Analyzing the CostEffectiveness of Interventions to Benefit Orphans and Vulnerable Children: Evidenc

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Analyzing the Cost-Effectiveness of Interventions
to Benefit Orphans and Vulnerable Children
Evidence from Kenya and Tanzania

• Paul L. Hutchinson, Ph.D.
• Tonya R. Thurman, MPH, Ph.D.
• Tulane University

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• Background Rationale
• Methodology
• Key Questions
• Results
• Conclusions

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What is cost-effectiveness analysis (CEA)?

• Cost-effectiveness analysis is form of economic
  evaluation in which health gains from an
  intervention are evaluated relative to their
  costs.

Cost Effectiveness per behavior change
per knowledge change per HIV infection
averted
Cost Utility per DALY saved per QALY
Cost Minimization per beneficiary per
capita per person reached
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Why is CEA important?

• We want to know the magnitude of the effect that
  our program will achieve (or has achieved) for a
  given level of resources.
• We want to know which activities are the most
  effective for given level of resources.
• We want to know how cost-effective OVC and
  guardian activities are relative to other health
  interventions so as to determine the optimal mix
  of health interventions

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Key Methodological Issues in CEA

• Ingredients Approach Quantifying inputs to
  deliver an intervention assigning appropriate
  monetary values to those inputs
• Salaries, materials, utilities, transportation,
  overhead
• Apportioning costs that are shared across outputs
  (e.g. overhead, staff time)

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Key Methodological Issues in CEA

• Discounting future costs, cost savings benefits
  occurring in different periods
• Valuing resources when market prices deviate from
  actual values of resources (e.g. donated inputs)
• Economic costs v. financial costs

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Key Issues in CEA

• Define the intervention and its components
• Example Home visiting for HIV/AIDS affected
  households
• How many volunteers are involved?
• How many households does a volunteer visit?
• How often do volunteers visit? (weekly?)
• What supplies and equipment are involved?
• What training (initial and refresher) is
  involved?
• What mode of transportation do they take?

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Key Issues in CEA

• Defining which costs to include Whose
  perspective matters?
• Program costs direct intervention costs
  support
• Private costs costs to households of medical
  care averted? Transport? Other care?
• Societal costs (and cost savings) value of HIV
  infections averted?

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Key Issues in CEA

• Defining which costs to include Whose
  perspective matters?
• Program costs direct intervention costs
  support

v
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Data Sources

• Workplans
• Budgets
• Expenditure Reports
• Interviews
• Government Documents / Surveys
• Judgment

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Some Costing Hurdles

• From whom (or from what source) to collect?
• Amounts were not always consistent across
  documents, workplans, etc.
• Budgeted amounts did not always correspond with
  expenditures (or only budget information was
  available)
• Cost (and input) information was not
  disaggregated by outputs
• Cost information was not always complete

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Key Question Cost Analysis

• What are the per beneficiary costs for
  psychosocial, educational, HIV knowledge, income
  generation, food security and counseling outcomes?

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Key Question Cost-Effectiveness Analysis

• What does it cost to achieve improvements in OVC
  and guardian psychosocial, educational, HIV
  knowledge, income generation, food security and
  counseling outcomes?

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OVC Programs with Demonstrated Effects
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Evaluation Design Samples

• Post-test study programs on-going for at least
  one year
• Focus only on OVC aged 8-14 years
• Survey administered to OVC and their caregivers

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Calculating Effectiveness

• Multivariate regression analysis
• Binary outcomes (e.g. food insecure)
• probit model
• Continuous outcomes (e.g. HIV knowledge)
• linear regression
• Instrumental variables regression to control for
  non-random program participation
• Test for endogeneity (i.e. selection on
  unobservable factors)

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Evaluation Design
Time
Year 0
Year 1
Intervention Group (OVCs)
Program begins OVC enrolled start Receiving
services
Survey Administered
Comparison Group 1 (OVCs)
Comparison OVCs start receiving services
Comparison Group 2 (non-OVCs) (IAP)
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Calculating Cost-Effectiveness

• Marginal effect of exposure in intervention
  relative to comparison group

CE
Per beneficiary cost of intervention
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4. Results

• Costs per beneficiary
• Costs per improvement in outcome

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Costs Per Beneficiary - OVC
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Costs Per Beneficiary - Guardian
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Psychosocial Outcomes (Indexes)
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CostEffectiveness of Home Visiting - OVCs
Family Self- Esteem (CRS)
Social Isolation (Allamano)
Self-Esteem (The Salvation Army)
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Results Kids Clubs

• 6.43 per marginal increase in an OVCs measure
  of family self-esteem (Allamano)
• No measurable effect for other outcomes

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Results School-based HIV Education

• Cost-effectiveness of school-based HIV Education
• Integrated AIDS Program 2.61 per incremental
  change in knowledge
• Cath. Relief Services 0.09 per incremental
  change in knowledge

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Results Educational Support

• Little difference in educational outcomes across
  all programs
• Programs ensure that educational achievement is
  at least as good among OVC as non-OVC

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Guardian Support Groups (1)

• Catholic Relief Services
• Guardian participation in care and support
  meetings was associated with a 0.11 unit
  reduction in family dysfunction
• CE 4.16 / incremental reduction in family
  dysfunction

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Guardian Support Groups (2)

• Integrated AIDS Program
• Guardian participation in care and support
  meetings was associated with a 0.75 unit
  reduction in negative feelings
• CE 75 / incremental reduction in negative
  feelings

p 0.011
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Income Generating Activities

• Cost-effectiveness of IGA
• A 10 reduction in (the probability of) food
  insecurity could be achieved for less than 10
  per month

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Food Support - Allamano
Marginal reductions in probability of food
insecurity from food support

• Receipt of consistent food aid was associated
  with a 0.437 reduction in the likelihood of food
  insecurity
• CE 0.74 / 10 reduction in food insecurity

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Food Security
A 10 reduction the probability of food
insecurity could be achieved for? All fairly
low cost Which is more sustainable?

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5. Conclusions (Analysis)

• Collect data on outcomes at baseline so as to
  measure changes
• Try (as hard as possible) to have equivalent
  comparison groups
• Targeted programs involve substantial
  complications in evaluation
• Measures of mental well-being should be
  standardized and more widely used

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5. Conclusions (Policy)

• OVC interventions can be effective AND
  cost-effective in improving OVC and guardian
  welfare across multiple dimensions.
• School-based HIV education programs can
  substantially increase knowledge at low cost.
• Food security can be improved substantially at a
  low per household cost.
• The data base of cost-effectiveness calculations
  should be expanded for larger numbers of OVC
  guardian activities in wider range of settings.
• Cost data, collected concurrent with program
  implementation, can provide a powerful tool for
  planners.

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Acknowledgements

• Staff from
• The Salvation Army
• Mama Mkubwa Kids Club program
• Allamano
• CARE
• Tanzania Tumaini Project
• Kilifi OVC Porject
• Pathfinder
• The Community Based Care and Support Program
  (COPHIA)

• The Constella Futures Group (MEASURE) Florence
  Nyangara, Minki Chatterji, Kathy Buek, Sarah
  Alkenbrack
• Kristin Neudorf Jeanne-Marie Tucker
• USAID Jerusha Karuthiru, Kate Vorley, Washington
  Omwomo (Kenya) Elizabeth Lema, Susan Monaghan
  (Tanzania) Rick Berzon John Novak, Kathleen
  Handley, and Scott Stewart (DC)
• USG OVC Technical Working Group
• Innumerable volunteers and local leaders in Kenya
  and Tanzania

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• If you are interested in the full paper, please
  refer to
• http//www.cpc.unc.edu/measure/publications/pdf/sr
  -09-51.pdf
• Contact Info
• Paul L. Hutchinson, Ph.D. / Tonya Thurman, Ph.D.
• Tulane University School of Public Health and
  Tropical Medicine
• Department of International Health and
  Development
• 1440 Canal Street, Suite 2200-TB46
• New Orleans, LA 70112
• USA
• Email phutchin_at_tulane.edu / tthurma_at_tulane.edu