Cost and Effective Analysis of the LINKAGES ... - Linkages Project

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The key factors affecting cost effectiveness include baseline and outcome behavior change rates andthe size of target population.Across all three regions, lower baseline rates are associated with a lower cost per new acceptor – forexample the North region has the lowest baseline rate and the lowest cost per new acceptor for LAMUser Rate. The data for LAM User Rate costs and outcome suggests there is a direct relationshipbetween higher baseline rates of LAM User Rate and lower cost effectiveness, which can beexplained by increasing marginal costs for behavior change at higher LAM User Rate levels.One of the interpretations of this analysis is that LINKAGES may be able to improve the costeffectiveness of its LAM interventions by targeting areas with low behavior change rates. It should benoted that these results relate to LAM interventions only and these data alone do not allow us to drawconclusions about the cost effectiveness of other behavior change indicators.Determining an optimal population size that the intervention activities should target appears to beanother factor in achieving cost effectiveness. While the study data alone do not allow for definiteconclusions, one suggestion from the analysis is that there may be economies of scale to be realizedup to a certain threshold population level, after which, further increase in the size of the targetpopulation will result in decreased cost effectiveness, since the program costs grow at a higher pacethan the target population. At that stage, additional and/or different activities targeted at increasingbehavior change outcomes within the current size of population may result in higher costeffectiveness. If, however, this threshold level is not reached, and economies of scale can be gained,then an increase in the target population may improve cost effectiveness.As there were only small differences in the level of partner participation in the three regions, andgiven the limitations of financial data, partner participation was not found to be a major factor indetermining cost effectiveness.3. What would it cost to replicate these activities and is it cost effective?To calculate the cost of replication of LAM promotion activities, only the costs of implementationactivities are included (start-up activities would not be incurred again, and evaluation costs do notproduce behavior change and are not included in comparable studies). The cost of replicating thepackage of LINKAGES and partner interventions to promote LAM is $68,403. The total cost perbeneficiary to replicate this set of activities is $1.56.The total cost per new LAM acceptor, if LAM interventions were replicated, is estimated to be$29.83. There is a significant regional variation in cost effectiveness. The cost per new LAM acceptoris higher in the South ($69.38) as compared with the Center ($36.11) and the North ($18.60).4. How can LINKAGES improve its cost effectiveness?LINKAGES may be able to improve its cost effectiveness by:• Lowering the cost of LAM interventions by mainstreaming LAM• Targeting activities in areas with low LAM baseline ratesThe cost structure of the interventions is such that most of the costs are fixed costs and activity costsare not tied to the target population. Mainstreaming LAM into an integrated package of existing MCHLINKAGES Project/AED Executive Summary iv
activities will allow spreading those costs across several interventions resulting in lower cost perintervention.An analysis of marginal costs shows that there is a clear relationship between selecting areas with lowbaseline rates of the targeted behavior and cost effectiveness. LINKAGES may improve its costeffectiveness by targeting areas with lower baseline rates, where impact may be achieved at lowermarginal cost.The data were insufficient to provide a thorough analysis of the effect of the target population size oncost effectiveness. Nevertheless, one suggestion from the analysis is that there appears to be anoptimal size of population that intervention activities should target. This optimal size is defined asthat, which fully realize economies of scale and any further increase the size of the target populationwill result in decreased cost effectiveness. Any further increase in cost effectiveness, after thisoptimal threshold is reached, may only be obtained through direct interventions affecting the behaviorchange rates in the current size of the target population through different or additional activities. Ifthe target population in the program area has not reached the determined optimal level, andeconomies of scale may still be gained, increasing the target population size may improve costeffectiveness. However, with only three data points and one variable used in this study, furtheranalysis is needed to make concrete recommendations.One important limitation of this study is that it does not allow for an analysis of the cost effectivenessof individual activities or the optimal mix of activities. Thus, no recommendation can be maderegarding ways to improve cost effectiveness by manipulating the package of activities.Implications for the FutureThe MOH/MCH has made the decision to mainstream LAM into all reproductive health programs inJordan, regardless of donor support. This means that the costs associated with offering and counselingin LAM will be shared across the costs of offering all family planning methods, thus increasing thecost effectiveness of LAM activities (assuming rates of LAM behavior outcomes are maintained).Additionally, the cost structure for USAID-funded programs will differ from the cost structure ofprograms implemented by UN agencies, NGOs and other donors. This also has implications for costeffectiveness.The MOH is establishing the Breastfeeding Unit in 2004. While its goal is to increase exclusivebreastfeeding among infants less than six months old, it would be cost effective to integrate relatedbehaviors, such as complementary feeding and LAM, into the Unit’s activities.Discussion and ConclusionsWhile this study provided data that will be useful in shaping future activities, there are nonethelessmany other important questions that could shape future activities that have not been addressed:• What is the impact of each of the individual activities?• What is the optimal mix of activities?• What is the level of input required for specific activities, given program parameters suchas target population, population density?LINKAGES Project/AED Executive Summary v
Page 1 and 2: Cost and Effective Analysisof the L
Page 5 and 6: AbstractThis study analyzes cost ef
Page 7 and 8: ContentsExecutive Summary .........
Page 9 and 10: Executive SummaryIntroductionThe La
Page 11: activities conducted in support of
Page 15 and 16: 1. Background to the StudyIn an eff
Page 17 and 18: 3. Description of LINKAGES and Part
Page 19: of MCH services are mostly women of
Page 22 and 23: the administrative and overhead str
Page 24 and 25: activities were implemented. This i
Page 26 and 27: 4.7. Comparability and Applicabilit
Page 29 and 30: 5. Financial Data Collection5.1. LI
Page 31 and 32: 6. FindingsThe findings presented a
Page 33 and 34: Table 6: Relationship Between Costs
Page 35 and 36: 6.2.3. Cost Effectiveness and Targe
Page 37 and 38: Table 11 shows the classification o
Page 39 and 40: some portion of the costs are fixed
Page 41 and 42: 7. Discussion and Conclusions7.1. R
Page 43 and 44: Annex A: List of All LINKAGES Activ
Page 45 and 46: LINKAGES' LAM Activity Costs by Ele
Page 47 and 48: Detailed MOH/MCH' LAM Activity Cost
Page 49 and 50: Percentage of Each Activity Allocat
Page 51 and 52: III. LAM Indicator Data by RegionLA
Page 53 and 54: LAM User Rate Calculations - CENTER
Page 55 and 56: 36. Al-Muwaqar37. Al-Faisaliya (Eas
Page 57 and 58: 118. Southern Al-Twa’l (Al-Dayat)
Page 59 and 60: 196. Jiffien197. Izma’lBani Kinan
Page 61 and 62: Kayak Health Directorate276. Al-Rab
Page 63:
LINKAGES Project/AEDAnnex B: Detail
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