Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Randomized Controlled Trial
. 2022 Mar 24;19(3):e1003827.
doi: 10.1371/journal.pmed.1003827. eCollection 2022 Mar.

Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries

Giulia Ferrari  1   2   3 , Sergio Torres-Rueda  2 , Esnat Chirwa  4 , Andrew Gibbs  4 , Stacey Orangi  5 , Edwine Barasa  5   6 , Theresa Tawiah  7 , Rebecca Kyerewaa Dwommoh Prah  7 , Regis Hitimana  8 , Emmanuelle Daviaud  9 , Eleonah Kapapa  10 , Kristin Dunkle  4 , Lori Heise  11 , Erin Stern  2 , Sangeeta Chatterji  11 , Benjamin Omondi  12 , Deda Ogum Alangea  13 , Rozina Karmaliani  14   15 , Hussain Maqbool Ahmed Khuwaja  15 , Rachel Jewkes  4 , Charlotte Watts  2 , Anna Vassall  2
Affiliations
Randomized Controlled Trial

Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries

Giulia Ferrari et al. PLoS Med. .

Abstract

Background: Violence against women and girls (VAWG) is a human rights violation with social, economic, and health consequences for survivors, perpetrators, and society. Robust evidence on economic, social, and health impact, plus the cost of delivery of VAWG prevention, is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in 6 countries.

Methods and findings: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 combined small group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (government-mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial's design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted and characterise uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. From a health sector perspective, the cost per DALY averted varies between US$222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants' health costs.

Conclusions: We demonstrate that investment in established community-based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health, and economic outcomes captured in future cost-effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.

PubMed Disclaimer

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: CW was the Chief Scientific Adviser at the Department for International Development (UKAid) at the time of writing. This work was conducted as part of her academic role as professor in epidemiology at the London School of Hygiene & Tropical Medicine.

Figures

Fig 1
Fig 1. Research setting, provider perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. CEAC, cost-effectiveness acceptability curve; DALY, disability-adjusted life year; VATU, Violence and Alcohol Treatment.
Fig 2
Fig 2. Research setting, societal perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. CEAC, cost-effectiveness acceptability curve; DALY, disability-adjusted life year; VATU, Violence and Alcohol Treatment.
Fig 3
Fig 3. Scale-up scenario 1, provider perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. CEAC, cost-effectiveness acceptability curve; DALY, disability-adjusted life year.
Fig 4
Fig 4. Scale-up scenario 1, societal perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. CEAC, cost-effectiveness acceptability curve; DALY, disability-adjusted life year.
Fig 5
Fig 5. Scale-up scenario 2, provider perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. DALY, disability-adjusted life year.
Fig 6
Fig 6. Scale-up scenario 2, societal perspective.
CEACs illustrating the probability that the intervention is effective for a range of thresholds. Dashed vertical line: country-specific opportunity cost threshold; dashed horizontal line: probability that the intervention is cost-effective at the country-specific threshold, given the cost per DALY averted by the intervention. DALY, disability-adjusted life year.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Sardinha L, Maheu-Giroux M, Stöckl H, Meyer SR, García-Moreno C. Global, regional, and national prevalence estimates of physical or sexual, or both, intimate partner violence against women in 2018. Lancet. 2022; 399:803–813. doi: 10.1016/S0140-6736(21)02664-7 - DOI - PMC - PubMed
    1. Creditor Reporting System (CRS). [cited 2020 Mar 26]. https://stats.oecd.org/Index.aspx?DataSetCode=CRS1#.
    1. What Works. What Works—What Works to Prevent VAWG: Research and Innovation Programme—Final Performance Evaluation. 2020 [cited 2020 Jul 27]. https://www.whatworks.co.za/resources/reports/item/716-what-works-to-pre....
    1. Abramsky T, Devries K, Kiss L, Nakuti J, Kyegombe N, Starmann E, et al.. Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala. Uganda BMC Med. 2014;12:122. doi: 10.1186/s12916-014-0122-5 - DOI - PMC - PubMed
    1. Ogum Alangea D, Addo-Lartey AA, Chirwa ED, Sikweyiya Y, Coker-Appiah D, Jewkes R, et al.. Evaluation of the rural response system intervention to prevent violence against women: findings from a community-randomised controlled trial in the Central Region of Ghana. Glob Health Action. 2020;13:1711336. doi: 10.1080/16549716.2019.1711336 - DOI - PMC - PubMed

Publication types