Research fills a gap in evidence on potential impact of initiatives such as workshops and meetings.
Investing in established community-based programmes, such as community workshops, to prevent violence against women and girls (VAWG) improves health and is good value for money, according to a new study published in PLOS Medicine.
The research was led by researchers at the London School of Hygiene & Tropical Medicine (LSHTM) and the London School of Economics and Political Science's Centre for Women, Peace and Security (LSE WPS).
The researchers worked with the South African Medical Research Council (MRC), and collaborators in six countries, as part of the 'What Works to Prevent Violence Against Women and Girls' programme, funded by the UK's Foreign, Commonwealth & Development Office (FCDO).
One third of women and girls globally experience violence during their lifetime. However, governments and donors have invested limited resources to scale up prevention programmes so far. In part, this is because there is still little high-quality evidence that prevention programmes achieve impact and value for money, compared to other investments in public health.
'What Works' is the first multi-country research programme to use randomised controlled trials and economic evaluation to assess the impact of VAWG prevention. The research team assessed the effectiveness and value for money of interventions designed to prevent VAWG in six countries: Ghana, Kenya, Pakistan, Rwanda, South Africa, and Zambia.
The researchers assessed interventions' value for money by estimating their cost per 'disability-adjusted life-year' (DALY) averted. DALYs are used by the World Health Organization to measure the global burden of disease.
Nearly all the VAWG prevention interventions had a positive impact on health and economic well-being. Several were cost-effective compared to other public health interventions.
The research team found that community action to change harmful gender norms and behaviours was a highly effective and cost-effective investment. For example, in Ghana, the cost per DALY averted among female participants of the Rural Response System (RRS) intervention was US$52. This value is in line with the social return from other essential public health services and warrants immediate scale-up, according to the researchers.
Community-based programmes include meetings and workshops led by community activists that challenge social norms, raise awareness of gender-based violence issues and laws to protect women, and try to facilitate positive behavioural change toward women and girls. The meetings usually follow detailed guidelines to support those delivering sessions, and community-based activists will have been trained on the content of the manual and delivery techniques. The activists often, though not always, come from the communities they work in.
Interventions that improve participants' livelihood skills also have a positive economic impact and can even be cost saving to society. The South African 'Stepping Stones and Creating Futures (SSCF)' programme to support young adults yielded good value for money, considering both the health and economic impact. School prevention programmes for children and young adolescents also improved mental health and show promise in terms of value for money.
Lead author, Dr Giulia Ferrari, an Assistant Professorial Research Fellow now based at the London School of Economics and Political Science (LSE), said: "Information that can support the case for investing in VAWG prevention is critical. Our paper fills this evidence gap and demonstrates that we need to increase investment from both a social and economic perspective. Our standardised methodology, already used in one additional study from Ethiopia, will enhance transparency and comparability even as a broader array of impacts are considered."
Sergio Torres-Rueda, Research Fellow at LSHTM, said: "We have known for some time that VAWG can be prevented. Now we have much greater evidence to show that it can be prevented in a way that is cost-effective for governments to fund. Even when compared to other public health needs in low- and middle-income countries, prevention of VAWG represents good value for money."
Sustainable Development Goal (SDG) 5 aims to achieve gender equality and empower all women and girls by 2030. As a result, governments have increased funding for the elimination of VAWG, with Official Development Assistance (ODA) to low- and middle-income countries (LMICs) increasing steadily since 2016. Yet, evidence to inform this investment is limited, presenting a major obstacle to the scale-up of impactful violence prevention programmes.
To date, just three studies on the value for money of VAWG prevention have been published, demonstrating a significant lack of evidence in this area. Evaluating the potential cost-effectiveness of these interventions, alongside the health and other social impacts of prevention, will help those working in VAWG prevention to advocate funding from those governments interested in improving women's health and wellbeing. As competition for funding is intense in resource scarce environments, being able to demonstrate the impact and cost-effectiveness of a prevention intervention is critical.
This evaluation is the first known standardised multi-country cost-effectiveness analysis of interventions for the prevention of VAWG. It provides a major body of evidence on the cost-effectiveness of VAWG prevention in LMICs and is a major step forward towards the achievement of SDG 5.
The six interventions were selected from 10 interventions evaluated by 'What Works' and were chosen as they had potential for being adopted by policymakers and were therefore likely to require economic evaluation to support their scale-up.
Potential cost-effectiveness was reported as cost per DALY averted from both a provider and societal perspective. A provider perspective includes health sector costs and outcomes. A societal perspective also examines wider social and economic impact.
The interventions evaluated were delivered in three different formats: classes within schools, community mobilisation, and one-on-one or small-group workshops. Two school-based interventions were aimed at early adolescents. The remainder (two workshop-based interventions, one community-based intervention, and one combined small-group and community-based programme) were aimed at men and women.
Senior author Anna Vassall, Professor of Health Economics at LSHTM, said: "While protection against violence is a human right, unfortunately funding remains scarce, and is a key barrier to achieving SDG5. Demonstrating, as we have, that we can deliver effective prevention programmes at a low cost is critical if we are to prevent violence against women and girls globally."
Publication
Giulia Ferrari et al. Prevention of violence against women and girls: A cost-effectiveness study across 6 low- and middle-income countries. PLOS Medicine. DOI: https://doi.org/10.1371/journal.pmed.1003827
