1、Analyzing the Cost-Effectiveness of Interventions to Benefit Orphans and Vulnerable Children: Evidence from Kenya and Tanzania,Paul L. Hutchinson, Ph.D. Tonya R. Thurman, MPH, Ph.D. Tulane University,Background & Rationale Methodology Key Questions Results Conclusions,What is cost-effectiveness anal
2、ysis (CEA)?,Cost-effectiveness analysis is form of economic evaluation in which health gains from an intervention are evaluated relative to their costs.,Cost Minimization$ per beneficiary$ per capita$ per person reached,Cost Effectiveness$ per behavior change$ per knowledge change$ per HIV infection
3、 averted,Cost Utility $ per DALY saved$ per QALY,Why is CEA important?,We want to know the magnitude of the effect that our program will achieve (or has achieved) for a given level of resources. We want to know which activities are the most effective for given level of resources. We want to know how
4、 cost-effective OVC and guardian activities are relative to other health interventions so as to determine the optimal mix of health interventions,Key Methodological Issues in CEA,Ingredients Approach: Quantifying inputs to deliver an intervention & assigning appropriate monetary values to those inpu
5、ts: Salaries, materials, utilities, transportation, overhead Apportioning costs that are shared across outputs (e.g. overhead, staff time),Key Methodological Issues in CEA,Discounting future costs, cost savings Valuing resources when market prices deviate from actual values of resources (e.g. donate
6、d inputs) Economic costs v. financial costs,Key Issues in CEA,Define the intervention and its components Example: Home visiting for HIV/AIDS affected households How many volunteers are involved? How many households does a volunteer visit? How often do volunteers visit? (weekly?) What supplies and eq
7、uipment are involved? What training (initial and refresher) is involved? What mode of transportation do they take?,Key Issues in CEA,Defining which costs to include: Whose perspective matters?Program costs: direct intervention costs & support Private costs: costs to households of medical care averte
8、d? Transport? Other care? Societal costs (and cost savings): value of HIV infections averted?,Key Issues in CEA,Defining which costs to include: Whose perspective matters?Program costs: direct intervention costs & support,Data Sources,Workplans Budgets Expenditure Reports Interviews Government Docum
9、ents / Surveys Judgment,Some Costing Hurdles,From whom (or from what source) to collect? Amounts were not always consistent across documents, workplans, etc. Budgeted amounts did not always correspond with expenditures (or only budget information was available) Cost (and input) information was not d
10、isaggregated by outputs Cost information was not always complete,Key Question: Cost Analysis,What are the per beneficiary costs for psychosocial, educational, HIV knowledge, income generation, food security and counseling outcomes?,Key Question: Cost-Effectiveness Analysis,What does it cost to achie
11、ve improvements in OVC and guardian psychosocial, educational, HIV knowledge, income generation, food security and counseling outcomes?,OVC Programs with Demonstrated Effects,Evaluation Design & Samples,Post-test study: programs on-going for at least one year Focus only on OVC aged 8-14 years Survey
12、 administered to OVC and their caregivers,Calculating Effectiveness,Multivariate regression analysis Binary outcomes (e.g. food insecure): probit model Continuous outcomes (e.g. HIV knowledge)linear regression Instrumental variables regression to control for non-random program participation Test for
13、 endogeneity (i.e. selection on unobservable factors),Evaluation Design,Program begins; OVC enrolled & start Receiving services,Intervention Group (OVCs),Time,Comparison Group 1 (OVCs),Year 0,Survey Administered,Year 1,Comparison OVCs start receiving services,Comparison Group 2 (non-OVCs) (IAP),Calc
14、ulating Cost-Effectiveness,Marginal effect of exposure in intervention relative to comparison group,Per beneficiary cost of intervention,CE =,4. Results,Costs per beneficiary Costs per improvement in outcome,Costs Per Beneficiary - OVC,Costs Per Beneficiary - Guardian,Psychosocial Outcomes (Indexes)
15、,CostEffectiveness of Home Visiting - OVCs,Family Self- Esteem (CRS),Social Isolation (Allamano),Self-Esteem (The Salvation Army),Results Kids Clubs,$6.43 per marginal increase in an OVCs measure of family self-esteem (Allamano) No measurable effect for other outcomes,Results School-based HIV Educat
16、ion,Cost-effectiveness of school-based HIV Education Integrated AIDS Program: $2.61 per incremental change in knowledge Cath. Relief Services: $0.09 per incremental change in knowledge,Results Educational Support,Little difference in educational outcomes across all programs Programs ensure that educ
17、ational achievement is at least as good among OVC as non-OVC,Guardian Support Groups (1),Catholic Relief Services Guardian participation in care and support meetings was associated with a 0.11 unit reduction in family dysfunction CE = $4.16 / incremental reduction in family dysfunction,Guardian Supp
18、ort Groups (2),Integrated AIDS Program Guardian participation in care and support meetings was associated with a 0.75 unit reduction in negative feelings CE = $75 / incremental reduction in negative feelings,p =0.011,Income Generating Activities,Cost-effectiveness of IGA A 10% reduction in (the prob
19、ability of) food insecurity could be achieved for less than $10 per month,Food Support - Allamano,Receipt of consistent food aid was associated with a 0.437 reduction in the likelihood of food insecurityCE = $0.74 / 10% reduction in food insecurity,Marginal reductions in probability of food insecuri
20、ty from food support,Food Security,A 10% reduction the probability of food insecurity could be achieved for?All fairly low cost Which is more sustainable?,5. Conclusions (Analysis),Collect data on outcomes at baseline so as to measure changes Try (as hard as possible) to have equivalent comparison g
21、roups Targeted programs involve substantial complications in evaluation Measures of mental well-being should be standardized and more widely used,5. Conclusions (Policy),OVC interventions can be effective AND cost-effective in improving OVC and guardian welfare across multiple dimensions. School-bas
22、ed HIV education programs can substantially increase knowledge at low cost. Food security can be improved substantially at a low per household cost. The data base of cost-effectiveness calculations should be expanded for larger numbers of OVC & guardian activities in wider range of settings. Cost da
23、ta, collected concurrent with program implementation, can provide a powerful tool for planners.,Acknowledgements,Staff from The Salvation Army Mama Mkubwa & Kids Club program Allamano CARE Tanzania Tumaini Project Kilifi OVC Porject Pathfinder The Community Based Care and Support Program (COPHIA),Th
24、e Constella Futures Group (MEASURE): Florence Nyangara, Minki Chatterji, Kathy Buek, Sarah Alkenbrack Kristin Neudorf John Novak, Kathleen Handley, and Scott Stewart (DC) USG OVC Technical Working Group Innumerable volunteers and local leaders in Kenya and Tanzania,If you are interested in the full
25、paper, please refer to: http:/www.cpc.unc.edu/measure/publications/pdf/sr-09-51.pdf Contact Info: Paul L. Hutchinson, Ph.D. / Tonya Thurman, Ph.D.Tulane University School of Public Health and Tropical MedicineDepartment of International Health and Development1440 Canal Street, Suite 2200-TB46New Orleans, LA 70112USAEmail: phutchintulane.edu / tthurmatulane.edu,
