COSTING GUIDELINES FOR HIV PREVENTION STRATEGIES
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Costing Guidelines
for HIV Prevention
Strategies
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UNAIDS
UNICEF • UNDP • UNFPA • UNDCP
UNESCO « WHO « WORLD BANK
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UNAIDS/00.31E (English original, October 2000)
© Joint United Nations Programme on HIV/AIDS
(UNAIDS) 2000.
All rights reserved.This document, which is not a formal
publication of UNAIDS, may be freely reviewed, quoted,
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source is acknowledged.The document may not be sold
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out prior written approval from UNAIDS (contact:
UNAIDS Information Centre).
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are solely the responsibility of those authors.
The designations employed and the presentation of the
material in this work do not imply the expression of any
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the legal status of any country, territory, city or area or
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Fhe mention of specific companies or of certain manu
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UNAIDS - 20 avenue Appia - 121 1 Geneva 27 - Switzerland
Telephone: (+4122) 791 46 51 - Fax: (+41 22) 791 41 87
e-mail: unaids@unaids.org - Internet: http://www.unaids.org
B E S T
PRACTICE
COLLECTION
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FOR HIV PREVENTION
STRATEGIES
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UNAIDS
Geneva, Switzerland
2000
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Contents
Foreword
Acknowledgements
5
6
INTRODUCTION
7
Background
Aim of the guidelines and audience
Structure of guidelines
7
8
8
Chapter 1: HIV PREVENTION STRATEGIES
9
1.1
1.2
Established prevention strategies
9
•
Screening blood for HIV infection
10
•
Use of the mass media
13
•
AIDS education in schools
16
•
Social marketing of condoms
18
•
Treatment of sexually transmitted diseases
21
•
Commercial sex worker peer education
24
•
Voluntary counselling and testing
26
•
Prevention measures among injecting drug users
29
•
Prevention of mother-to-child/vertical transmission
32
New and emerging HIV prevention strategies
35
•
Microbicides and female-controlled methods
35
•
Vaccines
35
Chapter 2: CONCEPTS OF COST ANALYSIS
37
2.1
37
38
39
39
What are costs?
Whose costs? Society, provider, household and private costs
Full and incremental costs
Total, average and marginal costs
2.5 Joint costs
2.6 Classification of costs
Unit costs and measurement of outcomes
1
2.8 Cost-effectiveness
2.2
2.3
2.4
2
40
40
42
44
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Contents
Chapter 3: PLANNING THE COSTING EXERCISE
3.1
Defining the question and objectives
47
•
Examining the efficiency of a project
47
•
Mcdification/sustainability
•
Replication
•
Cost-effectiveness
•
Private/provider perspectives
48
48
49
Identify the alternatives to be compared
49
3.3
Describe each alternative
50
•
Inputs
•
Activities
51
•
Organizational level
56
Decide on the data timeframe
50
61
3.5 Select a sample
64
3.6
65
Work itinerary
Chapters COLLECTION OF COST DATA
3
47
3.2
3.4
I
46
67
4.1
Financial and economic costs
67
4.2
Gathering background data
69
4.3
Collecting input data (Form C)
70
•
General
70
•
Data collection at the different organizational levels
71
•
Currency
71
•
Source of funds
71
•
Source of data
72
•
Converting to constant prices
72
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4.4
Data collection
CAPITAL COSTS
73
73
a)
Buildings (Form Cl)
73
b)
Equipment (Form C2)
75
0
Vehicles (Form C3)
d)
Consultancies (Form C4)
RECURRENT COSTS
e)
Personnel (Form C5a)
f)
Supplies (Form C6)
9)
Vehicle operation and maintenance (Form C7)
77
79
82
82
86
90
91
h)
92
i)
j)
Other recurrent costs (Form CIO)
9
k)
Private costs (Form C11)
95
Collection of outcome data
97
Chapter 5: COST ANALYSIS
101
4.5
5.7
Adding up costs
707
5.2
Cost profile
102
5.3
Unit costs
103
5.4
Using the cost analysis in planning and budgeting
10
annex: DATA COLLECTION SHEETS
106
REFERENCES AND FURTHER READING
123
UNAIDS
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Foreword
Foreword
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It is essential to know the costs of different prevention strategies to be able to
set public policy priorities in the fight against AIDS. Hence this important costing
tool, a new edition of Costing guidelines for HIV prevention strategies, first
issued by UNAIDS in 1998. The guidelines now contain cost analysis worksheets
and cover injecting drug users.
In many developing countries economists are scarce, but these guidelines make
it possible for other professionals such as accountants and planners to analyse
costs. Such analyses must be combined with a judgement of an intervention's
outcome. That an intervention has a low cost does not necessarily mean it is
worth while from an economic perspective; for example, if it does not slow the
spread of the disease or has unwanted side-effects that outweigh benefits.
As a companion tool to these guidelines, UNAIDS has created a number of
dynamic spreadsheet and mathematical models that estimate outcomes such as
number of cases of HIV transmission averted and cost per Disability Adjusted Life
Year (DALY), on a strategy-by-strategy basis. The models cover:
•
•
•
•
•
Mother-to-child transmission
School education
Sex worker intervention
Blood transfusion services
Prevention interventions for injecting drug users
The models are available at the UNAIDS website (www.unaids.org) and on the CDROM Economics in HIV/AIDS planning: getting priorities right, UNAIDS, June
2000.
The Global Programme on AIDS (GPA) at the World Health Organization first
began developing costing guidelines, working with the London School of
Hygiene and Tropical Medicine (LSHTM). UNAIDS has now taken the lead in both
disseminating these important and up-to-date guidelines and models and pro
moting their use in strategic planning.
UNAIDS
September 2000
5
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Acknowledgements
Our thanks go to a number of people "^^’^“^tt^patrrck Vaughan and
production of these Costing^Gu/di?! ne .
provided invaluable supAnthony Zwi, from the Health Poli y UmVeful feedback and com
port and feedback s.nce the -cept-on
jn
ments were also receive
Stefano B.ertozzi, Thierry Mertens
ZSZ
aSaP mso contributed in this wa.
Assistance was gratefully received from l^“e ^“J^Jeagtes Vf'fihe National
the Guideline in Zambia. Dr R°la"dmX^e in Cameroon. Alexis BoupdaAIDS. STD. TB and leprosy Control Program
C
KwenthKU of
Kuate and tean-Claude
^nd Zakanou Njoumem, of IRESCO; am'
o.
Xbes orSvXXX“comm,.tee and Roman Gai.evich of UNAIDS
Belarus.
Punam Mangtani ol LSHTM and ^lla °e'^°’ y fc'to express^ur appre-
assisted with field tests ,n Cameroon. F'n* *
readi
editing these
“SnesNand mlnlea^h... UNA.OS, who coordinated a.I publishing
aspects.
Microsoft and Excel are registered trademarks
of Microsoft Corporation.
Lilani Kuinaranay<
Jane Pepperall
Hilary Goodman
Anne Mills
Damian Walker
Health Economics and
London School of Hygiene & Tropical Medicine
UNAIDS
Introduction
Introduction
t
Background
More than a decade into the worldwide implementation of HIV prevention work,
there is a noticeable lack of costing and cost analysis specific to this field. There
is even less work on assessing the relative cost-effectiveness of different preven
tion strategies. Cost analysis is a tool that can provide useful insight into the
functioning of projects, as well as being a key component of cost-effectiveness
analysis.
Within HIV prevention, cost analysis has the potential to help managers at proj
ect level decide upon the most appropriate way to deliver a particular strategy.
Cost analysis will assist managers in a number of ways, which include:
•
•
•
•
l
providing an overview of the total amount of resources that are needed to
begin or continue a project;
assessing the use of different inputs (such as staff or equipment) within a
project, and assisting in discussions about the relative efficiency and equity of
projects;”’
guiding discussions about the most appropriate mix and volume of preven
tive strategies and the best way to allocate resources—for example, whether
more resources should be allocated to Sexually Transmitted Diseases (STD)
services relative to media education;
providing an idea of the extent of resources required for scaling-up or repli
cating interventions.
Cost and cost-effectiveness analyses serve to provide basic evidence for on-going
policy questions and debates. Cost analyses have always been identified with
issues of efficiency, cost-recovery and sustainability of programmes. However,
cost analysis can also play an important role in examining issues of equity and
targeting, which have recently come to the forefront of the policy debate (H 25)
With the on-going research and development of new HIV prevention strategies,
the question of their feasibility is integrally connected with issues of cost, effi
ciency and priorities for resource allocation. Cost and cost-effectiveness analyses
are even more germane in this context.
Cost data from on-going HIV prevention activities contribute to a more informed
national and international debate. Prevention activities may be extremely varied
both within and between countries. Therefore, it is important that, although cost
ing approaches will depend on the purpose of the specific exercise and on local cir
cumstances, there is consistency in the costing methods used. In this way, work
undertaken in one context can have maximum relevance to managers in other con
texts. In order to facilitate this consistency, recommended methodologies and stan
dardized worksheets are provided here for costing HIV prevention interventions.
□
UNAIDS
The principles of these Costing Guidelines are derived from Cost Analysis in Primary
Health Care—a training manual for programme managers (hereafter referred to as
the 'PHC Manual'). The manual was produced for programme managers to illus
trate how cost analysis might be used to address basic questions about the effi
ciency, equity and sustainability of the health activities for which they were respon
sible. It was hoped that the use of cost analyses would contribute to decisions
about the optimal use of resources within the health sector and within individual
programmes. Excerpts taken from the PHC Manual will be referenced as "PHC:
page number". The PHC Manual is one of a number of relevant costing manuals
produced over recent years hasas). Much of the guidance it provides is directly
applicable to managers of AIDS programmes who want cost analysis to contribute
to their own decision-making. The PHC Manual is recommended reading for users
of these Costing Guidelines, but is not required in order to understand and use
these Guidelines.
As in the PHC Manual, these Guidelines cost projects from the perspective of s
ice providers and not from a social perspective. This should be borne in mind when
interpreting the findings of the costing studies. The relevance and clarity of the
Guidelines have been tested by costing a sample of prevention projects in several
countries. This experience has been fed into the revision of the Guidelines.
Aim of the Guidelines and Audience
The specific aim of these Guidelines is to encourage and enable managers of HIV
prevention projects and programmes to conduct cost analysis. These Guidelines
relate the costing methodology presented in the PHC Manual and adapted to HIV
prevention activities. These Guidelines can be used to assess projects/programmes
at national, regional, district and community levels. We do not assume any prior
experience or training in economics for users of these Guidelines. Detailed exer
cises to practise concepts of cost analysis are found at the back of the PHC Man
Structure of the Guidelines
The Guidelines begin by introducing and describing different strategies for HIV
prevention. Chapter 2 provides an introduction to the basic economic concepts of
cost analysis, upon which these Guidelines are based. Chapters 3 and 4 take the
reader through a step-by-step guide to planning and undertaking a cost analysis,
including how to collect data. Chapter 5 looks at adding up costs and how to gen
erate different results from the analysis. Annex 1 provides the background work
sheets for individuals wanting to undertake a cost analysis. Finally the Guidelines
end with a section on relevant literature in the area of cost and cost-effectiveness
of HIV prevention strategies. A Microsoft Excel version of the spreadsheet is avail
able on the UNAIDS website (www.unaids.org/Dnbiications) or the CD-ROM: Economics in
HIV/AIDS planning: getting priorities right, UNAIDS (June 2000).
UNAIDS
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HIV prevention strategies
Chapter 1
HIV PREVENTION STRATEGIES
In order to conduct a cost analysis of a project or programme, it is crucial to
understand how a project functions. This section provides an introduction to dif
ferent HIV prevention strategies and highlights factors that are important to the
collection of the cost data. Under the heading of established strategies, exam
ples of nine strategies are presented. While it is recognized that there are other
strategies, these represent some of the most common strategies currently being
implemented. The discussion of cost analysis throughout these guidelines will
explicitly feature these strategies. The second section in this chapter discusses
new and emerging HIV prevention strategies, to which the same costing princi
ples would apply. While these strategies are described individually, this is not
meant to suggest the adoption of a vertical approach to HIV prevention pro
gramming. Rather, the aim of this chapter is to introduce readers to the various
strategies and highlight issues with respect to cost analysis. In practice, a num
ber of strategies may be used jointly.
7.1 Established prevention strategies
This section will provide an introduction to nine established AIDS strategies. It
discusses the description of potential projects, and key variables that are likely to
affect the costs of each strategy are also discussed. The nine strategies are:
•
•
•
•
•
•
•
•
•
9
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Screening blood for HIV infection
Use of the mass media
AIDS education in schools
Social marketing of condoms
Treatment of sexually transmitted diseases
Commercial sex worker peer education
Voluntary counselling and testing
Prevention activities among injecting drug users
Prevention of mother-to-child/vertical transmission
UNAIDS
s i sTu a-
I SCREENING BLOOD FOR HIV INFECTION
1. Introduction
An HIV blood screening strategy aims to reduce the estimated 5-10% of HIV
infections in developing countries that are transmitted through infected blood
transfusions <33). This aim can be achieved almost entirely through the testing of
all blood donations for HIV antibodies before transfusion, and the discarding of
donations that test HIV-positive.
HIV blood screening can only be conducted as an integral part of a more com
prehensive blood transfusion service (BTS) but, for the purposes of these guide
lines, consideration of the strategy is restricted to the HIV blood-screening com
ponent. Nonetheless, the methodology presented could be extended to cover the
other potential components. The main activities undertaken by a BTS are. donor
recruitment and selection; collection of blood; a variety of blood screening tests;
blood processing, storage and distribution; final transfusion of the blood, and
support activities such as management and administration and staff training. A
broader HIV blood safety strategy could have additional activities, such as more
rational use of blood transfusion by the health service and prevention of condi
tions that usually require blood transfusion as part of their treatment.
On a number of counts, screening blood for HIV stands out from the other
strategies that will be discussed in this chapter. Firstly, there is general agreement
on the degree of the strategy's effectiveness. Consensus that more than 95% of
HIV-negative patients transfused with HIV-infected blood will seroconvert
enables calculation of the number of cases of HIV infection preventable by HIV
blood screening. Calculations are, however, dependent on the reliability of the
blood tests, and the chances of transfusing infected blood. The number of units
of blood testing false positive will depend on the specificity of the test as well as
the prevalence of HIV in the donated blood.
Secondly, the responsibility for HIV infection acquired through infected blood
products lies almost entirely with health services. Preventive action therefore also
lies with them (in contrast to other strategies that stress prevention through indi
vidual responsibility and altered behaviour). This can lead to a medical and polit
ical imperative to implement the strategy, irrespective of its cost-effectiveness
relative to alternative HIV prevention strategies. It can also make it the least polit
ically sensitive HIV prevention strategy to adopt.
Nonetheless, at any prevalence level of HIV, only a small proportion of the popu
lation, namely blood transfusion recipients, will benefit directly from the strategy.
This leads to controversy over the priority to be afforded to HIV blood screening.
On the one hand, it is suggested’that only at certain levels of HIV prevalence will
HIV blood screening be a cost-effective strategy to pursue
On the other hand,
it is advocated that no unscreened blood should be transfused, except ih life-sav
ing situations. More information on the costs and effectiveness of implementing
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HIV prevention strategies
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HIV screening strategies may reduce the degree of controversy. Nonetheless, polit
ical and ethical considerations make it unlikely that any country would be able, or
inclined, to have a policy of transfusing untested blood on the grounds that
resources necessary for HIV screening would be better spent elsewhere.
In presenting the costs of the HIV blood screening strategy, other indirect bene
fits of the strategy should also be reported. These may include reduced transmis
sion of other blood-acquired infections such as hepatitis B and syphilis (which
results from the more comprehensive screening procedures established in con
junction with the HIV screening strategy), and enhanced accessibility to blood
transfusions. A detailed manual on costing blood transfusion services is available
from WHO
2. Description of potential projects
The nature of BTS projects can be very variable and one of the early tasks of the
costing exercise will be to describe the particular one to be costed. BTS may be
integrated with other health services, often as part of hospital services, or may be
run independently from other health services in a vertical fashion. Costing is likely
to be easier in the latter case, where the services are more easily identifiable, than
when they are integrated with other activities.
1
Countries' strategic responses to the risk of HIV transmission through blood will
also be variable and context-specific. The costs of adding HIV screening proce
dures to an established BTS may be quite small. For some countries, however, to
provide HIV-screened blood may entail major reorganization of the BTS. Some
examples of the ways in which HIV blood screening strategies may be imple
mented:
If
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a) Countries without organized blood transfusion services may collect and trans
fuse blood as and when needed. In this case, the HIV blood screening strat
egy is likely to be decentralized and entail one-test screening procedures at
peripheral locations.
d
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b) Countries may implement decentralized use of test kits as in (a), but supple
ment this with more centralized arrangements for supplementary testing of
the positive tests.
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c) Regional blood banks may be established with their own laboratory blood
testing facilities or with samples being sent to a more central facility for HIV
testing. At this organizational level and above, techniques such as pooling
blood for testing may be used to reduce costs. Decentralized use of one-test
kits may still be appropriate in peripheral services.
y3ill
d) The national BTS may be centralized with all blood collected and tested cen
trally and HIV-screened blood distributed from the centre. Decentralized use of
one-test kits may still be appropriate in peripheral services.
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These are only a few examples of an array of possible options for responding to
the risk of HIV transmission through infected blood. Clearly, the nature of the
services will strongly influence their costs, and these will differ from one model
to another. In undertaking costing and cost-effectiveness analyses of BTS, it is
important to appreciate that different country analyses will seldom be dealing
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with directly comparable systems.
3. Variables which affect costs
In addition to the cost implications of organizational and structural differences
between different BTS outlined in section 2 above, there are other factors that
vary between projects that affect absolute costs and relative cost-effectiveness.
Some of these are highlighted below:
12
•
HIV prevalence in the recipient and donor population. Firstly, the recip
ients: there is no HIV infection averted if a clean unit of blood is transfi d
to a patient who is already HIV-positive. Secondly, the donors, if the preva
lence of HIV in donated blood is 20%, then the amount of blood discarded
would be likely to be twice as much as when the prevalence is only 10%. This
will affect the costs of replacing blood and the cost per HIV infection averted.
•
Donor recruitment policies. HIV-infected donations will be fewer if meas
ures are taken to exclude donors at high risk of HIV infection and to actively
recruit low-risk voluntary donors. For example, in Zambia, schoolchildren are
the principal population from whom blood is collected. This necessitates
widespread travel by mobile blood collection teams. The cost of transport is
high, but is offset by the much-reduced need to discard blood.
•
Whether blood samples or patients are the focus of HIV testing Where
patients are the focus, the way in which HIV-positive donors are counselled
will have resource implications. In some cases, positive tests will lead to coun
selling of infected patients and tracing of their sexual contacts; sometim to
counselling of the patient only; and sometimes simply to discarding the dona
tion and no personal contact is made with the patient.
•
Economies of scale at different organizational levels. For example,
where blood is collected, tested and transfused on demand at the local level,
costs for recruitment, collection, storage and transport will be considerably
less than they are in more structured services. The volume of blood collected
at the local level will determine whether or not pooled or bulk testing of
blood can be conducted. At the national level, the size of the BTS will deter
mine the scale of operations and influence unit costs.
•
The type of HIV tests being used. Although the price of HIV tests has been
decreasing in recent years, the rapid serological test is still more expensive
(per unit tested) than testing a large batch using an ELISA: test. However,
depending on the volume and freguency of blood collected, the use of an
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HIV prevention strategies
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ELISA reader may or may not be most economic. The number of extra tests
used as controls also depends on the number of units being tested at once.
Rapid tests use essentially one control per test, whereas an ELISA test will use,
at most, one for every six tests. This will affect the total costs of testing.
t
•
The reliability of the HIV tests used. False tests will lead to the wastage
of good blood and the transfusion of infected blood. However, most tests
now have high levels of sensitivity and specificity.
•
Whether laboratory costs are exclusively attributable to HIV blood
testing or shared with other laboratory services.
•
The order in which different tests are conducted (e g. HIV, hepatitis,
syphilis and blood grouping) will affect the costs when the blood is discarded
and not tested further as soon as it tests positive for any one test. The most
cost-effective order will be a factor of the relative costs of the tests and the
prevalence of each condition in the donor population, which will in turn dic
tate the probability of each test leading to discarding of the blood. However,
not all services operate in this fashion, and sometimes all tests are performed
before any blood is discarded.
•
The skill mix of staff implementing the strategy. The skill mix of the staff
may also determine the degree to which choices are made between ELISA
and rapid tests.
USE OF THE MASS MEDIA
1
1. Introduction
A mass media strategy entails the development of IEC (information, education
and communication) materials and their dissemination to the general population
through a variety of media channels. The strategy can be implemented through
one or a series of individual campaigns.
I
Consideration of the strategy here is restricted to campaigns that achieve a high
coverage of the general population or large sub-groups such as 'the young'.
Campaigns targeted at high-risk groups or advertising associated with specific
commercial products are excluded. Issues relating to these two areas are raised
in the sections on sex worker peer education, condom social marketing and pre
vention strategies among injecting drug users. Also not considered here is use of
the press through passing AIDS news to journalists. This can supplement the
efforts of using other mass media.
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The objectives of most AIDS-associated mass media campaigns are:
to provide information, raise awareness and stimulate discussion;
to inform people about the availability of further information and services;
to encourage behaviour change to minimize the risk of infection, usually
through increased condom use; decreased number of sexual partners; and
decreased incidence of sex with high-risk partners;
• to reduce misinformation about casual transmission; and
• to prevent discrimination against those infected with HIV.
•
•
•
The first three of these are of relevance here in the context of HIV prevention.
The challenge in using mass media directed at the general population is to
develop messages that are generally understandable and acceptable yet that still
manage to be personally persuasive. The strategy has the potential to reach a
large number of people relatively easily. Its coverage depends on the form of
media used and access to that media amongst the groups targeted.
In the majority of countries where AIDS has been reported, the government has
taken some measures to inform people about the risks and prevention of the dis
ease. The extent and way in which media have been used have been very
diverse. Initial campaigns were rapidly developed in response to HIV and were
typically poorly prepared. Later campaigns were more appropriate for their
respective circumstances, had specific aims, and focused on particular audiences.
This was achieved through more careful planning, such as using focus group dis
cussions and market research to define the issues that needed addressing, and
then testing, revising and re-testing messages with prospective audiences and
key interest groups to ensure their clarity, appropriateness and acceptability and
to prevent any negative side effects (20L
2. Description of potential projects
There is considerable diversity in the way that mass media campaigns are con
ducted - their intensity, level of coverage, quality and the type(s) of media used.
Examples of the latter include radio, television, film, music, entertainment, news
papers, journals, posters, pamphlets and stickers. In developed countries, heavy
use has been made of television and newspapers to obtain high levels of IEC cov
erage. Some countries have supplemented these strategies with household dis
tribution of information brochures. Developing countries have tended to empha
size radio and printed materials distributed through a number of outlets such as
clinics, schools and public transport. Government mass media campaigns have
tended to use broadcast and print media channels whilst local groups have
emphasised print media and personal contact (20>.
In any one country, there are often several HIV prevention strategies running
simultaneously, and the boundaries of a mass media strategy Vis-^-vis other
strategies, such as social marketing or AIDS education in schools, may not be clear.
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UNAIDS
HIV prevention strategies
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To an extent, the boundaries are artificial because of the synergy between the
different strategies. For example, a government mass media campaign may
enhance the success of a social marketing organization and that organization
may popularize and reinforce the messages that the government advertising
campaign is imparting. In this way, the two strategies are reinforcing and cross
subsidizing each other. Similarly, the effectiveness of a mass media campaign
with an emphasis on condom use will be dependent, amongst other things, on
the availability and accessibility of condoms provided through other strategies.
The effects of person-to-person education strategies may also be strengthened
by mass media campaigns.
t
3. Variables which affect costs
Some of the variables affecting costs are highlighted below:
15
•
Materials development. The amount of time and type of work invested in
development of the IEC materials will influence costs. For example, external
consultancy resources may be drawn upon during this phase. These costs
may be reduced if the materials used had already been produced elsewhere.
For example, material such as films or educational programmes can be
bought from other countries, or material that has already been screened can
be re-broadcast.
•
Type of media used. There are clearly different costs associated with broad
cast media and, for example, print media.
•
Intensity of media use. For example, the length of a programme or publi
cation, the frequency with which it is transmitted, and the duration of the
campaign.
•
Quality of the media. For example, whether peak or off-peak airtime is
used for broadcasting.
•
Rate of charging for airtime or press space. Media coverage may be paid
for at commercial rates, or sponsored by the private sector, or subsidized by
the government.
•
Economies of scale. Mass media campaigns tend to have high fixed costs.
Therefore, the larger the population and the greater the population density,
the lower are likely to be mass media unit costs. Conversely, a small popula
tion widely scattered will be more expensive per person covered.
•
Country variation in the costs of media production and transmission.
This can be sizeable, and make international comparisons between projects
problematic.
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AIDS EDUCATION IN SCHOOLS
1. Introduction
AIDS education in schools is a specialized type of IEC (information, education
and communication) programme, implemented by teachers and other school
staff. In these guidelines it is assumed that the strategy is implemented during
school time. It will normally be undertaken after development of a school cur
riculum for AIDS education and will often be incorporated in wider sex educa
tion activities. The objectives of AIDS school education programmes will be sim
ilar to those of mass media programmes, including:
to provide information, raise awareness and stimulate discussion;
to encourage the development of safe behaviour to minimize the risk of infec
tion through, for example, delayed first intercourse or increased condom use;
• to correct misinformation about casual transmission;
• to prevent discrimination against those infected with HIV.
•
•
i
■'I ' i
1
II
’ h
i
As with a mass media strategy, resources will initially be invested in the devel
opment and production of education materials targeted at school children. The
type of media used will normally be printed materials for use in the classroom
(readers, activity sheets, booklets for students, teaching guides for teachers), but
videos, posters and magazines may also be produced.
School education programmes are relatively labour-intensive, engaging a variety
of school staff and students to deliver AIDS education. Staff involved may include
schoolteachers and school counsellors. Head teachers may be given training to
sensitize them to the importance of AIDS education in their schools. In the
absence of this sensitization, trained teachers may be inhibited from imple
menting the strategy because of resistance from their colleagues.
Schools have the potential to raise awareness and influence both short and
long-term behaviour because they provide an environment where children and
young adults are encouraged to learn and to respond to authority. It is generally
assumed that the target population is uninfected and that the benefits of the
strategy will accrue some time after its implementation through improved
knowledge, attitudes and behaviour.
AIDS education in schools is likely to be implemented as a discrete programme.
Potential benefits of the programme may, however, be reinforced by other com
plementary strategies, such as mass media campaigns aimed at the general pop
ulation or young adolescents, condom social marketing projects and other proj
ects that enhance condom availability.
UNAIDS
u HIV prevention strategies
2. Description of potential programmes
t
AIDS school education programmes are most commonly implemented in the
government sector, through additions to the school curriculum. A programme
may be implemented nationally or coverage may be more restricted, for
example, to a regional or municipal initiative. A programme may involve part
nership with other agencies such as NGOs running smaller-scale school edu
cation projects.
The acceptability of an AIDS school education programme and its content will be
highly dependent on the cultural context and therefore will vary a great deal
between countries. Programmes will also vary in terms of their quality and inten
sity. For example, a programme may entail only a brief training session for teach
ers followed by one-off sessions with children during which messages are relayed
and materials handed out. Alternatively, AIDS education may be incorporated
into the national curriculum, teachers may receive several weeks' training, and
children may have regular classes over several years. These classes may combine
AIDS education with more general health and sex education and use a variety of
participatory approaches to discuss HIV and promote healthy sexual behaviour.
3. Variables which affect costs
Some of the variables affecting unit costs are highlighted below:
17
•
Development of educational materials: the amount of time and type of
work invested in development of AIDS school curricula and supporting mate
rials. For example, external consultancy resources may or may not be drawn
upon during this phase.
•
Production of educational materials: the quantity and quality of educa
tional materials produced for each student and teacher covered by the
strategy.
•
Training school teachers: the amount of time invested in sensitization and
training of school staff.
•
The amount of school teaching time dedicated to AIDS education.
•
Personnel costs: the strategy is labour-intensive and the relative costs of
trainers and teachers should be borne in mind in making any international
comparisons or extrapolating cost data to other countries.
•
Economies of scale: the larger the target population, the more the strat
egy's fixed overhead costs, such as costs of curricula and material develop
ment, will be spread over more schools and schoolchildren, thus reducing
unit costs.
UNAIDS
SOCIAL MARKETING OF CONDOMS
1. Introduction
'Social marketing' is the marketing of public health goods or ideas through con
ventional marketing channels. Condom social marketing (CSM) was initially
undertaken as part of contraceptive social marketing. CSM has been developed
as a strategy for the prevention of AIDS because of its potential to distribute
large numbers of condoms. Condoms are one of the main ways in which indi
viduals can protect themselves from HIV infection, as well as from other STDs
that may facilitate HIV transmission during subsequent exposure to the infection.
Enhancing access to condoms or its complements are an integral part of the
majority of the other strategies discussed in this chapter.
In many countries, people cannot get condoms easily, regularly or cheaply.
Condoms may not be readily available at a time convenient to consume
Condoms tend to sell for a relatively high price in the commercial sector or be
distributed freely or at a nominal fee through the public sector. In the former sit
uation, price can bar access for many potential users; in the latter situation, con
dom quality is often low, or perceived to be so, and availability may be irregular.
The main objective of CSM projects is to increase the availability and use of
good-quality, low-cost condoms and hence contribute to preventing the trans
mission of HIV infection. The strategy usually promotes condom use in general
and use of the social marketing organization's own condom brand in particular.
The strategy also aims to disseminate messages concerning HIV prevention, safe
sexual behaviour and correct condom use. These objectives are achieved through
fairly standard marketing techniques with the main activities being to conduct
market research; to acquire and package condoms, to advertise and promote the
product; to train retailers; to distribute the product; and to manage the project.
The non-clinical nature of condoms allows a wide range of potential retailed
including health professionals, pharmacists, midwives, traditional birth attc
dants, traditional healers, shopkeepers and itinerant salesmen, to be involved in
the project. Condoms can be sold in both traditional outlets (e.g. pharmacies)
and non-traditional outlets (e.g. petrol stations, hotels). In practice, a variety of
means of distribution have been developed to ensure high coverage.
Project activities are adapted according to the context and environment in which
the strategy is being launched. Social marketing projects can stimulate demand
for condoms by conducting market research and then launching appropriate pro
motion and advertising campaigns. These may be similar to the mass media cam
paigns discussed above, but more focused on target groups and relying on local
promotions as well as on the wider coverage achieved through mass media. Once
demand is stimulated, commercial companies may themselves be prepared to
invest directly in the condom market. Where demand already exists and has clear
potential to rise, social marketing has a role to play in increasing the supply of
condoms and increasing access through strengthened distribution networks.
UNAIDS
HIV prevention strategies
Although social marketing aims to keep condom prices low, some projects launch
a variety of condoms to appeal to different parts of the market. In this way, rev
enue from more expensive condoms can be used to cross-subsidize condoms at
the lower end of the market.
t
I
Revenue collected through sales offsets programme costs and reduces the sub
sidy needed for project activities. The balance struck between cost recovery and
demand will to some extent be a political decision, reflecting the relative impor
tance given to sustainability and coverage <57). The costs of many social market
ing projects are subsidized by governments or donors, contributing to lower
prices and increased access to condoms. In contrast, some projects have
achieved complete self-sufficiency, continuing marketing activities without
donor financing or technical assistance. An example is the Indonesian DuaLima
Red condom project where commercial partners cover all costs (55).
■-
Large-scale CSM projects are usually overseen or implemented by private notfor-profit organizations. To date, the expertise for these projects has tended to
come from a small number of American organizations, either directly or through
their subsidiary in-country organizations. How project responsibilities are allo
cated between participating private and public sector organizations will vary
between countries and according to the politics of the overseeing organization.
r
I
2. Description of potential projects
There are several potential project designs, depending upon the environment in
which a project is launched and the varying emphases on sustainability and cov
erage of the implementing organizations. Cisek and Maher (1992) have grouped
the approaches into four types, with increasing degrees of private sector partic
ipation <55).
Type 1 projects increase availability of condoms through distribution of donated
supplies. The projects often set up and manage their own administrative struc
tures, implementing agencies and distribution networks. Condoms are heavily
subsidized and hence accessible to all if distribution networks are adequate.
These projects tend to be expensive for the donors financing them and tend to
remain donor-dependent.
fL.
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Type 2 projects use existing private and public infrastructure to a greater extent.
For example, a project may arrange for local private distributors to conduct dis
tribution and training activities. There is increased cost recovery to cover project
costs.
i
Type 3 projects diversify commodity sourcing and are no longer dependent on
donated products. One approach for acquisition of condoms is for a project to
negotiate reduced prices with condom manufacturers. In return for the manu
facturers putting condoms on the market at a reduced price, donor funds are
used for promotion and marketing of their products, in effect running specialized
19
UNAIDS
I'
I
V
IEC campaigns on the manufacturer's behalf. This may be the most appropriate
approach in countries where demand is low and potential manufacturers are wary
of investing in market development themselves. This type of project would use
the existing distribution network and contribute to its development.
Type 4 projects maximize the use of private sector infrastructures, including com
mercial sector management of the project. Donors' involvement is in market
building but the commercial partners may also contribute to this. The projects
have no management costs and no commodity costs. Condoms are retailed at a
price that covers all costs plus profit margins for the private sector distributors,
wholesalers and retailers.
I
3. Variables which affect costs
Some of file variables affecting costs ate highlighted below:
i
•
How long the project has been running Start-up costs are very often
high, given the need for market tesearch and product development. I his
stage often includes a high level of technical support that contributes to the
high cost. In addition, the longer the project runs, the more sales will
increase, which will imply a fall in unit costs over time.
•
Economies of scale. These depend on the size of the market.
•
The nature of the targeted population. For example, the distribution ol
the population between rural and urban areas will influence costs.
•
The source of project condoms These may be donated to the project,
bought on the international market, or put on to the market at negotiated
prices by commercial manufacturers.
•
The social marketing model used. In particular, costs will be influenced by
the role of the commercial sector in such activities as administration, man
agement, training, promotion and distribution. A Type 1 model will have
more costly distribution systems than a Type 4 model. The extent to which
the involvement of the commercial sector affects cost will depend on the per
spective of the costing exercise. If the perspective is of public sector costs
only, involvement of the private sector will greatly reduce costs. If the per
spective is of all providers, costs may be reduced slightly as it may be more
efficient for the private sector to take on these roles than for a social mar
keting organization to set up duplicate systems.
•
Levels of cost-recovery. These will affect net project costs.
•
Whether or not the main implementing organiation only markets con
doms. If other commodities (such as other types of contraceptives) are marketer.
UNAIDS
HIV prevention strategies
i
as well, overheads can be shared over the social marketing of a number of com
modities.
i
•
Variables that affect the promotion and advertising component of the
strategy. These include what forms of media are actually available to mar
ket condoms (similar to discussion in the mass media strategy about which
variables affect the costs).
TREATMENT OF SEXUALLY
TRANSMITTED DISEASES
>
1. Introduction
Sexually Transmitted Diseases (in the context of this strategy paper, curable
STD—in other words, not including HIV) are a major health problem in develop
ing countries. Over and Riot (1993) estimate that they are one of the ten main
health problems responsible for loss of healthy life years <19). As a significant
cause of morbidity, there would appear to be a strong case for the provision of
STD treatment, and this case is strengthened further when the interaction
between STD and HIV is considered (66>. Unprotected sexual intercourse is a risk
factor for both and there are a number of facets to the interaction between the
two. HIV infection, through its effect on the immune system, can increase sus
ceptibility to STD and also inhibit the effectiveness of any STD treatment. In turn,
STD can facilitate transmission of HIV, particularly in infections where there is
genital ulceration. This latter relationship indicates the value of treating STD as a
means of reducing the risk of HIV transmission, as well as of curing the STD
themselves and preventing their further transmission.
• n
n
This discussion focuses primarily on management of STD. This includes the treat
ment of the disease as well as health education and promotion activities such as
counselling, education and condom distribution. Preventive strategies for both
STD and HIV will be similar since risk factors and target populations are alike.
Some of the issues concerning prevention of STD and AIDS in a target group are
addressed in the discussion about commercial sex worker peer education.
One of the first steps in implementing the strategy should be to develop and dis
seminate standard STD diagnostic and treatment protocols. Dissemination
through seminars, workshops and training sessions should be followed by regu
lar supervision of clinicians treating STD. Additionally, training in areas such as
drug supply logistics, counselling and partner notification might enhance nonclinical skills.
I
t-
Treatment of patients is likely to entail diagnosis by clinical examination and,
where available, by laboratory microscopy, blood tests and culture techniques.
Diagnosis is difficult for most STD syndromes and particularly so in women.
21
UNAIDS
L;:
r•
•
The appropriateness of prescribing practices.
•
The activities provided. Which activities (e.g. development and distribution
of standard protocols, partner notification) are actually undertaken in a par-
ticular project and to what extent.
•
The costs of salaries. These may comprise a relatively high proportion of
total costs since the strategy is labour-intensive, involving one-to-one consul
tation. The relative costs of personnel should be borne in mind in making any
international comparisons.
COMMERCIAL SEX WORKER PEER EDUCATION
1. Introduction
Peer education projects are generally labour-intensive strategies. If the target
population is relatively accessible and/or a high-risk one, then potential benefits
can be higher and the intervention is likely to be more cost-effective.
Commercial sex workers (CSWs) are a high-risk group for HIV infection because
of their number of sexual partners and because they often have other STD that
enhance HIV transmission. They therefore tend to be a high-frequency HIV trans
mitter core group for the rest of the population.
Identifying and reaching CSWs in a given population may initially be quite time
consuming. Experience has shown that CSWs peer educators can be used effec
tively to locate other CSWs and to conduct peer education. It is assumed that
working CSWs are more receptive to learning and adopting behaviour change
when approached by peers. The main objectives of a peer education project are
to encourage CSWs to use condoms with all partners and to seek STD treatment
promptly. The CSW peer educator projects may also target CSW clients for eduI
cational activities.
The projects are almost always managed and implemented by nongovernmental .
organizations (NGOs). Initial strategy activities include development and produc
tion of targeted IEC materials and recruitment and training of CSW peer educa
tors. The majority of CSWs are women and projects often engage women who
are current or former CSWs to reach them. Once the project is under way, typi !
cal outreach activities include education, skills training (for negotiating with sex- |
ual partners and using condoms) and condom sales/distribution. Peer educators
can be an effective link between CSWs and STD services, encouraging CSWs and E
clients to seek screening and treatment. STD treatment is not included in this dis- |
cussion, as it was dealt with earlier.
The activities of a CSW peer education project overlap, or are complementary to, |
a number of the other strategies addressed in this document, including condom
UNAIDS
J 5 HIV prevention strategies
I
2. Description of potential projects
i
Some variation is found in the nature of projects. Facilities within which projects
are implemented can include bars, social centres, residences, STD clinics, broth
els and truck stops. Educational sessions may be conducted on a one-to-one
basis or organized as group sessions. Peer educators may engage in formal activ
ities (e.g. educational sessions arranged beforehand) as well as informal activi
ties (such as mentioning HIV/STD transmission when negotiating the price with
the client). IEC materials may or may not be used. Where used, they may range
from simple pamphlets, comics and posters, to promotional materials such as Tshirts and bags, and specially produced videos and films. Condoms may be dis
tributed freely or sold as part of cost recovery or a commercial enterprise. Peer
CSWs implementing the project may be volunteers or salaried staff. The success
of these projects relies on the ability of peer educators to mix freely in the com
munity. Using volunteers can significantly decrease the financial cost of imple
menting the project. This cost saving does, however, need to be weighed against
high drop-out rates seen amongst volunteers who may not always be able to
give priority to project work.
3. Variables which affect costs
Some of the variables affecting costs are highlighted below:
25
I
social marketing, mass media education and treatment of STD. The success of
the peer education strategy may be partially dependent upon these other strate
gies and, in turn, CSW peer educators can play a valuable role in increasing
STD/HIV awareness and increasing condom use. Some of the non-AIDS benefits
of this strategy, such as decreased STD prevalence and incidence, and possibly a
decreased number of unwanted pregnancies through condom use, should be
described when the costing results are presented.
•
The amount of time and type of work invested in development of
appropriate IEC materials. For example, external consultancy resources
may or may not be drawn upon during this phase. IEC materials may also be
periodically revised.
•
The amount of time invested in staff and peer educator training.
•
The geographical and social accessibility of target groups.
•
The total number of CSWs targeted. Large numbers may mean greater
expenditure on some of the IEC materials and on condoms but may con
tribute to lower average costs.
•
The intensity of contact between peer educators and CSWs For exam
ple, whether educational sessions are conducted with individuals or groups.
UNAIDS
salaried or voluntary staff.
•
Whether peer educators are
.
Types of educational materials used in the sessions (e.g. flashcards,
leaflets).
■
These may be bought on the international |
•
The source of project condoms
donated'to the project at inflated or subsidized prices.
|
market or (---------. or whether they are provided free. I
• Whether a charge is made for condoms
•
The existence of complementary
creche/childcare facilities.
activities such as income support or
VOLUNTARY COUNSELLING AND TESTING
1. Introduction
due to the increasing
HIV
EiSSSSSSSEl
n'^S^^Si'^omenX XX^'^fied ^art^
xs
and highlights the importance of fear and stigmatization as a barrier to use ot
these services.
A service providing VCT involves pre-test counselling, post-test counselhng jand
the test itself Necessary support activities include training of staff and deve p
m Xd d X n of ^materials. Counselling should be part o^any serv
ice mat involves testing for HIV. The objectives of VCT are numerous ™.
.
to strengthen motivation to change sexual and drug behaviours, in order that
seronegative people can protect themselves from infection, and to preven,
.
to encourage thoL^l'ikely'to be at high risk to come forward for testing;
.
to allow early identification of medical and social needs of HlV-mfecte peo
pie, and ensure that common infections are properly treated,
UNAID!
—..........
.14 . . .
HIV prevention strategies
•
•
•
I
to allow women to make informed decisions about reproductive health issues;
to enable people to cope with stress about HIV-related problems and relieve
anxiety associated with uncertainty about HIV serostatus;
to provide a service, including counselling, to those who seek knowledge of
their serostatus so that they can protect themselves and others from infection
and plan for the future.
The main activities of VCT include:
A pre-test counselling session, between a trained counsellor and a client, cou
ple or group;
ii. Laboratory tests, for those clients who decide to go ahead with the test;
iii. A post-test counselling session for those who have been tested.
i.
•r
There is controversy over the effectiveness of VCT at both the individual and popu
lation levels: evidence has been reviewed by De Zoysa et al. (1995) W). A review of
50 studies showed mixed results for the impact of counselling and testing on risky
behaviour <85>. A study in Rwanda showed increases in reported condom use <82).
Large increases in condom use and abstinence followed repeated and intensive
counselling among couples found to be discordant (i.e. only one partner infected) in
a research project in Zaire ,86L The AIDS Information Centre in Uganda, which offered
anonymous HIV testing and counselling, also showed substantial increases in con
dom use <88>. A study in the United Republic of Tanzania found that a significantly
higher proportion of woman than men did not want their spouse to know their HIV
status <97). Although several studies suggest that VCT may be effective, at least in the
short term, in modifying sexual behaviour amongst heterosexuals and especially
when couples are counselled together, the relationship between VCT and a reduc
tion in HIV transmission is complex. One strategy that may increase the effectiveness
of VCT is the use of rapid testing techniques rather than the widely-used ELISA <9496). This means that people can obtain results on the same day or relatively quickly.
•g
ar
ar
ig
of
?'s
ily
a
an
)8)t
There has been some concern that VCT, because of its emphasis on personal
counselling, is a very expensive strategy. It has been suggested that those who
come forward for VCT may be a special group, who could perhaps be reached by
other, less costly means (84\
as'
ies
of
Other non-HIV benefits of VCT that should be reported in the analysis include
diagnosis of STD and prevention of STD infection that may occur because of
changed sexual behaviour. There are concerns about adverse effects including
psychological distress, stigmatization, disruption in couple and family relation
ships, violence and divorce, which mean that people are reluctant to both
undergo tests and return for the results. Failures to maintain confidentiality may
lead to social or work discrimination.
nd
)p*rv-
hat
ent
eo- i
IDS
27
K
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b
I
Ir
r
h
At present, there is very little information available on the relative costs and effec
tiveness of the different models of VCT. Information on total costs will help organ
izations choose between different models (98,99)
fe
UNAIDS
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*
2. Description of potential projects
VCT is often provided by NGOs as well as by government health services, and
hence the nature of the services provided may be quite diverse. The service may I
be provided as a free-standing project, or may be integrated into other services
(e.g. antenatal clinics, STD clinics, drug treatment centres, HIV support groups,
blood transfusion services). The clinic may deliberately offer an anonymous service to reduce the risks of discrimination, or its activities may be tied in closely to
the provision of other health services. The targeted population may be the gen- |||
eral piiStoi « specify high-risk groups. VCT is now also being undertaken
■
in the private sector.
■
3. Variables which affect costs
These include:
The geographical and social accessibility of the population. This wi.
.
■i
influence the workload of the service.
■■.
•
HIV prevalence. As prevalence rises, the costs of testing will increase,
although economies of scale may be observed as well.
•
Whether or not particular groups are deliberately encouraged to
come for testing. For example, educational messages could be specifically
aimed at encouraging certain groups to attend, and this would increase the
costs of the service (though it may also increase its effectiveness).
•
The level of training of counsellors. Fully-trained counsellors may be used,
or most of the counselling may be done by health workers with some addi
tional training and fully-trained staff used only for supervision and training.
Lay counsellors (non-health professionals) from the community may also be
employed in VCT services.
•
The degree of emphasis placed on careful and intensive counselling
VCT services are labour-intensive. For example, in a study in the United
Kingdom of HIV testing in antenatal clinics, over 80% of the costs were asso
ciated with the time required to ensure that informed consent was given <83>.
•
The number attending relative to the capacity of the service.
•
The type of test and number of tests Various alternatives exist for the test
itself, and the cost of HIV antibody testing can be reduced in a number of :
ways (88), which is also discussed in the blood safety section.
•
The relative importance of the use of volunteers to support some of the-,
activities of the centre. NGO-run centres, in particular, may make use of vol
unteers to help run the service.
UNAIDS.
J
V?ihya a
C HIV prevention strategies
and
nay
ices
jps,
ervy to
jenken
■
WSTRK
•
The relative sophistication of the educational materials used, and their
costs of development and production.
•
Whether or not free supplies (e g condoms) are distributed, and the
source of condoms.
»■*
'•a
PREVENTION MEASURES AMONG
INJECTING DRUG USERS
1. Introduction
Injecting drug users (IDUs) are often at high risk of HIV infection due to the risk
of HIV transmission associated with sharing injecting equipment with others.
The rapid spread of HIV among IDUs has now been documented in an increas
ing number of countries including countries in Eastern Europe, Latin America
and Asia. The incidence of HIV has increased among IDUs and their sexual
partners. Vulnerable groups to IDU use include the urban poor, street children,
prisoners, sex workers, itinerant and guest workers and communities in drug
producing areas (105L The major risk factor for transmission of HIV among IDUs
is multiperson reuse or sharing of syringes. In addition, indirect sharing of
equipment such as water, cotton, cookers and other drug preparation equip
ment has also been attributed to assisting the transmission of HIV <106). Thus
one key aim of IDU interventions is to prevent multiperson reuse of syringes
and allow IDUs access to sterile syringes (107>. IDUs are also at high risk from
transmission of other bloodborne infections such as hepatitis B and C.
will
ase,
to
cally
the
sed,
ddiiing.
a be
ing.
lited
iSSOi <83).
■
■
'
The most effective way to prevent HIV transmission among IDUs is the elimi
nation of drug use. However, in reality, programmes work towards minimiz
ing or reducing harm. Thus there is a hierarchy of activities and educational
messages used: (1) stop using and injecting drugs; (2) if continuing to use
drugs, do not share equipment, but use own supplies; (3) if sharing, then dis
infect to reduce transmission (108>. The general objectives of HIV prevention
activities are to increase protective behaviour and reduce risk of HIV infection.
This includes changing drug use, needle practices and sexual behaviours
simultaneously. The HIV prevention strategies for IDUs are highly targeted.
.
.
A comprehensive strategy for HIV prevention among IDUs may include:
* test
?r of
•
•
•
f the
vol-
AIDS
•
FT1
primary prevention of drug abuse;
provision of information, education, counselling to reduce needle/syringe
sharing;
use of bleach to clean/disinfect syringes/needles and drug preparation
equipment;
changing laws to permit legal purchase of needle/syringe, outreach pro
grammes for IDUs, syringe/needle exchange activities;
i
F
i
i
i
UNAIDS
■
j i iiHi fc.-s
•
referral for treatment of medical problems such as STD, peer education
•
programmes;
access to substance abuse treatment noe.iog).
I
■
■
Educational messages are used to promote the one-time use of sterile
syringes/needles and their safe disposal. IDU programmes are relatively labourintensive, engaging a variety of staff and volunteers.
There are multiple interventions and multiple outcomes. In presenting the
costs of the IDU prevention strategy, the direct and indirect benefits of the
strategy should also be reported.
At present, there is very little information available on the costs of the differ
ent models of HIV prevention for IDUs in a developing or transitional country
context. Based on the limited evidence, projects promoting access to sterile
syringes are relatively cost-effective, especially when compared to the lifetime
cost of HIV treatment in the context of the United States <11OE
2. Description of potential projects
The nature of IDU projects is variable and one of the first tasks of a costing
exercise will be to describe the particular one to be costed. HIV prevention
activities can occur in conjunction with other health services or may be run
independently. They often operate on a relatively small-scale basis at the com
munity or city level. In general, IDU activities are likely to be implemented as a
discrete or stand-alone programme, separate from other HIV prevention strate
gies aimed at the general population, although there may be complementary
strategies such as condom social marketing or distribution and STD treatment.
Needle et al (1998) provides a summary of the major intervention strategies,
which have been put in place (108>.
Type 1 projects are community-based outreach projects and are designed to
reach the IDUs' sexual partners and drug-using networks. Using community
and IDU peer workers, these programmes include activities such as educational
messages for risk reduction, bleach distribution, HIV counselling and testing,
treatment referrals, condom distribution, as well as trying to change norms
related to unsafe drug use and risky sexual behaviours.
Type 2 projects, needle-exchange programmes (NEPs), provide sterile needles
and syringes to IDUs in exchange for used needles and syringes. Activities
include exchange of potentially contaminated syringes, bleach distribution,
treatment referrals, condom distribution, educational messages for risk educa
tion, HIV testing and counselling as well as screening for other infectious dis- i
eases.
Type 3 projects focus on drug abuse treatment. They aim to eliminate and
reduce drug use through replacement use of illegal drugs with substances such
Fl
UNAIDS
■
ls;.
Fu HIV prevention strategies
ation
as methadone. These programmes can include individual and group coun
selling, HIV testing and counselling and referrals to other health care services,
as well as educational messages to reduce risky drug use and sexual behaviour.
terile
Dour-
Type 4 projects try to influence risky behaviour by changing the norms of drug
use and sexual networks through network-style interventions. This is done
through the use of IDU peers who may be seen as opinion leaders in their net
works.
j the
f the
■
■
These activities may be complemented by media interventions such as televi
sion, radio and newspaper advertisements promoting the main educational
messages as well as the intervention.
liffer- :
Community-based outreach programmes are often used in settings where
NEPs are not viable legally. There have also been efforts to involve pharmacists
in the sale, distribution, or exchange of syringes in Europe, North America and
Asia. Pharmacy-based programmes often provide IDUs with a choice of pre
pared packs. Pharmacy-based activities have lower start-up costs because
there is already an established distribution network. Other advantages to phar
macy-based interventions are that they may be more accessible geographically,
with longer opening hours.
untfy
.terilew
?time ?
osting .
mtion
e run
comd as a I
.trate- I
?ntary
ment. j
egies, j
Using volunteers can significantly decrease the financial cost of implementing
the project. This cost saving does, however, need to be weighed against high
drop-out rates seen amongst volunteers who may not always be able to give
priority to project work.
■■
Initial strategy activities include development and production of targeted IEC
materials and recruitment and training of IDU volunteers/peers. Once the proj
ect is under way, typical outreach activities include distribution of educational
materials, peer (‘duration, and the distribution and exchange of supplies.
I
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led to
nunity 1
ational
esting, |
norms ; F®
3. Factors which affect costs
Key intervention-related factors, which will influence the level of costs, are:
leedles ;
ztivities j
Dution,
educa>us dis-
•
Nature of activities and integration with other services.
•
Materials development. The amount of time and type of work invested in
development of the IEC materials will influence costs. For example, external
consultancy resources may be drawn upon during this phase. These costs
may be reduced if the materials used have already been produced elsewhere.
•
The amount of time invested in staff and peer educator training.
•
The geographical and social accessibility of target groups.
ISF'
de and
es such
31
JNAIDS
.•
»-'
UNAIDS
/
•
The total number of IDUs targeted. Large numbers may mean greater
expenditure on some of the IEC materials and on supplies but may contribute
to lower average costs. Scale effects have not been observed in IDU pro
grammes, given that most interventions operate on a relatively small scale.
•
The intensity of contact between peer educators and IDUs. For exam
ple, whether educational sessions are conducted with individuals or groups.
•
Whether peer educators are salaried or voluntary staff.
•
Type, intensity and quality of media used. There are clearly different •
costs associated with broadcast media‘and, for example, print media relative
to radio and television. The length of a programme or publication, the fre
quency with which it is transmitted, and the duration of the campaign will ‘
also influence costs, as will the use of peak or off-peak airtime for broad
casting.
•
Rate of charging for airtime or press space. Media coverage may be paid
for at commercial rates, or sponsored by the private sector, or subsidized by I
the government.
•
Personnel costs. The strategy is labour-intensive and the relative costs of |
staff should be borne in mind in making any international comparisons or I
extrapolating cost data to other countries.
•
Provision of project condoms. These may be bought on the international
market or donated to the project at inflated or subsidized prices.
•
Whether drugs are provided by the project. Alternatively, they may be j
prescribed only, the costs falling on patients.
•
The existence of complementary activities: such as legal and welfare I
counselling.
PREVENTION OF MOTHER-TO-CHILD/VERTICAL
TRANSMISSION
1. Introduction
The risk of vertical transmission from an infected mother to her baby ranges from
21% to 43% in developing countries, depending on breastfeeding patterns d22)J
The virus may be transmitted during pregnancy (in utero), childbirth (intra-par-|
turn), or through breastfeeding (post-partum). The primary strategy for prevent
ing vertical transmission is avoiding HIV infection in girls and women. However,there are several interventions known to be effective during pregnancy, childbirth UNAIDS
!
i greater
mtribute
IDU pro
ll scale.
and post-natally to lower the probability of transmission from an HIV-positive
mother to her baby. The key interventions for prevention of mother-to-child
transmission (MTCT), which are currently relevant for low- and middle-income
countries, include:
□r examgroups.
1) Antiretroviral (ARV) therapies
Transmission to the baby can be reduced by two-thirds with the administration
of long-course antiretroviral therapy with zidovudine (ZDV) (123>. However, the
administration of this regimen is complex and expensive. Several clinical trials
have examined shorter and cheaper ARV regimens. The success of the Thai
short-course trial in reducing MTCT by 50% among a non-breastfeeding popu
lation led to a greater emphasis on non-breastfeeding strategies in developing
countries '12-1.125) Studies among breastfeeding populations find a 38%-44%
reduction in MTCT using a short-course ZDV regimen (126,138). |n 1999, a
Ugandan clinical trial found that a single dose of nevirapine (NVP) taken during
labour and by the infant after birth was almost 50% more effective than the
short-course ZDV regimen (127\
different
a relative
, the fre
sign VA/'II
)r brc^u-
y be paid
idized by
costs of
orisons or
^national
y may be
d welfare
■
2) Provision and advice on infant feeding
Given the success of ARV therapy in these clinical trials, there is increasing focus
on infant feeding and MTCT in developing countries. It is estimated that breast
feeding doubles the transmission of HIV ci28\ Factors that increase the risk of
transmission include longer duration of breastfeeding and the stage of infectivity.
Evidence from one trial suggests that exclusively breastfed infants were less likely
to become infected than non-breastfed or mixed-fed infants <129). It is unclear how
the duration of breastfeeding and early weaning affect these results (130\ MTCT
through breastfeeding has become a very significant source of debate, given the
intensive efforts on the part of both national and international communities to
promote breastfeeding over the past 20 years. There are significant concerns
about the use of formula feeding leading to increased morbidity/mortality of
infants, and other feeding options such as early weaning, surrogate breast-feed
ing and pasteurization of breast milk are being discussed. There is concern about
the difficult logistics of pasteurization, and there have been cases where surrogate
mothers have acquired the HIV infection from infected infants
VCT has also received increased prominence due to the high profile of MTCT
prevention.
nges from
terns 022>.
(intra-par<r preventHowever,
childbirth
UNAIDS
Given the efficacy of the ARV interventions, there have been several studies look
ing at the cost-effectiveness of MTCT prevention interventions (133-136). However,
there is limited information on the cost of implementing such activities, particu
larly outside a trial context. In general, the cost of the intervention has been
inferred by mixing data from a number of sources and countries (133,134,136). while
this approach can guide priority-setting in a global context, it is harder to infer
costs and resource requirements. The focus of analysis has been mainly on the
cost of ARV drugs, and there have been only a few attempts to model the infra
structure requirements for such an intervention (137). It is important to consider
UNAIDS ’
what additional infrastructure and staff are needed and also where they might
come from. There is very limited cost information on the provision and distribu
tion of formula feeding for the infants of HIV-positive women and the costs of
using replacement methods for HIV-positive women and their families.
2. Description of potential projects
The implementation of MTCT prevention interventions is still in early phases.in
many countries. Testing and offering of antiretrovirals generally occur within the
existing health and antenatal care infrastructure. The actual timing of the HIV
testing and counselling will depend on the type of regimen that is being under
taken and the stage of pregnancy at which a woman first attends antenatal serv
ices. There are significant problems associated with women consenting to and
then returning for HIV test results, before undertaking antiretroviral therapy (as
discussed in the VCT strategy). Different models of VCT and feeding advice are
currently being piloted.
3. Variables which affect costs
Key issues affecting costs that have been highlighted are.
.
Antiretroviral regimen. The choice and price of drugs for a particular regi
men will significantly affect the costs of the intervention.
•
HIV prevalence. As prevalence rises, the costs of testing and delivery of the
regimen will increase. However, economies of scale may also be observed.
•
Extent of additional capacity which is required to administer the reg
imen. Existing facilities and services may need to be strengthened (e.g. lab-
I
oratory capacity, additional staff to attend deliveries).
•
Feeding strategies. Provision of replacement feeding methods, such as for-1
mula-milk, will significantly increase costs.
•
,
The geographical and social accessibility of the population. This will
influence the workload of the service.
•
The number attending relative to the capacity of the service.
.
The type of test and number of tests. Various alternatives exist for the test I
itself,
the cost
of HIV
antibody testing
itself, and
and the
cost of
HIV antibody
testing can be reduced in a number of:
ways.
|
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■
HIV prevention strategies
1.2 New and emerging HIV prevention
strategies
!
In addition to those established strategies currently being implemented, there
are also new and emerging HIV prevention strategies. These strategies are in dif
ferent stages of development and clinical trials, and the feasibility of their use in
a low- and middle-income country context is still unclear.
This section provides a brief description of:
•
•
microbicides and female-controlled methods;
use of vaccines.
Microbicides and
female-controlled methods
There has been wide interest in female-controlled methods for prevention of HIV
There are several producers of female condoms, and these are actively being mar
keted through social marketing programmes in several countries. There is also
controversy about the role of existing spermicides in preventing STD/HIV (141\
The development of chemical barrier methods such as vaginal microbicides to
prevent HIV infections is on-going. Both product development, including clinical
evaluation, and product acceptability studies are under way. It is not anticipated
that microbicides will be available for some years.
S'
To date, there has been little discussion of programmatic issues such as introduc
tion, distribution and post-marketing surveillance, as well as analysis of the costs
and cost-effectiveness of microbicides. However, it is envisaged that microbicides
would be sold through current contraceptive marketing programmes (139,140).
■
Vaccines
Currently, vaccines for HIV are in the clinical trial stage in the United States and
Thailand. There is still the issue of whether these clades of the vaccine will be appro
priate in other settings, e.g. sub-Saharan Africa. Some preliminary modelling on the
cost-effectiveness of vaccines has highlighted a range of factors that will affect costs:
•
•
•
35
Iw
production costs including fixed costs
implementation costs including
- training and health education
- establishing stores/cold chains
programme costs (vaccine, staff, transportation, fixed costs)
- costs of adverse reactions
UNAIDS
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||
Further the cost-effectiveness of these vaccines will be affected by P°Pul^ K '•
access'(high-risk groups versus general population), the timing of expecte
effect on HIV incidence, requirements for booster doses and infectious rate |
among the target groups <88’.
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Concepts of cost analysis
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Chapter 2
CONCEPTS OF COST ANALYSIS
This chapter reviews the fundamental concepts underlying cost analyses. It high
lights that there are several choices about the type of cost analysis that will be
undertaken.
2.1 What are costs?
■
Economists define a cost as the value of resources used to produce a good or
service. However, the way these resources are measured can differ. There are two
main alternatives with respect to measurement of these resources: financial and
economic costing.
Financial costs represent actual expenditure on goods and services purchased.
Costs are thus described in terms of how much money has been paid for the
resources used in the project or service. In order to ascertain the financial costs
of a project, we need to know the price and quantity of all the resources used
or, alternatively, the level of expenditure on these goods and services.
Economists conceptualize costs in a broader way. They define costs in terms of
the alternative uses that have been forgone by using a resource in a particular
way. These economic or opportunity costs recognize the cost of using
resources, as these resources are then unavailable for productive use elsewhere.
"The basic idea is that things have a value that might not be fully captured in
their price. It is not difficult in many health programmes to identify resource
inputs for which little or no money is paid: volunteers working without payment;
health messages broadcast without charge; vaccines or other supplies donated
or provided at a large discount by organizations or individuals" (PHC: 57). Thus
the value of these resources to society, regardless of who pays for them, is meas
ured by opportunity cost.
3
37
UNAIDS
* nm *.•
I’,1’l
SSSSSESSS
and economic costs differ is in the way they treat:
.
.
donated goods and services;
other inputs whose prices are incorrect or distorted,
•
valuation of capital items.
i.
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The calculation of economic costs will be discussed in chapter 4.
The choice of whether to use financial, economic or both approaches^epends on
■$i V
ssgesgss- I
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donated good, is zero.
ill.
with additional information useful lor decision-making (PHC.
).
?
2.2 Whose costs? Society, provider,
household and private costs
A societal perspective would encompass strategy-related costs incurred by all1
members of society, including the private sector, the public sector and private cr
f
sumers (e g households and individuals). A provider perspective would exclude
costs incurred by private consumers or households. A public sector PersPec^ I
wou d exc ude costs incurred by the private sector and by private consumers and
□ate only those costs incurred by the public sector in implementing the strategy
These costs can be considered as the costs of providing particular programmes
and are borne by the organization delivering the services (although this does. no
mean thaMhe organization finances the entire cost of the services). In addition,
individuals and households may also incur costs when using these services.
As well as providing funds directly through the payment of user fees, private individ
uals mav also contribute to financing service delivery through the provision of goods.
For example some blood transfusion patients may have to purchase their bags and |
needE pr'vaW before com.ng to the service, and many STD treatment patients wHI |
have to purchase their drugs privately from pharmacies after their consultat
.
UNAIDS
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Concepts of cost analysis
;
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As in the PHC Manual, these guidelines calculate the cost of projects from the
perspective of service providers and not from the perspective of the society and
its individuals. The only part of the household cost that will be considered is the
amount of fees or payments made which contribute towards financing services
and will be known as private costs. The information on fees collected from
clients of HIV prevention services can contribute to the debate on cost recovery.
For example, analysis from specific projects can suggest the percentage of proj
ect running costs that can potentially be covered from fees—an issue that is very
pertinent to sustainability of projects and one that is often focused on by donors.
II
i-
Including full household costs would mean including a wider range of private
costs, such as travel and time costs. Module 8 of the PHC Manual should be
referred to for further information on measuring the costs that private individu
als incur in accessing services.
*
2.3 Full and incremental costs
A full cost analysis estimates the costs of all resources that are being employed
in running a project or programme, including basic infrastructure. An incremen
tal analysis looks at the cost of adding or implementing the additional project or
programme to existing services. It does not attempt to provide cost estimates for
existing services.
An incremental analysis accounts for the major 'new' inputs that are required by
the new intervention. However, since it assumes that the organizational infra
structure already exists, an incremental costing will underestimate costs that are
of a general administrative nature borne by the organization (particularly com
munications and office supplies). Similarly, it does not account for items such as
the overhead costs of running the organization as is done in a full costing analy
sis. It is also more difficult to generalize from incremental cost analyses, unless
the prior level of existing services and infrastructure is clearly specified. The incre
mental approach is particularly appropriate to use when the intervention or proj
ect is not the major component of the organization's overall cost structure
1
Rt?-
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■
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The availability and ease of data collection as well as organizational structures
may heavily influence whether a full or incremental costing is undertaken. This
is further discussed in chapter 3.
-
i!T i
2.4 Total, average and marginal costs
The total cost represents the cost of producing a quantity of services or output
for a particular project or programme. This can be the result of a full or incre
mental cost analysis.
39
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UNAIDS
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et
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The average cost is then the total cost per unit of output, and is calculated
dividing total cost by the units of output or services produced.
aS
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— .2 ;
The marginal cost is the additional cost of producing one more unit of outf:
This should not be confused with incremental costs that look at the additic
cost of adding on an entire service or project, whereas marginal costs are c
cerned with cost differences within a service or project <2).
Again the purpose of the cost analysis will determine whether to focus on a'
age or marginal costs. If you want to look at differences in costs between
ferent providers or clinics, you should compare average costs. If you want to I
at the impact of expanding services (e.g. expanding hours or number of st<
then you need to consider marginal costs <5).
2.5 Joint costs
The resources that you are costing may not be fully used in the specific project or
gramme that is being examined (e.g. a person may be working on a number of [
ects, some not dealing with HIV prevention). They may be used jointly with other
going projects. In this case, a decision needs to be made about what proportio
the resources should be allocated to the specific project or programme that is b
costed, and the way it should be allocated. The way you allocate the resources
vary according to the type of resource, and this will be discussed in chapter 4.
2.6 Classification of costs
i
"To estimate a health programme's costs, it is necessary to classify its cor
nents. Cost elements can be broken down in several ways, as illustrated be
A good classification scheme depends on the needs of the particular situa
but there are three essential elements:
•
•
•
it must be relevant to the particular situation
the classes (categories) must not overlap
the classes chosen must cover all possibilities
"Resources used for programmes can be described in many different ways
example, an HIV prevention programme might be described as using the
lowing resources: personnel, money from external sources and mass m
These categories are well defined and their meaning is clear. However, the
not constitute a very useful way of thinking about the resources used in this
•
4
gramme. The main problem is that the categories overlap; money from ext
• sources can be used to pay for personnel, and personnel are likely to be inv
in mass media operations. If we add up the value of these three categories,
may well come to more than the total cost of the programme.
UNi
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■
The average cost is then the total cost per unit of output, and is calculated by
dividing total cost by the units of output or services produced.
The marginal cost is the additional cost of producing one more unit of output.
This should not be confused with incremental costs that look at the additional
cost of adding on an entire service or project, whereas marginal costs are con
cerned with cost differences within a service or project(2>.
Again the purpose of the cost analysis will determine whether to focus on aver
age or marginal costs. If you want to look at differences in costs between dif
ferent providers or clinics, you should compare average costs. If you want to look
at the impact of expanding services (e.g. expanding hours or number of staff),
then you need to consider marginal costs (5\
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2.5 Joint costs
The resources that you are costing may not be fully used in the specific project or pro- gramme that is being examined (e.g. a person may be working on a number of proj
ects, some not dealing with HIV prevention). They may be used jointly with other on
going projects. In this case, a decision needs to be made about what proportion of
the resources should be allocated to the specific project or programme that is being
costed, and the way it should be allocated. The way you allocate the resources may |
vary according to the type of resource, and this will be discussed in chapter 4.
"To estimate a health programme's costs, it is necessary to classify its compo
nents. Cost elements can be broken down in several ways, as illustrated below.
A good classification scheme depends on the needs of the particular situation, ■
but there are three essential elements:
•
•
•
it must be relevant to the particular situation
the classes (categories) must not overlap
the classes chosen must cover all possibilities
"Resources used for programmes can be described in many different ways. For
example, an HIV prevention programme might be described as using the fol
lowing resources: personnel, money from external sources and mass media.
These categories are well defined and their meaning is clear. However, they do
not constitute a very useful way of thinking about the resources used in this pro
gramme. The main problem is that the categories overlap; money from external
sources can be used to pay for personnel, and personnel are likely to be involved
in mass media operations. If we add up the value of these three categories, they
may well come to more than the total cost of the programme.
CO
UNAIDS
■
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2.6 Classification of costs
■.
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Concepts of cost analysis
:
1-
"One reason why the categories above are difficult to use is that they confuse
different dimensions of resources, mixing activities (in this case 'mass media')
with sources ('money from external sources') and physical inputs ('personnel').
Obviously, several different classification schemes are involved here" (PHC: 5).
The main type of cost-classification is by inputs. "Inputs are considered as either
recurrent items (those that are used up in the course of a year and are usually pur
chased regularly) and capital items (those that last longer than a year). A scheme
for classifying costs by inputs (with examples of each category) is shown in Box 1.
Box 1. Classification of costs by inputs
S
Capital costs
• Vehicles: bicycles, motorcycles, four-wheel-drive vehicles, trucks
• Equipment: refrigerators, sterilizers, manufacturing machinery, scales, other
equipment with a unit cost (price) of $100 or more
• Buildings, space: health centres, hospitals, training schools, administrative
offices, storage facilities
• Training, non-recurrent: training activities for personnel that occur once or rarely
• Social mobilization, non-recurrent: social mobilization activities, e.g. pro
motion, publicity campaigns, that occur only once or rarely
• Start-up activities: activities which are likely to last the lifetime of the proj
ect, such as production of materials, recruitment of staff
■
■
I
Recurrent costs
• Personnel (all types): supervisors, administrators, consultants, casual labour
and volunteers
• Supplies: drugs, vaccines, syringes, educational materials, condoms, small
equipment (unit cost less than $100)
• Vehicles, operation and maintenance: petrol, diesel, lubricants, tyres, spare
parts, registration, insurance
• Buildings, operation and maintenance: electricity, water, heating, fuel, tele
phone, telex, insurance, cleaning, painting, repairs to electrical supply/appliances, plumbing, roofing and heating
• Training, recurrent (e.g. short in-service courses)
• Social mobilization: operating costs
• Other operating costs not included above
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“Other possible ways of classifying components are by:
•
•
•
•
41
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function/activity
organizational level (e.g. national, district, community)
source of funds (e.g. national and local governments, donors, nongovern
mental organizations)
type of currency" (PHC: 5-8)
UNAIDS
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Unit costs and measurement
of outcomes
0
"Unit costs are another term for average costs. They can be calculated for both
financial and economic cost analysis. For a specific project or programme, sev
eral types of unit costs can be calculated, depending on the type of outcome
that is specified" (PHC: 53). In general, we can classify three types of outcomes:
■y(
F -p-
Primary outcome, which measures the final effect or impact on health status
•
due to the intervention of the project;
•
Intermediate outcome, which reflects intermediate changes due to the inter
vention of the project, required before there is a health impact;
•
Immediate or process measure, which measures the activities or outputs of
I
I
I
the intervention.
In terms of HIV prevention strategies, the primary outcome measure is the num- |
ber of HIV infections averted. There are several practical problems in determin
ing the number of HIV infections averted. First, the most direct way to measure f
infections averted is through randomized clinical trials, which are both expensive ,
and rarely implemented for behavioural change interventions. Second, in order
to calculate the full impact of the intervention, we need to consider both infec
tions averted for those people involved in the intervention, as well as secondary
infections averted because the chain of transmission has been broken. This
requires information about the epidemiology, behavioural patterns and trans
mission efficacy in the specific population. Third, if several prevention strategies
are being used together, it is difficult to attribute infections averted to any spe
cific strategy <15).
Three approaches have been used to overcome these problems. First, other pri
mary outcome measures, such as Disability-Adjusted Life Years (DALYs), have
been suggested. Second, intermediate or process-outcome measures have been
used. Table 1 (source: adapted from <15. 'O discusses the strengths and weak
nesses of the different measures that have been used in measuring outcomes of
HIV prevention strategies. Third, model-based evaluation has developed as a
means of estimating HIV infections averted. These models attempt to capture
the dynamic nature of this transmission, as well as epidemiological and behav
ioural patterns. The models are used to provide simulations about the possible
impact of HIV prevention strategies on the total number of HIV infections |
averted (including secondary infections) <23>. The development of the models can
be quite complex.
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Table 1:
The strengths and weaknesses of different outcome measures
t
3
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Outcome measure
Strensths
f Disability-adjusted life
‘ years (DALYs) gainedprimary outcome.
•
Cross-sector, cross-programme
and cross-intervention compar
isons are possible.
•
Ability to assess impact of com
bined clinical management and
prevention strategies.
•
Morbidity and mortality effects
combined in one measure.
•
Ability to measure consequences
of clinical management when
death is certain outcome.
•
Can include indirect conse
quences such as TB or STD cases
treated and/ or
prevented.
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..... ........
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t
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his
nsjies
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^ Infections averted T primary outcome of an
• .HIV prevention strategy—
■ primary outcome.
;^™ters educated or
••counselled; cases detected
Jthrough screening for
•blood transfusions and
Counselling—intermediate
^outcome measure
pri<ave .
een I
?ak‘S of
as a
ture ;
hav- •’7
^Condoms distributed or .
•<sold/numbers receiving
.educational material;
Ipyrnbers tested/screened
^process-outcome
ggneasure.
sible
cions
■> can
1 fe
•
Based on subjective measures of
disability.
•
Possible over-simplification.
•
Derived from and dependent on
the primary outcome of the inter
vention.
•
Debate over their validity.
•
Not widely recognized outside the
health sector.
i
i.
Comparisons across different
prevention strategies are
possible.
•
Unable to evaluate strategies that
include clinical management com
ponent.
•
DALYs can be derived easily with
adequate information on mor
tality and life expectancy.
•
Unable to compare across health
interventions.
•
Unless measured through random
ized controlled trials, may need
sophisticated modelling to assess
impact on general population.
,
L
Weaknesses
•
I f».
■
t ’&
•
May not include indirect consequences of intervention._________
•
Relative ease of measurement
and interpretation.
•
No measure of impact on HIV <<
transmission.
•
May give some indication of
impact, even though final health
status unknown.
•
Does not account for variations in
populations' HIV seroprevalence.
•
•
Reflects operational efficiency of
programme.
Gain achieved may not reflect real
change in impact.
•
Can identify most efficient
method of delivery.
•
Ease of collection, these meas
ures are often part of routine
monitoring of programmes.
•
No measure of impact on HIV
transmission.
•
•
Reflects operational efficiency of
programme.
Does not account for variations in
populations' HIV seroprevalence.
•
•
Can identify most efficient
method of delivery.
Gain achieved may not reflect real
change in impact.
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there can be a number of unit costs
Givpn thp variation in outcome measures, t.
-_
lot ik x^nmp that W.
tee were 1040 eduction sessions in that year reaching 2496 peop e. n addu
changes and
increased use of condoms). Then, for this peer education programme among sex
workers, the following type of unit costs could be derived.
an immediate service or process (output): cost per education session
.
= $30,000/1040
= $ 28.85 per education session
an intermediate effect: cost per person educated
.
E
= $ 30,000/2496
= $ 12.01 per person educated
.
a final effect or impact on health status: cost per HIV infection averted
= $ 30,000/250
= $ 120 per HIV infection averted
It may be possible to calculate unit costs by activity within a project or pro- ;
know that £
gramme if activity-specific outputs are available (for example, if we 1......
60 people trained, then the cost
pelZ^on named ^$8333). In practice, the calculation of the final impact can I
be quite difficult and depends on the nature of the Prevent,on ^rategieS
considered For a strategy such as HIV blood screening, it is possible to calculate
the cases of HIV infection directly prevented. However, to estimate the numbe
of secondary infections requires model-based evaluation or randomized clinical
trials Thus for most studies, process or intermediate unit costs are o ten pre
sented (e g cost per condom distributed, number of people buying condoms).
However Ft is recommended that the calculation of unit cost should try and use
outcome measures that are closer to the health impact end of the spectru
Thus for the condom social marketing project, reporting costs per condom dis
tributed and reported used' will be more useful in terms of extrapolating impact.
2.8 Cost-effectiveness
"Cost-effectiveness analysis is a tool which enables programme managers to
make informed decisions about resource allocation. By measuring and compar ;
ing the costs and consequences of various interventions, their re ative efficiency
can be assessed and future resource requirements estimated
The key feature of cost-effectiveness analysis is that it is used to examine alter-|
natives that all work to meet the same objective. The results of the analysis
described in terms of the cost per unit of effectiveness for each alternative.
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Concepts of cost analysis
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The cost-effectiveness ratio is calculated for each alternative by dividing cost
by the unit of effect (e.g. HIV infection averted). Then a comparison is made
between these ratios. "The alternative with the lowest cost per unit of effec
tiveness is the most cost-effective, and is generally to be preferred on grounds
of economic efficiency" (PHC: 67).
•
"Cost analysis is one of the key building blocks for cost-effectiveness studies.
Unit costs based on intermediate outputs can be thought of as preliminary cost
effectiveness results; more ambitious cost-effectiveness analyses are directed at
health status impacts" (PHC: 54).
1
For this type of analysis, economic costing is used: cost-effectiveness looks at the
economic efficiency of different alternatives. More detailed discussion on under
taking and interpreting cost-effectiveness analysis are available from a number
of sources 0^7,8)
There is a dearth of data on the relative cost-effectiveness of the very varied pre
vention strategies that are being implemented around the world. Costing and
subsequent cost-effectiveness analysis can contribute to greater awareness in
this area and facilitate decision-making about the best use of present and new
resources. For example, if a country receives a loan or grant for AIDS-related pre
vention activities, cost-effectiveness data would help planners to assess which
strategies, and what combination and volume of each, might provide the best
value for money in the context of the objectives desired.
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Chapter 3
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PLANNING THE COSTING
EXERCISE
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The following three chapters will discuss the planning and collection of data, and t.
analysis of costs. To encourage a consistent approach to costing a wide variety
of HIV prevention projects, standard worksheets for field use are provided in
Annex 1. An Excel spreadsheet version of these tables is available on the accom
panying disk. These worksheets can be used directly on paper, or form the basis
for creating spreadsheets on data-management computer software . In the next '.
three chapters, we will discuss in detail how to fill out these forms, with refer
ence to the technical guidance in the PHC manual, and with additional guidance
on how best to complete them.
The forms are devised to allow cost data to be built up in the field, but where
accurate expenditure data are already collated and available,
available,, these can be
entered into the forms directly. There are 5 types of worksheets included in
Annex 1:
1. Background data sheet.
2. Form A—Project Summary sheet—presents costs by input and level.
This is a collation of all Form B summary sheets.
3. Form B—Summary of costs at each level.
This is a collation of all Forms Cl-CIO.
4. Forms Cl-CIO provide the basis for data collection by input category:
C11—cost recovery.
5. Form D—collection of output/outcome information.
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OFPlanning the costing exercise
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These worksheets will be referred to throughout the next three chapters. In addi
tion, there will be 'tips-of-the-trade' described in boxes. These tips are designed
to illustrate different issues in the collection of costs and possible ways to deal
with problems.
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3.1 Defining the question and objectives
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Analysis of the costs of HIV prevention may be undertaken for a number of rea
sons. Before making preparations for a costing study, a manager should be clear
about the questions s/he is seeking to answer, the purpose of the planned work
and the use to which the work will be put. These will help to establish the
boundaries for the costing exercise. For example, it should be clear whether the
exercise is being conducted to examine the costs and efficiency of only on-going
activities, or whether it is being conducted with a view to project replicability. If
these types of issues are clarified at the outset, it will be easier to ascertain
exactly what data are to be collected and there will be less risk of wasting time
in unnecessary activities.
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Objectives for a cost analysis can include:
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Examining the efficiency of a project
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The objectives of the costing exercise may be to analyse on-going costs of an
established project to identify potential cost savings and to improve the effi
ciency of the service. In this case, project start-up costs may be excluded. Within
a project, a manager may want to analyse expenditure by input to understand
which areas of the programme involve high or low spending. In order to exclude
project start-up costs, all activities that are undertaken to initiate the project are
excluded from the analysis.
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Modification/sustainability
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If the initiative to conduct the costing exercise is coming from the project itself,
managers may want information for one, or a combination, of the following
objectives: improving budgeting; monitoring costs; planning improvement of the
current system, and improving the future of the strategy. A manager may, for
example, be particularly concerned about the sustainability of the HIV prevention
programme and be seeking an accurate estimate of the budget necessary to
maintain it. If charging for services is an option, information on costs can help
to establish appropriate prices. Cost analysis may also be used in discussions
about the feasibility of scaling-up/expanding the project. If sustainability is the
main concern, start-up costs are excluded, but if one is considering the expan
sion of a project, then it is necessary to consider whether certain aspects of start
up activities need to take place.
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Replication
If the impetus for the costing exercise is coming from outside the project, objec
tives are more likely to concern replicability of the project and extrapolation of
results to other situations. Local managers will probably give considerable time
to the fieldwork phase and it is important that the resulting data also be of use
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and value to them.
This is particularly the case with CSM. Most formal CSM projects are overseen or
managed by foreign private groups or their subsidiaries. These organizations /
financial management tends to be strong and they will be monitoring costs for
their own purposes. The objective of a costing exercise is, therefore, not likely to
be that of collating information on the on-going costs of the project for management purposes, but rather that of assessing the costs of this strategy relative
to the other main strategies or providing information on costs of replication of ■
fc;I
the project elsewhere.
If the objective is to provide information on the total costs of the strategy with
a view
and start-up
View to
lu ireplication,
cpnvaiivji i, both
u'jui on-going
'_/i ■ vjvvi.
■ - — r costs
----------- -----should be collected.
d
Start-up costs include any development and production of information, education and communication (IEC) materials as well as dissemination of diagnostic
and treatment protocols, IEC, and recruitment of workers.
Cost-effectiveness
Cost-effectiveness studies can assist in priority setting, resource allocation deci- ■
sions and design of services. A manager may want more information on the rel- ■
ative cost-effectiveness of alternative ways of delivering the prevention strategy ■
for which s/he is responsible. As an example, decisions may need to be made .
within a sex worker/peer education project on whether to engage part-time vol- |
unteer workers or full-time salaried staff. Cost analysis may contribute to an
understanding of the differences between such options, weighing the tern
between increased costs and also increased effectiveness, and thereby contributing to the planning of new or expanded projects. Another objective of the ■
costing exercise may be to compare the cost-effectiveness of different HIV pre
vention strategies relative to each other (e.g. compare school education relative
to strategies of CSW peer education).
Since alternative delivery channels may be considered, it is important to include'
start-up costs if the objective is to determine relative cost-effectiveness.
There is great difficulty in ascertaining the effectiveness of mass media cam
paigns and, particularly, in attributing effects to the campaigns rather than toi
any other kind of media or information source. It is thus unlikely that costs will!
be studied to compare the relative cost-effectiveness of a mass media campaign;
with other strategies.
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Planning the costing exercise
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Private/provider perspectives
We assume here that private costs other than fees paid (e.g. for the purchase of
condoms) are excluded from the costing analysis; but they should be referred to
in the presentation of the costing data. However, some CSM projects are exclu
sively in the private sector and will, by definition, have a private provider per
spective. Other projects span the private and public sectors and the perspective
taken will depend upon who is commissioning the costing exercise and its objec
tives. If, for example, a Ministry of Health wants to know the financial implica
tions for its own budget of undertaking a CSM project, the cost analysis may be
based solely on public sector expenditure—i.e the expenditure of the govern
ment and donor-funded portion of the project.
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3.2 Identify the alternatives
to be compared
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Chapter 1 describes different HIV prevention strategies individually. In practice,
however, HIV prevention projects are unlikely to take place in such neatly
defined packages. Indeed, it is recognized that a combination of approaches
can be mutually and positively reinforcing. For example, the success of a school
education programme or a condom distribution programme may depend on
the success of a concurrently running mass media campaign. Similarly, a CSW
peer education project may combine STD treatment, counselling and condom
promotion. As the boundaries between strategies may be unclear, it is impor
tant to be specific about what exactly is being costed, what combination of
strategies is being examined, what alternatives are being compared and, if pro
ceeding to undertake cost-effectiveness analysis, what the appropriate meas
ures of effect/outcome are for the costs being measured.
5’"
S.
For example, it should be explicit at the outset whether the aim is to cost one
particular mass media campaign or to cost a broader mass media strategy that
may include a number of campaigns conducted by one or several organizations.
HIV blood screening is clearly not a stand-alone strategy but, rather, an addi
tional component to whatever form BTS take in a particular country. In practice,
there may be significant overlaps between CSW peer education projects and
other HIV prevention strategies. If VCT is integrated with other services, the cost
ing will need to consider which activities should be excluded. These activities
may include partner notification, assistance to support groups, preventive ther
apy for TB and treatment of STD.
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3.3 Describe each alternative
Once the question to be answered is clear, the purpose of the costing and the
scope of the work have been defined, and it is apparent what alternatives are
being costed, the exercise can proceed to describe each alternative in detail. To
do this, it is useful to be clear about how costs will be classified. To undertake
cost analysis of HIV prevention, a primary classification by input and organiza
tional level is recommended. It is also useful to make a secondary classification
of the strategies by the activities that are taking place within them. This helps
ensure that costs are not duplicated or omitted between inputs and activities. It
also provides a framework by which a strategy can be costed by activity if this is
deemed useful for decision-making.
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Inputs
The most common inputs to be found across all strategies are listed in Table 2
below and on the worksheets. When costing a particular project, it is necessary
to specify in detail the inputs within each category and this can be done on
worksheet forms 'C'.
Table 2:
Classification of costs by main input categories
Capital costs
fes
Buildings
Equipment
Vehicles
Consultancies (non-recurrent)
K
Personnel
Supplies
Vehicle operating and maintenance
Building operating and maintenance
Consultancies (recurrent)
Other (including media fees)
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It is important to remember that all items that have a life of more than a year are
treated as capital items. This means that capital items need to be annualized over
the number of years that the items are expected to last (annualization will be dis
cussed in chapter 4). Thus all IEC material, training and consultancies, whose
impact is expected to last more than a year, need to be treated as capital items.
In order to gauge whether an item lasts for more than one year, it is important
to look at the frequency of the item in the project—e.g. how often refresher
training is provided.
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Planning the costing exercise
Tip-of-the-Trade 7: Activities as inputs
he
are
To
ake
zaion
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s. It
is is
Another cost which may appear as an input category is start-up activities.
Although this is really an activity, adding activities to the input list can be
justified in certain cases. "If one activity is clearly separate from the others,
both financially and administratively, it may be easier not to attempt to
break it down into its component physical inputs, but merely to record the
total cost. For example, start-up, training and social mobilization activities
are treated as categories of inputs and included along with personnel, vehi
cles and the like. When this is done, it is assumed that all the resources
required for the activity (e.g. personnel and vehicles) are included in that
category (e.g. training) and not under the separate categories of person
nel, vehicles, and so forth. Thus, the full cost of all inputs used for training
is estimated and used as the value for that category" (PHC: 9). Start-up,
training and social mobilization activities whose impact is expected to last
more than one year are treated as capital items.
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sary
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In these guidelines, consultancies are also regarded as an input, for reasons
explained later. It is, therefore, important to ensure that none of the con
sultancy costs are double-counted. For example, fees and allowances paid
to individuals working on a consultancy input should not also be costed in
the personnel inputs.
Activities
■
Resource inputs combine to accomplish activities. It is useful to present cost data
by activity. Bringing together measures of cost and output by 'activity' rather
than by the more aggregated 'strategy' can provide an extra tool in project eval
uation. Each IIIV prevention strategy is likely to encompass a range of activities,
some of which will be common across all strategies and some of which will be
unique to particular strategies. Table 3 displays a categorization by activity for
each of our nine sample strategies.
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Table 3:
Classification of strategies by activity
Stotegy
-
1.
HIV bloodI
screening
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Donor recruitment—including everything related to motivating, edu
recruiting, selecting, screening, counselling and retaining blood donors.
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Blood collection—including all costs of collecting blood from accepted donors.
HIV testing—including the first and any subsequent confirmatory tests.
■■
Blood processing—including all costs (except HIV testing) related to the process
ing of blood, including other testing, blood grouping, preparation of blood prod
ucts, and all measures taken to ensure safety of blood prior to storage.
Blood storage/distribution—including all steps taken in storing and transporting
blood through to its final transfusion in hospital.
■<
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Training—training of all personnel, including laboratory, medical, managerial and
support staff.
b;
Management and administration—including planning and supervision of the
strategy.
2.
Mass media
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Development and production of IEC materials--often includes focus group
discussions and market research; testing, revision and re-testing of messages with
sample audiences; and translation of the materials into a range of local languages.
The costs of the production of the IEC materials, once they are designed, should
also be included here.
Transmission/distribution of IEC materials and messages—modes and costs
of transmission will vary according to the type of media being used. Sometimes
these activities will include pre-publicity by advertising firms, for example prior to
launching television or radio dramas.
Management and administration—including costs of the overheads of the
campaign, planning costs and the cost of evaluating the strategy (including base
line surveys and post-campaign evaluations).
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3.
HIV school
education
Development and production of curriculum and educational materials—
includes preliminary work such as focus group discussions and testing, revision and
re-testing of messages with sample audiences, as well as the production of the final
materials. There may also be continuous production of materials for the project, for
example when an AIDS magazine or newsletter is established.
Training—a variety of school staff may be taken away from their routine activities
and given training to implement the new curriculum. Ideally, training should
address teaching methods as well as provide information on AIDS. If the new cur
riculum becomes an on-going activity, staff should be given refresher training as
well as initial training.
Implementation of curriculum—comprises in-school teaching activities of the
staff responsible for teaching the AIDS curriculum.
Management/administration—day-to-day management and administration of
the strategy by the overseeing department (for example the Ministry of Education
or Ministry of Health); also includes the costs of planning and evaluating the
strategy.
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Planning the costing exercise
4.
Condom social
marketing
Development and production of IEC materials—may include market research,
testing, .x-testing and any necessary translation. Although promotional materials
may be produced for mass media transmission, some may also be produced for more
local distribution, particularly in countries where explicit advertising of condoms is
restricted. Local promotional materials may include such items as calendars, diaries,
key rings, stickers and T-shirts. Technical assistance from specialist marketing consult
ants is commonly brought in from time to time during the project.
Training—includes retailers receiving some guidance on the correct use of condoms
so that they can relay this information, and possibly other HIV prevention informa
tion, to their customers. Necessary training may be undertaken by the social market
ing organization or contracted to the commercial manufacturer.
Transmission of IEC materials/messages—includes all advertising and promotion
activities. Activities may include sponsored conferences and professional seminars,
award ceremonies for achievement, use of mass media, face-to-face distribution of
promotional materials through health professionals, pharmacists, midwives, tradi
tional birth attendants, traditional healers, shopkeepers and itinerant salesmen, and
mass distribution in hotels, bars and companies.
Condom distribution—includes costs of storing and packaging the condoms as
well as distributing them to wholesalers or retailers. Distribution channels may be pri
vate or public sector or both. Packaging and distributing may be contracted out.
Management and administration—includes day-to-day activities, planning and
evaluation activities and technical support from management consultants.
5.
STD treatment
Development/distribution of diagnostic and treatment protocols—this may
include strengthening of existing laboratory facilities.
Training—including clinical and support staff.
Diagnosis—includes both laboratory and syndromic diagnosis.
Counselling—including drug and condom provision.
Partner notification—partner tracing, notification and counselling.
Management and administration—including planning, supervision and evaluation.
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6.
Sex worker
peer education
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Development and production of IEC materials—for the target population.
Recruitment of peer educators—can be thought of as a social mobilization com
ponent in the project. This activity will occur throughout the lifetime of the project,
although the mam recruitment will occur at the beginning. Both staff and other peer
educators could do this.
Training—of all staff and particularly of the CSW peer educators who will have
responsibility for conducting the educational sessions; includes refresher training.
Transmission of IEC materials/messages—to the target population, through indi
vidual and/or group sessions.
Condom distribution/sales.
Management and administration—including planning, supervision and evalua
tion of the strategy.
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7.
Voluntary
counselling and
testing
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Development and production of IEC materials—clients may be shown a video,
or handed educational materials at the pre-test counselling session; materials
require development, testing, and production.
Training—counsellors need to be trained in appropriate techniques, with fullytrained counsellors available to conduct the training and supervise staff with lesser
levels of training.
Counselling—pre-test—done with individuals, couples, or groups. Individual
counselling may be followed or preceded by a group session, sometimes involving
showing a video. Condoms may be distributed free of charge or sold. Blood may
be drawn immediately for those who decide to proceed with the test, or at a sep
arate visit.
Testing—laboratory testing of blood may be done on site or at a central facility.
Counselling—post-test—all individuals may be given their results at a post-test
counselling session, or only those found positive.
Management and administration—especially for the free-standing centres,
there will be a number of management activities to be carried out.
8.
Harm reduction
£
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Development and production of IEC materials—often includes focus group dis
cussions and market research; testing, revision and re-testing of messages with
sample audiences; and translation of the materials into a range of local languages.
The costs of the production of the IEC materials once they are designed should also
be included here.
Transmission/distribution of IEC materials and messages—modes and costs of
transmission will vary according to the type of media being used.
Recruitment of peer educators—can be thought of as a social mobilization com
ponent in the project. This activity will occur throughout the lifetime of the project,
although the main recruitment will occur at the beginning. Both staff and other
peer educators could do this.
Counselling—designed to decrease risky behaviour, such as sharing equipment.
Syringe/Needle Exchange—exchange of used needles/syringes for clean ones.
Disposal of contaminated needles—this could include provision of sharps con
tainers, transport, biohazard disposal and possible incineration.
Bleaching/Distribution of substances to clean equipment—distribution of,
and advice on, cleaning solutions.
Condom distribution—includes costs of storing and packaging the condoms as
well as distributing them to wholesalers or retailers.
HIV testing—including the first and any subsequent confirmatory tests and coun
selling pre- and post-test.
Referral to other services—includes referral to other medical services (e.g. STD
treatment), social welfare and legal support.
Training—training of all personnel, including laboratory, medical, managerial and
support staff.
Management and administration—including planning and supervision of the
project.
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Planning the costing exercise
Strategy
9.
Mother-to-child
transmission
■Miffl
Strengthening Antenatal facilities—including provision for HIV testing.
Training—of staff.
Purchasing and storage of ARV drugs and replacement feeding.
Counselling—before notification of results, during ARV regimen and for follow-up.
Management and administration —including planning and supervision of project
and follow-up of mothers and infants.
In practice, not all cited activities may be happening within the implementation
of a particular strategy. It is, nonetheless, likely that implementation of each
strategy entails some combination of these activities. In some cases, a resource
input, as specified in the primary classification, will be used solely for one activ
ity and, in other cases, it will be shared between activities. For example, in a gov
ernment STD clinic, drug inputs may be entirely consumed by the 'STD treat
ment' activity, whilst a clinician's time may be split between 'STD treatment',
'counselling', 'condom distribution' and 'management and administration'.
Some specific comments about activities in different HIV prevention strategies:
j.
h
HIV Blood Screening. In a developed BTS, the majority of these activities will
have been taking place prior to implementation of HIV blood screening. It might,
therefore, be tempting to assume that an HIV screening strategy can be costed
by measuring only the incremental costs of adding the HIV blood testing. The sit
uation is, however, more complicated than this. In areas where HIV prevalence is
high, replacement of discarded blood can constitute the main cost of HIV safety
The cost of HIV blood screening can, therefore, be dependent more upon the
costs incurred on pre-testing activities than on the costs of the HIV testing itself.
For this reason, it is not sufficient to measure only the incremental costs of the
HIV blood testing activity. Rather, the costs of implementing an HIV blood screen
ing strategy will be the costs of all resources used in undertaking the HIV test
ing, plus the full replacement cost of the blood that tests HIV-positive and is dis
carded. The unit costs of this blood will be made up of the costs of donor recruit
ment, selection and counselling, blood collection, tests conducted before the
HIV test, and a proportionate share of overheads such as administration and staff
training, supervision and management.
To obtain such unit costs, the costs of some activities will have to be obtained
for the wider BTS and apportioned to the strategy activities in question. For
example, management and administration costs are likely to be shared between
pre-testing and post-testing activities and laboratory costs may be shared
between HIV tests and other tests. Having embarked this far into a costing exer
cise, it might be pragmatic to obtain costs for the BTS as a whole, rather than
go half way and measure only those costs relevant to the HIV screening strategy.
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How complete a costing exercise to conduct will depend upon the objectives of
that exercise and the audience interested in the results. The manager of a BTS
may be interested not only in the cost of making blood HIV-safe but also in more
comprehensive and more generally applicable cost data. By costing the whole
BTS, total costs can be presented by activity and the proportion of costs attrib
utable to the HIV blood screening strategy can also be disaggregated. If a full
costing is deemed appropriate, detailed guidance can be sought from WHO's
Costing of Blood Transfusion Services
■
CSW. There may be other complementary-activities taking place, such as initia
tives to reach clients for educational sessions. Other activities for CSW projects
may not be directly related to HIV prevention, e.g. creche and income-support
activities.
VCT Some centres provide support to HIV-positive groups, but this is not con
sidered here as a core activity of a VCT service.
IDU. In practice, not all cited activities may be happening within the implemen
tation of a particular strategy. It is, nonetheless, likely that implementation of
each strategy entails some combination of these activities. In some cases, a
resource input, as specified in the primary classification, will be used solely for
one activity and, in other cases, it will be shared between activities. For example,
a clinician's time may be split between 'STD treatment', 'counselling', 'condom
distribution' and 'management and administration'.
Tip-of-the-Trade 2:
What to include if calculating costs in a clinical trial
..
Frequently, cost and cost-effectiveness analyses of HIV prevention strate
gies are done in the context of on-going clinical trials. In order to consider
the feasibility of delivering these services, it is very important to include all
costs that were necessary to ensure the functioning of the project. For
example, if the project had to provide additional basic infrastructure before
looking at the efficacy of a particular intervention, the costs of this basic
infrastructure should be included. Similarly, it is important to exclude costs
associated with the research dimension of the intervention (e.g. some com
ponents of monitoring and evaluation).
Organizational level
Some of the HIV prevention strategies may have activities at a number of orga
nizational levels. National programmes may operate from the field through
districts and regions up to central-level administration. As one moves up organi
zational levels in the hierarchy, away from the point of service delivery, it can
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become increasingly difficult to obtain data and to tease out relevant costs.
Which costs at each organizational level are to be included in the costing study
will depend upon the scope of responsibility of the decision-maker who is
expected to use the results, and the way in which the results will be applied.
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It is recommended that a full costing be conducted at the main service deliv
ery level. For higher organizational levels, it is recommended that personnel
inputs be costed, and that any other additional or incremental costs incurred
by adding the HIV prevention strategy to existing work be included. Where HIV
prevention is integrated with other work, the incremental cost of its addition
may be very small at regional and national levels. Taking this approach means
that the main inputs to be costed at the higher organizational levels are per
sonnel, vehicle use and supplies. Overheads at those organizational levels,
such as buildings, office equipment, utilities and general administration, can
generally be excluded. Where, however, new HIV prevention strategies require
substantial new administrative, logistic or technical support from more central
levels, these incremental costs will involve a wider range of inputs and be more
substantial. These inputs should be costed and appropriately allocated to the
AIDS strategy. For example, the cost of strengthening the National AIDS
Control Programme to support a new preventive strategy should be costed in
that strategy.
hl'
In order to determine the organizational level, it is important to consider the
range of service providers available for a project or programme. Again, these
will differ by strategy:
HIV blood screening. The more localized the costing study, the more likely that
it will be concerned with just one provider. In contrast, a national strategy may
include a number of providers. For example, in Zaire the mining industry is
responsible for a significant proportion of transfusions but transfusions are also
available in the public and private sectors. Which providers to include should be
clear from the objectives of the study and, in particular, from consideration of
the decision-making audience.
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Decisions about the organizational levels from which costs should be recorded are
likely to be dictated by the objectives of each particular costing exercise. If the BTS
to be costed is localized—for example, HIV blood screening at one mission hos
pital—it may be necessary to cost only one service delivery level.
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If the study is looking at national costs, it will probably need to consider costs
at all organizational levels from the centre to the periphery. Starting from the
centre and moving down through the system, cost information for each orga
nizational level should be sought from expenditure records. If such expenditure
records are not available, costs may need to be built up from quantity and unit
cost information collected during field visits. Fieldwork may need to be
restricted to costing a representative sample of facilities at each of the organi
zational levels.
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Mass media. At any one time, there may be a number of AIDS media cam
paigns being conducted in a country by both government and nongovernmen
tal organizations. More so than in some of the other strategies, there can be an
array of providers involved in the strategy, or even in one campaign. For exam
ple, a radio drama in Zambia (47> entailed the involvement of the Health
Education Unit of the Ministry of Health, the Government National AIDS
Prevention and Control Programme, the National Radio Corporation, a number
of colleges and NGOs, drama groups, and the USAID public health communi
cation support programme, AIDSCOM. An array of implementers and organi
zations will need to be assessed for cost information. Some activities may be
contracted out to commercial enterprises, for example IEC production to pro
fessional advertising agencies. This may simplify cost collection as the fees
charged are likely to include the agency's own overheads and support costs for
the work conducted. In this case, the expenditure for the activity in question
can be treated as an aggregate input rather than broken down into its con
stituent inputs.
By definition, a mass media campaign is often implemented at the national level
and activities centralized. Costs may, therefore, need to be obtained from only
one organizational level, although there may be a number of providers involved
at that level. Costs collected will be those directly incurred by a particular cam
paign plus an appropriate share of the overhead costs of the organization with
primary responsibility for supervising, managing and administering the campaign
or strategy. This might, for example, be a share of the running costs of the
Health Education Unit of a Ministry of Health or its equivalent.
It is recommended that, apart from the lead agency in the campaign, no efforts
be made to cost the overheads of other organizations with partial involvement
in the strategy. A share of the personnel costs of those organizations should,
however, be included, and allocated according to the share of staff time spent
on the mass media campaign.
HIV school education. The main provider of the strategy is likely to be a gov
ernment ministry, such as the Ministry of Education or Ministry of Health.
Curriculum development and material production may be undertaken by them
or contracted out to a specialized agency. Similarly, training of staff may be
undertaken by the Ministry or by a contracted agency. The actual teaching of
AIDS education is undertaken by staff in the schools included in the strategy.
Donors may also provide inputs to the strategy, for example consultancies dur
ing the start-up phase. If the project is a more localized NGO initiative, the only
providers involved may be the NGO and the schools in which they are imple
menting the strategy.
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Most of the costing data should be available centrally from the organization with
overall responsibility for the strategy—for example, the relevant Ministry. Costs
of the time that school staff spend on the strategy during training and teaching
may need to be obtained from a sample of schools involved in the strategy.
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If any donors provide assistance to the project, for example start-up technical
assistance, it may be necessary to approach them directly for details of the costs
of their inputs. If the project is a more localized NGO initiative, cost data should
be collected directly from the NGO, and other costs, including personnel, from
the schools in which the strategy is being implemented
Condom social marketing. There are usually several institutions involved in a
social marketing project. A foreign donor may provide consultancies in the start
up phase and on-going financial assistance. Either the donor or a commercial man
ufacturer may be the source of condoms. In-country, most activities tend to be
coordinated by a social marketing organization. They may contract other organi
zations for marketing, promotion, and distribution. The Ministry of Health or
Family Welfare may be involved in project policy, monitoring and distribution of the
condoms through its own outlets. At the periphery, individual retailers will be pur
chasing and selling the condoms. In most instances, the social marketing organi
zation will have central expenditure records that collate the financial costs of these
decentralized activities. To obtain the economic costs of the strategy, it may be nec
essary to deal with some of the other agencies directly. For example, the social
marketing organization may not have information on the costs of donor inputs.
i
Due to the social marketing organization's role in centralizing expenditure data
from decentralized project activities, the majority of costing information should
be available from that organization's office. Field visits may, however, be neces
sary to obtain extra data, for example, costs of any inputs that do not entail proj
ect expenditure. It may be necessary to approach the organization's headquar
ters overseas as well as foreign donors for details of the costs of external
inputs—for example, condoms and consultancies. Only direct contributions to
the project should be included; overheads that are not specific to the country
project can be excluded.
L.
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Tip-of-the-Trade 3:
Gathering data from CSM organizations
L
Key information to obtain from the social marketing organization includes
the total cost of the project (and an idea of the methods used to calculate
this figure); the number of condoms sold; project expenditure on condoms;
and revenue returning to the project from condom sales. Although social
marketing organizations are usually prepared to share information, it may
be in their own format, which is not ideal for cost analysis. It may, there
fore, be necessary to adapt such information as is available. For example,
in a costing of a Futures Group project where condoms were part of a
broader contraceptive social marketing project, it was found that costs
were not tracked by contraceptive method <61). Costing, therefore, entailed
taking a share of direct project expenditures allocated in proportion to
Couple Years of Protection provided by condoms, plus the cost of the con
doms themselves.
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S' STD treatment. Any primary-level STD treatment service is likely to be provided
by a single organization, be that a government, private for profit or NGO provider.
Occasionally, however, private or NGO facilities may receive government support
for supervision, training or drug supplies. Some private and NGO facilities without
their own laboratory or referral services may rely on government facilities for these.
•
Government. If the study is looking at national costs, it should consider costs
at all levels from the centre to the periphery. Starting at the centre, cost infor
mation for levels below should be sought from expenditure records. If such
expenditure records are not available, costs will need to be built up from infor
mation collected through field visits to the lower levels. A sample of represen
tative primary-level facilities should be included in the costing study. The costs
of laboratory and referral services should be included in the costing study and
these may be incurred at higher organizational levels.
Overhead and support costs for managing and administering the service may
need to be collected at a number of levels. In vertical systems, relevant costs at
the different levels are likely to be well defined and should be included in their
entirety. There may, for example, be specific STD project offices at the national
and provincial levels. Where STD services are integrated horizontally with other
services, it will be harder to determine the costs that relate to support of the
STD services. In this situation, only the incremental costs incurred in supporting
the strategy should be included, together with the costs of the time that per
sonnel spend working on the strategy.
•
Private-for-profit and NGOs. Some projects may consist of only one special
ized STD clinic or one general clinic that provides STD treatment, and the costs
for these may be available from a visit to one organizational level only.
Elsewhere, the primary STD service may be linked to a private/NGO referral hos
pital and two organizational levels may have to be visited to obtain the neces
sary costing data.
Sex worker peer education. This type of strategy is normally implemented by
NGOs. A lead NGO may coordinate support from other NGOs and from national
or international donors. Occasionally, government institutions may provide some
inputs to the project, such as condom supplies, building space or salary support.
Donors may also provide condoms, as well as technical assistance. Condoms may
also be sold by peer educators rather than just distributed free.
It may be necessary to deal with only one or two organizational levels to cost this
type of project. The main source of data will be the NGO's management office. The
second organizational level, for information that the NGO office is unable to pro
vide, is the community level where peer educators conduct educational activities,
although at this level, the organization may be much more informal. Government
contributions may need to be investigated separately, for example at the district or
municipal level. It may also be necessary to approach donors for the costs of their
inputs.
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VCT. Where VCT is provided by a variety of agencies, the objectives of the study
will determine whether a representative sample is required, or a study of the
service thought to be most replicable or most effective.
Where VCT centres are provided routinely by governments, and if the study
looks at costs nationwide, costs will have to be considered at all levels from the
centre to the periphery. Starting from the centre, cost information for levels
below should be sought from expenditure records. If these are not available,
costs will need to be built up through visits to lower levels. A sample of VCT facil
ities should be selected for detailed costing. The incremental costs of support
given to the VCT clinics by higher levels should be included.
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If a VCT service provided by an NGO is being costed, there may be only one level
of interest or, at most, the level of the service plus the incremental costs of sup
port provided from a head office. Since VCT services may be funded from a num
ber of different sources, including NGOs, government subsidies, and external
donors, a variety of contacts may need to be made with funders at different lev
els to obtain comprehensive cost data.
I
IDU. An IDU project is typically implemented by NGOs. A lead NGO may coordi
nate support from other NGOs and from national or international donors.
Occasionally government institutions may provide some inputs to the project,
such as condom supplies, building space or salary support. Donors may also pro
vide condoms, as well as technical assistance. Condoms may also be sold by peer
educators rather than just distributed free.
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3.4 Decide on the data timeframe
"Usually, you should attempt to measure the costs incurred over one full year.
This is likely to be consistent with the records of most types of relevant data,
such as expenditure on personnel and services provided. A one-year period
avoids any distortions that might be caused by seasonal effects. Occasionally,
limitations of information, e.g. for a new programme, or for study time, might
make it necessary to choose a shorter period. If you study costs for less than one
year, you will probably need to discuss with other knowledgeable persons ways
of avoiding serious distortions.
"In general, it is recommended that, to enhance accuracy and relevance of cost
data, you should choose the most recent year for which cost data are likely to
be available. If the year chosen is too far in the past, important information may
be lost. If the year is too recent, some routinely collected statistics may not yet
be available. Sometimes the financial year (the period for which routinely col
lected expenditure data are summarized) is not the same as the calendar year
(the period for which effectiveness statistics are likely to be aggregated). If this
is the case, see whether it is possible to obtain disaggregated data for each
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month covering costs or effectiveness, so that you can construct either annual
effectiveness data for the financial year or expenditure figures for the calen
dar year"(PHC: 26). If you are collecting more than one year's worth of infor
mation, then you need to keep careful track of which year the expenditure
took place.
When undertaking a costing exercise, cost data can be collected retrospec
tively from such sources as accounting records, questionnaires and interviews.
Alternatively, information systems can be specially established to collect cost
ing data prospectively over a suitable time period. Once collected, these data
will also be analysed retrospectively.
Costs are likely to vary during the course of a project's implementation, espe
cially if there are high initial start-up costs. These costs are associated with
start-up activities that are conducted at the beginning of a project and rarely
repeated, such as the purchase of vehicles or project infrastructure. For exam
ple, development of standard diagnostic protocols may be one of the start-up
costs of an STD treatment strategy. If start-up costs are being included in the
costing, they should be treated in the same way as capital costs and annual
ized over the expected lifetime of the project.
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Different timeframes for data collection may be chosen according to the objec
tives of costing studies, in particular:
•
Concern with operational efficiency and modification of on-going projects
may mean that start-up costs can be ignored and only on-going recurrent
and annualized capital costs collected. If only on-going costs of regular
services are being considered, it is recommended that annual costs be col
lected for a recent appropriate year. They should include recurrent costs
and annualized capital costs.
•
If the study is seeking information on total project costs, costs should be
recorded for all years in which they were incurred. These costs will include
start-up costs such as planning, staff recruitment and project site identi
fication.
•
Identification. This is particularly important for CSM, as unit costs tend to
decrease over the life of a CSM project due to the increasing volume of
sales. In making comparisons between projects, it is important to consider
how long each project has been running. CSM projects tend to have high
start-up costs incurred in market research, project design and project
launch.
•
If the costing exercise is addressing future modification or sustainability
of the project, the costs of on-going activities (including depreciation of
capital inputs) should be collected from a routine phase of the project.
These should ideally be costs for the most recent year for which data are
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available. If costs are taken from a period early in the project, it is impor
tant to exclude one-off start-up costs that would inflate estimates of the
resources needed to sustain the project in the future.
•
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If information is required on the costs of replicating the project, all costs
incurred over the history of the project since its inception should be col
lected. This includes both start-up and on-going activities. Costs incurred in
all years of the project should be recorded, including the costs of organiza
tional changes made as part of the HIV prevention strategy. For example,
for HIV blood screening, changes may include establishing a national BTS
for the first time, reorganizing an already established BTS, adding facilities
such as laboratories, or adding a new set of tests in laboratories. Start-up
costs may also include operations such as the establishment of new
national policies for BTS blood-screening practice.
•
The selected timeframe may also depend on the maturation of the project.
If the strategy is of limited duration, a costing exercise may need to encom
pass all costs, including those incurred by start-up activities. If the strategy '
has become institutionalized and is now an established operation, it may
be appropriate for the costing exercise to investigate on-going costs only.
•
Mass media campaigns will normally be a time-bound discrete exercise
rather than a continuous on-going set of activities. Because of this, each
mass media campaign is most appropriately costed from its conception to
completion. The costing exercise will, therefore, capture all costs rather
than differentiate between start-up and on-going costs in the way appro
priate for some of the other strategies. If the objective is to cost a broader
strategy that is, in fact, on-going, the strategy as a whole may include a
series of campaigns. It may then be necessary to cost overheads for devel
oping and overseeing the series, in addition to costing each campaign.
To undertake cost-effectiveness analysis it is important that data on both costs
and effectiveness be linked in such a way that only the costs of those resources
that produce the effects are measured. It is usually recommended practice to
estimate both costs and effects over the period of a year. Nonetheless, con
sideration needs to be given to what is most appropriate for a particular strat
egy. One year of cost data may be appropriate for prevention activities that are
on-going, for example blood screening programmes. However, in some strate
gies, such as mass media campaigns, costs may be incurred over a shorter time
period and effects may happen over a longer time period in the future. In all
cases, it is essential that a record be made of the timeframe to which data
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If cost data have been collected from more than one year, it will be necessary
to convert them to a constant Base Year value before adding them together
(see chapter 4). The chosen Base Year should normally be the most recent year
for which data are available.
63
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3.5 Select a sample
Sometimes it may be necessary to cost a national programme that consists of
geographically widespread and multiple units, for example a national blood
transfusion service or STD programme. In this case, it may be practicable to cost
only a sample of facilities from each organizational level or levels. Even when
costing a more localized project such as a peer education project, it may be nec
essary to sample time allocations of representative members of staff during rep
resentative weeks of the year.
J
Tip-of-the-Trade 4: Selection of samples
"There are several ways in which you can make your selection. Usually, in
taking a sample, you are not just interested in the particular units you
select. You wish to be able to draw conclusions about the population as a
whole. If this is the case, there are certain rules you must follow.
Statisticians have devised many different approaches to satisfy the condi
tions necessary to allow valid conclusions to be drawn about the popula
tion from samples. Four of these approaches are described below. For each
of them, the size of the sample drawn will influence the degree to which
inevitable statistical variation will affect the confidence to be placed in the
estimate for the whole population. Disregarding expense and other prob
lems, the larger the sample, the greater the confidence (i.e. the smaller the
range of probable error). Another factor is the extent of variation among
units of the population; smaller variations permit a smaller sample size. You
might wish to consult a statistician about these matters.
"One of the customary approaches to selection is random sampling. This is
a good technique to use if you can feasibly list (and number) all the ele
ments of the entire population and if there are no subgroups you are par
ticularly interested in. You could, for instance, use it in selecting health cen
tres within a district. Having decided on the sample size, you would select
the required number of units at random from a numbered list, using a table
of random numbers.
"Systematic sampling is a second approach. It is easier to use than simple
random sampling, and is most useful when there are large numbers in the
population (say, patients attending a hospital). The procedure is as follows:
• Obtain a list of all the units (n) (in no systematic order) from which the
sample is to be selected.
• Decide on the size of the sample (s).
• Calculate the ratio n/s (= k). Select every kth item on the list, starting at
any point. For example, say you want a sample of 50 patients (i.e. s =
50) out of 2000 attending the clinic in a year (i.e. n = 2000). Then k =
2000/50 = 40, and you would then select every 40th patient. If s does
not divide exactly into n, e.g. k = 40.54, then round k up or down to
the nearest whole number.
UNAIDS
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If you were interested in the health centre costs of a PHC programme in
the country as a whole, studying a random (or stratified) sample would
probably require a lot of travelling and effort, since these units are likely to
be widely dispersed. An alternative approach is to first select a sample of
districts and then to look at the health centre costs only in those districts.
This is called cluster sampling. It gives less valid results than pure random
sampling, but can have major logistical advantages. First, select a random
sample to determine the clusters (in this case, districts) to be studied; then,
in the selected clusters, either select all the units (health centres) or a ran
dom sample of them.
"A fourth approach with a formal statistical basis is stratified sampling. You
may wish to ensure that you include units with particular characteristics in
your sample (e.g. health centres in both rural and urban areas), so that you
can compare them. To do this, first divide the total population (in this case,
all the health centres) into subgroups (urban and rural); then take a ran
dom or systematic sample or even a clustered sample in each subgroup.
"While the mathematical 'merits of the above approaches are well known
to specialists, there are situations when a less formal, but more practical,
sampling technique might be used, which may be referred to as judgement
sampling. In a substantial number of practical cases, barriers to statistical
sampling might exist, for example excessive costs or limited co-operation
from staff in specific delivery units. When one of these problems occurs,
random sampling may not be possible, and you may need to use your own
judgement to select a reasonably typical group of units for study. The prac
tical advantages of this method are evident, but the inability to draw gen
eral conclusions about the entire population on a formal statistical basis is
a clear drawback to the use of a judgement sample. It is offered as a less
than ideal, but occasionally practical, approach to the task of choosing S
your sample" (PHC: 27-28).
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The basis upon which any sample is selected should be explicitly reported in the
presentation of results. When the costs of the sample facilities or activities are
analysed, it will be necessary to multiply these data up to acquire costs for the
population that the sample represented.
"Three important ground rules in the process of data collection are:
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3.6 Work itinerary
•
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Collect the information at the highest organizational level at which it is avail
able for main service delivery (if it is of reasonable quality) to minimize study
time and expense.
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•
Be careful to avoid counting the same cost element (input) twice ('double
counting') when you have obtained data at more than one level (for exam
ple, when staffing or salary figures have been provided at both the delivery
unit and higher levels).
•
Put your greatest efforts into finding (and using) information on the largest
input categories rather than the smaller, less important categories (such as
supplies and building operation in most programmes). The latter can often be
handled by rough calculations, perhaps based on rules of thumb, such as
assuming operating costs of buildings to be equal to a certain percentage of
their annual capital costs" (PHC: 29).
UNAIDS
Collection of cost data
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Chapter 4
COLLECTION OF COST DATA
In this chapter, we present a step-by-step guide to collecting the cost data
and consider how to make any necessary adjustments to the data. This chap
ter should be read in conjunction with the worksheets presented in Annex 1
and available in Microsoft Excel format on the UNAIDS website
(www.unaids.org/pubiications) or the CD-ROM: Economics in HIV/AIDS planning—
getting priorities right, UNAIDS (June 2000).
s
4.7 Financial and economic costs
Before proceeding to specify how to collect cost data, the difference between
financial and economic costs should be appreciated as in some situations it will
be important to carry out analysis with one rather than the other. By having sep
arate columns for financial and economic costs, the worksheets record explicitly
which inputs have entailed actual project expenditure (financial costs) and which
have been attributed economic costs.
1
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If the costing exercise is going to be used to undertake a cost-effectiveness
analysis, then all resources consumed should be valued in terms of their oppor
tunity cost, i.e. their full economic cost.
There are three main areas in which economic costs differ from financial costs:
■
Donated items. The economic cost or value of donated goods and services can
most easily be estimated by taking their equivalent market prices. "For example,
in the case of radio time you could find out what the radio station normally
charges for advertising (if this is what it would otherwise do with the time slot
allocated to your programme), taking into account the duration and time of day.
For volunteer labour, you could find out whether those people receive a salary or
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wages elsewhere and use that to cost their donated time" (PHC: 58). Varying
degrees of effort can be put into estimating economic costs. Donated goods and
services should always be valued.
If the input price is wrong or distorted. If some of the consumed resources have
market prices that do not reflect their true value—for example they are too low due
to subsidies, too high because of inclusion of transfer taxes or are distorted through
government-set foreign exchange rates—it may be necessary to replace the stated
prices with 'shadow prices' for purposes of analysis. "Economists use the term
'shadow price' to refer to a price that has been adjusted for various reasons, includ
ing donations, to yield economic cost" (PHC: 58). The actual shadow price you use
will depend on the nature of the good. For instance, if official exchange rates are
distorted, you may want to use prevailing black market rates.
It is recommended that effort be expended on shadow pricing in proportion to the
contribution that the resource in question makes to the overall cost of the project.
Capital inputs. "Capital goods are defined as inputs that last for more than one
year. If you studied expenditure only in one particular year, you could easily get
a distorted view of long-term average annual costs. For example, a great deal of
equipment might have been purchased in the year before your study, with no
expenditure on capital at all during the study period. One way to get an idea of
long-term financial commitments is annualize or spread out costs by:
identifying all the capital goods (vehicles, equipment, buildings, etc.) being
used in that year;
• finding out the current (replacement) cost of purchasing them (C);
• estimating the total number of years each is likely to last from when it was
purchased (N) (the 'working life' or 'useful life');
• estimating the average annual cost of each capital item in terms of a simple
'straight line' depreciation" (PHC: 32-33/
This average annual cost is what you would put down for the cost of each cap
ital item for one year under financial costs.
•
"With economic costs, you will usually be concerned with the cost of resources
used over a specific period (say, one year), rather than at the time they are pur
chased. Simply obtaining the straight-line of capital items is a way of spreading
capital costs over a period of time, but it is not adequate if one is interested in
economic costs, which must take into account the value of alternative opportu
nities for using the resources tied up in the capital inputs.
"To calculate the economic cost of capital on an 'annualized' (cost per year)
basis, use the following approach.
•
Current value. Estimate the current value of the capital item, as the amount
you would have to pay to purchase a similar item now (i.e. the replacement
value rather than the original price).
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Collection of cost data
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Useful life. Estimate the total number of years of useful life the item can real
istically be expected to have (from the time of purchase).
•
Discount rate. Find out the discount rate used by the economic planning
office or Ministry of Finance. Annualization factor. Consult a standard table
(found at the end of this chapter) to find the correct annualization factor.
•
Calculation of annual cost. Calculate the annual cost by dividing the current
value of the item by the annualization factor. This factor is determined by the
discount rate and useful life of the item.
"For a single $10,000 piece of equipment with a useful life of 5 years, the
approach above would be applied as follows:
Discount rate: 10%
- Annualizing factor (from standard table): 3.791
- Calculation of annual economic cost: $10,000/3.791 = $2,638 per year
(rounded figure).
"To compare this economic cost with the corresponding financial cost, note that
the latter would be $10,000/5 = $2,000 per year. The investment of funds 'up
front', to pay for the equipment in full at the start of its use, raises the annual
economic cost—which is to be expected" (PHC: 59-61).
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The practical steps to be taken in collecting cost data are very similar whether
the desired result is financial or economic cost data. Each worksheet in the
Annex is designed so that financial and economic costs can be clearly distin
guished and it is important that the two categories of cost are not confused.
Whether economic or financial costs are used, whether a manager analysing
financial costs chooses to take a project budget perspective and exclude costs of
donated goods, or to take a wider perspective and include them, and whether
or not shadow pricing is introduced into economic costs, will depend upon the
objectives of the costing study being undertaken. The worksheets are designed
to accommodate these different purposes. It is always important to accurately
record the way in which economic costs have been derived from financial costs.
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4.2 Gathering background data
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The information recorded on the background data sheet is needed for analysis
of the cost data, including calculation of economic costs, where necessary, and
for making the results of the study more generalizable.
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The information required can usually be obtained from the Central Economic
Planning Office, the Finance Ministry or the Central Bank. Which of these is more
accessible may, in practice, depend upon contacts between the officials with
whom one is dealing in the health or other ministries, and in these other insti
tutions. The numbers recorded should be the average figures for the Base Year.
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The choice of discount rate—a rate that reflects the opportunity cost of tying up
funds in the project—is particularly critical since it can significantly influence the
relative cost-effectiveness of strategies being compared. If there is no particular
recommended rate for the country, then a rate can be taken from economic proj
ect appraisals done by other organizations such as the World Bank. A more dif
ficult approach would be to calculate the real rate of interest, i.e. the rate of
interest that would be obtained by depositing the money in the bank minus the
rate of interest. Alternatively, a simpler approach is to take a 'high side' World
Bank discount rate of 10%. The effects of using different rates can be explored
by conducting sensitivity analyses. In order to see how sensitive your results are
to the choice of rate, you can consider three scenarios: (i) your choice of rate; (ii)
twice that rate; (iii) half that rate. Then the costs should be calculated based on these three different scenarios, in order to determine if your analysis is highly
sensitive to your assumptions (PHC: 72).
4.3 Collecting input data (Form C)
General
This set of forms is the main tool for data collection in the field. A set of 'C'
forms can be collated for each organizational level (see discussion in chapter 3).
If data are being recorded manually, each set should be stapled together and
attached to a Form 'B' summary sheet, by organizational level. There is a sepa
rate Form 'C' to collect data for each category of input:
Cl
C2
C3
C4
C5a
C5b
C6
C7
C8
C9
CIO
capital costs: buildings
capital costs: equipment
capital costs: vehicles
capital costs: consultancies
recurrent costs: personnel
example of personnel time allocation form
recurrent costs: supplies
recurrent costs: vehicles operation and maintenance
recurrent costs: building operation and maintenance
recurrent costs: consultancies
recurrent costs: other
Best estimates often have to be made for some costs for which there is consid
erable uncertainty. If these costs represent a significant proportion of the overall
total, the effects of altering the estimates can be explored by conducting sensi
tivity analyses similar to the discussion on discount rates above.
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Data collection at the different
organizational levels
The 'B' forms have been developed to accommodate collation of costs in as
many organizational levels as are relevant to the costing exercise in hand. The
number of levels included is likely to vary according to the strategy, the type of
service provider and the questions being addressed. The 'B' forms can them
selves then be collated and totalled into a single Form 'A', which is a cost sum
mary sheet for the strategy.
Currency
Forms should generally be completed and worked in the local currency and this
currency should be stated on all forms.
Where inputs have been purchased in foreign currency, you will need to differ
entiate between those bought from inside the country, and those bought from
abroad. Where an input, such as office rent, has been purchased in foreign cur
rency inside the country, note the amount and convert it to the equivalent price
in local currency. In order to do this, use the market exchange rate at the time
the cost was incurred. The foreign exchange price should also be noted in a
footnote on the form.
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However, where an input has been bought in foreign currency from abroad, con‘ vert its cost to Base Year costs first, and then convert this figure into local cur
rency using the market exchange rate for the Base Year (see 'Converting to con
stant prices' below).
When an organization keeps all its records in US dollars, it is suggested that con
version to local currency take place at the end of the costing exercise.
Source of funds
All 'C' forms have a column in which to record the source of funds for each input.
Information on source of funds may be particularly important for planning the
sustainability of programmes and for assessing the cost to private individuals for
the prevention services that they receive. Funding sources are likely to include:
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6.
7.
Ministry of Health (all organizational levels)
Other ministry (specify)
Municipality/local authority
NGO/community groups
Private for-profit organization
Private individual
External donor (specify)
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It is recommended that a list of funders be drawn up for each project and that
each main source of funds be given a code to simplify data entry on the forms.
Source of data
Each form also has a line to record the source of cost data by input. The source
of data cited should state both the organizational source, for example Accounts
Department in the Ministry of Health, and the type of source, for example bal
ance sheets, interviews, accounting records or questionnaires.
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Converting to constant prices
If cost data have been collected from more than one year it will be necessary to
convert them to a constant Base Year value before adding years together. This
allows for the fact that inflation causes the value of money to alter from one year
to another. When it comes to data analysis, the most recent year for which data
were available should be chosen as the Base Year and costs in all other years
should be converted to their equivalent values in the Base Year. For example, if
costing data were collected from 1990 to 1999, then 1999 should be treated as
the Base Year.
This conversion is done using measures of domestic inflation such as Consumer
Price Indices that should be available from the Finance Ministry, National Bank or
Department of Statistics. To convert expenditure in year Y to the prices of the
chosen Base Year, multiply the expenditure in year Y by the consumer price index
for the Base Year and divide by the consumer price index for year Y. If foreign
currency has been used to buy inputs from inside the country, it is appropriate
still to use the domestic price index. However, if foreign currency has been used
to buy inputs from abroad, then an appropriate foreign price index should be
used to convert the sum to constant prices. For example, if a vehicle is purchased
with US$ from the United States in 1990, then in order to convert prices to the
Base Year 1999, a US Price Index must be used for that vehicle cost. Convert
1990 $ to 1999 (Base Year) $ first, and then convert into local currency for 1994,
using 1994 market exchange rates.
The bottom row of the final two columns of each Form 'C' should be used to
convert the toLi unancial or economic costs into total costs for the Base Year.
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Tip-of-the-Trade 5: Time is important
Often data are available for a number of years. It is important to be con
sistent in terms of the time frame that you adopt for the cost analysis. If
you are collecting from different years, it is important to note this down,
variable by variable. It is helpful to have a separate set of sheets Cl-CIO,
with each set corresponding to one year. The importance of noting down
the year becomes apparent as you try to convert exchange rates (you need
to use the exchange rate that is appropriate for the time-period). If you are
collecting from different time-periods and want total costs for the entire
period, you need to convert the data to the same year, using the domestic
inflation rate.
4.4 Data coilection
CAPITAL COSTS
Capital resources are those resources that have a life expectancy of more than
one year.
a) Buildings (Form Cl)
Buildings may include health centres, hospitals, offices, staff houses and ware
houses.
Financial cost
We recommend costing the buildings being used for implementation of the
strategy by recording the annual rent (if rented) or by estimating the equivalent
annual rent (if owned). "This means obtaining an estimate of the annual price
charged for renting similar space. The estimate should distinguish between fur
nished and unfurnished buildings and between air-conditioned and non-air-con
ditioned space. In effect, this approach treats buildings as recurrent, instead of
capital, inputs. You will probably need the assistance of a real-estate agent or
someone else who is familiar with the rental market in the area" (PHC: 52).
Each building being used should be listed in column 1 of Form Cl and the source
of funds for the building noted in column 2. The actual annual rent or equiva
lent rent for a similar unfurnished building should be recorded in column 3. Ten
per cent (10%) of the annual rent price should be recorded in column 5 to cover
the costs of furnishings. The total of these two costs can then be recorded in col
umn 6. There may also be field offices located in other cities, whose costs should
also be counted.
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Collection of cost data
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If there are buildings that are only hired occasionally for implementation of the
strategy, the actual hire fees over the course of a year should be recorded in col
umn 6. It is assumed that any space hired for such short-term use is furnished
and that it is, therefore, not necessary to add extra costs for furnishings.
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Economic cost
Use of some premises may be provided free of charge. For example, the Ministry
of Health may dedicate a room in the Ministry to oversee the strategy. Although
this entails no financial cost to the project itself, the provision of such premises
does represent an economic opportunity cost. An economic analysis should
value that space in case free provision is not sustainable in the future; for exam
ple, if the space is allocated to another project. The cost at market rates to hire
or rent such space, as and when it is needed, over the course of a year should
be recorded in column 4. However, it is possible that, if an organization had to
pay rent, it would choose to relocate to a different, cheaper, area. It may be nec
essary to make a couple of estimates of opportunity cost, e.g. rent in city c^..cre
as well as rent out-of-town. Efforts need not be made to cost the capital over
heads of other organizations with partial involvement in the strategy. Any
agency to which work is contracted out is, in any case, likely to include a pro
portionate share of its overheads—including buildings—in its fees.
Tip-of-the-Trade 6: Floor space
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If you are trying to obtain an annual rent for a space, it is useful to know
the floor space (e.g. in square metres or square feet). Commercial rents are
often quoted in terms of this floor space. If the area is unknown, you may
want to do a rough approximation by pacing out the length and width of
the space.
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Allocation
If buildings are shared, a proportion of their costs should be allocated to
HIV/AIDS prevention on the basis of floor space used, or as a percentage of total
floor space for which rent is being quoted and/or by the share of time that that
space is used for the AIDS work. The allocated percentage and the resulting cost
should be entered in columns 8 and/or 9.
Strategy-specific comments:
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HIV blood screening is likely to have incremental resource implications only
if laboratories are newly established or if reorganization of the system to
accommodate the HIV prevention strategy necessitates new buildings.
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Implementing HIV school education is unlikely to require any additional
space in schools. Capital costs of the schools can, therefore, be excluded.
Only capital costs of lead agencies such as the Ministry of Education should
be considered.
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Capital costs tend to be a low proportion of overall project costs in social
marketing projects, sex worker peer education projects and HIV pre
vention projects among IDU users.
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In vertical systems, where premises are used only for STD or VCT services, the
capital and recurrent costs of buildings should be attributed to the strategy.
For STD or VCT services integrated with other services at the primary level,
and for joint laboratory facilities, only a proportion of the capital and recur
rent costs of the buildings should be attributed to the strategy. These should
be allocated by space and/or time and/or activity indicators. At organizational
levels above the primary level, only incremental costs of buildings need be
costed against these strategies.
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b) Equipment (Form C2)
Capital equipment refers to supplies that last for more than one year. Use the
current cost for a similar piece of equipment, not the original purchase price. The
cost should include freight. Sources of cost data could include recent govern
ment contracts, supply records from donors or local dealer estimates. The work
ing life of a piece of equipment can be ascertained by asking individuals who
operate it how long this type of equipment generally lasts before it is beyond
repair (PHC: 33-34).
A handy cut-off is to classify all capital equipment according to a unit price of
$100 or more (unless national accounting procedures specify a different cut-off
point) and these items should be listed in column 1 of Form C2, and the fund
ing source for the equipment noted in column 2. Equipment with a unit price of
less than $100 should be treated as a recurrent input and the cost recorded on
Form C6.
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Financial cost
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The replacement price of the equipment should be recorded in column 3. If the
equipment is imported, the foreign exchange price, including freight and insur
ance, should be noted in column 3 and converted (see sections on 'Currency'
and 'Converting to constant prices' in 4.3). The life expectancy or working life of
the equipment when new should be recorded in column 5. When such an esti
mate cannot be provided, a five-year life can be assumed for most equipment.
The average annual financial cost should be calculated by straight-line deprecia
tion and entered in column 6 (see chapter 3).
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Equipment, such as audiovisual equipment, may need to be purchased for the
development of the IEC materials. If the equipment will continue to be used over
the length of its life, then a proportion of its annualized costs should be allocated
to the strategy or campaign being costed. If the equipment will have no further
use at the end of the project, its capital cost should be annualized over either its
own life expectancy, or the length of the project, whichever is the shorter. For
example, if the campaign is implemented from beginning to end in eight
months, then two-thirds of the annualized cost of any equipment used exclu
sively for the strategy should be allocated to the campaign. If, however, equip
ment purchased to produce the campaign has no foreseeable future use, the
total capital costs of that equipment should be written off against the eightmonth period.
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It is assumed that the depreciation and running costs of equipment used by con
tracted organizations will be included in their fees.
Economic cost
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If the market replacement price is significantly divergent from the economic
value of the equipment, a shadow price can be estimated and entered in column
4. This might be the case where equipment is imported and there is a distorted
foreign exchange rate. The average annual economic cost of equipment can be
calculated following the above methodology and entered in column 7.
Allocation
If equipment is shared between the HIV prevention strategy and other work as,
for example, National Blood Service laboratory equipment, costs should be allo
cated by the proportionate share of a relevant activity measure or by the pro
portion of time that the equipment is used for each. The allocated percentage
and the resulting costs should be entered in columns 8 and/or 9.
Strategy-specific comments
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An HIV blood-screening strategy is likely to entail the purchase of new
equipment if laboratory services are to be part of the strategy. These costs
may be a significant component of the total costs of the strategy.
•
For HIV education in schools, there will be only a limited need for equip
ment to implement the strategy.
•
A share of the equipment in the social marketing organization's office should
be allocated to the strategy. Such equipment as is needed by the strategy will
tend to be for the production of the promotion and marketing materials.
•
The majority of the equipment necessary for STD treatment is laboratory
equipment but some diagnostic equipment will also be present in clinics.
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In specialized STD clinics, the full cost of this equipment should be
included and, in integrated clinics, a share of the costs. The costs of the
STD-related equipment should be allocated to the strategy in the same
ratio as staff time allocations or by activity levels such as the percentage
of total tests conducted that are for STD.
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For CSW peer education projects, the main need for equipment will be for
training and education activities. Items such as video cameras, televisions,
video players, slide projectors, overhead projectors and computers may be
purchased specifically for the project.
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For VCT, if the tests are done on the premises, then the separate elements of
the costs of the tests need to be investigated, including the equipment. If the
tests are done outside and charged for, then the fee can be taken as the
financial cost of the test. If there is reason to believe that this cost is highly
subsidized, then the test will need to be costed. If the test is free (for exam
ple, done at a government hospital), then the actual cost of the test will need
to be studied. The simplest approach to cost the test will be to estimate the
annual cost of the testing equipment and relevant laboratory staff (ignoring
other laboratory costs and overhead costs since these will relate to many
other activities), and express the cost per HIV test done in a year.
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c) Vehicles (Form C3)
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The kinds of vehicles you may need to value include bicycles, motorcycles, fourwheel-drive vehicles, cars and trucks. Use the current cost for a similar vehicle,
not the original purchase price. The cost should include freight. Recent govern
ment contracts, supply records from donors, or local dealer estimates are useful
sources of information. The working life of a vehicle will vary considerably,
depending on vehicle type, terrain, use and maintenance. Consequently, you
should try to obtain a local consensus on the expected working life of each type
of vehicle. Ask several people who use, drive or service cars for an estimate of
how long this type of vehicle has lasted in the past (i.e. how long before the
vehicle reached a stage where it was not worth repairing). For consistency, it is
best to use the same time period (e.g. three or five years) for a given type of vehi
cle for the entire analysis, unless there are major differences in terrain, etc. that
would justify the use of different figures.
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In the event that some of the data described above are not available, a rough
approximation of annual vehicle capital costs can be obtained from local rates
for hiring vehicles. In such a case, the cost of vehicles looks like a recurrent,
rather than a capital, item, but it should still be considered a capital cost.
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Financial costs and economic costs should then be calculated as described in
chapter 3 (e.g. straight-line depreciation and economic calculation of capital)
and form C3 should be completed, as described above for equipment.
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The capital and recurrent costs of any vehicles purchased for the strategy should
be included in the costing exercise. If the strategy opportunistically uses other
vehicles that are available (e.g. borrowed from elsewhere), the actual expendi
ture incurred by using them for strategy activities should be included as financial
costs. Any economic analysis should include an appropriate share of the capital
and recurrent economic value of the use of these vehicles.
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Allocation
If a vehicle is shared between implementation of the AIDS strategy and other
work, the capital costs of that vehicle should be apportioned accordingly. See
section (g) below on allocation of running costs of vehicles for recommended
methodologies that can also be applied to the apportionment of their capital
costs. The preferred method would be apportionment by mileage, followed by
duration of vehicle use.
It is important not to double-count vehicles that travel between different orga
nizational levels. For example, if the cost of a vehicle is included at district level
then none of its cost should be recorded at the field level to which it makes
supervisory visits.
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✓ Tip-of-the-Trade 7: Travel costs
Travel (other than by vehicles owned by the organization) may also be a
separate category of costs. Some travel may not be done using vehicles
belonging to the organization, but rather by public transport (e.g. taxis and
by air). For example, in community-based CSW peer education projects,
field staff may often attend all educational sessions and travel by taxi to the
sites.
Travel should not be confused with vehicle cost, but rather included as an
item under other recurrent costs (see section h). The total expenditure on
travel should be included as part of financial costs. Economic costing is
required if the price of this travel seems to be distorted.
If travel is included, it is important not to double-count its components
under other categories (e.g. consultant's travel could be included here or
under 'consultancy'; it is suggested that their travel be included under
'consultancy activities').
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Strategy-specific comments
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For HIV blood screening, vehicles used to implement the strategy are likely
to vary. Recruitment of donors at low risk of being HIV-infected may require
mobile blood collection services. Reorganization of services may necessitate
additional transport for the central testing and subsequent distribution of
blood
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For mass media and HIV education in schools, vehicles may be needed
during training activities and for the distribution of educational materials.
Transportation costs may be relatively high if printed IEC materials have to be
distributed. This is not contracted out and hence costed as an aggregate
input elsewhere.
•
In CSM, most transport requirements, for example for promotion or distribu
tion activities, will usually be contracted out to other agencies. If the social
marketing organization owns and runs its own vehicles, an appropriate share
of the capital and recurrent costs of these should be allocated to the CSM
project.
•
For CSW peer education, vehicles may be used by NGO staff to identify new
project sites, hold education meetings and make supervisory and monitoring
visits.
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Purchase of vehicles specifically for STD treatment is most likely in vertical
systems.
•
For VCT, vehicles may be used to transport samples for testing, and to pro
vide follow-up support to those tested.
•
For 1DU interventions, elements of transportation or travel may be used in
training staff and volunteers, distribution of IEC and other supplies and safe
disposal of contaminated supplies and equipment.
d) Consultancies (Form C4)
Short-term consultancies can be treated as a separate input. Since many HIV pre
vention projects have been initially set up vertically, they have been externally
supported and are characterized by consultancy inputs provided by either expa
triate or local experts. It is important to record these costs separately as they can
be relatively high, often financed in foreign currencies and may skew analyses if
recorded as integral parts of other input categories.
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Consultancies may involve technical assistance from a variety of organizations,
both national and international, for example from donor or specialized agencies
or from advertising firms. Inputs may be provided by consultants external to the
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implementing organization or by experts from the organization's own head
quarters. The costs of consultancy packages usually comprise salaries or fees,
international and/or local travel and subsistence and miscellaneous reimburse
ments. Some consultancies, such as those contributing to pilot projects or mar
ket research, will be provided once only during project start-up and, if relevant
to the analysis being undertaken, these costs should be recorded as capital costs
on form C4. Start-up costs will be relevant when analysis is of total costs of a
project since inception but not relevant when analysis is focused on efficiency
and sustainability of on-going activities. Some consultancies may not just be
restricted to the start-up phase but may instead be a capital component of the
on-going project. Examples are training consultancies whose effects are antici
pated to remain over several years.
It is important to decide which consultancies to include, since different missions
will have very different purposes. Where a project is partially donor-financed
there may be regular donor consultancies, especially for monitoring and evalua-,
tion purposes. The project itself may not incur financial costs for these inputs
but, if they are deemed essential to its local implementation, their economic
costs should be included in any economic analysis. It is suggested that costs be
included where the consultancy forms an important part of project support, but
excluded where it is for the purpose only of satisfying donor requirements, for
example those monitoring or evaluation missions for the donor headquarters
overseas. Long-term consultants, present for 12 months or more, should be
recorded and costed on personnel form C5a.
Consultancy inputs are likely to vary considerably in terms of the number of indi
viduals involved, the lengths of inputs and their purpose. Column 1 of Form C4
can be used to record these details briefly, but sufficiently to distinguish the par
ticular consultancy for future reference. The funder of the consultancy can be
recorded in column 2.
Financial cost
Often only part of the costs of the consultancy package will be met from the pro
ject's in-country budget. Expatriate inputs, in particular, may be funded by multior bilateral donors, sometimes even from non-project expenditure subheads.
Only actual expenditure by the project needs be recorded as a financial cost in
Form C4. If a total expenditure figure is available for the consultancy, this can be
recorded directly in column 6 without being broken down into its component
parts in columns 3, 4 and 5.
The same approach should be taken to annual costing of capital consultancies
as for other capital items. The number of years for which the effects of the con
sultancy are expected to last should be recorded in column 8. The total cost of
the consultancy should be divided by the duration of effect, and the average
annual cost should be recorded in column 9.
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Economic cost
The full value of the consultancy inputs (even if 'donated' from external funding)
should be recorded on Form C4 if the analysis is to use economic costs. Donors
can be approached for information on consultants' daily fees and subsistence
rates and prices paid for air fares. Precise information on these costs, often paid
by headquarters offices overseas, may not be available, but rough figures should
at least be estimated and entered in columns 3, 4 and 5. The total economic cost
of the input should be entered in column 7. Where costs are met in foreign cur
rency, this should be recorded in a footnote and the local currency equivalent
entered (see sections on 'Currency' and 'Converting to constant prices' in 4.3).
Annualization of the costs of the consultancy should be undertaken, as for the
other economic capital costs. The average annual economic cost should be
entered in column 10.
Allocation
If the consultancy input is being shared between HIV prevention and other work,
the costs of the input should be allocated on the basis of the proportion of the
consultants' time spent on each type of work. The allocated percentage and the
resulting costs should be entered in columns 11 and/or 12.
Strategy-specific comments
Start-up consultancies, often used for training of trainers and the production of
IEC materials, are important for many strategies. Although some governments or
National AIDS Control Programmes may launch IEC campaigns alone, mass
' media and CSW peer education projects are increasingly incurring consultancy
costs, particularly in the design and development of IEC materials. For HIV edu
cation in schools, some consultancy costs may be incurred in the design and
development of the strategy and its curricula and materials. CSM projects tend to
have high start-up costs incurred by market research, project design and project
launch. For STD treatment, some consultancies might provide technical assis
tance for development of diagnosis and treatment protocols. Start-up consultan
cies may also establish baseline studies to monitor different HIV prevention strate
gies, and be used for training of trainers and the production of IEC materials.
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in terms of the loss of clients and lowering the price of the transaction,
because they insisted on the use of a condom.
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In order to get an estimate of the opportunity cost, the average loss of
clients in a month was multiplied by the average price of a transaction. This
average price was obtained by looking at the various sub-groups in the
CSW population and the range of prices charged for a transaction <74).
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f) Supplies (Form C6)
Supplies are materials that are used up in the course of a year. Equipment cost
ing under $100 (unless national accounting procedures specify a different cut
off point) can also be treated as supplies even if they will last longer than the
year. All categories of supplies consumed should be listed in column 1 of Form
C6 and their funding source noted in column 2. "You might wish to distinguish
between supplies acquired with local currency and supplies requiring foreign
exchange. The general data-handling process will be similar. In some instances,
it will be useful to identify separately, and summarize, major supply categories or
categories of particular interest (i.e. calculate subtotals for drugs, stationery).
"The full cost of supplies should include the cost of transport to the point of use
(i.e. any freight charges for import of materials and any internal distribution
costs). The cost should be that of all the material consumed, including any that
is lost or wasted as well as that which is actually used for its intended purpose.
Losses can result from misplaced shipments, damage (e.g. from water or
rodents), pilfering and materials becoming out of date. This loss has to be paid
for by the programme, and should be included in the estimates. Supplies to be
costed do not include those that are distributed but kept in store (as inventory
stocks). Only those that are consumed should be counted.
"Unless expenditure records are very detailed, they are unlikely to be useful for
estimating the costs of most of the materials specific to your programme.
Instead, you will need information on quantities and prices.
"Quantities: For many supplies, there will be stores at different levels (national,
regional, health centres), which will usually have their own inventory records.
The quantity distributed from these stores during the year will be equal to the
inventory at the beginning of the year plus the quantity received during the year
less the inventory at the end of the year.
"The amount distributed is not necessarily the amount consumed: commodities
may be stored at a lower level. Only at the lowest level of the distribution sys
tem, such as the health centre, are supplies dispensed the same as supplies con
sumed. However if you measure only consumption, you will fail to take into
account the wastage that has occurred.
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"Prices: Supply invoices, order forms, price lists and catalogues are sources of
information about purchase prices or replacement prices. Costs of interna
tional and internal transport should be included. International freight costs can
usually be readily determined (supply invoices and order forms should include
them) and should not be overlooked, since they often add a further 10-20%
to the original price. It may be more difficult to estimate internal transport
costs; in fact, if supplies are transported by vehicles belonging to the pro
gramme, the costs will be included in the vehicle running costs and should not
be included here" (PHC: 36-38).
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Financial cost
If detailed expenditure records are available, the financial costs of supplies con
sumed should be entered directly in column 6. These costs should include
transportation of the supplies to the point of use. Where reliable expenditure
records are not available, costs should be calculated from quantities con
sumed, including loss and wastage (column 3), and unit costs (column 4/5). If
quantities consumed are not available, it may be necessary to estimate con
sumption based on output. For example, to estimate the consumables used in
blood collection and testing, an inventory of all the consumables needed per
unit of blood could be costed, and then multiplied by the number of units col
lected. Allow a margin (approx. 10%) for loss and wastage.
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Imported supplies should be grouped together and, where purchased in for
eign exchange, this should be recorded in a footnote on the form. The equiv
alent local currency costs should be calculated using the procedure outlined in
'Currency' and 'Converting to constant prices' in 4.3.
Remember that if materials have a life longer than a year (e.g. a film), then
their value will need to be annualized over their length of life, and these mate
rials should be treated as capital items.
Economic cost
Market prices should be taken as the economic unit costs of donated goods
and these prices should be entered in column 5. Where market prices for cer
tain supplies are known to be highly divergent from the true opportunity costs,
a shadow price should be substituted as the economic cost in column 5 or 7.
This may be particularly relevant in the case of drug and condom supplies
where import prices may be subsidized, inflated due to economic/political
tying to certain exporters, or distorted through unrealistic exchange rates.
Shadow prices can be calculated from the international market prices or can
be from the Essential Drugs Programme or from a supplier such as UN Supplies
Division and converted into local currency prices using the market exchange
rate.
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Allocation
Data, especially when taken from expenditure records, may aggregate supplies
consumed by HIV prevention and other work. It may, therefore, be necessary to
allocate only a proportion of the costs of the supplies to HIV prevention. This
would most usually be done on the basis of activity measures as shown in some
of the examples in Part 3. The percentage allocation of costs and the resultant
cost to the strategy should be entered in column 8 and/or 9.
•
*
•
•
Additional supply costs will be incurred for HIV blood screening. These will
include one-test kits, small pieces of equipment, and chemical reagents for use
in the laboratories. There may also be an increase in the cost of medical and
surgical equipment for collecting blood, such as blood bags and needles, since
a greater volume of blood will need to be collected to allow for discarding.
Some office supply costs might also increase, in line with increased strategyrelated administration
For mass media and HiV education in schools; if the lead organization is
producing some of its own IEC materials then considerable supply costs may
be incurred directly for such commodities as photocopying supplies, ink,
videos, cassettes and batteries or, indirectly, through the use of government
printing facilities. Alternatively, IEC material production may be contracted out
and costed as an aggregate activity. For example, commercial printers may be
used to produce campaign posters and pamphlets and specialized advertising
agencies may be used to produce television and radio materials.
The recurrent costs of CSM projects can be high and this is, in part, attributable
to the costs of the condom supplies. Their source and price can be highly vari
able. The financial cost of the condoms should be obtained and, if imported, this
should include the cost of transportation into the country. The financial price of
condoms may be highly inflated or subsidized. Inflated prices occur when
donors' commodities are purchased in home markets and are considerably more
expensive than those on the international market. The financial cost to the proj
ect may be zero if the commodities are donated but the financial cost to the
donor may exceed the economic opportunity cost of those commodities.
Many CSM projects receive condoms from donors and their supply prices are
higher than prices on the international market. If there is a possibility that, in
the future, condoms bought at competitive prices will be provided to the proj
ect, then a shadow economic price could be used in the cost analysis. An
appropriate price can be obtained from the Essential Drugs Programme or
from a supplier such as UN Supplies Division. In reality, however, many social
marketing projects will continue to be sourced with donors' condoms for the
foreseeable future and the inflated prices may, therefore, be most relevant for
any medium-term analysis of these projects.
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Where the project is able to negotiate with commercial condom suppliers to
provide subsidized condoms in return for financing some of their marketing
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and promotion activities, there may again be a requirement to calculate a
shadow economic price for the costing analysis. This is particularly true if the
present subsidized price cannot be guaranteed in the future.
•
Supplies for STD treatment will mainly include diagnostics, laboratory supplies,
condoms and drugs. Costs of these are likely to be relatively high and should,
therefore, be calculated with some care. Costs of some supplies may need to
be allocated between STD and non-STD work and this should be done accord
ing to the activity measures outlined in the personnel section above.
•
To record the quantity and cost of drugs consumed by an STD clinic, expen
diture information should be sought from the next organizational level up—
say, the district level—where cost and quantities may have already been com
bined and recorded in accounting information. If that information is not avail
able, drug use should be investigated at the clinic in question, for example
from their inventories. In both these situations, drug costs may need to be
allocated between treatment of STD and other illnesses. If neither of the
above methods is possible, clinicians could be asked to record their prescrip
tions prospectively over a period of, say, one week. Total STD drug costs could
then be estimated from average prescription costs and facility utilization data.
The total costs derived this way should be inflated by a locally agreed factor
to allow for the additional costs of drug wastage and loss.
s/
Tip-of-the-Trade 9;
Calculating the total costs of drugs in an
STD treatment programme in the United Republic of Tanzania
The quantity of drugs prescribed was estimated through the analysis of a
sample of health units. Data on drugs prescribed for the last 20 registered
STD cases were recorded from a survey of treatment registers. The drugs
prescribed were costed from unit prices provided by the national Essential
Drugs Programme in the United Republic of Tanzania (inclusive of cost,
insurance and freight). Then the total cost of drugs supplied was estimated
on the basis of the total number of STD cases seen in all the health units
and an estimate of the proportion of patients actually provided with drugs.
Since drugs are often in short supply, it was estimated that only 40% of
patients were supplied drugs (with sensitivity analysis of 20% and 60%
used). Costs of drug storage and delivery within the country were esti
mated crudely as a cost per health unit (multiplied by the number of health
units) and then added to the total drug costs (65>.
•
For CSW peer education, the main supply costs will be for IEC materials and
for condoms. The relatively high recurrent costs of the strategy can, in part,
be attributed to condom supplies, the source and price of which can be
highly variable.
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g) Vehicle operation and maintenance (Form C7)
Many health programmes rely on vehicles to distribute supplies, permit coordi
nation and supervision, and otherwise implement the provision of care. Often,
transport is a weak link; vehicles are available but fail to operate efficiently
because of a lack of fuel or spare parts. It is important to know what it costs to
operate and maintain vehicles. Unfortunately, these costs are among the most
difficult to measure.
The costs of operating, maintaining and repairing vehicles should all be meas
ured. These will include materials, such as fuel, lubricants, insurance and regis
tration fees, tyres, batteries and spare parts. The cost of drivers should be
recorded under 'personnel'. If a mechanic is assigned to the programme, the
cost will also be included under 'personnel'. However, where repairs and main
tenance are contracted out, or where they are performed by a different office or
agency, their cost should be included under 'vehicle operating costs' (i.e. you,
should make an estimate of total repair costs, including an allowance for the
mechanic's salary, rather than including the salary under personnel costs).
"Expenditure records may give some indication of the cost of operating and main
taining vehicles, but it is likely that you will need to interview drivers and mechan
ics and consult logbooks to get a sufficiently detailed picture. Fuel consumption
is one input for which records are probably reasonably good. If not, you should
be able to estimate fuel consumption based on the mileage of the vehicle.
Logbooks should indicate distance travelled (say, 5000 kilometres), and drivers
should be able to tell you the average distance travelled per litre of fuel consumed
for that particular type of car in the prevailing conditions (say, 10 km per litre).
Total consumption is then 5000/10 = 500 litres. The price paid per litre for fuel
multiplied by the number of litres used gives the total cost of the fuel (even if it
is merely charged to a government account). If logbooks and other information
sources are not adequate for the calculations suggested (which is all too often the
case), alternative data sources can probably be employed. For example, your min
istry's central motor pool personnel may be able to give you a rough estimate of
the total annual cost of operating and maintaining each type of vehicle. With
information on the vehicles used (and the fraction of their time devoted to your
programme) you can make a 'rough and ready' calculation that will suffice.
"Oil and filter changes and other maintenance may be done irregularly or on a
routine basis, either after a set number of kilometres or at regular time intervals
(e.g. once a year). If you are unable to calculate these inputs in the same way as
fuel, you could simply increase fuel costs by a set percentage (e.g. 15%) to allow
for them. Again, the central motor pool may help you with this" (PHC: 39).
Financial cost
Form C7 summarizes the mam inputs for operating, maintaining and repairing
project vehicles. The easiest and preferred method is to access expenditure
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Collection of cost data
records for vehicle running costs. If such expenditure records are not available,
logbooks and staff interviews should be used. If logbooks are not available, staff
interviews alone will have to provide the necessary information. If no reliable
information can be gleaned from any of the above, the least preferred method
is to apply the value of standard’government mileage allowances to the mileage
undertaken in implementation of the strategy. These mileage allowances are
devised to reimburse officers for official use of private vehicles or to charge them
for private use of official vehicles and are deemed to cover running costs plus
depreciation. In this situation it is important to ensure that the capital costs of
the vehicles are not double-counted between this form and Form C3.
Economic cost
Where financial costs are clearly different from opportunity costs, for example
where mechanics work voluntarily on vehicles, estimated economic costs can be
entered in column 4. Where vehicle running costs are a relatively small compo
nent of overall costs, limited time should be spent trying to calculate economic
costs and shadow prices.
Allocation
Some vehicles may.be used exclusively for implementing the AIDS strategy.
Others, however, may be shared between the strategy and other work and their
running costs must be apportioned accordingly. In columns 5 and 6 of Form C7,
the allocation made can be recorded and used to apportion costs. It is recom
mended that all inputs on Form C7, apart from personnel, be allocated by
mileage undertaken for the strategy as a proportion of total mileage in a sam
ple month. If logbooks are not available from which to derive this information,
’ staff should be interviewed to ascertain the proportion of days in a sample
month that the vehicle is used to implement the strategy.
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The way in which all the above allocations are made should be recorded either
as a footnote on the worksheet or separately.
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h) Building operation and maintenance
(Form C8)
"Operation and maintenance of inputs is quite easily handled. Although
observers are sometimes concerned with utility expenses, these do not form a
large proportion of the total. If it is difficult to obtain information, draw on past
experience (and other opinions) to obtain a rough estimate of building operation
and maintenance as a proportion of the annual market rent. Multiply the annual
rent by this proportion to obtain an amount for operation and maintenance.
"Operation and maintenance for buildings should include charges for lighting,
water, telephones, heating, insurance, cleaning materials, painting, and repairs
91
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to plumbing, roofing, heating and office furniture. As previously noted, the
salaries of guards, cleaners, etc. should be counted under 'personnel'.
"This is one category where recorded expenditure data are sometimes quite ade
quate. Recurrent costs for buildings will normally be listed under such headings
as 'utilities, maintenance or cleaning, and security"' (PHC: 40).
3
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Financial cost
If expenditure information is available, then it should be used to complete Form
C8. Information should ideally be recorded for a full year to allow for seasonal
fluctuations in utility expenditure. If annual utility expenditure figures are avail
able, then a total figure can be inserted for the year in row 15 rather than being
built up by month. If expenditure information is not available, then a percentage
of the rental, value of the building should be used to cover these costs. The
appropriate percentage should be estimated by local managers and will var
according to the quality of building construction, the age of the building and the
nature of the services being provided there. The figure calculated should be
entered in row 16 of Form C8, together with an explanatory footnote. This
rough estimation is acceptable, as these costs are unlikely to be significant in the
overall profile of costs.
1
Economic cost
If it is felt necessary to substitute any shadow prices for financial costs, clear foot
notes should indicate where and why this has been done.
Allocation
If a building is shared between HIV prevention and other work, the running costs
of that building will need to be allocated accordingly. This should be done by calculating the proportion of floor space used by the HIV-related work as a propor
tion of the total floor space of the building that the running costs relate to, and/or
by the share of time that that space is used for the HIV work. The percentage allo
cation of costs and the resulting cost to the strategy should be entered in row 17.
!
i) Short-term consultancies (recurrent) (Form C9)
For a discussion of short-term consultancy inputs, see section (d) under 'Capital
costs' above. Under recurrent costs, consultancy inputs that recur throughout
the life of the project should be recorded, for example consultancy inputs to
annual monitoring and review missions. Judgement should, however, be made
as to whether such consultancies are an essential and necessary part of the
progress of the project, in which case they should be included, or whether they
are conducted for donors' own monitoring purposes and should be excluded
from the costs of the project.
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Financial cost
See section (d) above. The frequency of the consultancy inputs being costed
should be recorded in column 8 of Form C9. (If a project document is available,
this should indicate the planned frequency of these inputs.) The frequency of the
inputs may indicate the need to translate costs recorded for one particular year
into average annual costs. For example, if consultants are provided for monitor
ing missions every other year, the costs for each mission should be halved to pro
vide an average annual cost. Average annual costs can then be recorded in
columns 9 and/or 10.
Economic cost and Allocation
See section (d) above.
j) Other recurrent costs (Form CIO)
"This is the residual category. It was recommended that all the inputs to training
and social mobilization programmes should be added together to give a single
figure, rather than including them under separate headings (personnel, build
ings, etc.). Each of these input categories has its recurrent counterpart, when
activities are repeated periodically. The sum of these activities over one year is a
recurrent cost of the programme. There are probably no special problems
involved, or instructions needed, for calculating the costs of these two categories
of inputs. If a training or social mobilization programme serves more than one
programme, the total cost should be distributed among those served. If training
and social mobilization are costed as discrete inputs, care must be taken not to
duplicate any of the costs elsewhere in the exercise.
■
"Recurrent equipment costs include fuel (e.g. kerosene for cold-chain refrigera
tors) or electricity operating costs (but only if these are not included under build
ing operation and maintenance), as well as the cost of spares for maintenance
and repairs. Other categories might include postage, printing, photocopying and
the costs of operating and maintaining equipment, but not stationery, which is
counted under 'supplies’.
"Expenditure records may contain some data, but they are unlikely to be detailed
enough. For a piece of electrically operated equipment you will need to know its
power requirements (the number of kilowatt-hours), the length of time it is oper
ated over the year, and the cost per unit of electricity. You will probably need to
ask the people directly responsible for the equipment about the kind of mainte
nance and repairs that were necessary and what spare parts were needed. There
are a variety of 'rules of thumb' to estimate the likely operating and maintenance
costs of equipment used in health programmes. Most of these rules relate recur
rent costs to the original capital expenditure. The specific relationships will
depend on the price structure in the country, the nature of the equipment, and
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so forth. You should explore the precise cost relationships in your own situation
rather than relying on approximations from elsewhere" (PHC: 40-41).
For most HIV prevention strategies, this cost category will be relatively insignifi
cant. It will, however, be more significant for mass media and condom social
marketing strategies as media costs will be included here. How these are dealt
with is discussed further under the 'strategy-specific comments'. Potential inputs
for other strategies include equipment maintenance, operating and repair costs,
postage, photocopying and printing. Only minor effort should be made to cost
these inputs where they are likely to be negligible in the overall profile of costs.
Financial cost
If available, cost information should be taken from expenditure records. If
unavailable, rough estimates of costs should be made from quantities of incuts
consumed and prices.
Economic cost
Ip
If any of the financial prices clearly do not reflect opportunity costs, a shadow
price should be substituted in column 4, but effort in doing this should be pro
portional to the cost. Media fees are dealt with separately below.
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Allocation
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Shared costs should be apportioned in a manner appropriate to the way that
they are incurred. The percentage allocation of costs and the resulting cost to the
strategy should be entered in column 5 and/or 6.
Strategy-specific comments:
•
In HIV blood screening, where blood donors are given financial incentives,
there may be an increase in payments, proportional to the increased volume
of blood collected. This applies also to any refreshments or gifts provided for
blood donors, and should be counted as other recurrent items.
•
For mass media and CSM, this category of costs will include the costs of
media time and/or space. Extrapolating from other public health media cam
paigns, it can be expected that media costs will vary greatly between coun
tries. This reflects absolute and relative differences in the price of media,
which affects the project's purchasing power, and also differences in the type
and quality of media used ns).
•
In countries where there are state-run newspapers and radio and television
channels, the financial costs of using these media may be subsidized or free
to the project. In some countries, it may even be legislated that a certain per
centage of air time or press space is to be dedicated to educational messages.
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If it is felt that this situation cannot be guaranteed in the future, then any
economic analysis should include the economic opportunity cost of the
media used. This is best calculated by ascertaining the cost of the same
amount and quality of media time or space for a commercial campaign.
•
Where media slots are charged at a commercial price to the project, it can be
assumed that these costs are economic ones, including all associated costs
and overheads.
•
For HIV educations in schools and CSW peer education, where expendi
ture for initial or refresher training is available, it is likely that training costs
will be a significant component of total costs. The training packages may
include the costs of preparation, the venue used, transport, materials, train
ers' personnel costs, per diems of attendees and the cost of the time of the
school staff participating.
k) Private costs (Form C11)
Private individuals have been mentioned as a source of funds in this chapter.
Each of the 'C' Forms seeks information on the source of funds for inputs, and
the fact that some inputs are privately financed can be recorded there. Although
these guidelines take the perspective of service providers, these expenditures
should be recorded in order to calculate project revenues and hence the net
costs of the project.
Form Cl 1 provides a separate record of the cash fees that are raised from indi
vidual clients. The form is very general, allowing collection by month for a num’ ber of types of fees and will, therefore, need to be adapted to particular cir
cumstances. The preferred method of obtaining the data is from fee collection
registers or income records. If these are not available, estimates of fees raised
should be made from volume of clients and average official fee’rates, although
these estimates will clearly miss over- and under- charging and any leakage of
funds. Data on fees paid should be kept separate and not added to total costs
(otherwise there will be double-counting).
To set the data in context, more qualitative information should also be recorded
on how the fees are administered and managed; for example, whether they can
be kept at the level at which they are collected and what they can legitimately
be used for.
»
For HIV blood screening, the most common private costs will be fees paid
for transfusions. Data on fees collected should be obtained from the BTS.
However, it will probably be possible only to record gross fees for the trans
fusion provided, and not to disaggregate the element of the overall fee that
patients are implicitly paying for 'HIV-safe' blood.
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Table 4: Annualization factors
Discount rate
Number of remaining years of useful life
n
c
z
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on
5.747
6.247
6.710
9%
0.917
1.759
2.531
3.240
3.890
4,486
5.033
5.535
5.995
6.418
10%
0.90
1.73
2.48
3.17
3.79
4.35
4,86
5.33
5.75
6.14
11%
0.90
1.71
2.44
3.10
3.69
4.23
4.71
5.14
5.53
5.88
12%
0.89
1.69
2.40
3.03
3.60
4,11
4.56
4,96
5.32
5.65
13%
0.88
1.66
2.36
2.97
3.51
3.99
4,42
4,79
5.13
5.42
14%
0.877
1.647
2.322
2.914
3.433
3.889
4.288
4.639
4.946
5 216
15%
0.870
1.626
2.283
2.855
3.352
3.784
4,160
4.487
4,772
5.019
16%
0.862
1.605
2.246
2.798
3.274
3.685
4.039
4,344
4.607
4.833
17%
0.855
1.585
2.210
2.743
3.199
3.589
3.922
4,207
4,451
4.659
18%
0.847
1.566
2.174
2.690
3.127
3.498
3.812
4.078
4,303
4.494
19%
0.84
1.54
2.14
2.63
3.05
3.41
3.70
3.95
4.16
4.33
20%
0.83
1.52
2.10
2.58
2.99
3.32
3.60
3.83
4.03
4.19
7.499
7.943
_8 358
8.745
9.108
9.447
9.763
10.05
10.33
10.59
7,139
7,536
7,904
8.244
8,559
8,851
9.122
9.372
9.604
9.818
6.805
7,161
7.487
7,786
8.061
8.313
8.544
8.756
8.950
9.129
6.49
6.81
7,10
7.36
7.60
7.82
8.02
8.20
8.36
8.51
6.20
6.49
6.75
6.98
7.19
7.37
7.54
7.70
7,83
7.96
5.93
6.19
6.42
6.62
6.81
6.97
7.12
7.25
7.36
7.46
5.68
5.91
6.12
6.30
6.46
6.60
6.72
6.84
6.93
7.02
5.453
' 5.660
5.029
5.197
5.342
5.468
5.575
5.668
5.749
5.818
5.877
5.929
4.836
4,988
5.118
5.229
5.324
5.405
5.475
5.534
5.584
5.628
4.656 4,48
4.793 ‘ 4.61
5.842
6.002
6.142
6.265
6.373
6.467
6.550
6.623
5.234
5.421
5.583
5.724
5.847
5.954
6.047
6.128
6.198
6.259
5.273
5.316
5.353
5.03
5.07
5.10
4.32
4,43
4,53
4,61
4.67
4.73
4,77
4,81
4,84
4.87
10.83
11.06
11.27
11.46
11.65
11.82
11.98
12.13
12.27
12.40
10.017
10.201
10.371
10.529
10.675
10.810
10.935
11.051
11.158
11.258
9.292
9.442
9.580
9.707
9.823
9.929
10.027
10.116
10.198
10.274
8.64
8.77
8^88
8.93
9.07
9.16
9.23
9.30
9.37
9.42
8.07
8.17
8.26
8.34
8.42
8.48
8.54
8.60
8.65
8.69
7.56
7.64
7.71
7.78
7.84
7.89
7.94
7.98
8.02
8.05
7.10
7.17
7.23
7.28
7.33
7.37
7.40
7.44
7.47
7.49
6.687
6.743
6.792
6.835
6.873
6.906
6.935
6.961
6.983
7.003
6.312
6,359
6.399
6,434
6.464
6.491
6.514
6.534
6.551
6.566
5.973
6.011
~6.044
5.665
5.696
5.723
5.746
5.766
5.783
5.798
5.810
5.820
5.829
5.384
5.410
5.432
5.451
5.467
5.480
5.492
5.502
5.510
5.517
5.12
5.14
5.16
5.18
5.19
5.20
5.21
5.22
5.22
5.23
4.89
4.90
4.92
4,93
4.94
4.95
4.96
4.97
4.97
4.97
1
2
3
4
5
6
7
8
9
10
1%
0.990
1.970
2.941
3.902
4.853
5.795
6.728
7.652
8.566
9.471
2%
0.980
1.942
2.884
3.808
4,713
5.601
6.472
7.325
8.162
8.983
3%
0.971
1.913
2.829
3.717
4,580
5.417
6.230
7.020
7.786
8.530
4%
0.962
1.886
2.775
3.630
4.452
5.242
6.002
6.733
7,435
8.111
5%
0.952
1.859
2.723
2.546
4.329
5.076
5.786
6.463
7.108
7.722
6%
0.943
1.833
2.673
3.465
4.212
4.917
5.582
6.210
6.802
7.360
7%
0.935
1.808
2.624
3.387
4,100
4.767
5.389
5.971
6.515
7.024
11
12
13
14
15
16
17
18
19
20
10.36
11.25
12.13
13.00
13.86
14,71
15.56
16.39
17.22
18.04
9.787
10.575
11.348
12.106
12.849
13.578
14.292
14,992
15.678
16.351
9.253
9.954
10.635
11.296
11.938
12.561
*3.166
13.754
14.324
14.877
8.760
9.385
9.986
10.56
11.11
11.65
12.16
12.65
13.13
13.59
8.306
8.863
9.394
9.899
10.380
10.838
11.274
11.690
12.085
12.462
7.887
8.384
8.853
9.295
9.712
10.106
10.477
10.828
11.158
11.470
21 18.85
22 19.66
23 20.45
24 21.24
25 22.02
26 -22.79
27 23.56
28 24.31
29 25.06
30 25.80
17,011
17.658
18.292
18.914
19.523
20.121
20.707
21.281
21.844
22.396
15.415
15.937
16.444
16.936
17.413
17,877
18.327
18.764
19.188
19.600
14.02
14.45
14.95
15.24
15.62
15.98
16.33
16.66
16.98
17.29
12.821
13.163
13.489
13.799
14.094
14.375
14.643
14.898
15.141
15.372
11.764
12.042
12.303
12.550
12.783
13.003
13.211
31.406
13.591
13.765
8%
0.926
1.783
2.577
3.312
3.993
4,623
5.206~
6.073
6.097
6.118
6.136
6.152
6.166
6.177
4.910 4.71
5.008 4.80
5.092 4,87
5.162 ~ 4.93
5.222 j 4,99
-JU
^3-
fer?
E
f
Cost Analysis
Chapter 5
COST A^ALYS^S
Once all the component costs have been collected, then the data need to be
aggregated or collated. Sheets Cl-CIO allowed you to collect costs at different
levels. Form B is a summary of costs at each level. Once this is done, all the lev
els can be added up and entered onto Form A—the Project Summary sheet—to
get total costs.
I
i
5.1 Adding t'p costs
As indicated in the introduction, those projects with access to a computer can
enter data direc.ly into a spreadsheet package using the Microsoft Excel spread
sheets available on the UNAIDS website (www.unaids.org/pubiications) or the CD-ROM:
Economics in HIV/AIDS planning: getting priorities right, UNAIDS (June 2000).
They would be advised to apply the same methods to facilitate collation of data
from Forms C onto summary forms A and B (World Health Organization also
provides such software <91)- If a computer is not available, data can be collated
manually.
Form B (collating all Form C data at a particular organizational level) can be com
pleted with either financial or economic costs, or both. The Base Year costs in
the final column or row of each Form C should be transferred to their appropri
ate rows on Form B and then all of the input categories summed up to give a
total cost of the AIDS strategy at that organizational level. It must be remem
bered that if only a sample of units had been costed to represent all units at a
particular level, it is the total cost of the population of units from which the sam
ple was derived that should be calculated and transferred to Form B. A record
should be made of this calculation.
Form A collates the costs from each organizational level (the Form B data) to pro
vide the overall cost of the HIV prevention strategy or programme. Form A can
UNAIDS
■
be completed with either financial or economic costs (completing a form for
each, if necessary).
If the set of B forms shows all costs at all organizational levels, then they can be
added together to derive the overall total cost. If, however, the strategy being
costed is only part of a larger programme, then it may be necessary to allocate
only a proportion of higher-level costs to the overall cost calculation. For exam
ple, we may be interested in costing an AIDS strategy in one district only, within
a region of 10 districts and a country of 20 regions. In this example, if costs were
allocated equally between sub-units at a particular organisational level, Form A
would need to collate 100% of the costs calculated for the district, 10% of the
costs calculated for the region and 5% of the costs calculated for the central
level. Only these relevant proportions of costs at each organizational level should
be transferred to Form A for the final summation. If it is apparent that sub-units
(for example districts or regions) do not make eq’ual demands on the level above,
it may be decided to make a more accurate allocation of costs, for example
weighted by share of total budget or number of staff per sub-unit. A clear record
should be made of how this proportion was derived, both in footnotes on the
forms if they are being compiled manually and also more formally. ■
5.2 Cost profile
Once Form A is completed, you have essentially derived a cost profile of the proj
ect or programme that you have examined. It will look like the table below:
test
tettl tbit
?
■>
—' - I- --
........
;
t%)
Capital__________________
Buildings___________ ______
Equipment________________
Vehicles__________________
Consultancies (non-recurrent)
Total Capital Costs
5 000
5 000
5 000
____ 0
15 000
Recurrent______ _______________
Personnel_______________________
Supplies________________________
Vehicle operation and maintenance
Building operation and maintenance
Consultancies (recurrent)
Other
~
Total Recurrent Costs
20 000
5 000
5 000
1 000
4 000
____ 0
35 000
70
TOTAL COSTS
50 000
100%
10
10
10
30
40
10
10
2
8
Source: PHC: 12
UNAIDS
I
Cost Analysis
Alternatively, you could obtain a cost profile in terms of activities rather than
inputs. These profiles are useful in highlighting major cost components (and thus
identifying potential areas where improvements in efficiency may have signifi
cant impact on costs). For example, high drug costs could indicate wastage.
These cost profiles can be compared across different projects and programmes,
as well as within programmes. Within programmes the profiles can be presented
by different delivery units or providers, and a comparison can be made between
them. "If there are significant differences in cost profiles, then this may mean
that there may be ways to re-structure and improve efficiency" (PHC: 13).
However, comparison of cost profiles across countries or regions is problematic
due to different price structures. Comparison of cost profiles over time might be
more useful than the comparison across different projects. Thus, one must be
careful only to generalize from cost profiles, and then only when appropriate.
5.3 Unit costs
Once total costs of a programme or project have been calculated, then unit
costs can be derived. These can be calculated in terms of the outcome indica
tors for which you have collected data in sheet D, and are simply calculated as
total costs divided by the outcome measure.
Unit costs can be used to compare costs between similar projects, and consider
issues of project efficiency. There are several factors affecting unit costs,
including:
•
different prices paid for inputs by projects in different locations;
•
different mix of inputs used by different projects (e.g. more staff or more
supplies);
•
different levels of staff productivity,
•
there may be efficiencies gained due to the size or scale of the project
(economies of scale). For example, condom social marketing projects seem to
have lower unit costs in countries with large populations <51);
•
there may be efficiencies gained due to having a number of services or proj
ects undertaken together (economies of scope).
However, not all differences in unit costs should be attributed to differences in
efficiency. A higher unit cost may not indicate a less efficient programme. There
may be other factors driving these differences, for example:
•
22
Differences in unit costs may indicate differences in ease of delivery of serv
ices. For example, a project that is based in rural areas with a more dispersed
UNAIDS
4
population, or projects reaching more marginalized groups, might engender
higher costs. Thus there may be equity reasons why more resources are allo
cated to this project.
•
The duration of a project or programme may affect unit costs. Comparing an
established programme with a relatively new programme should take this
into account. This is particularly true for CSM projects, where some projects
have gone from start-up to accruing profits in the span of 12-15 years <52).
In addition, you may want to obtain unit costs by activity. For example, if you
have the costs of IEC production within a condom social marketing programme
and the number of lE't materials produced, then you can calculate the unit costs
of the materials produced. If training is an activity, then you can produce the unit
cost per training session. This can facilitate analysis of efficiency of particular
activities within a project.
5.4 Using the cost analysis in planning and
budgeting
Once the basic cost analysis is done, the information can be used in a variety of
ways to aid planning and budgeting for the future. In general, current cost data
can serve as a baseline for extrapolating information for both the future and for
other projects. What is clearly important is to consider to what extent the proj
ect from which you are obtaining cost information is similar to the activities that
you are hoping to do.
The financial cost analysis can contribute to an understanding of budgeting
requirements of a specified project. The financial cost analysis will give you an
idea of the total volume of resources that have been spent. The financial analy
ses will also serve as a basis for future budgeting. There are several ways that you
can use existing cost data to help in budgeting <1);
•L
•
An ingredients approach would mean that you list all of the possible inputs
and then consider to what degree you will be using them in the future proj
ect for the expected level of output (e.g. number of persons counselled) that
you would like to achieve. Once you have determined the 'quantity', you can
then work out the price and the cost. For example, if you think that you will
need 1.25 nurses, you can consider whether to hire one full-time nurse and
one part-time nurse, or whether it is feasible to hire one nurse and pay for
extended hours. This approach requires a lot of detailed cost information and
is appropriate if programme conditions are changing quickly.
•
A less detailed approach to budgeting would be to take the current costs of ‘
a project, extrapolate to your own circumstances, and then do a. rough
UNAIDS
Cost Analysis
adjustment depending on how similar you think the projects are. An impor
tant thing to consider is whether the project you are taking the costs from is
actually running efficiently. Alternatively, you could apply some mark-up to
the costs (e.g. 20%) to allow some margin of error.
Regardless of the method you use, if you are budgeting for the future you need
to adjust the price or cost information for inflation. You will need to consider
what level of inflation to take into account, and that prices will rise every year.
So, for instance, in a country with a relatively stable level of inflation of 8%, you
may choose 10% as the proportion by which you expect prices to increase each
year. However, if you are in an environment with rapid inflation, you may wish
to convert your costs to a more stable currency such as the US dollar and then
do your budget calculations
Financial cost analyses will also help to consider the affordability of projects, as
they provide information on the amount of money that is required to run a proj
ect. This information can be used to consider the range of sources and funds
that are available to finance the project.
However, as discussed in Chapters 2 and 3, financial cost analyses only reflect
the actual expenditure on a project. If a project had substantial donated com
ponents, then relying on financial cost analyses will give a distorted view of the
actual resources being used. Thus when considering issues such as replication of
projects to different settings or scaling-up projects in size, it is critical to consider
what basic infrastructure may have been in place which was not accounted for
in a financial cost analysis. For example, many NGO-based projects often receive
assistance in the start-up phase (e g. exchange of goods in kind or subsidized
printing). It is here that economic analyses are useful.
For an example of the implementation of the costing guidelines, please refer to:
The cost-effectiveness of HIV preventive measures among injecting drug users
in Svetlogorsk, Belarus, draft report, UNAIDS, 2000, which can be found on the
UNAIDS CD-ROM, Economics in HIV/AIDS Planning: Getting Priorities Right,
June 2000.
UNAIDS
Annex
Data Collection Sheets
This annex contains the data collection sheets, which are arranged as follows:
1.
Background data sheet
2.
Form A — Project Summary sheet—presents costs by input and level.
This is a collation of all Form B summary sheets.
3.
Form B — Summary of costs at each level.
This is a collation of all Forms Cl-CIO.
4.
Forms Cl-CIO provide the basis for data collection by input category:
Cl
— capital costs: buildings
C2
— capital costs: equipment
C3
— capital costs: vehicles
C4
— capital costs: consultancies
C5a — recurrent costs: personnel
C5b — example of personnel time allocation form
C6
— recurrent costs: supplies
C7
— recurrent costs: vehicles operation and maintenance
C8
— recurrent costs: building operation and maintenance
C9
— recurrent costs: consultancies
CIO — recurrent costs: other
Cl 1 — cost recovery: private costs
5.
Form D
collection of output/outcome data
UNAIDS
li,'
li
Annex
BACKGROUND DATA SHEET
Country
Project
Local currency
Discount rate (for base year)
Source
Consumer Price Indices (CPI) for years spanned by data collection:
Year
CPI
Market Exchange Rates for years spanned by data collection:
$
Other
Year
Official Exchange Rates for years spanned by data collection:
$
Other
Year
Local Market Interest Rates for years spanned by data collection:
Year
Local Official Interest Rates for years spanned by data collection:
Year
UNAIDS
FORM A
PROJECT SUMMARY SHEET
(Collation of all Form 'B' summary sheets)
Country
Project
Local currency
Costs for Base Year
Financial costs / economic costs (delete as applicable)
Cost Category
i
i’
Level
Level
Level
Total cost
(%)
Capital
Buildings
Equipment
Vehicles
Consultancies (non-recurrent)
Total Capital Costs
Recurrent
Personnel
Supplies
(•
Vehicle operation and
maintenance__________
Building operation and
maintenance__________
Consultancies (recurrent)
Other
Total Recurrent Costs
TOTAL COSTS
UNAIDS
i
Annex
FORM B
SUMMARY OF COSTS AT EACH LEVEL
(Collation of Forms Cl - CIO).
Country
Project
Project Level
Local currency.
Costs for Base Year
Cost Category
Financial costs
Economic costs
Capital
Buildings
Equipment
Vehicles
Consultancies (non-recurrent)
Total capital costs
Recurrent
Personnel
Supplies
Vehicle operation and maintenance
Building operation and
maintenance
Consultancies (recurrent)
Other
Total recurrent costs
TOTAL COSTS
Once all the component costs have been collected, then the data need to be
aggregated or collated. Sheets Cl - CIO allowed you to collect costs at differ
ent levels. Form B is thus a summary of costs at each level. Once this is done, all
the levels can be added up on Form A—the Project Summary sheet.
UNAIDS
FORM Cl
£
CAPITAL COSTS: BUILDINGS
Country
Project
Project Level
(1) Buildings (list)
Cost data collected from months
Source of data
Chosen Base Year
(2) Funded Annual rent/hire (5)
by
Furnishing @
10%
(3) Fin.
Total
c
z
>
0
LH
(4) Ec.
Total cost
(6) Fin.
(3+5)
(7) Ec.
(4+5)
(% allocation)
Cost
(8) Fin.
(9) Ec.
(10) Fin. (11) Ec.
FORM C2
CAPITAL COSTS: EQUIPMENT
Cost data collected rom months
Source of data .
Chosen Base Year
Country
Project
Project Level
Local currency
(1) Equipment
(list)
(3) Fin.
TOTAL
—
Life
expectancy
or working
life
Cost
(2)
Funded by
(4) Ec.
Annua: cost
(6) Fin.
(7) Ec.
(% allocation)
Cost
(8) Fin.
(9) Ec.
Base Year Cost
(10) Fin.
(11) Ec.
FORM C3
CAPITAL COSTS: VEHICLES
Country
Project
Project Level
Local currency
(1) Vehicles (list)
Cost data collected from months
Source of data
Chosen Base Year
(2)
Cost
Funded by
(3) Fin.
cz
z
o
on
Total
Life
expectancy
or working
life
(4) Ec.
Annual cost
(6) Fin.
(7) Ec.
(% allocation) Cost Base Year Cost
(8) Fin.
(9) Ec.
(10) Fin.
(11)
Ec.
FORM C4
CAPITAL COSTS: CONSULTANCIES
Cost data collected from months
Source of data
Chosen Base Year
Country
Project
Project Level
Local currency
(2)
(3)
(1)
Consultancy Funded Fees
detail
by
(4)
(5)
Travel Subsistenc
e + misc
Total cost
(8)
(3) + (4) + (5)
Life of I cost
effect
(6) Fin (7) Ec
TOTAL
c
z
>
c
CD
3
• Annua
%
allocati
on Cost
(9) Fin (W) Ec (11) Fin
Base
Year
Cost
(12) Ec (13) Fin
(14) Ec
FORM C5a
RECURRENT COSTS: PERSONNEL
Country
Project
Project Level
Local currency
(1) Category of
(2)
personnel (list with Funded
grade where
by
appropriate)
TOTAL
c
>
o
Cost data collected from months
Source of data
Chosen Base Year
Gross annual
salary
Cost of annual
Total annual
allowances (specify) cost
Cost
(3) Fin
(5) Fin
(9) Fin
(4) Ec
(6) Ec
(7) Fin
(8) Ec
(3) + (5) (4) +
(6)
(% allocation)
Base Year Cost
(10) Ec (11) Fin
(12) Ec
FORM C5b
EXAMPLE OF PERSONNEL TIME ALLOCATION FORM
Cost data collected from months
Source of data
Chosen Base Year
Country
Project
Project Level
Local currency
Time/Day
12
1
2
Mon
Tues
Wed
Thur
Fri
Sat
Sun
Total hours
Percentage of hours
List time allocation by arrows as indicated:
HIV prevention strategy work
Non - HIV prevention strategy work
C
Z
o
cn
3
4
Total strategy hours
FORM C6
RECURRENT COST: SUPPLIES
Country
Project
Project Level
Local currency
(1) Supplies (list)
Cost data collected from months
Source of data
Chosen Base Year
(2)
Funded by
(3)
Quantity
consumed
(including
loss and
wastage)
Unit cost
Cost
(5) Ec.
(6) Fin.
(3) x
(4)
Total
Base Year Cost
Cost
(4) Fin.
c
z
c
(% allocation)
(7) Ec.
(8) Fin.
(9) Ec.
(10) Fin.
(11) Ec.
FORM C7
RECURRENT COSTS: VEHICLE OPERATION AND MAINTENANCE
Country
Project
Project Level
Local currency
(1) Supplies (list)
Cost data collected from months
Source of data
Chosen Base Year
(2)
Funded by
Cost
Oil
Maintenance
Insurance
Registration
Repairs
Spare parts
Total
c
z
O
U1
Base Year Cost
Cost
(4) Fin.
Petrol/diesel
(% allocation)
(5) Ec.
(6) Fin.
(7) Ec.
(8) Fin.
(9) Ec.
£
FORM C8
g
RECURRENT COSTS: BUILDING OPERATION AND MAINTENANCE
Country
Project
Project Level
Local currency
(1) Utility
(2) Source of funds
(3) January
(4) February
(5). March
(6) April
(7) May
(8) June
(9) July
(10) August
(11) September
(12) October
(13) November
(14) December
(15) Annual cost
c
z
o
(16) Total annual cost
(17) (% allocation) Cost
(18) Base Year cost
Cost data collected from months
Source of data
Chosen Base Year
Telephone/fax
Insurance
Maint./repair
Other
FORM C9
RECURRENT COSTS: CONSULTANCIES
Country
Project
Project Level
Local currency
(D
(3)
(2)
Consultancy Funded Fees
detail
by
Total cost
(4)
(5)
Travel Subsistence (3) + (4) + (5)
+ misc
(6) Fin (7) Ec
Annual cost (% allocation)
(8)
Frequency
Cost
(9)
Fin
1 ■
TOTAL
c
z
>
o
X
Cost data collected from months
Source of data
Chosen Base Year
(W) Ec (11) Fin
(12)
Ec
Base Year Cost
(13) Fin
(14) Ec
FORM CIO
E
RECURRENT COSTS: OTHER
Country
Project
Project Level
Local currency
(1) Input (detail)
Cost data collected from months
Source of data
Chosen Base Year
(2) Funded
by
Annual cost
(3) Fin.
c
z
6
uo
TOTAL
(4) Ec.
Base Year cost
(% allocation) Cost
(5) Fin.
(6) Ec.
(7) Fin.
(8) Ec.
FORM C11
COST RECOVER:
Country
Project
Project Level
Local currency
Fee type (specify)
January
February
March
i. ■
April
May
June
<
July
August
September
October
November
December
Annual total
Strategy total
c
z
0
cn
Base Year Equivalent
Value
: PRIVATE COSTS
Cost data collected from months
Source of data
Chosen Base Year
X3
Q
X
FORM D
OUTPUT/OUTCOME DATA
Country
Project
Outputs for Base Year
Indicators
Units
Quantity
Process Indicators
Intermediate Indicators
UNAIDS
References and further reading
REFERENCES AND FURTHER READING
COST-EFFECTIVENESS GUIDANCE AND METHODS
fFF!
1.
Creese A and Parker D. (eds) (1994) Cost Analysis in Primary Health Care:
a training manual for programme managers. WHO Geneva.
2.
Drummond MF, O'Brien B, Stoddart GL, Torrance GW: (1997). Methods for
the Economic Evaluation of Health Care Programmes. Oxford: Oxford
Medical Publications.
3.
Gold M, Siegel J, Russell L, Weinstein W. (1996). Cost-Effectiveness in
Health and Medicine. Oxford: Oxford University Press.
4.
Hanson K and Gilson L. (1993) Cost, Resource Use and Financing
Methodology for Basic Health Services. Bamako Initiative Technical Report
Series Number 16. UNICEF, New York.
5.
Janowitz B and Bratt JH. (1994) Methods for Costing Family Planning
Services. United Nations Population Fund and Family Health International.
6.
Over M. (1991) Economics for Health Sector Analysis: concepts and cases.
Economic Development Institute of the World Bank, The World Bank,
Washington, DC.
7.
Phillips M, Mills A and Dye C. (1993) Guidelines for Cost-Effectiveness
Analysis of Vector Control. PEEM Secretariat, World Health Organization.
Geneva. WHO/CWS/93.4.
8.
Rowley J and Anderson RM. (1994) Modelling the Impact and Cost-effec
tiveness of HIV Prevention Efforts. AIDS 8: 539-548.
9.
World Health Organization. (1989) EPICOST Software for Costing an
Immunisation Programme. World Health Organization, Geneva.
10
World l le<illh Organization (1988) Estimating Costs for Cost-effectiveness
Analysis: Guidelines for Managers of Diarrhoeal Diseases Control
Programmes. World Health Organization, Geneva. WHO/CDD/SER/88.3
11.
Reynolds J and Gaspari KC. (1988) Operations Research Methods:Cost
Effectiveness Analysis. PRICOR Monograph Series. Bethesda, Maryland.
12.
Kumaranayake L (2000). "The Real and the Nominal: making inflationary
adjustments to cost and other economic data.n Health Policy and Planning.
15(2):230-234.
UNAIDS
GENERAL HIV PREVENTION STRATEGIES
13.
Bertozzi SM. (1991) Combating HIV in Africa: a role for economic research.
AIDS 5 (Supp 1) S45-54.
14.
Foster S and Lucas S. (1991) Socio-economic Aspects of HIV and AIDS in
Developing Countries. PHP Departmental Publication No.3, London School
of Hygiene and Tropical Medicine.
15.
UNAIDS. (1998) Technical Brief on Cost-effectiveness of HIV Prevention
Strategies. Geneva: UNAIDS.
16.
Kaplan EH and Brandeau ML. (1994) AIDS policy modelling by example.
AIDS 8 (Supp 1): S333-340.
17.
Kahn JG. (1996) The Cost-effectiveness of HIV Prevention Targeting: h
much bang for the buck? American Journal of Public Health 86(12): 1709-12.
18.
Mertens TE, Belsey E, Stoneburner R et al. (1995) Global Estimates of HIV
Infections and AIDS: further heterogeneity in spread and impact. AIDS 9
(Supp i): S251-272.
19.
Over M and Piot P. (1993) HIV Infection and Sexually Transmitted Diseases.
In: Jamison D and Mosley W et al. (eds) Disease Control Priorities in
Developing Countries. Oxford Medical Publications, Oxford University Press
for World Bank, Washington, DC, 455-525.
20.
Population Reports. (1989) AIDS Education—a beginning. Volume XVII,
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UNAIDS
The Joint United Nations Programme on HIV/AIDS (UNAIDS) is the leading advocate for global
action on HIV/AIDS. It brings together seven UN agencies in a common effort to fight the epidemic:
the United Nations Children’s Fund (UNICEF), the United Nations Development Programme (UNDP),
the United Nations Population Fund (UNFPA), the United Nations International Drug Control
Programme (UNDCP), the United Nations Educational, Scientific and Cultural Organization
(UNESCO), the World Health Organization (WHO) and the World Bank.
UNAIDS both mobilizes the responses to the epidemic of its seven cosponsoring organizations and
supplements these efforts with special initiatives. Its purpose is to lead and assist an expansion of
the international response to HIV on all fronts: medical, public health, social, economic, cultural,
political and human rights. UNAIDS works with a broad range of partners — governmental and NGO,
business, scientific and lay - to share knowledge, skills and best practice across boundaries.
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Join! United Nations Programme on HIV/AIDS
(JH UNAIDS
UNICEF • UNDP • UNFPA • UNDCP
UNESCO • WHO • WORLD BANK
Joint United Nations Programme on HIV/AIDS (UNAIDS)
20 avenue Appia, 1211 Geneva 27, Switzerland
Tel. '-M1221 "01 46 SI
Fax '+4122' 791 41 87
e-mail: unaick^ unaids.org
Internet: http; www.unaids.org
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