Costing the implementation of public health interventions in resource-limited settings: a conceptual framework

Abstract

Background Failing to account for the resources required to successfully implement public health interventions can lead to an underestimation of costs and budget impact, optimistic cost-effectiveness estimates, and ultimately a disconnect between published evidence and public health decision-making. Methods We developed a conceptual framework for assessing implementation costs. We illustrate the use of this framework with case studies involving interventions for tuberculosis and HIV/AIDS in resource-limited settings. Results Costs of implementing public health interventions may be conceptualized as occurring across three phases: design, initiation, and maintenance. In the design phase, activities include developing intervention components and establishing necessary infrastructure (e.g., technology, standard operating procedures). Initiation phase activities include training, initiation of supply chains and quality assurance procedures, and installation of equipment. Implementation costs in the maintenance phase include ongoing technical support, monitoring and evaluation, and troubleshooting unexpected obstacles. Within each phase, implementation costs can be incurred at the site of delivery (“site-specific” costs) or more centrally (“above-service” or “central” costs). For interventions evaluated in the context of research studies, implementation costs should be classified as programmatic, research-related, or shared research/program costs. Purely research-related costs are often excluded from analysis of programmatic implementation. Conclusions In evaluating public health interventions in resource-limited settings, accounting for implementation costs enables more realistic estimates of budget impact and cost-effectiveness and provides important insights into program feasibility, scale-up, and sustainability. Assessment of implementation costs should be planned prospectively and performed in a standardized manner to ensure generalizability.

Effectiveness and cost-effectiveness of a health systems intervention for latent tuberculosis infection management (ACT4): a cluster-randomised trial

“…Understanding these start-up and implementation costs is key for public health decision making, yet very few economic analyses have accounted for these costs, and even then have not actually measured these costs prospectively. 24 Similar to other studies that considered cost allocation of prevention efforts, we found that personnel were the major driver of cost in all countries during programme strengthening. 25,26 We also found that the costs for initial evaluation, start-up, and initial training accounted for the great majority of costs, and the ongoing running costs for the LTBI programme were much lower.…”

“…*The number of household contacts that are estimated to be eligible for tuberculosis preventive treatment include all children younger than 5 years, and household contacts older than 5 years who are expected to test positive with the tuberculin skin test based on prevalence data collected at sites 16 and published data 17 (average for Canada 0•55, average for all other countries 0•70). phase showed ongoing improvement at sites, compared with the initial cascade analysis (appendix pp [19][20][21][22][23][24][25].…”

“Our Choice” improves use of safer conception methods among HIV serodiscordant couples in Uganda: a cluster randomized controlled trial evaluating two implementation approaches

“…We conducted a cost-effectiveness analysis (including implementation strategy costs [ 22 ];) based on program costs for personnel, supervision, training, and materials across both active study arms. Personnel costs included those for counselors, nurses, and expert clients, who over the course of the study were asked to recall how much time they spent weekly delivering intervention activities.…”

Cost-Effectiveness Analysis in Implementation Science: a Research Agenda and Call for Wider Application

“…Planning for Implementation, Scaling Up, and Sustaining Impact While calls to explicitly account for the costs attributable to implementation strategies are not novel [51], reporting remains uncommon [23]. Proposals of pragmatic approaches are still recent [52,53], particularly when considering preimplementation activities that may have a direct impact on scale of implementation [54] or program feasibility and sustainability [55]. In estimating costs for implementing combinations of EBIs in HIV/AIDS for six US cities, we derived public health department costs attributable to planning activities to coordinate implementation in local healthcare facilities [9].…”

“…There are a number of high-quality microcosting examples in both the public health [66] and the implementation science literature [54]. Similarly, some studies have proposed approaches for the standardized reporting of preimplementation and implementation component costs [52,54,55,67] but these have not yet been used widely or applied to population-level EBIs. Moreover, CEA typically uses assumptions of constant average costs (i.e., linear cost functions) yet the functional form of costs can matter, particularly for widespread implementation of EBIs [68].…”