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Base de données d'évaluation

Evaluation report

2001 SAF: The Cost-effectiveness of Six Models of Care for Orphaned and Vulnerable Children in South Africa

Author: Desmond, C.; Gow, J.; Health Economics and HIV/AIDS Research Division of the University of Natal

Executive summary


UNICEF funded a three-part study to develop policy recommendations for the care of orphaned and vulnerable children. This report is the third part; the first part is a rapid appraisal of children living with HIV/AIDS; the second part developed the typology of care and the essential elements of care used in this report, and also provided an assessment of quality of care.

Purpose / Objective

This report examines variations in cost between the different options of care, using cost-effectiveness analysis, to allow for comparison of the resource requirements of each model. The purpose is to provide information needed to plan efficient allocation of resources for the care of orphaned and vulnerable children in South Africa.


Six different types of care were identified: informal or non-statutory foster care; community-based support structures; home-based care and support; unregistered residential care; statutory adoption and foster care; and statutory residential care. One site from each of these types of care was selected for the cost analysis study. These six were Nazareth House, Durban Children's Society, Sophie Jardim House, Sinosizo, the Pin Project, and Nceba Village. This decision was based primarily on the availability of data.

Two adjustments were made to the traditional cost calculations to make the results more useful. Firstly, the costs were adjusted to the cost of replicating that model of care. The purpose of this paper is not the calculation of the cost effectiveness of providing care at each site, but rather the model, which could be replicated elsewhere. Therefore costs particular to the site were changed to the costs of doing the same elsewhere.

Secondly, the cost of providing a minimum standard of care in that setting was then estimated. The minimum standard is defined as the availability of a caregiver and the achievement of the survival category of the essential elements of care which are identified in the first part of the study.

Key Findings and Conclusions

At first glance the results suggest that the most cost-effective way of caring for children is through community-based organisations, represented here by The Pin Project. This is indeed what the results suggest, but further discussion is required to highlight other issues relevant to policy makers, the main one being the differences in the quality of care between the different models.

As well as having different benefits, the models have different success in providing for the minimum standard. The estimation of costs for a number of sites was based on what it would cost to provide a minimum standard in that setting, as a minimum standard was not achieved. It is necessary, therefore, to consider ways of improving access to resources so that the minimum standard can be achieved. This situation highlights the difficulties in gaining access to resources necessary in childcare, and how the most cost-effective models are not viable ways of meeting the basic needs of children, unless these difficulties of access are removed.

In the case studies, two avenues of obtaining support were identified: government grants and income generation projects. The simplification of the grant system and the establishment of successful income generation projects would, therefore, allow for the more efficient care in the community to achieve adequate levels of care. Aside from financial support, if these models are to be successful, infrastructure needs to be developed where it prevents the achievement of adequate care.

Aside from financial support to maximise the number of children kept within the community, attention needs to be paid to development and support of safety net structures. Both Nceba Village and the home based care models provide examples of existing arrangements. The apparent effectiveness of the addition of identification of further orphans in the home based care operations came out during the case study. Support should, therefore be given to such organisations so that they can expand in this way.

The results outline the expensive nature of the more formal models, particularly Nazareth House and Jardim House. Here too consideration needs to be given to additional issues. At both Nazareth House and Jardim House it was made clear that children were placed there because there was nowhere else to go. The local children's societies try first to place children in one of the less formal arrangements, but when they fail they are placed at homes like the ones mentioned. The costs, therefore, although high, may in some circumstances be the only option to abandonment and life on the street for the children. Furthermore some of the high costs are associated with the care of sick and abused children. Again this needs to be kept in made when making comparisons.

It is apparent that the extended family cannot always cope. Ways in which to identify vulnerable children and place them in alternative care arrangements need to be promoted. The addition of identification and placement programmes for orphans to home-based care structures is an effective means of providing such a safety net. This is highlighted by the small cost associated with this process in the Sinosizo case study, particularly when compared to other expenses incurred in that operation.

Finally, a child's HIV status is a major determinant of the cost of care, requiring expensive medical treatment, and high staff-to-child ratios. These costs only reinforce the humanitarian argument that efforts should be made to reduce the rate of mother-to-child HIV transmission.


Simplification of the grant system and establishment of income-generation projects would assist communities to achieve adequate care of orphaned and vulnerable children.

Attention needs to be paid to the development and support of safety net structures. The addition of identification and placement programmes to home-based structures provides a safety net at a small additional marginal cost.

Formal, institutional models must continue to exist for emergency care and for care of very ill children who are difficult to place elsewhere.

The bulk of resources could be allocated to the more cost-effective approaches, with sufficient additional resources devoted to them so that at least a minimum standard is met.

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South Africa


Child Protection - OVC



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