1. www.hivtools.lshtm.ac.uk Developing a Methodology for Cost-Benefit Analysis of GFATM Lilani Kumaranayake, Charlotte Watts and Philip Carriere

2. www.hivtools.lshtm.ac.uk Background Huge international investments in HIV/TB & Malaria Increasing questions about value for money Is it possible to estimate the cost-benefits of specific global initiatives?

3. www.hivtools.lshtm.ac.uk Purposes of Analysis Develop a pilot methodology to estimate cost and benefits of HIV/AIDs programming for Global Fund

4. www.hivtools.lshtm.ac.uk Challenges Limited data available from Global fund  currently data available by disease area (HIV) and grant basis  No details as of yet on intervention types (although currently working on it) Current analysis based on country and grant information from GFATM and examination of country programming from individual countries  where details available

5. www.hivtools.lshtm.ac.uk Methodological Development

6. www.hivtools.lshtm.ac.uk Methods 1 - Literature Reviewed Evidence of intervention impact Cost-effectiveness Summaries of priorities for HIV/AIDS programmes in different epidemic settings Results: As of yet we have almost no data on cost-benefit of HIV/AIDS interventions, Cost-effectiveness data available across some interventions, by region

7. www.hivtools.lshtm.ac.uk Methods 2 What can we do with available evidence to think about global fund programming? Estimate Health Impact associated with expenditures (DALYs or HIV infections averted) Health Benefits associated with expenditures (2008 Constant $) Results expressed in present value terms (3%)  e.g. discounting future costs and benefits

8. www.hivtools.lshtm.ac.uk CE Data Used for Analysis

9. www.hivtools.lshtm.ac.uk Nature of Programming Upstream  support planning, improved financing, enabling environments,  typically do not result in direct contact with population groups or specific programmes of activities involving them. Downstream  Support to direct programme activities with populations

10. www.hivtools.lshtm.ac.uk Conceptual framework Downstream Programming Intn 1 Intn 3 Intn 2 Intn 4 Intn 5 Impact DALYs Upstream Programming Impact DALYs Impact DALYs Impact DALYs Impact DALYs Impact DALYs Valuation of DALY benefits

11. www.hivtools.lshtm.ac.uk Methods 3 – Regional Analysis Impact and cost-effectiveness vary by stage of HIV/AIDS epidemic Analysis uses UNAIDS classification  Concentrated Epidemic (Asia, Americas, Europe)  Generalised Low Level Epidemic (some Africa)  Generalised High Level Epidemic

12. www.hivtools.lshtm.ac.uk Methods 4 – Programmes and Interventions Hard to assess how programming translates into intervention-specific expenditure  For analysis, develop attribution weighting  Directness category used to reflect relationship between programming and different forms of HIV/AIDS intervention  Relative classification 9 = directly related, 3=fairly related, 1=less directly related

13. www.hivtools.lshtm.ac.uk Programme Weighting by Intervention – example PMTCT Mass Media Sex worker interventions Condom provision Youth education Harm Reduction VCTPMTCT 0.700 07.978.9 STI Treatment Reduction of Stigma Prophylaxi s PLHA support Home based care Palliative Care ART 0.7 Most directly related Fairly direct Less direct

14. www.hivtools.lshtm.ac.uk Methods 5 - Valuing Upstream and Downstream Investments Not all investment will immediately translate into intervention activity and short-term impact Multipliers for expenditure  Upstream 0.25  Downstream 0.75

15. www.hivtools.lshtm.ac.uk Methods 6 – Calculation Steps Estimate upstream and downstream expenditure by grant and region Use weightings to estimate expenditure by programme and intervention activity Use multipliers to estimate proportion of expenditure by programme and intervention resulting in short- term impact

16. www.hivtools.lshtm.ac.uk Calculation Steps continued Use intervention CE data to estimate impact in DALYs gained Use cost-of-illness approach to value impact gains  $6000 for life-time treatment cost, which is the average value of life-time costs obtained from two recently published cost-effectiveness studies  Thus, using the ratio of 22 DALYs per one HIV infection averted, we can compute the value of a DALY gained as $264.

17. www.hivtools.lshtm.ac.uk Our first Guesstimate of CBA

18. www.hivtools.lshtm.ac.uk Results – Committed Funds – the potential It was estimated that the present value of DALYs gained was 2,958,000 estimated cost-effectiveness of HIV/AIDS portfolio $181 per DALY gained. Cost-benefit terms:  Net present Value: $2,009,120  Benefit-Cost Ratio: $ 1.34 Results were robust to changes in key assumptions related to discount rates and methods of monetising benefits.

19. www.hivtools.lshtm.ac.uk Results – Disbursements - Actual To-date only 28% of committed funds have been disbursed  Continuing to obtain data which gives us a better breakdown of programming for disbursed funds Disbursement profile suggests that perhaps only a third of these benefits have currently been accrued

20. www.hivtools.lshtm.ac.uk Constraints and Limitations

21. www.hivtools.lshtm.ac.uk Calculations Make Many Assumptions Speculative analysis Upstream benefits result only from downstream activities Downstream activities related to interventions with CE data  Limited number of interventions considered  Impact is health-related (DALYs), does not value other aspects  Assume interventions like sustainable livelihoods translate into DALY benefits (NO evidence)  Assume distribution of interventions across programming

22. www.hivtools.lshtm.ac.uk Limitations Continued Assume multipliers for upstream/downstream (NO evidence) Assume valuation of DALYs into benefits by cost-of- illness (preventing costs of treating)  Does not consider other aspects of valuation Larger uncertainty about multilateral analysis  Constrained by level of data available Using CE approach means that prevention has greater impact

23. www.hivtools.lshtm.ac.uk Next Steps Continue to collect more detailed grant and intervention level data by country Anticipating more comprehensive data from GFATM