There are various models of home-based care for people living with HIV (PLHIV). Each has a different delivery scheme, offers a mix of services, has different staff and outreach, and emphasizes different programmes [1
]. The models include facility-based, community-based and integrated approaches [1
]. The facility-based programmes often focus on the medical aspects of care and involve teams that include health professionals who can provide higher levels of care. Community home-based care (CHBC) programmes provide psycho-social support for PLHIV and their families, and deliver services primarily through volunteer networks in the community [1
]. The integrated model emphasizes collaboration between a number of partners, and the programmes are often integrated into some health care services [3
Community home-based care, which informs our present work, is the preferred health care delivery model used by the Government of Botswana to provide care for PLHIV. CHBC has been defined as the care given to an individual in his or her own environment (home) by his or her family. The family members are supported by skilled welfare officers and communities to meet not only the physical and health needs, but also the spiritual, material and psycho-social needs of the clients [4
As the number of people living with HIV and AIDS increases, the gap between the demand for and the availability of health care services continues to widen. Relying mainly on the family and community as caregivers, CHBC has become a significant contributor in the treatment, care and support of those infected and affected by HIV and AIDS.
CHBC primary (family members) or volunteer (community members) caregivers for PLHIV [6
] experience poverty, are socially isolated, endure stigma and psychological distress, and lack basic care-giving education [7
]. CHBC also imposes considerable costs on patients, their caregivers and families in terms of time, effort and commitment. The costs have been classified by Gold et al
] as "direct medical costs" (such as those for medication, physician fees, hospitalizations and office visits) and "direct non-medical costs" (such as transportation, dietary supplements, labour costs and lost wages associated with time spent on care giving).
The direct non-medical costs arise from replacement of employees who quit their employment due to their care-giving responsibilities, absenteeism costs, and costs due to partial absenteeism, workday interruptions and supervision of employed caregivers [9
]. Direct non-medical costs will continue to grow as more and more people with HIV and AIDS are transferred from the hospital to the home setting, and as the burden of caring for the client falls increasingly on families and volunteer caregivers.
An estimation of the cost of care giving is very important in a comprehensive economic analysis. A number of studies [8
] have shown that costs incurred by care recipients and unpaid caregivers account for a significant proportion of the total healthcare expenditure, while Moalosi et al
] notes that the cost of care giving to caregivers of tuberculosis and lung disease patients has remained substantial in relation to the income levels of home-based caregivers.
Yet many economic evaluations do not include these costs [11
]. It was reported by McDaid [13
] that the variation in the proportions of the total costs of care giving represented by informal care, which includes home nursing and domiciliary care, as well as caregiver time in selected studies for people living with Alzheimer disease in the community, was between 36% and 85%.
This paper, which follows from a study by the authors [14
] between June and September 2008, focuses on the costs incurred in care giving by primary and volunteer caregivers for PLHIV under the CHBC programme. It adopts the opportunity cost method [11
] to value the time investment of caregivers in informal care and to determine the direct non-medical costs the caregivers incur in providing care to PLHIV. These costs were examined within the context of: increased cost of living; decreased income due to loss of jobs and/or job opportunities; transport to and from the place of giving care as well as to health facilities; death and/or funeral costs; financial donations to the clients or their families; disruption of their daily routines, social relationships and emotional well-being; and expectations about care giving.
Based on the caregivers' responses, this paper: describes the characteristics of the caregivers; estimates the direct non-medical costs of care giving; estimates the average cost incurred by caregivers per home visit and per client and/or family; and compares the cost incurred with the amount of government allowances given to the caregivers.
An analysis of the cost incurred by caregivers in providing care to PLHIV is critical. It will assist health and social care decision makers in planning the most appropriate ways to meet future service needs of PLHIV and the caregivers. Public health departments in Botswana will be able to develop interventions for the improvement of the CHBC programme.