1. The effects of scale on costs of Targeted HIV Prevention Interventions Among Female and Male Sex workers, MSM, and Transgenders in India Abstract No. 10818: Poster Code-A-072-0228-10818) International AIDS Economics Network Symposium XVII International AIDS Pre-Conference in Mexico City 3-8 August 2008 Chandrashekar S 1,4, Kumaranayake L 1, Bhaskar Reddy R 2, Govindraj Y 2, Alary M 3 1 London School of Hygiene and Tropical Medicine, London, UK; 2 Karnataka Health Promotion Trust, Bangalore, India Centre hospitalier affilié universitaire de Québec, Canada 3 Centre hospitalier affilié universitaire de Québec, Canada 4 St.John’s Research Institute

2. Objectives 1.Estimate economic cost of resources used to implement programme 2.To study the cost variation by NGO implementing targeted interventions over a two year period

3. Overall Costing Methodology

4. Framework of Economic Analysis  Include all 62 districts in 4 Southern States where Avahan has Intervention activities for a four-year period.  For each SLP: – Some districts will have detailed cost analyses, chosen in consultation with SLP. Detailed cost analyses undertaken twice. – Other districts will rely on routinely collected data and data gathered from detailed districts – Data collection is at level of implementing NGO within district – Analysis is undertaken by NGO and district for each SLP

5. Summary of District Analysis SLPNumber Districts Detailed Districts (Number NGOs) Number NGOs TAI-VHS12Dharmapuri (2) Madhurai (5) 26 KHPT16All 16 (17)17 Pathfinder11Ahmednagar (1) Parbhani (1) 12 FHI2Mumbai (5) *Not all NGOs in district chosen, 5 chosen by typology 14 HLFPPT8Guntur (1)10 Alliance13Karimnagar (3) Rangareddy (1) 28 All Avahan6224 (36)107

6. Costing Approach  Provider perspective –excludes costs of clients using services (e.g. travel time)  Full costing –includes all costs of running program including administration, infrastructure etc.  Economic cost –Includes value of all items used in implementing services, even if not paid for or donated –This contrasts to financial costs, which only include expenditures which are actually paid

7. Specific Considerations in Costing  By Input: capital versus recurrent items  By Activity: training, STI services etc  Annualizing capital costs so that costs are spread over period of project, not just one year  Allocating shared resources  Donated goods and services  Timeframe: start-up versus implementation. Start-up treated as a capital item.  Multi-year Costing: establish base year (2006) and adjust by inflation

8. Organizational levels for costing District Support District NGO most common level for costing Our Analysis SLP LEVEL NGO

9. Data Sources  Retrospective and prospective  Financial records from NGOs and SLPs Using routine financial and management reporting  Process and outcome data from routine reporting  Interviews with SLP staff related to district programming  Districts in detailed costing – additional data collection instruments

10. Specific Data Collection Instruments for Detailed Costing  Records review –designed to review all data that is being routinely reported (financial and programming).  Key informant interviews with project staff –questionnaires for the field officers and project/district coordinators  Focus group discussion guidelines – –discussions with peer educators  Time-sheets – to collect data regarding allocation between activities undertaken by field officers and STI doctors

11. Overall Results Costing 2004-2006  Avahan scale up from Y1-Y2 consisted addition of 18 districts and 36 NGOs in the 4 implementing states. Avahan Scale-up

12. Total District level Economic cost (2004-06)  The total economic costs have increased by $ 4,760,294(70.5%) from Y1 to Y2 Total Economic Cost

13. Analysis by Input  Main types of inputs: capital and recurrent –Capital costs: items which last for multiple years –Recurrent costs: Incurred for use of resources that produce benefits for one year or less, incurred on a continual basis (e.g. salaries, supplies)  Annualisation of capital items –Ensures early years of the programme do not overestimate annual costs –Makes recurrent and capital costs comparable –Recognises the investment aspect of capital items (benefits are spread over a number of years)

14. Main differences between financial and economic costs Valuation of donated condoms Donated space (taluka offices, government buildings) opportunity of cost of peer education Interviews with Project Co-ordinator & Field Officers gave insights into the extent of donated inputs (free or subsidised space, mobilization of free doctors for outreach camps, joint events with other local groups)

15. District level Economic Costs By Input : Y 1+ Y 2 (Constant 2006 Rs)

16. Cost Analysis by activity  Main categories for activity -Capacity building, outreach, STI services, condom promotion, enabling environment, Community mobilization, IEC, Planning and co-ordination, Essential AIDS care, Monitoring and evaluation,  Method of allocation – district specific  Where costs directly allocable to category (e.g. training, STI, start- up) put in respective category  Personnel time – based on time-sheet analysis  Other recurrent items were allocated based on allocation factors derived from personnel time-sheets; then capital which was non- allocable was based on overall recurrent cost percentages  Time-sheets – had been prospectively collected during Year 1  PC, FO, some ORW were asked to fill in individual time-sheet for 1 week, showing how their time was allocated over activities  For peers from peer group FGD and job descriptions  General staff time was allocated equally across the activities

17. District level Economic Costs By Activity : Y 1+ Y 2 (Constant 2006 Rs)

18. Process Output Measures  64% of Estimated Key population were registered by end of 2 nd Year

19. Average Costs By Scale – Year 1 +Year 2 ( per Person registered )

20. Average Costs By Scale – Year 1 +Year2 (Clinic visits)

21. Results continued…..  64% of Estimated Key population were registered by end of 2 nd Year (116,542 ) The scale of activity varied from 37-6315 people registered, and 7-8004 people contacted across NGO interventions.  The median cost per person registered was US$36, with a mean cost of US $72 (95 Confidence Interval $55-$87).  Large reductions in the cost per person registered were observed. Costs declined from $427 for low scales of activity to $ 9 for the highest scale of activity. (R 2 =.209)  Scale was significantly associated with decreasing average costs (Pearson correlation coefficient -0.457, p=0.001)  Scale explains 21% of the variations in the cost across NGOs

22. Results continued…..  About 1,24,669 had availed STI Services during the 2 year period  The median cost per person availing STI Services $68.4 (Range $10.54 to $1406)  Scale was significantly associated with decreasing average costs (Pearson correlation coefficient -0.321, p=0.001)  Scale explains 10% of the variations in the cost across NGOs and there was significant reduction in costs as the scale increased (R 2 =.103)

23. Conclusions  During rapid scale-up of targeted HIV preventions, a significant reduction in average costs was observed as the scale of activity increased.  Scale effects are important to quantify for planning future resource requirements of large- scale interventions.

24. Acknowledgements State lead partner staff, NGO staff at district and headquarters, Peer educators and community members " Support for this study was provided by the Bill & Melinda Gates Foundation through Avahan, its India AIDS Initiative. The views expressed herein are those of the author(s) and do not necessarily reflect the official policy or position of the Bill & Melinda Gates Foundation and Avahan