Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries

BackgroundViolence 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 6 countries. Methods and findingsWe conducted a trial-based cost-effectiveness analysis of VAWG prevention interventions using primary data from 5 randomised controlled trials (RCTs) in sub-Saharan Africa and 1 in South Asia. We evaluated 2 school-based interventions aimed at adolescents (11 to 14 years old) and 2 workshop-based (small group or one to one) interventions, 1 community-based intervention, and 1 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 uncertainty in the estimates with probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEACs), which show the probability of cost-effectiveness at different thresholds. We report a subgroup analysis of the small group component of the combined intervention and no other subgroup analysis. We also report an impact inventory to illustrate interventions' socioeconomic impact beyond health. We use a 3% discount rate for investment costs and a 1-year time horizon, assuming no effects post the intervention period. 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. 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. ConclusionsWe demonstrate that investment in established 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. Author summary Why was this study done? Governments are increasing funding for the elimination of violence against women and girls (VAWG) by 2030 as part of sustainable development goal five (SDG5).The evidence to inform investment in this area is extremely limited, including from low- and middle-income countries (LMICs), presenting a major obstacle to scaling up violence against women prevention programming.Investigating the potential cost-effectiveness, health, and nonhealth impacts of prevention helps those working in violence against women prevention justify funding from the health sector or other sectors interested in health improvement and women's well-being. What did the researchers do and find? We report trial-based cost-effectiveness estimates for 6 interventions designed to prevent VAWG in 6 countries: Ghana, Kenya, Pakistan, Rwanda, South Africa, and Zambia.We find that some interventions are likely to improve population health, even within current health budgets in each country. Interventions are more likely to be cost-effective at preventing women's exposure to violence, rather than men's perpetration. One-to-one psychosocial support interventions for secondary prevention, while impactful, are likely to be less cost-effective than primary prevention interventions in low-resource settings. Community- and school-based interventions are more likely to be cost-effective from a health sector perspective.Considering all effects, interventions that improve participants' livelihood skills, including their financial management skills, can be cost saving, while also reducing perpetration of violence from men, even if they do not reduce experience of violence among women and girls in the short term. What do these findings mean? The evidence suggests that established community-based interventions to prevent violence against women warrant consideration for immediate scale-up.However, to reach all populations in need with appropriate interventions, more investment is required to further develop and refine a range of prevention delivery models that are impactful and contain costs, while developing the human resource expertise in LMICs.Research funding is required to continue to enable rigorous impact, process, and economic evaluation of VAWG prevention that captures impact not only on violence exposure and perpetration, but also broader health and nonhealth impacts to ensure that the strongest case for investment in the prevention of VAWG continues to be made globally.