Estimating the cost of HIV services for key populations provided by the LINKAGES program in Kenya and Malawi.

BACKGROUND: Data remain scarce on the costs of HIV services for key populations (KPs). The objective of this study was to bridge this gap in the literature by estimating the unit costs of HIV services delivered to KPs in the LINKAGES program in Kenya and Malawi. We estimated the mean total unit costs of seven clinical services: post-exposure prophylaxis (PEP), pre-exposure prophylaxis (PrEP), HIV testing services (HTS), antiretroviral therapy (ART), sexually transmitted infection (STI) services, sexual and reproductive health (SRH) services, and management of sexual violence (MSV). These costs take into account the costs of non-clinical services delivered alongside clinical services and the pre-service and above-service program management integral to the LINKAGES program. METHODS: Data were collected at all implementation levels of the LINKAGES program including 30 drop-in-centers (DICs) in Kenya and 15 in Malawi. This study was conducted from the provider's perspective. We estimated economic costs for FY 2019 and cost estimates include start-up costs. Start-up and capital costs were annualized using a discount rate of 3%. We used a combination of top-down and bottom-up costing approaches. Top-down methods were used to estimate the costs of headquarters, country offices, and implementing partners. Bottom-up micro-costing methods were used to measure the quantities and prices of inputs used to produce services in DICs. Volume-weighted mean unit costs were calculated for each clinical service. Costs are presented in 2019 United States dollars (US$). RESULTS: The mean total unit costs per service ranged from US$18 (95% CI: 16, 21) for STI services to US$635 (95% CI: 484, 785) for PrEP in Kenya and from US$41 (95% CI: 37, 44) for STI services to US$1,240 (95% CI 1156, 1324) for MSV in Malawi. Clinical costs accounted for between 21 and 59% of total mean unit costs in Kenya, and between 25 and 38% in Malawi. Indirect costs-including start-up activities, the costs of KP interventions implemented alongside clinical services, and program management and data monitoring-made up the remaining costs incurred. CONCLUSIONS: A better understanding of the cost of HIV services is highly relevant for budgeting and planning purposes and for optimizing HIV services. When considering all service delivery costs of a comprehensive HIV service package for KPs, costs of services can be significantly higher than when considering direct clinical service costs alone. These estimates can inform investment cases, strategic plans and other budgeting exercises.

Impact of Safety Nets on Household Coping Mechanisms for COVID-19 Pandemic in Malawi.

Background: Covid-19 pandemic induced various shocks to households in Malawi, many of which were failing to cope. Household coping mechanisms to shocks have an implication on household poverty status and that of a nation as a whole. In order to assist households to respond to the pandemic-induced shocks positively, the government of Malawi, with support from non-governmental organizations introduced Covid-19 Urban Cash Intervention (CUCI) and other safety nets to complement the existing social protection programs in cushioning the impact of the shocks during the pandemic. With these programmes in place, there is a need for evidence regarding how the safety nets are affecting coping. Therefore, this paper investigated the impact that safety nets during Covid-19 pandemic had on the following household coping mechanisms: engaging in additional income-generating activities, receiving assistance from friends and family; reducing food consumption; relying on savings; and failure to cope. Methods: The study used a nationally representative panel data from the Malawi High Frequency Phone Survey on Covid-19 (HFPS Covid-19) and complemented it with the fifth Integrated Household Panel Survey (IHPS), also known as living standards measurement survey. Five Random Effects Probit Models were estimated, one for each coping mechanism. Results: Findings from this study indicated that beneficiaries of safety net programs were more likely to rely on remittances from friends and family than the people who had no safety nets. Furthermore, the safety net recipients were less likely to reduce food consumption or rely on savings than the non-recipients. Despite the interesting findings, we also noticed that safety nets had no significant impact on household engagement in other income-generating activities in response to shocks. Conclusion: The results imply that safety nets in Malawi during the Covid-19 pandemic had a positive impact on consumption and prevented the dissolving of savings. Therefore, these programs have to be scaled up, and the volumes be revised upwards.

Independent Evaluation of the integrated Community Case Management of Childhood Illness Strategy in Malawi Using a National Evaluation Platform Design.

We evaluated the impact of integrated community case management of childhood illness (iCCM) on careseeking for childhood illness and child mortality in Malawi, using a National Evaluation Platform dose-response design with 27 districts as units of analysis. "Dose" variables included density of iCCM providers, drug availability, and supervision, measured through a cross-sectional cellular telephone survey of all iCCM-trained providers. "Response" variables were changes between 2010 and 2014 in careseeking and mortality in children aged 2-59 months, measured through household surveys. iCCM implementation strength was not associated with changes in careseeking or mortality. There were fewer than one iCCM-ready provider per 1,000 under-five children per district. About 70% of sick children were taken outside the home for care in both 2010 and 2014. Careseeking from iCCM providers increased over time from about 2% to 10%; careseeking from other providers fell by a similar amount. Likely contributors to the failure to find impact include low density of iCCM providers, geographic targeting of iCCM to "hard-to-reach" areas although women did not identify distance from a provider as a barrier to health care, and displacement of facility careseeking by iCCM careseeking. This suggests that targeting iCCM solely based on geographic barriers may need to be reconsidered.