program planners to generate timely, accurate, and useful data to inform policy. The costing tools were uniquely designed to support effective policymaking by allowing program planners to collect accurate cost information and project funding scenarios for use in advocacy, strategic planning, and policy dialogue. Costing tools and models The section below describes each of the costing tools used by the USAID Health Policy Initiative, Costing Task Order. Additional detail is provided about how the tools can be used, the information that can be generated from them, and an example of how the tools have been used. HIV program costing methodologies follow this core approach: 1. Identify program inputs required for delivery of the HIV-related service (labor, pharmaceuticals, medical supplies, office supplies, transportation, etc.). 2. Input cost data for each program input. 3. Consider additional factors that also impact costs (delivery methods, coverage levels, etc.). 4. Calculate some or all of the following: total program cost, unit cost, and potential health outcomes. 5. Critically assess the impact of current HIV strategies and plan for the future use of additional resources. Though the approach is similar, each costing tool is uniquely designed to account for the peculiarities of a specific intervention. Overview of HIV/AIDS Program Costing Tools and Models This chart below (Table 4) can be used as a quick reference for general information on each HIV costing tool and model, including its purpose, uses and methodology. The narratives that follow provide more detailed information about each tool. 8

15 Table 4. Overview of HIV costing tools and models Tool Description AIDS Impact Model for Business (AIM-B) Format Inputs Outputs Antiretroviral Therapy Unit Cost Spreadsheet (ART) Format Inputs Outputs Decision-Makers Program Planning Tool (DMPPT) Format Inputs Outputs Gender-Based Violence Program Cost Calculator (GBV) Format Inputs Goals Model Outputs Format Inputs Outputs Determines costs of HIV-related health care to a business and potential savings realized through averted illnesses, deaths, and productivity loss Module of Workplace Policy Builder and stand-alone tool Staffing levels, salaries, workforce HIV prevalence, recruitment costs, training costs, health care costs, funeral-related leave, death benefits, business revenues, business expenditures HIV/AIDS cases in workforce, HIV/AIDS-related costs with/out HIV activities, company profits with/out HIV activities Estimates unit cost per client of providing ART to a defined population of beneficiaries MS Excel Antiretroviral drug (ARV) prices, ARV regimen distribution, lab test costs, lab test schedules, staff salaries and time requirements, consultation schedules, opportunistic infect costs, other drug costs Total ART program cost, cost per patient Helps decision-makers understand the potential cost and impact of various options for scaling up male circumcision (MC) services MS Excel MC-related program inputs (staffing, drugs, supplies, facility costs, training, etc.), sexual behavior data, HIV prevalence, HIV transmission rates, MC effectiveness, MC service delivery options, priority populations, etc. Total program cost, cost per MC performed, total number of MCs performed, HIV infections averted, net savings due to ART avoided Helps program planners estimate the unit cost of their GBV programs across four delivery models: health facility-based, community-based, group, and individual programs MS Excel GBV cases served annually, staff time and salaries, drugs and supply costs, facility costs, equipment costs, vehicle costs Total program cost by cost type, cost per GBV encounter by cost type Enhances strategic planning by showing how the amount and allocation of funding are related to the achievement of national goals. Also can be used to estimate impact of a particular funding level. Module of Spectrum Software Suite (Futures Institute) Demographic information, sexual behavior by risk group, HIV/STI prevalence, prevention activities costs, population coverage, HIV activity coverage, HIV activities costs, budget allocations, ART success rates Total HIV budgets required, projected impacts on HIV prevalence and activity coverage 9

16 HIV Testing & Counseling Service Delivery Costing Model (HSDC) Format Inputs Outputs Key Populations Costing Workbook Format Inputs Outputs Medication-assisted Therapy Costing Worksheet (MAT) Format Inputs Outputs PMTCT and Pediatric ART Costing Tools (PMTCT/Peds) Format Inputs Outputs Resource Needs Model (RNM) Format Inputs Outputs Determines costs and impacts of alternative combinations of HTC service delivery options, including through stand-alone clinics, integrated programs, and mobile or home-based services. MS Word and MS Excel Staff time and salaries, testing supplies, training costs, equipment costs, facility costs, clients tested, clients referred to ART, etc. Total program costs for MOH, donors, and each service modality; unit costs per client, per HIV case identified, per ART referral, per client with low CD4 count, and per person tested for the first time. Facilitates the collection and consolidation of costing data for a single HIV program targeting key populations in multiple countries MS Excel Staff time and salaries, supplies and commodities, travel, technical assistance, publications, workshops, equipment, office costs Total program cost by country, unit cost by country Estimates unit costs for programs targeting injecting drug users and to project future resource requirements for scale-up of MAT MS Excel Staff time and salaries, drugs and medical supply costs, medical equipment, non-medical equipment, facility costs, travel Total program cost, cost by facility, cost per patient Determines the cost per beneficiary for PMTCT and pediatric ART programs and estimates the cost of scaling a national program MS Excel and web-based Patients per year, patients served by PMTCT/pediatric ART, staff time and salaries, drugs and supplies, training costs, lab costs, facility costs, transportation costs, equipment costs Unit cost of PMTCT, unit cost of pediatric ART, national program cost estimate Calculates the resources required for expansion of an array of HIV/AIDS services at the national and district levels Module of the Spectrum Software Suite Target population size, program coverage, unit cost of intervention for all interventions Total cost of national HIV response by year, cost by intervention 10

17 AIDS Impact Model for Business (AIM-B) HIV activity: Workplace policy Economic evaluation type: Cost analysis Costing scope: Employer Available at: Simplified web tool: Background Because HIV primarily impacts individuals of working age (ages 15 and above), individual workplaces will also feel the effects of the HIV epidemic. Due to advances in HIV care and treatment, most workers will remain productive members of the workforce for years after diagnosis, but there are financial implications to both a company s efforts to prevent new HIV infections and the costs associated with providing benefits and services to employees and their families living with HIV. The AIDS Impact Model for Business (AIM-B) tool estimates the main direct costs for a business associated with health care, recruitment and training, and benefits costs. It then shows how these costs impact the business bottom line. Costing tool AIM-B is an economic and demographic model for managers that examines the effects of HIV/AIDS on their businesses and projects how it may affect their workforce and profits. The tool is meant to show the tangible impacts that HIV can have on a business, and motivate management to invest in policies and interventions that prevent new HIV infections and mitigate the impacts of HIV on employees and the business. The tool develops HIV and AIDS prevalence estimates for a workforce and models how these will develop in the future. These estimates are used to calculate the potential additional costs to the company due to HIV/AIDS. Costs considered include health care provision, recruitment, training, productivity loss, and death benefits. AIM-B outputs include the number of HIV/AIDS cases in the workforce, and company profits with and without HIV-related impacts. AIM-B is available as a tool within the Workplace Policy Builder software and as a stand-alone tool. The AIM-B can answer the following questions that employers may have about the effects of HIV in the workplace: What is the additional cost to the business of HIV-related health care? What is the financial impact of productivity loss? What is the cost of training and recruitment due to HIV-related turnover? What is the cost of death benefits due to HIV-related mortality? changes over time? Data collection and tool considerations In order to generate its projections, AIM-B requires several types of data about the business. First, the user must input data about staff numbers and salaries, as well as estimates of HIV prevalence within each tier of employees. If prevalence estimates are not available, AIM-B provides country-specific estimates. Secondly, the tool asks for estimates of the cost and time associated with recruiting and training new employees. Next, it considers the costs associated with health care and funeral benefits for employees with HIV. Lastly, the tool requests gross revenues and expenditures, which allow it to calculate the business bottom line with and without HIV. 11

18 Antiretroviral Therapy Unit Cost Spreadsheet (ART) HIV activity: Antiretroviral therapy (ART) Economic evaluation type: Cost analysis Costing scope: Program, sub-national, and national Available at: Background Increasing access to antiretroviral therapy (ART), especially for people who would not have qualified in previous years, has become a major goal in the international response to HIV and AIDS. In 2013 the World Health Organization (WHO) updated its medical guidelines to raise the CD4 count threshold for beginning ART, meaning that more people will be starting antiretroviral drugs (ARVs) sooner and staying on them longer. Furthermore, WHO now recommends that all HIV-positive children under the age of 5, all HIV-positive partners in sero-discordant relationships, and all HIV-positive women who are pregnant or breastfeeding should also begin ART. In the face of these demands for scale-up, health care systems and HIV program implementers must clearly understand the resources that ART programs demand. Previous studies have shown that costs can vary greatly from country to country and setting to setting, so it is extremely important for decision-makers to have estimates that are as context-specific as possible. Costing tool The ART Unit Cost Spreadsheet is an MS Excel-based tool to estimate the unit cost per client of providing pre-antiretroviral therapy, pediatric AIDS treatment, and adult AIDS treatment with the option to allow for changes over time to regimen mix, testing, and visit schedules. The tool improves upon the previously used Cape Town Model and will be particularly useful for countries as they reflect on the newly issued WHO Treatment Guidelines and grapple with how best to update their national guidelines and priorities in response. The ART Unit Cost Spreadsheet can be used to answer the following policy questions: What is the current cost of providing first-line ART to an adult patient for a year? What is the cost of providing second-line ART to a patient for a year? What is the cost of providing ART to a pediatric patient? What will be the unit cost of providing ART in five years if the regimen mix changes over time? The ART Unit Cost Spreadsheet works by estimating the resources required to provide ART to a single patient. The spreadsheet was designed to work hand-in-hand with the AIDS Impact Model (AIM) and Resource Needs Model (RNM) components of the Spectrum software suite which project the population receiving ART and multiply that population times the per-patient cost of care, respectively. 12

19 Data collection and tool considerations The ART Unit Cost Spreadsheet requires the following data for its calculations: ARV prices ARV regimen distribution Lab test costs Lab test schedules Staff salaries and time requirements Consultation schedules Opportunistic infection costs Other drug costs Default values are provided for ARVs, lab tests, personnel, and unit costs, but users are encouraged to change these values if more appropriate data are available for the target population. 13

20 Decision-Makers Program Planning Tool for Male Circumcision (DMPPT) HIV activity: Male circumcision Economic evaluation type: Cost analysis, CEA, CBA Costing scope: Facility Available at: Background In late 2006, findings from three randomized controlled trials of male circumcision found that following circumcision, the incidence of HIV infection was reduced in men by more than half (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007). In 2000, a systematic review and meta-analysis of 28 studies revealed that circumcised men are two to three times less likely to be infected by HIV than uncircumcised men (Weiss et al., 2000). Based on this evidence, models have estimated that up to six million new HIV infections and three million deaths can be prevented in the next two decades with routine male circumcision across sub-saharan Africa (Williams et al., 2006). Circumcision has also been shown to provide other health benefits for men, including reduced incidence of some sexually transmitted infections, and a reduction in penile human papillomavirus and cervical cancer in female partners (Castellsagué et al., 2002). In 2007, a WHO/UNAIDS technical consultation (WHO/UNAIDS, 2007) delivered a set of conclusions and recommendations on male circumcision that emphasized the need for swift and urgent action to prioritize male circumcision in high HIV prevalence countries (where most HIV infection is due to heterosexual transmission and where few men are currently circumcised). At approximately $50 per procedure, male circumcision has many cost benefits. Findings from several studies revealed that the greatest public health impact in high HIV prevalence settings will come from prioritizing expanded male circumcision services for younger men (e.g., years), while in lower prevalence settings, the highest and fastest impact will be achieved if priority is given to men of any age with indications of being at higher risk for HIV (i.e., men presenting with an STI or with an HIV-positive partner). Costing tool The Male Circumcision Decision-Makers Program Planning Tool (DMPPT) was developed by the USAID Health Policy Initiative, Costing Task Order in collaboration with UNAIDS/WHO. The tool helps decision-makers understand the potential cost and impact of various options for scaling up male circumcision services. It can calculate the cost of male circumcision services by delivery mode based on clinical guidelines and local data (staff time and salaries, supplies, Understanding the costs and impacts of MC can: Engage local leadership to prioritize MC among a spectrum of prevention, care and treatment services Address gender- and stigma-related issues that increase vulnerability to HIV equipment, etc.). The tool also estimates the impact of male circumcision on the HIV epidemic. It allows the user to vary coverage levels and speed of scale-up, and to examine the potential cost and impact under different scenarios. The DMPPT includes two sub-models. The costing model estimates the total average cost for a facility to provide MC services to an adult male (ages 15-49) or a newborn male (ages 0-1 month). It allows for data inputs such as percentage of complications, personnel, supplies, training, indirect capital and overhead costs. The impact model uses the costing outputs and country-specific data (i.e., demographics, sexual behavior, and HIV prevalence trends) to calculate the impact of a male circumcision program on 14

21 an HIV epidemic and the associated cost per infection averted. The tool also incorporates sensitivity analysis for key inputs, including the impact of male circumcision on women. The DMPPT is able to address several policy areas, including: Priority populations (adult males, young adults, adolescents, newborns, most-at-risk groups) Target coverage levels and pace of scale-up (slow, fast, linear, and s-shaped) Service delivery modes Task shifting scenario The DMPPT can be used to answer the following policy questions: What is the cost of MC services by delivery mode (hospital, clinic, private or public provider, NGO, etc.)? What impact can MC have on the HIV epidemic? If MC were scaled up, what would be the potential cost and impact of MC? Based on the number of MCs performed, what will be the impact on HIV incidence? Prevalence? Number of AIDS-related deaths? Overall costs? Net cost per infection averted? Data collection and tool considerations The costing model of the DMPPT requires the following data inputs for each type of facility in which MC is performed: Facility circumcision share, which is used to determine the portion of indirect costs attributed to MC [facility circumcision share = sum of adult and newborn circumcision cases per year/number of total (equivalent) cases in the facility per year] Total percentage of complications that can occur with adult or newborn circumcision, and the frequency of their occurrence (since complications add to the cost of the procedure) Personnel: the time needed by each staff member directly involved in MC and their salary Drugs and supplies: the number of treatment units and unit cost for each consumable and nonconsumable drug or supply Training: the total number of training days for all staff needing training x cost per staff per training day Information, education and communication (IEC) campaign: the sum of the costs for each mode of communication used in a national MC education campaign Indirect capital costs Indirect overhead costs In order to calculate the impact of MC on the HIV epidemic, the following information must be entered into the DMPPT: Country-specific demographic data to determine population trends and break them down by gender and age so that projections can be made Country-specific sexual behavior data Country-specific HIV prevalence trend data, which provides information on the scale of the epidemic Epidemiological and economic assumptions on the effectiveness of MC from literature, which is used to calculate infections averted Epidemiological assumptions from literature for the probability of transmission from mother to child and the fertility reduction due to HIV 15

22 Economic assumptions: discount rate on future expenditures and savings, to calculate the net savings per infection averted Completion of the Fit the Model worksheet to determine the force of infection rates by gender and age group Specification of priority population groups and target coverage levels Specification of service delivery options In a DMPPT application, someone not directly involved in providing clinical care usually collects these data. As a result, DMPPT data collection will require informed consent and ethical review to ensure that client privacy is protected. 16

23 Gender-Based Violence Program Cost Calculator (GBV) HIV activity: Community and clinical gender-based violence (GBV) programs Economic evaluation type: Cost analysis Costing scope: Facility, program Available at: Background Increasingly, studies show that widespread gender-based violence (GBV) exacerbates the HIV/AIDS epidemic. Women who experience partner violence are more likely to be HIV infected, and fear of violence makes women less likely to seek HIV services. Therefore, combatting GBV will strengthen efforts to fight HIV. Accurate information about the costs of gender-based violence programs is crucial if planning and programming decisions are to be evidence-based. Costing tool The USAID Health Policy Initiative, Costing Task Order developed the Gender-based Violence Program Cost Calculator to help program planners estimate the unit cost of their GBV programs across four delivery models: health facility-based, community-based, group, and individual programs. The Gender-based Violence Program Cost Calculator can be used to answer the following policy questions: What are the costs of different GBV programs? How do costs differ between GBV delivery models? What is currently being spent on a particular program? What cost elements are the greatest drivers of total program cost? The GBV Program Cost Calculator is implemented in MS Excel and contains a separate input sheet for each of the four program types. With small variations, the unit cost per GBV client encounter is calculated according to the following general formula. The results page of the tool then provides breakdowns of total program cost and cost per encounter for both recurrent costs and capital costs. Data collection and tool considerations In order to successfully utilize this tool, the user will need to gather the following input data: Total number of GBV cases served per GBV activity in a year Salaries and benefits of staff who interact directly with GBV cases (i.e., nurse, GBV counselor, community agent, etc.) Estimates of the time spent by all staff working on GBV activities Salaries and benefits of staff who play administrative, support and supervisory roles in the GBV program(s) (i.e., program coordinator, manager, accountant, M&E officer, etc.) 17

24 Per-client costs of drugs, commodities, materials and supplies Invoices and expenditures on operations (i.e., rent, electricity, water, telephone, etc.) Building value and/or construction/renovation costs An inventory of office and/or clinical equipment and vehicles used as part of providing or administrating GBV activities Price or original cost and purchase year of office and/or clinical equipment and vehicles used as part of providing or administrating GBV activities 18

25 The Goals Model 1 HIV activities: Many, including but not limited to condom distribution, voluntary testing and counseling, antiretroviral therapy (ART), prevention of mother-to-child transmission, youth peer outreach, media campaigns, workplace programs, etc. Economic evaluation type: Costing, cost-effectiveness analysis Costing scope: National, provincial (if sufficient data are available) Available at: Background Designing and implementing a national HIV/AIDS program is a complex task, in which many priorities ranging from preventing new infections, to caring for people living with HIV, to mitigating the impact of the pandemic must be considered and addressed. In addition, countries must also consider their needs, goals, and circumstances in relation to available resources, challenges, opportunities, and emerging issues. As such, it is crucial that countries have the tools to help identify priority goals within national strategic plans, as well as a way to link these goals to budgets and resource allocation options that will be the most effective. The Goals Model can be used to answer the following policy questions: How much funding is required to achieve the goals of the strategic plan? What goals can be achieved with available resources? What is the effect of different resource allocation options on the achievement of program goals? Costing tool The Goals Model is a module in the Spectrum Software Suite that is designed to enhance strategic planning by showing how the amount and allocation of funding are related to the achievement of national goals, such as the reduction of HIV prevalence and expansion of treatment, care, and support. The Goals Model estimates the resources required to implement specific interventions to achieve national goals. The model is a powerful tool that brings together information on costs and evidence of program impacts and relates these data to trends in the country s HIV situation. Its user-friendly design and ability to explore different scenarios allows for widespread use by program planners and encourages dialogue between government and civil society. The Goals Model simulates an HIV epidemic by estimating the number of new HIV infections occurring in various population risk groups (low-, medium-, and high-risk heterosexuals, injecting drug users, and men who have sex with men) according to their behaviors. It projects those newly infected as they potentially infect other partners and as they progress from primary infection, to the asymptomatic stage, to needing treatment, and to AIDS-related death. The coverage of key behavioral and biomedical interventions can be varied to explore the costs and impacts associated with the program. The results are displayed in terms of incidence, prevalence, and AIDS-related deaths among adults ages The model also calculates the cost per infection averted and deaths averted. 1 The Goals Model was developed with support from the Population Council under the Horizons project supported by USAID. It is available at: 19

26 Data collection and tool considerations In addition to being its own module, the Goals Model draws on several other modules from the Spectrum Software Suite. Therefore, the data requirements are many. The categories of data are listed here. Demographic information Sexual behavior by risk group Rates of condom use by risk group HIV-STI prevalence by risk group Unit costs of prevention, care and treatment activities Proportion of total population covered by each program Historical information about ART and PMTCT coverage 20