The Cost of Providing Comprehensive HIV Services to Key Populations: An Analysis of the LINKAGES Program in Kenya and Malawi.

INTRODUCTION: Timely data on HIV service costs are critical for estimating resource needs and allocating funding, but few data exist on the cost of HIV services for key populations (KPs) at higher risk of HIV infection in low- and middle-income countries. We aimed to estimate the total and per contact annual cost of providing comprehensive HIV services to KPs to inform planning and budgeting decisions. METHODS: We collected cost data from the Linkages across the Continuum of HIV Services for Key Populations Affected by HIV (LINKAGES) program in Kenya and Malawi serving female and male sex workers, men who have sex with men, and transgender women. Data were collected prospectively for fiscal year (FY) 2019 and retrospectively for start-up activities conducted in FY2015 and FY2016. Data to estimate economic costs from the provider's perspective were collected from LINKAGES headquarters, country offices, implementing partners (IPs), and drop-in centers (DICs). We used top-down and bottom-up cost estimation approaches. RESULTS: Total economic costs for FY2019 were US$6,175,960 in Kenya and US$4,261,207 in Malawi. The proportion of costs incurred in IPs and DICs was 66% in Kenya and 42% in Malawi. The costliest program areas were clinical services, management, peer outreach, and monitoring and data use. Mean cost per contact was US$127 in Kenya and US$279 in Malawi, with a mean cost per contact in DICs and IPs of US$63 in Kenya and US$104 in Malawi. CONCLUSION: Actions undertaken above the service level in headquarters and country offices along with those conducted below the service level in communities, comprised important proportions of KP HIV service costs. The costs of pre-service population mapping and size estimation activities were not negligible. Costing studies that focus on the service level alone are likely to underestimate the costs of delivering HIV services to KPs.

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.

Scope and magnitude of private sector financing and provision of immunization in Benin, Malawi and Georgia.

BACKGROUND: Little is known about the role of private sector providers in providing and financing immunization. To fill this gap, the authors conducted a study in Benin, Malawi, and Georgia to estimate (1) the proportion of vaccinations taking place through the private sector; (2) private expenditures for vaccination; and (3) the extent of regulation. METHODS: In each country, the authors surveyed a stratified random sample of 50 private providers (private for-profit and not-for-profit) using a standardized, pre-tested questionnaire administered by trained enumerators. In addition, the authors conducted 300 or more client exit interviews in each country. RESULTS: The three countries had different models of private service provision of vaccination. In Malawi, 44% of private facilities, predominantly faith-based organizations, administered an estimated 27% of all vaccinations. In Benin, 18% of private for-profit and not-for-profit facilities provided vaccinations, accounting for 8% of total vaccinations. In Georgia, all sample facilities were privately managed, and conducted 100% of private vaccinations. In all three countries, the Ministries of Health (MoHs) supplied vaccines and other support to private facilities. The study found that 6-76% of clients paid nominal fees for vaccination cards and services, and a small percentage (2-26%) chose to pay higher fees for vaccines not within their countries' national schedules. The percentage of private expenditure on vaccination was less than 1% of national health expenditures. The case studies revealed that service quality at private facilities was mixed, a finding that is similar to those of other studies on private sector vaccination. The three countries varied in how well the MoHs managed and supervised private sector services. DISCUSSION/CONCLUSION: The private sector plays a growing role in lower-income countries and is expanding access to services. Governments' ability to regulate and monitor immunization services and promote quality and affordable services in the private sector should be a priority.

Health financing at district level in Malawi: an analysis of the distribution of funds at two points in time.

There is growing attention to tracking country level resource flows to health, but limited evidence on the sub-national allocation of funds. We examined district health financing in Malawi in 2006 and 2011, and equity in the allocation of funding, together with the association between financing and under five and neonatal mortality. We explored the process for receiving and allocating different funding sources at district level. We obtained domestic and external financing data from the Integrated Financial Management Information System (2006-11) and AidData (2000-12) databases. Out-of-pocket payment data came from two rounds of integrated household budget surveys (2005; 2010). Mortality data came from the Multiple Indicator Cluster Survey (2006) and Demographic and Health Survey (2010). We described district level health funding by source, ran correlations between funding and outcomes and generated concentration curves and indices. 41 semi-structured interviews were conducted at the national level and in 10 districts with finance and health managers. Per capita spending from all sources varied substantially across districts and doubled between 2006 and 2011 from 7181 Kwacha to 15 312 Kwacha. In 2011, external funding accounted for 74% of funds, with domestic funding accounting for 19% of expenditure, and out of pocket (OOP) funding accounting for 7%. All funding sources were concentrated among wealthier districts, with OOP being the most pro-rich, followed by domestic expenditure and external funding. Districts with higher levels of domestic and external funding had lower levels of post-neonatal mortality, and those with higher levels of out-of-pocket payments had higher levels of 1-59 month mortality in 2006. There was no association between changes in financing and outcomes. Districts reported delayed receipt of lower-than-budgeted funds, forcing them to scale-down activities and rely on external funding. Governments need to track how resources are allocated sub-nationally to maximize equity and ensure allocations are commensurate to health need.

Maternal influenza immunization in Malawi: Piloting a maternal influenza immunization program costing tool by examining a prospective program.

BACKGROUND: This costing study in Malawi is a first evaluation of a Maternal Influenza Immunization Program Costing Tool (Costing Tool) for maternal immunization. The tool was designed to help low- and middle-income countries plan for maternal influenza immunization programs that differ from infant vaccination programs because of differences in the target population and potential differences in delivery strategy or venue. METHODS: This analysis examines the incremental costs of a prospective seasonal maternal influenza immunization program that is added to a successful routine childhood immunization and antenatal care program. The Costing Tool estimates financial and economic costs for different vaccine delivery scenarios for each of the major components of the expanded immunization program. RESULTS: In our base scenario, which specifies a donated single dose pre-filled vaccine formulation, the total financial cost of a program that would reach 2.3 million women is approximately $1.2 million over five years. The economic cost of the program, including the donated vaccine, is $10.4 million over the same period. The financial and economic costs per immunized pregnancy are $0.52 and $4.58, respectively. Other scenarios examine lower vaccine uptake, reaching 1.2 million women, and a vaccine purchased at $2.80 per dose with an alternative presentation. CONCLUSION: This study estimates the financial and economic costs associated with a prospective maternal influenza immunization program in a low-income country. In some scenarios, the incremental delivery cost of a maternal influenza immunization program may be as low as some estimates of childhood vaccination programs, assuming the routine childhood immunization and antenatal care systems are capable of serving as the platform for an additional vaccination program. However, purchasing influenza vaccines at the prices assumed in this analysis, instead of having them donated, is likely to be challenging for lower-income countries. This result should be considered as a starting point to understanding the costs of maternal immunization programs in low- and middle-income countries.

Tobacco growing and the sustainable development goals, Malawi.

Negative impacts of tobacco result from human consumption and from tobacco-growing activities, most of which now occur in low- and middle-income countries. Malawi is the world's largest producer of burley tobacco and its population is affected by the negative consequences of both tobacco consumption and production. In countries like Malawi, tobacco control refers to control of the tobacco supply chain, rather than control of consumption. We review the impact of tobacco cultivation, using Malawi as an example, to illustrate the economic, environmental, health and social issues faced by low- and middle-income countries that still produce significant tobacco crops. We place these issues in the context of the sustainable development goals (SDGs), particularly 3a which calls on all governments to strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control. Other goals address the negative effects that tobacco cultivation has on development. The SDGs offer an opportunity for low- and middle-income countries that are dependent on tobacco production and that are not yet parties to the Convention, to reconsider joining the FCTC.

Les impacts négatifs du tabac résultent de la consommation humaine et des activités de culture du tabac, qui sont aujourd'hui exercées pour la plupart dans les pays à revenu faible et intermédiaire. Le Malawi est le plus grand producteur mondial de tabac Burley et sa population subit les effets négatifs de la consommation et de la production de tabac. Dans des pays comme le Malawi, le contrôle du tabac porte davantage sur le contrôle de la chaîne d'approvisionnement que sur le contrôle de la consommation de tabac. Nous examinons ici l'impact de la culture du tabac, en prenant le Malawi comme exemple pour illustrer les problèmes économiques, environnementaux, sanitaires et sociaux que rencontrent les pays à revenu faible et intermédiaire qui continuent de produire d'importantes récoltes de tabac. Nous plaçons ces problèmes dans le cadre des objectifs de développement durable (ODD), en particulier du 3.a, qui appelle tous les gouvernements à renforcer l'application de la Convention-cadre de l'Organisation mondiale de la Santé pour la lutte antitabac (CCLAT). D'autres objectifs s'intéressent aux effets négatifs de la culture du tabac sur le développement. Les ODD offrent l'opportunité aux pays à revenu faible et intermédiaire qui dépendent de la production de tabac et qui ne sont pas encore parties à la Convention de réenvisager de la signer.

Los impactos negativos del tabaco se derivan del consumo humano y las actividades de cultivo de tabaco, la mayoría de las cuales suelen realizarse actualmente en países con ingresos bajos y medios. Malawi es el mayor productor de tabaco burley del mundo y su población se ha visto afectada por las consecuencias negativas del consumo y la producción de tabaco. En países como Malawi, el control del tabaco hace referencia al control de la cadena de suministro de tabaco, en lugar del control del consumo. Se revisó el impacto del cultivo de tabaco, utilizando Malawi como ejemplo, para ilustrar los problemas económicos, medioambientales, sanitarios y sociales a los que se enfrentan los países de ingresos bajos y medios que siguen produciendo grandes cosechas de tabaco. Se situaron estos problemas en el contexto de los objetivos de desarrollo sostenible, principalmente el 3.a, que hace un llamamiento a todos los gobiernos para que fortalezcan la implementación del Convenio Marco de la OMS para el Control del Tabaco (CMCT). Otros objetivos abordan los efectos negativos del cultivo de tabaco en el desarrollo. Los ODS ofrecen una oportunidad para que los países con ingresos bajos y medios que dependen de la producción del tabaco y que aún no forman parte del convenio reconsideren incorporarse al CMCT.

Tobacco growing and the sustainable development goals, Malawi

Negative impacts of tobacco result from human consumption and from tobacco-growing activities, most of which now occur in low- and middle-income countries. Malawi is the world's largest producer of burley tobacco and its population is affected by the negative consequences of both tobacco consumption and production. In countries like Malawi, tobacco control refers to control of the tobacco supply chain, rather than control of consumption. We review the impact of tobacco cultivation, using Malawi as an example, to illustrate the economic, environmental, health and social issues faced by low- and middle-income countries that still produce significant tobacco crops. We place these issues in the context of the sustainable development goals (SDGs), particularly 3a which calls on all governments to strengthen the implementation of the World Health Organization Framework Convention on Tobacco Control. Other goals address the negative effects that tobacco cultivation has on development. The SDGs offer an opportunity for low- and middle-income countries that are dependent on tobacco production and that are not yet parties to the Convention, to reconsider joining the FCTC

Countdown to 2015 country case studies: what can analysis of national health financing contribute to understanding MDG 4 and 5 progress?

BACKGROUND: Countdown to 2015 (Countdown) supported countries to produce case studies that examine how and why progress was made toward the Millennium Development Goals (MDGs) 4 and 5. Analysing how health-financing data explains improvements in RMNCH outcomes was one of the components to the case studies. METHODS: This paper presents a descriptive analysis on health financing from six Countdown case studies (Afghanistan, Ethiopia, Malawi, Pakistan, Peru, and Tanzania), supplemented by additional data from global databases and country reports on macroeconomic, health financing, demographic, and RMNCH outcome data as needed. It also examines the effect of other contextual factors presented in the case studies to help interpret health-financing data. RESULTS: Dramatic increases in health funding occurred since 2000, where the MDG agenda encouraged countries and donors to invest more resources on health. Most low-income countries relied on external support to increase health spending, with an average 20-64 % of total health spending from 2000 onwards. Middle-income countries relied more on government and household spending. RMNCH funding also increased since 2000, with an average increase of 119 % (2005-2010) for RMNH expenditures (2005-2010) and 165 % for CH expenditures (2005-2011). Progress was made, especially achieving MDG 4, even with low per capita spending; ranging from US$16 to US$44 per child under 5 years among low-income countries. Improvements in distal factors were noted during the time frame of the analysis, including rapid economic growth in Ethiopia, Peru, and Tanzania and improvements in female literacy as documented in Malawi, which are also likely to have contributed to MDG progress and achievements. CONCLUSIONS: Increases in health and RMNCH funding accompanied improvements in outcomes, though low-income countries are still very reliant on external financing, and out-of-pocket comprising a growing share of funds in middle-income settings. Enhancements in tracking RMNCH expenditures across countries are still needed to better understand whether domestic and global health financing initiatives lead to improved outcomes as RMNCH continues to be a priority under the Sustainable Development Goals.

Malawi and Millennium Development Goal 4: a Countdown to 2015 country case study.

BACKGROUND: Several years in advance of the 2015 endpoint for the Millennium Development Goals (MDGs), Malawi was already thought to be one of the few countries in sub-Saharan Africa likely to meet the MDG 4 target of reducing under-5 mortality by two-thirds between 1990 and 2015. Countdown to 2015 therefore selected the Malawi National Statistical Office to lead an in-depth country case study, aimed mainly at explaining the country's success in improving child survival. METHODS: We estimated child and neonatal mortality for the years 2000-14 using five district-representative household surveys. The study included recalculation of coverage indicators for that period, and used the Lives Saved Tool (LiST) to attribute the child lives saved in the years from 2000 to 2013 to various interventions. We documented the adoption and implementation of policies and programmes affecting the health of women and children, and developed estimates of financing. FINDINGS: The estimated mortality rate in children younger than 5 years declined substantially in the study period, from 247 deaths (90% CI 234-262) per 1000 livebirths in 1990 to 71 deaths (58-83) in 2013, with an annual rate of decline of 5·4%. The most rapid mortality decline occurred in the 1-59 months age group; neonatal mortality declined more slowly (from 50 to 23 deaths per 1000 livebirths), representing an annual rate of decline of 3·3%. Nearly half of the coverage indicators have increased by more than 20 percentage points between 2000 and 2014. Results from the LiST analysis show that about 280,000 children's lives were saved between 2000 and 2013, attributable to interventions including treatment for diarrhoea, pneumonia, and malaria (23%), insecticide-treated bednets (20%), vaccines (17%), reductions in wasting (11%) and stunting (9%), facility birth care (7%), and prevention and treatment of HIV (7%). The amount of funding allocated to the health sector has increased substantially, particularly to child health and HIV and from external sources, but remains below internationally agreed targets. Key policies to address the major causes of child mortality and deliver high-impact interventions at scale throughout Malawi began in the late 1990s and intensified in the latter half of the 2000s and into the 2010s, backed by health-sector-wide policies to improve women's and children's health. INTERPRETATION: This case study confirmed that Malawi had achieved MDG 4 for child survival by 2013. Our findings suggest that this was achieved mainly through the scale-up of interventions that are effective against the major causes of child deaths (malaria, pneumonia, and diarrhoea), programmes to reduce child undernutrition and mother-to-child transmission of HIV, and some improvements in the quality of care provided around birth. The Government of Malawi was among the first in sub-Saharan Africa to adopt evidence-based policies and implement programmes at scale to prevent unnecessary child deaths. Much remains to be done, building on this success and extending it to higher proportions of the population and targeting continued high neonatal mortality rates. FUNDING: Bill & Melinda Gates Foundation, WHO, The World Bank, Government of Australia, Government of Canada, Government of Norway, Government of Sweden, Government of the UK, and UNICEF.

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.

A cost function analysis of child health services in four districts in Malawi.

BACKGROUND: Recent analyses show that donor funding for child health is increasing, but little information is available on actual costs to deliver child health care services. Understanding how unit costs scale with service volume in Malawi can help planners allocate budgets as health services expand. METHODS: Data on facility level inputs and outputs were collected at 24 health centres in four districts of Malawi visiting a random sample of government and a convenience sample of Christian Health Association of Malawi (CHAM) health centres. In the cost function, total outputs, quality, facility ownership, average salaries and case mix are used to predict total cost. Regression analysis identifies marginal cost as the coefficient relating cost to service volume intensity. RESULTS: The marginal cost per patient seen for all health centres surveyed was US$ 0.82 per additional patient visit. Average cost was US$ 7.16 (95% CI: 5.24 to 9.08) at government facilities and US$ 10.36 (95% CI: 4.92 to 15.80) at CHAM facilities per child seen for any service. The first-line anti-malarial drug accounted for over 30% of costs, on average, at government health centres. Donors directly financed 40% and 21% of costs at government and CHAM health centres, respectively. The regression models indicate higher total costs are associated with a greater number of outpatient visits but that many health centres are not providing services at optimal volume given their inputs. They also indicate that CHAM facilities have higher costs than government facilities for similar levels of utilization. CONCLUSIONS: We conclude by discussing ways in which efficiency may be improved at health centres. The first option, increasing the total number of patients seen, appears difficult given existing high levels of child utilization; increasing the volume of adult patients may help spread fixed and semi-fixed costs. A second option, improving the quality of services, also presents difficulties but could also usefully improve performance.