There is an urgent need worldwide to increase the coverage and scope of HIV/AIDS interventions, particularly in countries where HIV is spreading rapidly. A substantial body of experience and best prevention practices have been developed during the last two decades of the HIV pandemic. Obtaining sufficient funding for proven interventions, however, has been a challenge to many countries. The good news is that financing is increasing for international HIV/AIDS programs.
Module 6, Costing and Use of Resources:
Provides information to assist planners and program managers in making the best use of funds received, including criteria for resource allocation and ECR cost estimates by type and capacity of HIV/AIDS program.
Contains tables that break down the components of various costing tasks.
Lists key implementation questions for costing and use of resources for ECR.
Provides references and resources for further reading.
Criteria for Resource Allocation
The following three criteria can help countries determine how best to allocate their resources to the priorities selected.
Need-based proportional allocation. This approach, often the simplest, involves allocating financial resources for HIV/AIDS interventions on a per capita basis. An example of this is in the United States, where federal HIV prevention programs are broadly allocated in direct proportion to reported AIDS cases.
A more relevant method for developing countries may be to allocate resources on the basis of forward-looking criteria – for example, targeting social groups or communities at high risk for HIV and allocating funds to these communities on a per capita basis.
Institutional constraints. These types of constraints apply particularly in care and treatment. Human capacities and the health infrastructure often are used as criteria for deciding whether a specific set of care interventions can be provided. An example of how the continuum of prevention and care can look in a country is illustrated in Table 1.
Cost effectiveness. Resource allocation decisions generally are made on the basis of cost-effectiveness analysis. While it is ideal to use cost-benefit analysis – assessing the benefits as well as the costs of interventions – it is complex in practice and difficult to conduct.
An important aspect of cost-effectiveness analysis is that it allows planners to rank interventions that generate comparable results. For example, in the case of workplace intervention programs, output can be measured in terms of indicators, such as how many new HIV infections and sexually transmitted infections (STIs) were avoided. By dividing these indicators by the estimated cost of other alternative programs, the cost-effectiveness ratio of interventions can be determined and ranked. (Refer to Module 2 for a detailed overview of ECR technical interventions and to Module 3 for operational strategies.)
Table 1: ECR Interventions by Need, Complexity and Cost
Essential activities
HIV prevention programs for target groups and youth
HIV voluntary counseling and testing
Palliative care and treatment for common opportunistic infections (OIs): pneumonia, oral thrush, vaginal candidiasis, pulmonary tuberculosis (TB) or DOTS
Nutritional care
STI care and family planning services
Cortrimoxazole prophylaxis for persons living with HIV/AIDS (PLHAs)
Community activities that mitigate the impact of HIV, including legal restrictions against stigma
Intermediate complexity and cost
All of the above plus:
Active case finding and treatment for TB
Preventive therapy for TB for PLHA
Systemic antifungals for systemic mycosis such as cryptococcosis
Treatment of HIV-associated malignancies: Kaposi's sarcoma (KS), lymphoma, cervical cancer
Treatment of severe herpes
Prevention of mother-to-child transmission (MTCT)
Post-exposure prophylaxis for occupational exposure to HIV and for rape
Reduction of economic and social impact of HIV/AIDS
High complexity and cost
All of the above plus:
Triple antiretroviral therapy (ARV)
Diagnosis and treatment of difficult-to-diagnose and expensive-to-treat OIs, such as drug-resistant TB
Advanced treatment of HIV-related malignancies
Public services to reduce the economic and social effects of PLHA
Costing Steps for ECR by Type and Capacity of HIV/AIDS Program
While there is some information on costs of community- and district-level programs and individual facilities, little exists on costs of large-scale programs. The following four steps can be used as guidelines to estimate the cost of implementing a set of HIV/AIDS interventions on a large, or national, scale.
Costing Steps for ECR on a Large, or National, Scale
Step 1: Establish Size of Target Groups
Step 2: Define Current and Future Coverage for Interventions
ECR Costing Step 1: Establish Size of Target Groups The first step in costing HIV/AIDS interventions for ECR is to estimate the potential target groups (PTG) to be reached by prevention and care activities. For each intervention considered, a relevant target group is defined using epidemiological, behavioral and intervention data. A list of selected target groups with their corresponding interventions is shown in Table 2.
ECR Costing Step 2: Define Current and Future Coverage for Interventions For most interventions, existing capacity and health system infrastructure may limit the target groups that can be reached. These limits are reflected in the number of people who can be reached by the health system and the envisioned programs, and are referred to as the potential target group (PTG). The target levels of coverage reflect what is thought to be realistically achievable by 2005.
The concept of PTGs is used to ensure that the projected level of activities being planned is based on what may be feasible to implement, given current capacity and infrastructure. A model is used, based on the PTGs and projected coverage levels, to estimate the (increased) volume of activity required for each intervention to reach specific coverage targets. The box above shows how to apply the PTG concept to MTCT interventions.
Table 2: Potential Target Groups for HIV/AIDS Interventions and Activities
Intervention/Activity
Potential Target Group
Interventions for school youth and out-of-school youth
Male and female youth enrolled in primary schools (age 6—11)Male and female youth enrolled in secondary schools (age12—16)
Male and female youth aged 6—11 not enrolled in schools
Male and female youth aged 12—16 not enrolled in schools
Male and female youth enrolled in tertiary education
Sex worker interventions
Sex workers in urban areas
Interventions for migrant or mobile workers
Miners
Truckers
Farm workers
Interventions for uniformed services
Police
Armed forces (Army, Air Force, Navy, Special Forces)
Immigration/border control
Customs and excise
Prisons
Strengthening public sector condom distribution and Condom social marketing (male and female condoms)
Protection by condoms for all casual sex acts and sex acts in regular partnerships (proportion of sex acts in regular partnerships set at 2% for the analysis)
Improving STI services
Men (aged 15—49) with curable, symptomatic STIs and access to health services
Non-pregnant females (aged 15—49) with curable, symptomatic STIs and access to health services
Pregnant women with syphilis and access to health services
Voluntary counseling and testing (VCT)
Current sexually active population
Workplace interventions
HIV prevention activities for males and females in formal employment
STI treatment: same groups as those for strengthening STI services, but limited to workplaces that have STI treatment
Condom distribution: the number of sex acts requiring a condom (set at 100% casual and 2% regular partnerships) for those in formal employment
Strengthening blood transfusion services
Units of blood used in transfusions
Preventing MTCT
Screening (VCT) for pregnant women 15—49 with access to ante-natal services
ARV treatment for pregnant women testing HIV positive and formula for infants
Mass media
National campaigns for entire country
Palliative care
PLHAs who are symptomatic
Clinical management for opportunistic illnesses
PLHAs with access to health services
Home-based care
PLHAs with access to health services
Clinical care for children
Includes palliative care for all children who are HIV positive and symptomatic, and clinical care for children who are HIV positive and symptomatic with access to health services
Prevention of OIs (Cotrimoxazole and TB preventive therapy)
PLHAs who are symptomatic and have access to health services
Support for orphans
All AIDS orphans less than 15 years old
Psychosocial support and counseling
PLHAs who are symptomatic
Treatment (HAART)
PLHAs who are symptomatic and have access to health services
ECR Costing Step 3: Consider Existing Implementation Constraints Planning involves looking at the expected coverage of target groups that can be achieved by 2005. It assumes that the feasibility of expanding coverage of target groups will be higher in countries with strong HIV/AIDS programs than in countries where programs are more challenged and/or fragmented.
Applying the Potential Target Group (PTG) Concept to MTCT Interventions
Defined target group for MTCT interventions is pregnant women attending antenatal facilities.
Once the target group is defined, the coverage of a target group by specific interventions needs to be determined. In this MTCT example, two interventions related to MTCT were costed:
VCT among the antenatal population who receive antenatal services, and
delivery of antiretroviral/feeding intervention.
Coverage levels for these interventions are the proportion of women being tested for HIV and the proportion of women who agree to take the antiretroviral (ARV) drug regimen. Specific assumptions are then made concerning these two proportions. In the case of care, countries are classified by the strength of their existing HIV/AIDS programs.
The coverage of HIV/AIDS programs will depend on institutional characteristics, particularly the strength of existing programs. For example, African countries are classified into four categories by strength of existing HIV/AIDS programs: very low, low, medium and strong HIV/AIDS programs. Strong program countries include Uganda and Senegal, which have slowed the HIV epidemic. "Very low" program countries include those that are currently in conflict, such as Liberia and Eritrea, or those where conflict has only recently stopped, such as Somalia. This classification is shown in Table 3.
The potential coverage of HIV/AIDS interventions thought to be feasible to achieve by 2005 is projected for interventions and activities in Table 4. Because of the paucity of information about current levels of coverage for care activities, baseline coverage for care strategies cannot be estimated. Instead, potential increases in coverage for care that could be achieved between 2000 and 2005 are estimated, taking into account the ability of current health systems to absorb a higher level of activity (Table 5).
It is important to note that these percentages are approximations. For each intervention/activity, the proposed increase in coverage from baseline to 2005 is based on what is realistically achievable in a five-year time period, according to capacity and infrastructure constraints. Given the low levels of coverage among the PTGs, these figures reveal that large sections of the population could be reached by existing infrastructures within countries.
ECR Costing Step 4: Estimate Costs Facility- or project-level cost data are taken from published and unpublished literature to obtain baseline average costs for delivery of each type of program or activity. The costs of expanding or scaling-up interventions are based on current and projected (year 2005) target levels of coverage. The model estimates costs associated with different levels of coverage for PTGs. Planners and program managers can consider these estimated costs in relation to the PTG because they depend on the projected level of coverage sought.
Unit cost data are calculated when estimating costs:
Financial costs represent actual expenditure on goods and services purchased. Costs are described in terms of how much money is being paid for the resources used in the program or service.
Economic costs include the estimated value of goods or services for which there were no financial transactions. They also pertain to situations in which the price of the good did not reflect the cost of using it productively elsewhere, including donated goods and services and other inputs whose prices may not be accurate.
Table 3: Estimated Strength of HIV/AIDS Program Activities by Countries
Very Low
Low
Medium
Strong
Angola Congo DR Congo Djibouti Eritrea Ethiopia Liberia Nigeria Sierra Leone Somalia
Benin Burkina Faso Burundi Chad Equatorial Guinea Gabon Gambia Ghana Guinea Guinea Bissau Madagascar Mali Mauritius Niger Rwanda Togo
Botswana Cameroon Central African Rep. Côte d'Ivoire Kenya Lesotho Malawi Mauritania Mozambique Namibia South Africa Swaziland Tanzania Zambia Zimbabwe
Senegal Uganda
Note: Due to a lack of data, countries in italics are not included in estimates presented in Tables 4 and 5.
Analyzing costs can be done in two ways:
Full cost analysis estimates the costs of all resources that are used to run a program or service, including basic infrastructure.
Incremental analysis looks at the cost of adding the additional program or service to existing ones.
When calculating unit cost data, all prevention and basic care costs are best determined from the perspective of the provider. Where possible, consider economic costs and full cost analysis. Unless indicated, all unit costs include recurrent and annualized costs for capital inputs. A detailed review regarding the costs of prevention is found in Kumaranayake and Watts (2000b). For purposes of this analysis, countries classified as high income are Botswana, Djibouti, Gabon, Mauritius, Namibia, South Africa and Swaziland.
Table 6 describes unit cost by intervention. Planners and program managers can use these data to develop cost estimates for interventions at the national, district and/or community levels.
Table 4: Proposed Estimates of Baseline and Target Levels of Coverage for 2005 for HIV/AIDS Interventions (by Program Strength)
Proportion units of blood for transfusion tested, urba
60%
80%
95%
100%
100%
100%
100%
100%
Proportion units of blood for transfusion tested, rural
40%
70%
90%
100%
80%
95%
100%
100%
MTCT interventions
% urban pregnant women attending ANC in facility tested
0.5%
0.5%
0.5%
0.5%
10%
10%
10%
10%
% rural pregnant women attending ANC in facility tested
0%
0%
0%
0%
5%
5%
5%
5%
% women offered regimen request and complete
0%
0%
0.5%
0.5%
90%
90%
90%
90%
% women testing HIV positive take formula
0%
0%
0.5%
0.5%
50%
50%
50%
50%
Mass media
Average number of campaigns per year
2
2
2
2
6
6
6
6
Table 6. Description of Source of Unit Cost Estimates Note: 1) For all cost scenarios, activities are coordinated primarily through the ministries of education. 2) There is no available information regarding the costs of primary school education for Tanzania, other than approximations by Boerma and Bennett (1997).
Table 5: Proposed Percentage Increase in Coverage for Basic HIV/AIDS Care by 2005
Country Program Strength
Very Low
Low
Medium
Strong
Palliative care
Proportion of symptomatic people receiving palliative care
40%
40%
30%
30%
Clinical management of opportunistic illnesses
Proportion of symptomatic people requiring clinical management of OIs with access to health services receiving care
20%
20%
20%
20%
Prevention of OIs
Proportion of symptomatic people with access to health services who are receiving palliative care
25%
25%
35%
35%
Home-based care
Proportion of PLHA receiving home-based care
20%
20%
20%
20%
Care for HIV-positive infants
Proportion in last year of life receiving palliative treatment
40%
40%
30%
30%
Proportion requiring care for opportunistic infectionswith access to health services receiving care
20%
20%
20%
20%
Care for orphans
Proportion of orphans in orphanages
5%
5%
5%
5%
Proportion of orphans in community receiving assistance
5%
5%
15%
20%
Proportion of all orphans receiving subsidy for school educatio
5%
5%
15%
20%
Psychosocial support and counseling
Proportion of PLHA cases receiving psychosocial support
15%
30%
30%
15%
Treatment
HAART
10%
10%
25%
25%
Table 6: Source of Unit Cost Estimates
Youth Interventions
Cost per teacher trained, primary school education
Low:
$75; simple program with teacher training and provision of basic material
Medium:
$200; includes development of training materials and establishment of school curriculum
Cost per teacher trained, secondary school education
Low:
$121; simple program; assumed to be financial and incremental cost; (Boerma and Bennett 1997), Tanzania
Medium:
$241; more extensive program; assumed to be financial and incremental cost, Tanzania
Cost per youth targeted/peer education for out-of-school youth
Assumed a peer education program in place for out-of-school youth. Given the lack of data, it was assumed that the costs would be higher than for a workplace intervention but lower than for a commercial sex worker (CSW) intervention because clients are easier to reach. The cost calculations are an average of the relevant scenarios for the CSW and workplace peer education programs.
Low:
$8.00
Medium:
$10.81
Sex Worker Interventions
Cost per CSW targeted
Peer education project in Cameroon, educators not salaried and condoms not freely distributed; economic and full costing (Kumaranayake et al. 1998)
Low:
$15.83
Medium:
$21.12
Cost per male condom distributed, urban
Costs from a CSW program in Zimbabwe; assumed to be economic costing (Soderlund et al. 1993); this provided a figure for the medium scenario, extrapolated for low cost.
Low:
$0.10
Medium:
$0.14
Cost per female condom distributed
Commodity and marketing/distribution costs from existing Population Services International (PSI) CSW programs in Zambia and Zimbabwe (personal communication, Guy Stallworthy); financial and incremental costs
Low:
$1.00
Medium:
$2.00
These figures include estimates of market and distribution costs associated with the female condom. The negotiated wholesale price for the female condom is about $0.64 in 2000 prices. Marketing is much more intensive for the female condom than for the male condom.
Note: 1) For all cost scenarios, activities are coordinated primarily through the ministry of education. 2) There is no available information regarding the costs of primary school education for Tanzania, other than approximations by Boerma and Bennett (1997).
Increased Public Sector Condom Distribution
Taken from Zambia, where condoms were distributed free of charge through public channels; economic and full costing (Goodman and Watts 1995); both urban and rural costs are assumed to be the same.
Cost per male condom distributed in the public sector
Low:
$0.10
Medium:
$0.34
Cost per male condom for strengthening condom logistics
Low:
$0.045
Medium:
$0.07
Condom Social Marketing
Figures were taken from Stallworthy and Meekers (1998), which presented range of costs for PSI's CSW programs by low-, medium- and high-cost programs in 1996 dollars; assumed to be financial and full cost.
Cost per male condom distributed, urban
Low:
$0.12
Medium:
$0.29
Cost per male condom distributed, rural
Low:
$0.25
Medium:
$0.45
Cost per female condom distributed
Same as for cost per female condom distributed in CSW interventions
Improving STI Services
Cost per STI case treated/visited (syndromic management)
Low:
$12.65; intensified intervention through existing health services in Tanzania with syndromic management; economic and incremental (Gilson et al. 1997)
Medium:
$15; integrated STI/HIV control program in Mozambique; included costs for pre-consultation, partner notification, syndromic management, but excluded planning and management; assumed to be financial and incremental (Bastos et al. 1992)
Cost per woman screened for syphilis in reproductive health services
Low:
$0.91; cost per woman screened in Tanzania, assumed to be financial (Kigadye et al. 1993)
Medium:
$2.00 from Mozambique program described above (Bastos et al. 1992).
Cost per STI case treated, ANC service
Same as for cost per STI case treated/visited
VCT
Cost per person counseled and tested
Low:
$3.80; cost of adding VCT to a rural South African hospital, excluding all overhead costs, but including all commercial costs of test kits, laboratory staff and equipment used; rapid Capillus test, economic and incremental
Medium:
$13.82; estimated costs of running VCT in freestanding clinic in Uganda (Alwano-Edyegu and Marum 1999); assumed to be economic and full
Workplace Interventions
The unit cost data for peer education are taken from Soderlund et al. (1993) and come from a workplace intervention in Uganda. Figures are taken for low cost and are extrapolated upward to obtain a medium cost; assumed to be economic and full costing.
Cost per person in employment reached (peer education)
Low:
$0.26
Medium:
$0.50
Cost per STI case treated/visited
As per strengthening STI treatment
Cost per male condom distributed
As per CSW intervention
Strengthening Blood Transfusion System
The unit cost data are derived from Soderlund et al. (1993). These figures are based on national and centralized blood transfusion systems in Zimbabwe and Uganda; assumed to be full and economic costing.
Cost per safe unit collected
Low:
$5.34
Medium:
$18.22
MTCT
Cost per woman screened
As per VCT intervention; all these costs are just the drug cost
Cost per woman testing HIV positive and receiving regimen
Low:
$5; HIVNET 012 Nevirapine regimen; cost per course based on dose given to women at labor and then dose for infant after birth, based on Marseille et al. (1999); assumed to be financial and incremental
Medium:
$50; CDC Thai – ZDV only pre- and intrapartum. Cost per course if using Thai generically manufactured drug (UNAIDS, 1999b); no inclusion of freight costs just the drug prices; assumed to be financial and incremental
Cost of strengthening delivery services in facilities to undertake regimen per woman testing HIV positive
The cost of providing training and additional staff to meet these needs is extrapolated; these costs are derived from Wilkinson et al. (1998), and are based on the costs of additional nurse training and midwives in rural South Africa.
Low:
$13.70 – 40% of Wilkinson et al. (1998) costs
Medium:
$24.00 – 70% of Wilkinson et al. (1998) costs
Cost per woman of six months of formula milk
Low-cost data from Pazvakavambwa (1999). Assumed to be financial and incremental; do not include freight and transport costs; medium cost is extrapolated from low price; costs of ensuring access to safe water are not included.
Low:
$50
Medium:
$55
Mass Media
Cost per campaign
The cost data for mass media campaigns come from Soderlund et al. (1993) and Kumaranayake et al. (1998). Both are economic and full cost. The low-cost scenario corresponds to a program in Gabon, where the campaign was contracted to a private firm and includes salary and overheads; the medium-cost scenario relates to a mass media program run for three months in Cameroon, paying commercial rates for broadcast time; this excludes overhead costs and salaries of people involved.
Low:
$489,565
Medium:
$516,817
Palliative Care
Cost per patient year
These costs are based on the estimated frequency of these symptoms for PLHA in sub-Saharan Africa and the drug costs of treating common symptoms (such as fever, cough, diarrhea, skin rashes, headaches, nausea), which are used to derive a cost per patient year; assumed to be economic and incremental (World Bank 1997a).
Low:
$21.50
Medium:
$25.80
Clinical Management of OIs
Cost per adult per year of treatment
The costs of clinical management include the costs of treating common opportunistic infections (OIs) in sub-Saharan Africa (such as tuberculosis, oral thrush, pneumonia/septicemia). The cost is based on the estimated frequency of OI, drug costs and costs of inpatient and outpatient care in sub-Saharan Africa. The cost of the drugs is taken from the World Bank (1997a). Costs of inpatient and outpatient facilities were estimated separately for low-income countries (based on World Bank 1997a; Hansen et al. 2000). These costs include both direct patient-related costs (drugs and laboratory services) and indirect costs (staff and facility costs). To obtain figures for high-income countries, multipliers are calculated for direct and indirect costs based on the relative costs of ambulatory and inpatient TB treatment in South Africa (Floyd et al. 1997), Malawi, Mozambique and Tanzania (De Jonghe et al. 1994); assumed to be economic and full cost.
Low-income countries:
Low:
$247
Medium:
$359
High-income countries:
Low:
$471
Medium:
$698
Prevention of Opportunistic Infections (OIs)
Cost per adult per year of prophylaxis for OI (INH and Cotrimoxazole)
Given the duplication of activities in providing preventive TB therapy and Cotrimoxazole (monitoring, costs of outpatient visits), the joint costs of administering INH and Cotrimoxazole are estimated. For low-income countries, cost data are adapted from Aisu et al. (1995) in Uganda for six months of INH preventive therapy and include costs of initial skin test, screening (chest X-ray, sputum smears) for active TB and personnel and administration costs. High-income country costs are adapted from Masobe et al. (1995) in South Africa and include costs of testing, administration of drugs (INH five times a week for six months), monitoring and personnel and transport costs. Data related to the cost of Cotrimoxazole are taken from Guinness (2000). No additional costs for HIV testing are included, because they were assumed to be included in costs related to VCT; costs are assumed to be financial and incremental.
Low-income countries:
Low:
$30
Medium:
$36
High-income countries:
Low:
$64
Medium:
$79
Home-based Care
Cost per person living with HIV/AIDS supported
The cost estimates come from projects in Zimbabwe and Zambia (Chela et al. 1994; Gilks et al. 1998). They are from interventions that tend to have a very low coverage among their target populations (less than 10% of the eligible population in Zambia and Zimbabwe); assumed to be financial and full cost.
Low:
$63
Medium:
$197
Care for HIV-positive Children
Cost of palliative care per child
Taken to be two-thirds of the costs of care of adults
Low:
$14.30
Medium:
$17.20
Cost of clinical management of OI per child
Low-income countries:
Low:
$163
Medium:
$237
High-income countries:
Low:
$311
Medium:
$461
Support for Orphans
Cost per child in an orphanage
Living expenses include food, clothing and basic commodities. School expenses include subsidies for fees and uniforms. Based on estimates from Boerma and Bennett (1997) for orphanage care in Tanzania; assumed to be financial and full cost.
Low:
$120
Medium:
$180
Cost per child for community assistance with living expenses
Taken from Drew et al. (1998) for programs in Zimbabwe, implemented by community-based organizations, using volunteers who visit families with orphans; cost assumed to be financial and full.
Low:
$9
Medium:
$35
Derived from Boerma and Bennett (1997), in the context of district-based programs for communities in a high-prevalence setting. This includes support to new orphans and community feeding posts; cost assumed to be financial and full.
Cost per child for school expenses
Based on estimates from Boerma and Bennett (1997) for Tanzania. Weighted average of primary and secondary school costs; assumed to be financial and full cost.
Low:
$25
Medium:
$33
Psycosocial Support and Counseling
Cost per person reached
Costs are extrapolated from VCT cost. There are no published estimates of costs.
Low:
$3
Medium:
$6
Institutional Strengthening
These costs are related to existing program strength (very low, low, medium and strong) and are based on estimates for implementation of the MTP-III in Tanzania.
Cost per capita for very low-program-strength countries
Low:
$0.021
Medium:
$0.026
Cost per capita for low-program-strength countries
Low:
$0.015
Medium:
$0.019
Cost per capita for medium-program-strength countries
Low:
$0.010
Medium:
$0.013
Cost per capita for strong-program-strength countries
Low:
$0.006
Medium:
$0.008
Treatment (HAART)
Cost per person treated with triple combination therapy
The structure for calculating the costs of HAART follows the UNAIDS Care Model (UNAIDS 2000a). The cost per person includes the costs of drugs, monitoring, staff training, transport, strengthening of facilities for administration of ARV treatment, and appropriate clinical management and provision of drugs to deal with side effects and adverse reactions and basic pain relief, as well as prophylaxis for OIs. The largest component of the unit cost is the cost of the drugs. These prices change rapidly and reflect the different combinations of drugs that may be prescribed. For the low-cost scenario, an average drug price of $1,400 (US) per person annually is used. This is based on recent negotiations between Senegal and the pharmaceutical companies related to the bulk buying of ARV (Drug Companies 2000). The drug price for the medium-cost scenario is $2,635 (US), based on the 1999 Brazilian experience with ARV purchases (Panos 2000). By comparison, the negotiated price for Uganda's purchases in May 2000 was $4,201(US), and the price in the United States was $9,905 (US).
The monitoring costs reflect the costs of viral load monitoring, CD-4 cell counts, blood chemistry, transport and outpatient visits drawn from a range of sources (Guinness 2000; Panos 2000; World Bank 1997a). The staff training courses are based on the estimate of Masobe et al. (1995) for the costs of training for implementation of preventive therapy and are adjusted downward for low-income countries based on the ambulatory multiplier for direct costs described above in the calculation of the costs of clinical management. The costs for appropriate clinical management, for drugs to deal with side effects, adverse reactions and basic pain relief, and for prophylaxis for OIs are drawn from the same sources above. Costs are assumed to be financial and incremental.
Low-income countries:
Low:
$1,993
Medium:
$3,468
High-income countries:
Low:
$2,393
Medium:
$4,049
Key Implementation Questions for Costing and Use of Resources
The following is a summary of the key implementation questions for costing and use of resources in Module 6.
Key Implementation Questions for Costing and Use of Resources in ECR
ECR Resource Allocation
What criteria are used to allocate resources in your program?
Have you considered criteria based on need? Have you prioritized target groups?
Have you evaluated or rated the relative strength of your program?
Have you considered the cost effectiveness of your ranked interventions? Have you considered the complexity of delivering ranked interventions? Have you considered the per capita cost for delivering ranked interventions?
ECR Costing
When costing your ECR plan, have you implemented each of the following steps?
Step 1 – Establish size of target groups.
Step 2 – Define current and future program coverage.
Primarily adapted from: World Bank. Costs of Scaling HIV Program Activities to a National Level in Sub- Saharan Africa: Methods and Estimates. Prepared for the Africa Development Forum, December 2000.
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Overview
