Above Service Delivery Activities in Global Health: Assessing the Current State of Knowledge and Practice

The Challenge

While the costs of service delivery in health programs in low and middle income countries are often analyzed, costs incurred for activities conducted above the front-line setting are less frequently studied. Yet these costs can constitute a substantial share of health program spending. For example, for 2014, expenditures above the point of service delivery for the President’s Emergency Plan for AIDS Relief (PEPFAR) amounted to over 1.5 billion USD, or 45 percent of the total expenditures reported. Costs incurred above the point of service delivery for major global health initiatives—“above-service delivery level costs,” or ASD costs—constitute a substantial share of program costs, yet far less is known about these costs in low and middle income countries than about costs incurred at the point of service delivery. These costs encompass core activities of global health programs, including monitoring & evaluation, training, supervision, program management, supply chain & procurement, laboratory services, advocacy, and record-keeping.

The Opportunity

Understanding the costs, impact, and efficiency of above service delivery activities should be a priority for all stakeholders. Policy-makers and funders who seek to make their expenditures on large health programs more efficient and have a greater impact and beneficiary countries assuming responsibility for a larger share of spending as they transition away from donor funding should focus on understanding these costs.  In instances in which spending on ASD activities is inefficient or wasteful, the funds could be reallocated to fund front-line services. Conversely, ASD activities that have a strong positive impact on the quality or efficiency of service delivery could be supported further to maximize scarce resources.

To improve understanding of ASD activities and costs, R4D has received a grant from the Bill & Melinda Gates Foundation to investigate what these costs are how these costs may vary across health subject and over time, and if and how they contribute to program inefficiencies in HIV interventions and programs.

Our Work

R4D explored above service delivery activities from May 2015 to May 2016 in order to capture and critically assess the current state of knowledge and practice regarding the above-facility costs of major global health initiatives. R4D conducted desk research and expert interviews to inform a report on ASD costs and activities, identifying opportunities for additional investments to support research and programming for ASD efficiency gains, and highlighting gaps in knowledge and efficiency analysis of ASD. The research and report focused on initiatives in HIV, malaria, tuberculosis, family planning, and immunization.

R4D presented the preliminary findings of this study at a stakeholder consultation meeting in April. Stakeholder feedback from this meeting and from key partners informed the publication of a final report on above service delivery activities and technical efficiency. This report provides a robust landscape analysis of the ASD space, providing researchers, policymakers, and global health program managers with a useful resource summarizing the current state of knowledge and avenues for future inquiry and development.


Bill & Melinda Gates Foundation



Global & Regional Initiatives

R4D is a globally recognized leader for designing initiatives that connect implementers, experts and funders across countries to build knowledge and get that knowledge into practice.