We analyze determinants of economic efficiency for three HIV prevention interventions in Kenya: HIV testing & counselling (HTC), prevention of mother-to-child transmission (PMTCT), and male circumcision (MC). As part of the “Optimizing the Response of Prevention: HIV Efficiency in Africa” (ORPHEA) project, input data were collected retrospectively from sample of government and non-governmental health facilities for 2011-12.
Multi-stage sampling was used to determine the sample of health facilities by type, ownership, size, and interventions offered totaling 175 sites in 78 health facilities in 33 districts across Kenya. Data sources included key informants, registers and time-motion methods. Total costs of production were computed using both quantity and unit price of each input. Average cost was estimated by dividing total cost per intervention by number of clients accessing the intervention. Forward-selection stepwise regression methods were used to identify and analyze significant determinants of log-transformed average costs (p<0.1).
Results show evidence of economies of scale for all three interventions: doubling the number of clients per year was associated with average cost reductions of 39% for HTC, 49% for PMTCT, and 69% for MC. Moreover, task shifting was associated with reduced costs for both PMTCT (47%) and MC (44%), but not for HTC. Costs in hospitals were higher for both HTC (56%) and PMTCT (60%) in comparison to non-hospitals, but this was not the case for MC. Performance incentives for staff were associated with increased costs in both HTC (50%) and PMTCT (64%), but not in MC. Facilities that performed community-based testing had higher HTC average costs (49%); and lower MC costs were associated with availability of male reproductive health services (81%) and presence of community advisory board (58%).
Aside from increasing production scale, HIV prevention costs may be contained by using task shifting, non-hospital sites, service integration and community supervision. The extant results have implications for HIV prevention programs in Kenya, and sub-Saharan Africa more generally.