Determining costs and financing
When planning HIV testing and counselling services it is essential to have accurate cost estimates from which budgets can be constructed. In order to implement and scale up it is necessary to secure adequate financing for all aspects of the programme. Failure to predict realistic costs and secure sufficient funding has sometimes led to the inability of existing HIV testing and counselling services being unable to scale up so as to meet demand.
The costing and financing requirements of HIV testing and counselling services vary with the setting and with the services offered. This section considers the following issues:
- estimating costs by developing a costing framework;
- cost implications of different models of HIV testing and counselling services;
- cost-sharing and cost recovery;
- financing mechanisms and resource mobilization;
- resources available including accounting materials;
- challenges and opportunities in estimating costs and securing funding.
The estimation of costs for a testing and counselling programme requires detailed data on the numbers of people who are expected to access the services and on the planned components of the services and their costs. Several tools exist for estimating the costs of HIV/AIDS programmes.
In order to estimate programme costs it is necessary to:
- define programme targets (numbers of people expected to access testing and/or related services);
- estimate start-up and ongoing costs for the site or sites;
- estimate start-up and ongoing costs for all cadres of staff;
- estimate any potential income generated by the programme (e.g. cost-sharing / cost recovery).
A Step-by-Step Methodological Guide for Costing HIV/AIDS Activities
This step-by-step guide is intended to provide project managers in the field with a framework for how to do measure costs for a single, recent year in the life of an HIV/AIDS program. An illustrative activities list in the report annex will assist the user to develop an activities-based framework. The information gleaned from the costing framework will enable policy makers and program managers to make informed resource allocation decisions.
Setting national targets for moving towards universal access by 2010: operational guidance (UNAIDS 2006)
This document provides operational guidance to country-level partners and UN staff to facilitate the next phase of the country-level consultative process on scaling up towards universal access to prevention, treatment, care and support services. It concerns the setting of ambitious targets for the national HIV response to achieve by 2008 and 2010, and builds on previous guidelines.
Costs to consider
The cost and financing needs depend on the site chosen. HIV testing and counselling may be integrated into existing health services (ANC, TB, STI), added to the work of community organizations (youth centres, community centres) or established on stand-alone sites. When planning HIV testing and counselling services and/or writing funding proposals it is important to be as comprehensive as possible and not to underestimate costs, particularly the start-up costs. It is also a good idea to include a contingency in the budget to cover unexpected or emergency expenditures.
When determining costs and organizing accounting practices it is helpful to separate start-up costs from permanent ongoing costs as well as separating fixed costs from variable costs. Fixed costs are those that stay the same in total over the relevant range but change inversely per unit as activity changes. Variable costs stay the same per unit but change overall in direct proportion to changes in activity or scale.
The following is a non-exhaustive checklist of costs that may have to be considered when a testing and counselling site and programme are being set up and run:
- Furniture, equipment
- Services related to HIV testing and counselling, including community mobilization
- Monitoring and evaluation, including external evaluation
- Staff health and safety
- Training and technical assistance
- HIV test kits
- Other supplies
This 2-page costing checklist consists of 2 tables. Firstly Testing and Counselling site costs (including furniture and transport), and secondly staff costs (including training and technical assistance). It can be filled in according to start up and recurrent costs.
Tools for Evaluating HIV Voluntary Counselling and Testing
This document comprises a series of tools, in the form of questionnaires and checklists, for the evaluation of VCT. These can be altered and/or adapted as required. There are 8 tools that include: evaluation for the national preparedness for VCT implementation; VCT site evaluation - logistic considerations and coverage; evaluation of counsellor selection, training and support; evaluation of counselling skills (pre-test, post-test, no test); evaluation of counselling for special interventions (TBPT, MTCT); evaluation of group work; evaluation of client satisfaction; evaluation of VCT costs. There is also a section on difficulties that may be encountered when attempting supervision or viewing of counselling sessions for quality assurance.
Lack of data when projections and predictions are being made can be a particularly problematic when a service is being set up, because it may be difficult to anticipate how many people will attend HIV testing and counselling services, how many people from different populations groups will attend, and how many people will need follow-up services.
Justifying costs and budgets is important for presentations to potential funding sources, which may have a clear idea of what similar projects cost and what competing projects may be requesting. It is important for budgets to be as realistic and comprehensive as possible. Evidence of changing epidemiological and demographic trends can be presented as part of the justification for the required budgets.
Inflation and exchange rates - many developing countries have high rates of inflation or fluctuating exchange rates. This may make it difficult to budget for both expenditure within the countries and for consumables (such as test kits) that are purchased elsewhere. It is therefore important to make realistic predictions of inflation with a stated margins of error. Donor agencies may have regulations about the currencies in which budgets should be drawn up. The exchange rates that are used should be stated.
Unplanned activities - even if the most careful plans and budgets have been made there are often additional activities that require funding and other unplanned expenses. This is a particular problem for new HIV testing and counselling services. However, circumstances may change even for well-established services. There should be a contingency for unplanned or emergency expenses. Some donor agencies may be reluctant to agree to contingency budget lines but may provide additional funding if circumstances change.
Competition with other programmes and organizations for donor resources - despite an increased emphasis on funding for HIV activities through new funding mechanisms, e.g. the Global Fund, there is still intense competition for limited funds. Participation in coordinating funding approaches such as GFATM's CCM may facilitate access to funds. Furthermore, this can help organizations that provide or intend to provide testing and counselling services, to form linkages with other HIV support organizations offering care and support , community based advocacy work and legal services. For example, linkages with groups of people with HIV, health service providers, condom social marketing programmes and church-based, faith-based and other community groups enhance testing and counselling services and may reduce costs if support services are available from these bodies.