This article is divided into two parts: cost analysis and threshold analysis.
Cost analysis
The following methods were used to answer the research questions on cost of the YFHS programme. The costs were analysed from a programme perspective (healthcare provider’s perspective). All the costs related to delivering the YFHS programme in the selected four centres were included in the analyses. Financial and material support from local authorities and international donors were included. Unpaid voluntary work and beneficiaries’ out-of-pocket payments (e.g. medicine costs in a pharmacy) were excluded. The time horizon of the cost analysis was one year. The cost analyses were conducted for year 2011, which was the closest complete financial year at the time of conducting this study. All costs are at 2011 prices and presented in 2011 USD. Costs in Moldovan leu (MDL) were translated to USD at a rate of 11.72 [
8].
The cost analyses were based on financial records of: 1) Finance Services of Public Medical Health Institutions for YFHCs (FSPMHI), 2) NHIC, 3) National Centre of Reproductive Health and Medical Genetics (NCRHMG), 5) Health for Youth Association, 5) Family Doctors Centres (FDCs) and local authorities, and 6) information received from UNICEF, SDC and other donors.
Personnel salaries constitute a large part of the budget of the YFHS programme. A special time use form was developed and tested to measure how the personnel spend their working time at the centres. The self-reported survey was used to monitor time use of 28 salaried employees during a period of two weeks in September 2012. The collected data was statistically analysed by using SPSS software.
First, the cost of providing good quality services in the four YFHCs in 2011 were calculated. Then the total annual costs of the four YFHCs were analysed per financing source. Next, the total costs were presented in five standardized expense categories: 1) salaries, 2) medical supplies, 3) information materials, 4) personnel training, and 5) operations. Salary costs relate to gross salaries of the personnel of the YFHCs and the programme-related portion of salaries of financial and monitoring and evaluation personnel. Medical supplies include costs of: tests (smears, pregnancy and HIV tests), medicines for emergency care and medical materials used in the centres, distributed condoms and contraceptives. Information materials covers procurement and production costs of informational materials, brochures and leaflets. Training costs relate to training and capacity building of personnel of the four centres. Operation costs include computers, office supplies and -furniture, facilities and maintenance of the centres and transport costs.
The services of the YCHCs were grouped into six main categories. SRH services were: 1) STI, 2) HIV, and 3) early pregnancy and contraception. Other non-SRH services were: 4) general health services and 5) psychological counselling. In addition, informational and educational services were categorized as 6) IEC activities.
STI services include testing, diagnostics, treatment and follow-up consultations. HIV services include IEC HIV prevention activities, voluntary confidential counselling and testing (VCCT) at the centres or referrals to specialized service providers and in case of an HIV + result referral for treatment and social support. Early pregnancy and contraceptive services were grouped together. These cover information, contraceptive counselling and contraceptives distribution (condoms, COCs); pregnancy diagnostic (tests, examination, USG), referral for safe abortion or antenatal care, and social support. Currently only Neovita centre has permission to offer safe abortion services; for other centres abortions are conducted elsewhere. General health services include consultations related to a variety of medical advices and interventions, as well as health promotion activities. Psychological counselling include psycho-emotional, violence related and substance abuse information, counselling and referral.
‘Costs per service type’ were calculated as follows: 1) the salary costs were divided into: medical service-, IEC activity- and overhead salaries. The distribution was based on the results of the time use survey. 2) The medical service and IEC salary costs were allocated to each service type according to percentage of used working hours. 3) The remaining overhead salary costs were divided between medical services and IEC activities according to the number of working hours. 4) Personnel training costs were handled in the same way as the salary costs. 5) All medical supply costs were allocated to medical services. Additional costs for rapid HIV tests were added for HIV services, because YFHCs are planning to start providing rapid VCCT services in the near future. 6) Information material and operation costs were split between medical services and IEC by using number of services delivered in 2011. Finally, the cost per service was calculated by dividing the allocated budget by the number of services delivered.
In order to estimate ‘cost per person reached’, the services were divided into two groups: 1) Healthcare services, and 2) IEC activities. Next, the following assumptions were made: for all the healthcare services there were on average two consultations per patient, and for IEC services there was one activity per person. These assumptions were based on expert opinions of employees of the YFHS programme.
Finally, national level cost of scale-up good quality YFHSs to all 38 YFHCs of Moldova were estimated, by extrapolating average budget of three smaller well performing centres: Atis, Salve and Tineri Pentru Tineri. The Neovita centre was excluded from the extrapolation, because it fulfils several national functions for the programme and has a much higher budget than other centres. The purpose of this extrapolation was to provide MoH with an estimation for national level decision making on funds needed on scale-up of good quality YFHSs.
Threshold analysis
The following methods were used to answer the research questions on potential cost-effectiveness of the YFHS programme. It was not possible to carry out a classical retrospective cost-effectiveness analysis, because this requires: 1) impact assessment of the YFHSs programme, and 2) comparison with the incidence of infections and unwanted pregnancies in a comparable area where the YFHS do not exist. Such data was not available. Therefore, cost-effectiveness was approached from a different angle. Threshold analyses were conducted on: What would be the required impact levels for SRH services to break-even and become cost saving in a well performing centre in 2011?
The threshold analysis focuses on three SRH outcomes: 1) STIs, 2) unwanted pregnancies, and 3) HIV infections. Other non-SRH services (general health services and psychological counselling) were excluded from the analysis. The cost of delivering the SRH services were compared with cost savings resulting from averted treatment costs. The averted treatment costs are cost savings resulting from avoided negative SRH outcomes. Calculations were made to estimate break-even points for each SRH outcome. A break-even point is a point where the cost of delivering a healthcare service and cost savings resulting from averted treatment costs are equal. An intervention is cost saving, if the number of averted cases is higher than at the break-even point. Please note that this is a hypothetical analysis on impact levels required for the SRH services to break-even, not an actual impact assessment of the programme.
The threshold analysis was carried out from a healthcare provider’s perspective. Costs related to: 1) delivering the SRH services (results of the costing part of this study) and 2) cost savings resulting from averted treatment costs, were included in the analyses.
In the threshold analysis different STIs were grouped as a ‘generic STI’. This was done because in the YFHS programme costing the expenses were analysed on healthcare service group level (in this case all STI services), not per treated infection. The STI costs included testing, diagnostics and follow-up consultations, and cost of IEC services related to STI prevention as well. A typical STIs treatment consist of three consultations and cost USD 15.06 in the YFHCs. Treatment costs of syphilis and gonorrhoea were covered by the NHIC and were therefore included in the analysis (USD 220) [
9]. According to medical personnel of the YFHCs 5% of STI patients have syphilis or gonorrhoea. Patient’s out-of-pocket medicine costs were excluded from the analysis. The time horizon for the treatment cost was limited to successful treatment of an STI. The following parameters were used to estimate cost savings resulting from treatment of STIs in the YFHCs: 1) Moldovan adolescents, who have casual sexual partners (i.e. 38% of all sexually active adolescents) [
10], have on average 3.5 casual sex partners per year [
10], 2) condoms are used in 52.8% of these intercourses [
10], and 3) an STI infected adolescent would infect on average 1.9 partners in a year (calculations based points 1 and 2).
Early pregnancy and contraceptive services were categorized as ‘unwanted pregnancy’ related. The consequences of an unwanted pregnancy were divided into: 1) abortions (34%), and 2) deliveries (66%) [
11]. The time horizons for the costs were limited to completion of an abortion or a delivery. Abortion costs were limited to medicine costs of medical abortions (USD 38) [
12]. According to medical personnel of Neovita YFHCs, 95% of the girl patients, who decide to have an abortion, choose for a medical abortion. According to Boderscova (2005) 45% of deliveries in the age group 15–19 years in Moldova were normal deliveries and 55% had moderate or severe complications [
13]. Delivery costs include: 1) normal delivery USD 141 [
9], 2) delivery with complications USD 327 [
9], 3) ANC co-payment (USD 30) [
9] for all deliveries. Importantly, not all teenage births are unwanted. Results of the latest available Demographic and Health Survey in Moldova 2005 indicate that the weighted average (recalculated) percentage of unwanted births among all births to mothers up to 24 years old was 19.2% [
14].
‘HIV services’ included general IEC HIV prevention activities and VCCT. UNAIDS report on Assessment of Expenses for Antiretroviral Therapy for People Living with HIV and AIDS [
15] was used as a source for lifetime treatment cost of patients on first-line of ARV in Moldova. The expected remaining lifetime of an HIV infected person was assumed to be 21.5 years [
16]. The lifetime treatment costs were discounted with 3.5% annually to present the value of costs, as recommend by the National Institute for Health and Clinical Excellence [
17].