Background: Violence against women and girls (VAWG) is a human rights violation with social, economic and health consequences for survivors, perpetrators and society. Robust evidence on economic, social and health impact, plus the cost of delivery of VAWG prevention is critical to making the case for investment, particularly in low- and middle-income countries (LMICs) where health sector resources are highly constrained. We report on the costs and health impact of VAWG prevention in six countries.
Method: We conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from five randomised controlled trials in sub-Saharan Africa and one in South Asia. We evaluated two school-based interventions aimed at adolescents (11-14 years old); and two workshop-based (small-group or one-to-one) interventions, one community-based intervention, and one combined small-group and community-based programme all aimed at adult men and women (18+ years old). All interventions were delivered between 2015 and 2018 and were compared to a do-nothing scenario, except for one of the school-based interventions (Government mandated programme) and for the combined intervention (access to financial services in small groups). We computed the health burden from VAWG with disability-adjusted life-year (DALY). We estimated per capita DALYs averted using statistical models that reflect each trial’s design and any baseline imbalances. We report cost-effectiveness as cost per DALY averted, and characterise
72 uncertainty in the estimates with probabilistic sensitivity analysis and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a sub-group analysis of the small-group component of the combined intervention, and no other sub-group analysis. We also report an impact inventory to illustrate interventions’ socio-economic impact beyond health. We use a 3% discount rate for investment costs and a one-year time horizon, assuming no effects post the intervention period.
Results: From a health sector perspective, the cost per DALY averted varies between US$ 222 (2018), for an established gender attitudes and harmful social norms change community-based intervention in Ghana, to US$ 17,548 (2018) for a livelihoods intervention in South Africa. Taking a societal perspective and including wider economic impact improves the cost-effectiveness of some interventions but reduces others. For example, interventions with positive economic impacts, often those with explicit economic goals, offset implementation costs and achieve more favourable cost-effectiveness ratios. Results are robust to sensitivity analyses. Main limitations: our DALYs include a subset of the health consequences of VAWG exposure; we assume no mortality impact from any of the health consequences included in the DALYs calculations. In both cases, we may be underestimating overall health impact. We also do not report on participants’ health costs.
Conclusion: We demonstrate that investment in established 89 community based VAWG prevention interventions can improve population health in LMICs, even within highly constrained health budgets. However, several VAWG prevention interventions require further modification to achieve affordability and cost-effectiveness at scale. Broadening the range of social, health and economic outcomes captured in future cost effectiveness assessments remains critical to justifying the investment urgently required to prevent VAWG globally.
