Unit cost repositories for health program planning and evaluation: a report on research in practice with lessons learned.

BACKGROUND: Most low- and middle-income countries have limited access to cost data that meets the needs of health policy-makers and researchers in health intervention areas including HIV, tuberculosis, and immunization. Unit cost repositories (UCRs)-searchable databases that systematically codify evidence from costing studies-have been developed to reduce the effort required to access and use existing costing information. These repositories serve as public resources and standard references, which can improve the consistency and quality of resource needs projections used for strategic planning and resource mobilization. UCRs also enable analysis of cost determinants and more informed imputation of missing cost data. This report examines our experiences developing and using seven UCRs (two global, five country-level) for cost projection and research purposes. DISCUSSION: We identify advances, challenges, enablers, and lessons learned that might inform future work related to UCRs. Our lessons learned include: (1) UCRs do not replace the need for costing expertise; (2) tradeoffs are required between the degree of data complexity and the useability of the UCR; (3) streamlining data extraction makes populating the UCR with new data easier; (4) immediate reporting and planning needs often drive stakeholder interest in cost data; (5) developing and maintaining UCRs requires dedicated staff time; (6) matching decision-maker needs with appropriate cost data can be challenging; (7) UCRs must have data quality control systems; (8) data in UCRs can become obsolete; and (9) there is often a time lag between the identification of a cost and its inclusion in UCRs. CONCLUSIONS: UCRs have the potential to be a valuable public good if kept up-to-date with active quality control and adequate support available to end-users. Global UCR collaboration networks and greater control by local stakeholders over global UCRs may increase active, sustained use of global repositories and yield higher quality results for strategic planning and resource mobilization.

Frontloading HIV financing maximizes the achievable impact of HIV prevention.

INTRODUCTION: Due to the nature of funding, national planners and international donors typically balance budgets over short time periods when designing HIV programmes (˜5-year funding cycles). We aim to explicitly quantify the cost of short-term funding arrangements on the success of future HIV prevention programmes. METHODS: Using mathematical models of HIV transmission in Kenya, we compare the impact of optimized combination prevention strategies under different constraints on investment over time. Each scenario has the same total budget for the 30-year intervention period but the pattern of spending over time is allowed to vary. We look at the impact of programmes with decreasing, increasing or constant spending across 5-year funding cycles for a 30-year period. Interventions are optimized within each funding cycle such that strategies take a short-term view of the epidemic. We compare these with two strategies with no spending pattern constraints: one with static intervention choices and another flexible strategy with interventions changed in year ten. RESULTS AND DISCUSSION: For the same total 30-year budget, greatest impact is achieved if larger initial prevention spending is offset by later treatment savings which leads to accumulating benefits in reduced infections. The impact under funding cycle constraints is determined by the extent to which greater initial spending is permitted. Short-term funding constraints and funds held back to later years may reduce impact by up to 18% relative to the flexible long-term strategy. CONCLUSIONS: Ensuring that funding arrangements are in place to support long-term prevention strategies will make spending most impactful. Greater prevention spending now will bring considerable returns through reductions in new infections, greater population health and reductions in the burden on health services in the future.

HIV prevention where it is needed most: comparison of strategies for the geographical allocation of interventions.

INTRODUCTION: A strategic approach to the application of HIV prevention interventions is a core component of the UNAIDS Fast Track strategy to end the HIV epidemic by 2030. Central to these plans is a focus on high-prevalence geographies, in a bid to target resources to those in greatest need and maximize the reduction in new infections. Whilst this idea of geographical prioritization has the potential to improve efficiency, it is unclear how it should be implemented in practice. There are a range of prevention interventions which can be applied differentially across risk groups and locations, making allocation decisions complex. Here, we use mathematical modelling to compare the impact (infections averted) of a number of different approaches to the implementation of geographical prioritization of prevention interventions, similar to those emerging in policy and practice, across a range of prevention budgets. METHODS: We use geographically specific mathematical models of the epidemic and response in 48 counties and major cities of Kenya to project the impact of the different geographical prioritization approaches. We compare the geographical allocation strategies with a nationally uniform approach under which the same interventions must be applied across all modelled locations. RESULTS: We find that the most extreme geographical prioritization strategy, which focuses resources exclusively to high-prevalence locations, may substantially restrict impact (41% fewer infections averted) compared to a nationally uniform approach, as opportunities for highly effective interventions for high-risk populations in lower-prevalence areas are missed. Other geographical allocation approaches, which intensify efforts in higher-prevalence areas whilst maintaining a minimum package of cost-effective interventions everywhere, consistently improve impact at all budget levels. Such strategies balance the need for greater investment in locations with the largest epidemics whilst ensuring higher-risk groups in lower-priority locations are provided with cost-effective interventions. CONCLUSIONS: Our findings serve as a warning to not be too selective in the application of prevention strategies. Further research is needed to understand how decision-makers can find the right balance between the choice of interventions, focus on high-risk populations, and geographical targeting to ensure the greatest impact of HIV prevention.

Lessons learned from stakeholder-driven sustainability analysis of six national HIV programmes.

BACKGROUND: In light of the decline in donor HIV funding, HIV programmes increasingly need to assess their available and potential resources and maximize their utilization. This article presents lessons learned related to how countries have addressed the sustainability of HIV programmes in a stakeholder-driven sustainability analysis. METHODOLOGY: During HIV/AIDS Programme Sustainability Analysis Tool (HAPSAT) applications in six countries (Benin, Guyana, Kenya, Lesotho, Sierra Leone and South Sudan), stakeholders identified key sustainability challenges for their HIV responses. Possible policy approaches were prepared, and those related to prioritization and resource mobilization are analysed in this article. RESULTS: The need to prioritize evidence-based interventions and apply efficiency measures is being accepted by countries. Five of the six countries in this study requested that the HAPSAT team prepare 'prioritization' strategies. Countries recognize the need to prepare for an alternative to 'universal access by 2015', acknowledging that their capacity might be insufficient to reach such high-coverage levels by then. There is further acceptance of the importance of reaching the most-at-risk, marginalized populations, as seen, for example, in South Sudan and Sierra Leone. However, the pace at which resources are shifting towards these populations is slow. Finally, only two of the six countries, Kenya and Benin, chose to examine options for generating additional financial resources beyond donor funding. In Kenya, three non-donor sources were recommended, yet even if all were to be implemented, it would cover only 25% of the funding needed. CONCLUSIONS: Countries are increasingly willing to address the challenges of HIV programme sustainability, yet in different ways and with varying urgency. To secure achievements made to date and maximize future impact, countries would benefit from strengthening their strategic plans, operational plans and funding proposals with concrete timelines and responsibilities for addressing sustainability issues.