Costs and cost-effectiveness of HIV/noncommunicable disease integration in Africa: from theory to practice

Abstract

: The current article reviews economic aspects of selected HIV/noncommunicable disease (NCD) service delivery integration programs to assess the efficiency of integration in limited capacity settings. We define economies of scope and scale and their relevance to HIV/NCD integration. We summarize the results of a systematic review of cost and cost-effectiveness studies of integrated care, which identified 12 datasets (nine studies) with a wide range of findings driven by differences in research questions, study methods, and health conditions measured. All studies were done in Africa and examined screening interventions only. No studies assessed the cost of integrated, long-term disease management. Few studies estimated the cost-effectiveness of integrated screening programs. The additional cost of integrating NCD screening with HIV care platforms represented a 6-30% increase in the total costs of the programs for noncancer NCDs, with cervical cancer screening costs dependent on screening strategy. We conducted 11 key informant interviews to uncover perceptions of the economics of HIV/NCD integration. None of the informants had hard information about the economic efficiency of integration. Most expected integrated care to be more cost-effective than current practice, though a minority thought that greater specialization could be more cost-effective. In the final section of this article, we summarize research needs and propose a 'minimum economic dataset' for future studies. We conclude that, although integrated HIV/NCD care has many benefits, the economic justification is unproven. Better information on the cost, cost-effectiveness, and fiscal sustainability of integrated programs is needed to justify this approach in limited-resource countries.

Figure 1.

Economies of Scale As the number of outputs grow, the average unit cost (AC in the figure) decreases as production rises until the point of highest production efficiency. As production rises past this point the average unit cost increases, providing diseconomies of scale.

Figure 2.

Economies of Scope The lines show possible production possibility curves for two products while holding cost constant. The blue line shows the maximum possible goods produced for a certain cost if only products A or B are produced, or if some of both products are produced, with no economies of scope present. The orange line shows the maximum possible amount of Products A or B, or both, for a certain cost when economies of scope in production exist.