Diarrhea, malaria, and HIV together account for one third of total disease burden in Sub-Saharan Africa, as measured in disability adjusted life years (DALYs;[1]). Simple interventions such as the provision of safe drinking water, bed nets, and HIV voluntary counseling and testing, offer the prospect of substantial reductions in disease incidence, morbidity, and mortality[2-4]. The World Health Organization and national governments, including the Government of Kenya, have endorsed principles of universal access to these interventions. Wide access will advance progress toward health targets in the millennium development goals[5].

However, achieving high access is challenging, and has thus far been elusive. In African settings, coverage of voluntary counseling and testing (VCT) ranges from 10% to one-third, with a high proportion of HIV-infected adults (about 80% in Kenya) unaware of HIV status[6]. Surveys in 18 African countries reported in 2008 found that 34% of households owned an insecticide-treated bednet[7]. Use of "improved" water (i.e., piped, a tub well, a protected spring, or rainwater collection) is 49% in rural Kenyan households[8]. Efforts so far have focused mainly on providing ongoing services at health facilities (e.g., for VCT), social marketing (e.g., condoms), and community-based implementation focused on a single disease (e.g., bed net provision and safe water). However, delivering multiple interventions in a single program is increasingly seen as effective and efficient for children; for example, mass immunization campaigns are serving as a platform for providing other child services such as bed nets, deworming medicine and vitamin A[9,10]. However, no comparable strategy exists for adults.

The potential to quickly reach high coverage for multiple prevention interventions - HIV testing, condoms, and counseling; bed nets; and water filters - was recently demonstrated in a community integrated prevention campaign in Western Province, Kenya, implemented by our group[11]. This campaign was designed to address HIV, malaria, and diarrheal disease, to overcome possible resistance to VCT by offering material goods (nets and filters) that offer an additional health incentive for participation, and reduce potential stigma associated with HIV testing. The campaign was based in village centers, where it distributed and instructed on use of bed nets and filters, and offered opt-out VCT. Over one week, more than 80% of the district's estimated 51,178 15-49 year olds attended the campaign. A post-campaign survey indicated commodity use levels of 60% - 90%, depending on the measure used (unpublished data: Grabowsky, M).

Our goals for the present analysis were to (a) document the resources and costs expended by the initial community integrated prevention campaign, and (b) project the cost of scaled-up replication. The latter is based on our observations on operation of the initial campaign and likely efficiencies with routine and larger scale operation, and is supported by data from subsequent community integrated prevention campaign efforts.

This study documented the cost of a successful community-level integrated prevention campaign for HIV, malaria, and diarrhea in rural Kenya. We used these data to project the cost of achieving further scaled-up coverage of these interventions, with specified anticipated efficiencies in resource use and in unit costs. We project that participants could be provided with a high performance water filter, a long-lasting insecticide-impregnated bed net, HIV counseling and testing, health education regarding the use of these commodities, and 60 condoms at an estimated cost of $31.98 per person.

This estimate is consistent with subsequent experience with IPC implementation in Western Kenya. In a smaller campaign in Kisii and Kisumu (6 sites and 10,206 individuals reached), the total estimated cost per person was $31.08, slightly below the SUR estimate. Planning and set-up costs were $1.19 per person, as compared with $1.07 estimated in SUR. For a planned provincial level implementation, we received a price quote for social mobilization equivalent to $0.45 per person expected to be served by the campaign, lower than our SUR estimate ($0.83).

Compared with prior reports of the cost of providing these services, the integrated campaign approach appears to be efficient. HIV counseling and testing in Africa has had cost estimates ranging widely: $101 in South Africa[12], $26 in Kenya[13], $16 in Kenya[14], $7-11 in South Africa[15], $3-$100 (median $10.50) in Uganda[16], $8-$19 in Uganda[17], and $3-6 in Tanzania[18]. Of these, only one[17] is for programs that achieve high (>90%) community coverage. Our estimate of $9.92 for the SUR integrated campaign is toward the low end of this range, and includes 60 condoms valued at $1.40, as well as CD4 testing for those found to be HIV-positive. A formal comparison across studies is difficult, because varied timing affects both the technology (which has dropped in price), as well as rising prices for consistent inputs such as labor. The door-to-door VCT Uganda cost of $8.29 [17] was for 2007, and thus to be financially comparable to our 2008 estimate would be inflated by 6%ⁱ, to $8.79.

Long-lasting insecticide-impregnated bed nets have had cost estimates (including delivery) in a narrower range: $6 in Togo in 2004[19], $9-27 including insecticide retreatments in several African settings[20], and $8 in Tanzania in 2006[21]. The cost we estimated for a scaled-up campaign, $6.27, is in the lower end of this range, using a long-lasting bed net[22].

Water filters have been estimated to cost $3 per person-year of use[23]. Transforming the cost of $15.79 per campaign participant (allowing for 2.5 participants per household, 7.73 individuals per household, and two years' benefit) yields an estimated $2.55 per person-year, slightly below the average for filters. Other strategies (e.g., chlorination) are less expensive, but may be less effective, as they require more frequent replenishment of supplies. Solar disinfection, though also low cost and effective, has limited evidence of scalability.

A likely explanation for the low delivery cost is apparent economy of scope in providing all the interventions at once. Seventeen percent of costs were associated with the general campaign infrastructure and general personnel, as compared with 83% for the intervention-specific components (e.g., commodities and training on their use, as well as HIV counseling). If we treat these 17% of costs as fixed, then the incremental costs of adding second and third interventions - i.e., the interventions that "integrate" - are decreased by 17% to $5.20 for malaria, $13.11 for diarrhea, and $8.23 for HIV. Thus, the first intervention incurs the full cost of the general campaign structure, and subsequent interventions require only the incremental costing specific to that disease. In other words, the second and third disease programs build efficiently on the base of the general campaign structure established for the first disease program.

We believe that our findings may apply to other rural areas with a similar mix of disease burden from HIV, diarrhea, and malaria and a similar level of service need for HIV testing and care, clean water, and protection from insect vectors. This might include much of Sub-Saharan Africa and many parts of Asia.

Our analysis has important limitations. First, our estimate of the cost of scaled-up replication (SUR) is based on our best assessment of potential reductions in resource intensity and unit costs, albeit supported by subsequent IPC activities. We could not find a validated method for this analysis. As shown in the sensitivity analyses, key uncertainties are associated with a 4-10% variation in results. Empirical verification with a scaled-up implementation is imperative. This is especially true for different country settings, where political, social, and health care contexts may affect IPC logistics and participation.

Second, we examined the cost of using specific commodities, such as the LifeStraw^® water filter. Filters were an integral component of social mobilization for the campaign, serving as an incentive to achieve high VCT coverage. We cannot predict participation with a different approach.

Third, our analysis did not examine the effect of the IPC. We have separate publications under review on commodity uptake and use, and on cost-effectiveness, as well as two encouraging qualitative assessments of reactions to IPC participation [24,25]. A post-campaign survey found commodity use levels of 60% - 90% (unpublished data, Grabowksy, M). Sustained use (e.g., 2-3 years) is essential to benefit, though we note that studies of the magnitude of health effects of commodity distribution are typically conducted at the community level, not for individuals with confirmed use. Commodity use should be encouraged by the substantial on-site health education component. Further, the Ministry of Health was a key partner in implementation, and referrals for HIV care were coordinated with local providers.

Fourth, it is possible that a more efficient, larger campaign might compromise quality. Key features of campaign quality include: ability to attract participants; acceptability of the participant experience; effective training in the use of nets and filters; HIV counseling and testing up to usual standards; and commodity use in the community. However, we believe that there is reason to be optimistic. As noted above, service delivery staffing in the SUR is at levels used in the campaign. Manager staffing is above levels found adequate in the latter parts of the campaign and in a subsequent smaller campaign. Ultimately, both efficiency and quality must be directly assessed in a campaign implemented on a larger scale, e.g., provincial.

Various managerial strategies may be employed to achieve efficient scale-up. A modular approach, in which several geographically defined population groups are targeted each week, appears reasonable to us, and is reflected in our SUR analysis. This approach builds on the initial implementation, which was in effect one module. The number and size of modules can be adjusted according to the availability of HIV testing counselors (likely the limiting resource) and the desired speed of large-scale implementation.

Financial incentives are another tool. For example, productivity-based payment (a fixed amount per campaign participant) may encourage continued or increased efficiency. Quality and financial controls may be especially important under such a system. For example, if the average counselor time per individual receiving VCT is shortened, direct supervision and counseling records must assure that key risk reduction messages are delivered and that HIV-infected individuals, who appear to offer the best opportunity for significant risk reduction, are fully and effectively counseled.

The economic value of an integrated community campaign appears substantial: the ability to achieve high levels of coverage with economic efficiency equal or potentially superior to non-integrated (vertical) programs, without having to organize multiple programs. If the fully scaled up programs accomplish the intended coverage and efficiency, the potential public health benefits may be large.

JGK and BH were contracted to conduct this analysis by Vestergaard Frandsen, which manufactures the bed nets and water filters used in the campaign; JGK retained full control of publication and editorial decisions. MVF and NG are owner and senior executive, respectively, for VF, with competing interest forms available on request. EL and TC were paid by VF for other work related to this campaign. There are no other competing interests, financial or nonfinancial.

JGK designed the study, oversaw data collection, guided analyses, and drafted the manuscript. BH assisted in study design, designed and implemented data collection, conducted analyses, and edited the manuscript. JM advised on study design and participated in manuscript revision. TC advised on study design and edited the manuscript. EL assisted with data collection, advised on analysis, and edited. MG advised on study design and edited. MVF conceived the study and edited the manuscript. NG conceived the study, participated in study design, assisted with data collection and analysis, and edited and drafted the manuscript. All authors read and approved the final manuscript.

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1472-6963/11/346/prepub