Controlling sexually transmitted infections (STI) can reduce the spread of HIV in the early stages of the epidemic. But high-risk groups are especially hard to reach. A trial in Managua, Nicaragua, shows that a targeted competitive voucher scheme is a cost-effective way to reduce STIs among the most vulnerable groups.
The scheme, implemented by researchers from the Instituto Centroamericano de la Salud (ICAS), targeted sex workers (including transvestites and male and female adolescent glue-sniffers), their clients, and men who have sex with men. Users could choose to redeem their vouchers at one of 7 to 12 private and non-governmental organisation (NGO) clinics, in exchange for:
- medical consultation
- screening for syphilis, trichomoniasis, candidiasis, gardenerella and cervical cancer
- diagnosis of other STIs through physical examination
- presumptive treatment with a single dose of one gram azithromycin for several STI, including chlamydia and gonorrhoea.
- health education including an information booklet aimed at sex workers
- 24 free condoms at each visit.
The researchers found that:
- The annual cost of providing comprehensive STI services through vouchers was US$ 62,495, compared with an estimated US$ 17,112 for regular service provision.
- The scheme distributed 4,815 vouchers, tested 1,543 patients for STI and effectively cured 528 infections. Of these infections, 28 percent were chlamydia, 25 percent syphilis or chancroid, 19 percent gonorrhoea and 19 percent trichomoniasis.
- In the absence of the scheme, only an estimated 85 STI infections would have been cured from 1,396 consultations.
- The average cost of the voucher scheme per patient treated was US$ 41 and US$ 118 per STI effectively cured, compared with US$ 12 per patient treated and US$ 200 cured without the scheme.
- The incremental cost of curing an STI through the voucher scheme was US$ 103.
Total direct costs to voucher redeemers were US$ 4.46, including transport, snacks and limited medical expenses. Eighty-seven percent lost income as a result of attending the clinic. The average opportunity cost of time was US$ 2.64. Without the voucher scheme, users would have to spend an additional US$ 5.10 for a consultation in NGO facilities or up to US$ 28.19 at a private clinic, excluding drugs and lab tests.
Additional benefits of the scheme not included in the analysis are: the number of secondary infections averted by preventing or curing STIs in sex workers, which has been estimated to be more than 100 times greater than the general population; the likely increase in condom use; savings in terms of averted medical treatment and productivity gains from HIV cases prevented; and savings from reducing STI illness.
The researchers draw the following conclusions for policymakers wishing to use this scheme for high-risk groups elsewhere:
- Cost effectiveness would increase significantly in countries with lower personnel costs.
- There are likely to be economies of scale if expanded to a larger population.
- It may be cost-effective to subsidise transport and time costs to increase redemption rates in the lower redeeming groups.
Source(s):
‘The cost-effectiveness of a competitive voucher scheme to reduce sexually
transmitted infections in high-risk groups in Nicaragua’, Health Policy and
Planning 20(4): 222-231, by J. Borghi, A. Gorter, P. Sandiford and Z. Segura,
2005
'A guide to competitive vouchers in health', Private Sector Advisory
Group, The World Bank Group, Washington D.C., by P. Sandiford, A. Gorter, Z.
Rojas and M. Salvetto, 2004
Funded by:
UK Department for International Development; Elton John AIDS Foundation;
Ministry of Foreign Affairs, The Netherlands; NOVIB (Oxfam Netherlands)
id21 Research Highlight: 18 January 2006
Further Information:
About the costing study:
Josephine Borghi
Infectious Disease Epidemiology Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK
Tel:
+44 (0)20 7612 7887
Fax:
+44 (0)20 7637 5391
Contact the contributor: jo.borghi@lshtm.ac.uk
Instituto Centroamericano de la Salud (ICAS), Nicaragua
About the voucher scheme:
Anna Gorter
Instituto Centro Americano de la Salud (ICAS)
P.O. Box 2234
Managua
Nicaragua
Contact the contributor: agorter@ibw.com.ni
Other related links:
Instituto Centroamericano de la Salud (ICAS), Nicaragua: A voucher scheme
for adolescents in Nicaragua to improve the uptake of reproductive health
services
'Can health vouchers help vulnerable groups?'
'Competitive voucher schemes: can they improve healthcare for the poor?'
'Vouching for health: HIV prevention for sex workers in Nicaragua'
'Malaria prevention – can social marketing net the poorest?'
'Paid to be healthy: health prevention in Honduras'
'Analysis on demand: ‘demand side’ issues in pro-poor health policy'
