, Volume 30, Issue 10, pp 887–902 | Cite as

Counting the Cost of Not Costing HIV Health Facilities Accurately

Pay Now, or Pay More Later
  • Eduard J. Beck
  • Carlos Avila
  • Sofia Gerbase
  • Guy Harling
  • Paul De Lay
Review Article


The HIV pandemic continues to be one of our greatest contemporary public health threats. Policy makers in many middle- and low-income countries are in the process of scaling up HIV prevention, treatment and care services in the context of a reduction in international HIV funding due to the global economic downturn. In order to scale up services that are sustainable in the long term, policy makers and implementers need to have access to robust and contemporary strategic information, including financial information on expenditure and cost, in order to be able to plan, implement, monitor and evaluate HIV services.

A major problem in middle- and low-income countries continues to be a lack of basic information on the use of services, their cost, outcome and impact, while those few costing studies that have been performed were often not done in a standardized fashion. Some researchers handle this by transposing information from one country to another, developing mathematical or statistical models that rest on assumptions or information that may not be applicable, or using top-down costing methods that only provide global financial costs rather than using bottom-up ingredients-based costing.

While these methods provide answers in the short term, countries should develop systematic data collection systems to store, transfer and produce robust and contemporary strategic financial information for stakeholders at local, sub-national and national levels. National aggregated information should act as the main source of financial data for international donors, agencies or other organizations involved with the global HIV response. This paper describes the financial information required by policy makers and other stakeholders to enable them to make evidence-informed decisions and reviews the quantity and quality of the financial information available, as indicated by cost studies published between 1981 and 2008. Among the lessons learned from reviewing these studies, a need was identified for providing countries with practical guidance to produce reliable and standardized costing data to monitor performance, as countries want to improve programmes and services, and have to demonstrate an efficient use of resources. Finally, the issues raised in this paper relate to the provision of all areas of healthcare in countries and it is going to be increasingly important to leverage the lessons learned from the HIV experience and use resources more effectively and efficiently to improve health systems in general.


Supply Chain Health Facility Cost Data Financial Information Strategic Information 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



No sources of funding were used to prepare this manuscript. The authors have no conflicts of interest that are directly relevant to the content of this article.

EJB, SG and GH collected and analysed the data; CA and PDL provided ideas for the analyses and paper; all authors reviewed and commented on successive drafts. EJB had the idea for the paper and is the guarantor for the overall content.


  1. 1.
    UNAIDS World AIDS Day Report. How to get to zero: faster, smarter, better. UNAIDS, Geneva 2011 [online]. Available from URL: [Accessed 2012 Jul 3].
  2. 2.
    World Bank. World Bank country classification. Washington 2008 [online]. Available from URL: [Accessed 2012 Jul 3].
  3. 3.
    Global Health Observatory (GHO). Antiretroviral therapy (ART) coverage among all age groups. WHO, Geneva 2012 [online]. Available from URL: [Accessed 2012 Jul 3].
  4. 4.
    UNAIDS. Setting national targets for moving towards universal access: further guidance to complement “Scaling up towards universal access: considerations for countries to set their own national targets for AIDS prevention, treatment, and care and support”, Geneva, 2006 [online]. Available from URL: [Accessed 2012 Jul 3].
  5. 5.
    Mandalia S, Mandalia R, Lo G, et al., for the NPMS-HHC Steering Group. Rising population cost for treating people living with HIV in the UK, 1997–2013. PLoS One 2010; 5 (12): e15677.PubMedCentralCrossRefPubMedGoogle Scholar
  6. 6.
    Kates J, Boortz K, Lief E, et al. Financing the response to AIDS in low-and middle-income countries: international assistance from the G8, European Commission and other donor governments in 2009. Kaiser Family Foundation and UNAIDS [online]. Available from URL: [Accessed 2012 Jul 3].
  7. 7.
    Beck EJ, Mays N. Some lessons learned. In: Beck EJ, Mays N, Whiteside A, et al., (editors). The HIV pandemic: local and global implications. Oxford: Oxford University Press, 2006: 757–76.Google Scholar
  8. 8.
    The American Heritage Dictionary of the English Language, 4th edition. Houghton Mifflin Company, 2007 [online]. Available from URL: [Accessed 2012 Jul 3].
  9. 9.
    Beck EJ, Miners AH. Effectiveness and efficiency in the delivery of HIV services: economic and related considerations. In: Gazzard B, Johnson M, Miles A, editors. The effective management of HIV/AIDS: UK key advances in clinical practice. London: Aesculapius Medical Press, 2001: 113–38.Google Scholar
  10. 10.
    UNDP. The Millennium Development Goals [online]. Available from URL: [Accessed 2012 Jul 3].
  11. 11.
    UN General Assembly. Progress made in the implementation of the Declaration of Commitment on HIV/AIDS and the Political Declaration on HIV/AIDS: report of the Secretary-General. New York: United Nations, 2010 [online]. Available from URL: [Accessed 2012 Jul 3].
  12. 12.
    Wikipedia. Resource allocation [online]. Available from URL: [Accessed 2012 Jul 3].
  13. 13.
    Roberts RA, Hickey A, Rosner Z. The role of community involvement in HIV programmes in South Africa. In: Beck EJ, Mays N, Whiteside A, et al., editors. The HIV pandemic: local and global implications. Oxford: Oxford University Press, 2006: 720–33.Google Scholar
  14. 14.
    World Health Organization. A guide to producing National Health Accounts: with special applications for low-income and middle-income countries. Geneva: World Health Organization, 2003 [online]. Available from URL: [Accessed 2012 Jul 3].
  15. 15.
    Young D, Glandon D. National Health Accounts (NHA) subaccounts: tracking health expenditures to meet the Millennium Development Goals. Washington: USAID, 2009 [online]. Available from URL: [Accessed 2012 Jul 3].
  16. 16.
    UNAIDS. National AIDS Spending Assessment (NASA): classification and definitions. Geneva: UNAIDS, 2009 [online]. Available from URL: [Accessed 2012 Jul 3].
  17. 17.
    Izazola J, Wiegelmann J, Aran C, et al. Financing the response to HIV and AIDS in low- and middle-income countries. J Acquir Immune Defic Syndr 2009; 52 Suppl. 2: S119–26.Google Scholar
  18. 18.
    USAID Health Systems 20/20 Project, UNAIDS, World Health Organization. Linking NASA and NHA: concepts and mechanics, 2009 [online]. Available from URL: [Accessed 2012 Jul 3].
  19. 19.
    Finkler SA. The distinction between costs and charges. Ann Intern Med 1982; 96: 102–9.CrossRefPubMedGoogle Scholar
  20. 20.
    Beck EJ, Beecham J, Mandalia S, et al. What is the cost of getting the price wrong? J Public Health Med 1999; 21: 311–7.CrossRefPubMedGoogle Scholar
  21. 21.
    Tolley K, Gyldmark M. Towards a standardized framework for costing HIV and AIDS treatment and care in Europe. In: Fitzsimons D, Hardy V, Tolley K, editors. The economic and social impact of AIDS in Europe. London: Cassell, 1995: 25–39.Google Scholar
  22. 22.
    Beck EJ, Miners AH, Tolley K. The cost of HIV treatment and care: a global review. Pharmacoeconomics 2001; 19: 13–39.CrossRefPubMedGoogle Scholar
  23. 23.
    Beck EJ, Harling G, Gerbase S, et al. The cost of treatment and care for people living with HIV infection: implications of published studies, 1999–2008. Curr Opin HIV AIDS 2010; 5: 215–24.CrossRefPubMedGoogle Scholar
  24. 24.
    Krentz HB, Gill MJ. Cost of medical care for HIV-infected patients within a regional population from 1997 to 2006. HIV Med 2008 Oct; 9 (9): 721–30.CrossRefPubMedGoogle Scholar
  25. 25.
    Beck EJ, Mandalia M, Lo G, et al., for the NPMS-HHC Steering Group. Cost-effectiveness of early treatment with first-line NNRTI-based HAART Regimens in the UK, 1996–2006. PLoS One 2011; 6 (5): e20200.PubMedCentralCrossRefPubMedGoogle Scholar
  26. 26.
    Bautista-Arredondo S, Gadsden P, Harris JE, et al. Optimizing resource allocation for HIV/AIDS prevention programmes: an analytical framework. AIDS 2008; 22 Suppl. 1: S67–74.CrossRefPubMedGoogle Scholar
  27. 27.
    Adam T, Koopmanschap MA, Evans DB. Cost-effectiveness analysis: can we reduce variability in costing methods? Int J Technol Assess Health Care 2003; 19 (2): 407–20.CrossRefPubMedGoogle Scholar
  28. 28.
    Harling G, Wood R, Beck EJ. Efficiency of intervention in HIV infection, 1994–2004. Dis Manag Health Outcomes 2005; 13: 371–94.CrossRefGoogle Scholar
  29. 29.
    Beck EJ, Mandalia S, Gaudreault M, et al. The cost- effectiveness of HAART, Canada 1991–2001. AIDS 2004; 18: 2411–9.PubMedGoogle Scholar
  30. 30.
    Anis AH, Guh D, Hogg RS, et al. The cost-effectiveness of antiretroviral regimens for the treatment of HIV/AIDS. Pharmacoeconomics 2000; 18 (4): 393–404.CrossRefPubMedGoogle Scholar
  31. 31.
    Beck EJ, Santas X, DeLay P. Why and how to monitor the cost and evaluate the cost effectiveness of HIV services in countries. AIDS 2008; 22 Suppl. 1: S75–85.CrossRefPubMedGoogle Scholar
  32. 32.
    Tierney WM, Beck EJ, Gardner RM, et al. Viewpoint: a pragmatic approach to constructing a minimum dataset for care of patients with HIV in developing countries. J Am Med Inform Assoc 2006; 13: 253–60.PubMedCentralCrossRefPubMedGoogle Scholar
  33. 33.
    United States Government Accountability Office. Global health: trends in U.S. Spending for global HIV/AIDS and other health assistance in fiscal years 2001–2008. Washington: GAO, 2010 Oct [online]. Available from URL: [Accessed 2012 Jul 3].
  34. 34.
    Galárraga O, Wirtz VJ, Figueroa-Lara A, et al. Delivery unit costs for antiretroviral treatment and prevention of mother-to-child-transmission of HIV: a systematic review for low and middle income countries. Pharmacoeconomics 2011; 29 (7): 579–99.PubMedGoogle Scholar
  35. 35.
    UNAIDS. Manual for costing HIV facilities and services. UNAIDS: Geneva, 2011 [online]. Available from URL: [Accessed 2011 Jul 28].
  36. 36.
    UNAIDS. Workbook for collection of cost information of HIV services. UNAIDS: Geneva 2011 [online]. Available from URL: [Accessed 2012 Jul 3].
  37. 37.
    Justice AC. HIV and aging: time for a new paradigm. Curr HIV/AIDS Rep 2010; 7: 69–76.CrossRefPubMedGoogle Scholar
  38. 38.
    Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of health care programmes. Oxford: Oxford University Press, 2005.Google Scholar
  39. 39.
    Gold MR, Siegel JE, Russell LB, et al. Cost-effectiveness in health and medicine. New York: Oxford University Press, 1996.Google Scholar
  40. 40.
    Mogyorosy Z, Smith P. The main methodological issues in costing health care services: a literature review. CHE Research Paper 7. York: Centre for Health Economics, University of York, 2005.Google Scholar
  41. 41.
    Department of Health. NHS costing manual. London: Department of Health, 1997 [online]. Available from URL: [Accessed 2012 Jul 3].
  42. 42.
    Dickey B, Beecham JK, Latimer E, et al. Estimating per unit treatment costs for mental health and substance abuse programs. PN-37. The Evaluation Center @ HSRI, 1999 [online]. Available from URL: [Accessed 2012 Jul 3].
  43. 43.
    Adam T, Bishai D, Kahn M, et al. Methods for the costing component of the multi-country evaluation of IMCI. Geneva: World Health Organization, 2004 [online]. Available from URL: [Accessed 2012 Jul 3].
  44. 44.
    Shepard DS, Hodgkin D, Anthony YE. Analysis of hospital costs: a manual for managers. Geneva: World Health Organization, 2000.Google Scholar
  45. 45.
    Bebbington A, Beecham J. Hospital service provision for people with AIDS and HIV infection: a basis for costing. PSSRU Discussion Paper 684. Canterbury: University of Kent, 1989.Google Scholar
  46. 46.
    Hanson K, Gilson L. Cost, resource use and financing methodology for district health services: a practical manual. Bamako Initiative Technical Report Series, No. 34, 2nd edition. New York: UNICEF, 1996.Google Scholar
  47. 47.
    World Health Organization. Guidelines for cost and cost-effectiveness analysis of tuberculosis control. WHO/CDS/TB/2002.305. Geneva: World Health Organization, 2002.Google Scholar
  48. 48.
    SAFE International Research Partnership. Costing manual for the strategy development tool: a guide for developing strategies to improve skilled attendance at delivery. The Dugald Baird Centre for Research on Women’s Health, University of Aberdeen, 2003 [online]. Available from URL: [Accessed 2012 Jul 3].
  49. 49.
    Kumaranayake L, Pepperall J, Goodman H, et al. Costing guidelines for HIV prevention strategies. Geneva: UNAIDS, 2000 [online]. Available from URL: [Accessed 2012 Jul 3].
  50. 50.
    Marseille E, Dandona L, Saba J, et al. Assessing the efficiency of HIV prevention around the world: methods of the PANCEA project. Health Serv Res 2004; 39 (6 Pt 2): 1993–2012.Google Scholar
  51. 51.
    Bollinger L, Stover J, Boulle A, et al. Resource needs for HIV/AIDS: model for estimating resource needs for prevention, care and mitigation. Glastonbury, CT: Futures Institute, 2006.Google Scholar
  52. 52.
    World Bank. ASAP HIV/AIDS Costing Tool v1.2, October 2008 [online]. Available from URL: [Accessed 2012 Jul 3].
  53. 53.
    Asian Development Bank/UNAIDS. Costing guidelines for HIV/AIDS intervention strategies. ADB-UNAIDS Study Series: Tool 1, 2004 [online]. Available from URL: [Accessed 2012 Jul 3].
  54. 54.
    Beck EJ, Blandford J, Boulle A, et al. Essential information for countries to monitor & evaluate the economic aspects of HIV service provision: proceedings from a workshop. WHO/TDR Generic Tools Workshop; 2006 Jan 16–18; Geneva [online]. Available from URL: [Accessed 2012 Jul 3].
  55. 55.
    Kinghorn A. National ART unit cost measurement: analysis of cost data collection and costing methods and proposal for draft data-collection and costing instruments. Consideration of ART Unit costing design concepts. Johannesburg: Health & Development Africa, 2010 June.Google Scholar
  56. 56.
    UNAIDS/PEPFAR. Guidelines on protecting the confidentiality and security of HIV information: proceedings from a workshop. 2006 May 15–17; Geneva [online]. Available from URL: [Accessed 2012 Jul 3].
  57. 57.
    NIH News. Treating HIV-infected people with antiretrovirals protects partners from infection: findings result from NIH-funded international study, 2011 May 12 [online]. Available from URL: [Accessed 2012 Jul 3].
  58. 58.
    Hankins CA, de Zalduondo BO. Combination prevention: a deeper understanding of effective HIV prevention. AIDS 2010; 24 Suppl. 4: S70–80.CrossRefPubMedGoogle Scholar
  59. 59.
    Bajko MS. HIV study: 76% drop in cases with expanded treatment. San Francisco: Edge, 2011 Apr 18 [online]. Available from URL: [Accessed 2012 Jul 3].
  60. 60.
    NASTAD. ADAP Watch, from National Alliance of State and Territorial AIDS Directors, 2012 Apr 20 [online]. Available from URL: [Accessed 2012 Jul 3].
  61. 61.
    Ford N, Mills E, Calmy A. Rationing antiretroviral therapy in Africa: treating too few, too late. N Engl J Med 2009; 360: 1808–10.CrossRefPubMedGoogle Scholar
  62. 62.
    Anonymous. First ASIA regional training workshop on costed national strategic plans, 2008 Sep 15–26; Bangkok [online]. Available from URL: [Accessed 2012 Jul 3].
  63. 63.
    Hecht R, Bollinger L, John Stover J, et al. Critical choices in financing the response to the global HIV/AIDS pandemic. Health Aff 2009; 28: 1591–605.CrossRefGoogle Scholar
  64. 64.
    Schwartlander B, Stover J, Hallett T, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011; 377: 2031–41.CrossRefPubMedGoogle Scholar
  65. 65.
    United Nations, Political declaration on HIV/AIDS: intensifying our efforts to eliminate HIV/AIDS. UN: New York; 2011 Jun 10 [online]. Available from URL: [Accessed 2012 Jul 3].
  66. 66.
    Rabkin M, El-Sadr WM. Why reinvent the wheel? Leveraging the lessons of HIV scale-up to confront non-communicable diseases. Glob Public Health 2011; 6 (3): 247–56.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2012

Authors and Affiliations

  • Eduard J. Beck
    • 1
  • Carlos Avila
    • 2
  • Sofia Gerbase
    • 1
  • Guy Harling
    • 1
  • Paul De Lay
    • 1
  1. 1.Office of the Deputy Director, Programme BranchUNAIDS SecretariatGenevaSwitzerland
  2. 2.Department of Evidence, Strategy and ResultsUNAIDS SecretariatGenevaSwitzerland

Personalised recommendations