"'I'm a Health Worker' - Abduaraman Gidi" made by IntraHealth International.
There is growing evidence on the benefits of comprehensive packages of community health services as a key strategy to promote healthy behavior and improve access to high-impact maternal, newborn, and child health interventions from pregnancy to adolescence. However, countries do not have a way to determine the cost and financing needs for these packages and, without this information, programs cannot be properly designed, developed and financed and they are, therefore, often under-funded and financially unsustainable. Until now, there have been no suitable tools for countries to use to determine the coverage gaps, to estimate the resources needed to bridge those gaps, and to prioritize and plan the expansion of services.
To provide such a tool, MSH and UNICEF joined forces to develop the Community Health Planning and Costing Tool (CHPCT) to help countries plan their services and calculate the resources needed.
The tool is based on a previous tool developed by MSH for USAID for planning and costing integrated community case management (iCCM) services (treatment of children with malaria, pneumonia and diarrhe
a), which has been used in many countries. The new tool covers a comprehensive package of community health care services provided by Community Health Workers (CHWs), including iCCM but also preventive, promotive, and other curative services for the whole community.
As an open-source spreadsheet tool, users can see exactly how it works and can make changes if needed. It can be used to project the costs and financing for the introduction, maintenance, or scale-up of services at national and sub-national levels, and the results can be combined with bottleneck and impact analyses to help prepare investment cases. The tool can also be used to calculate the cost of adding new services, tests and medicines; to compare the efficiency of different service delivery platforms; to calculate reimbursement rates for results-based financing or insurance; and to prepare “what-if” scenarios to model a package in line with financing limitations.
The principal audience for the tool is policy makers and planners in low and middle income countries, but other users may include international organizations who assist governments and local and international non-governmental organizations.
To date, the tool has been used mainly to help develop investment cases for introducing or expanding community health services. It has been used in several countries including Madagascar, Malawi, Sierra Leone, South Sudan, Burkina Faso and Angola and reports on these country studies can be obtained from MSH.
South Sudan provides one of the most interesting case studies in how the tool has been used. In 2018, the Ministry of Health, with help from UNICEF and MSH, used the tool and approach to project the costs and financing of the Boma Health Initiative (BHI) and to combine them with bottleneck and impact analyses to prepare the elements of an investment case. The BHI is a government strategy to improve access to a standard package of essential health services which is intended to replace the fragmented community health services supported by non-governmental organizations (NGOs) with funding from different donors. BHI services focus on child health, the control of communicable and non-communicable diseases, and safe motherhood - including new-born care and disease surveillance.
Based on MOH guidance, an initial set of cost projections was prepared on the assumption that the entire population of the country would be covered by the BHI. Realizing that the projected costs would not be affordable in the near future, the MOH requested four new scenarios which would reflect different levels of geographical coverage and which would assume that CHWs will only serve the 56 per cent of the rural population living more than five kilometres from a functional health facility. The four scenarios and the projected numbers of services are shown for the first year of the programme (2019) in Table 1.
Table 1. South Sudan BHI. Geographical coverage scenarios – Year 1
|100% geographic coverage||80% geographic coverage||50% geographic coverage||30% geographic coverage|
|Total Number of Services||19,324,909||15,459,930||9,662,451||5,797,472|
|Community Health Workers (CHWs)||28,755||23,004||14,378||8,627|
|CHWs per Boma||13||13||13||13|
|Average services per capita||2.8||2.8||2.8||2.8|
|Average services per CHW||672||672||672||672|
The models show that major activities would be safe motherhood and child health (Figure 1).
Figure 1. South Sudan BHI. Numbers of services under different geographical coverage scenarios in Year 1
The projections show that 100% coverage would cost US$ 36.1 million in the first year, which would include CHW equipment amounting to US$ 6.9 million and start-up training of US$ 7.5 million (Table 2). In the second year the start-up, equipment and training costs would not be a factor and the total cost would be US$ 30.6 million. The cost per capita for the population covered (all ages) in Years 1 and 2 would be US$ 5.24 and US$ 4.31.
The highest cost component would be CHW salaries, which are based on the proposed annual salary per CHW of US$ 386.40 per year (equivalent). Refresher training and the initial training of replacement CHWs would be the second highest cost from the second year onward.
Table 2. South Sudan BHI. Costs breakdown for 100% coverage (US $)
|Year 1||Year 2||Year 3||Year 4||Year 5|
|Medicines and supplies||$5,760,900||$5,927,966||$6,099,878||$6,276,773||$6,458,801|
|Recruitment Training (CHWs)||$0||$9,643,351||$9,922,982||$10,210,760||$10,507,012|
|Recurrent Training (Supervisors)||$0||$51,600||$51,600||$51,600||$51,600|
|Start-up Training (CHWs)||$7,204,565||$0||$0||$0||$0|
|Start-up Training (Supervisors)||$355,204||$0||$0||$0||$0|
|Start-up Training (Managers)||$15,840|
The highest cost programme would be child health, followed by safe motherhood (Figure 2),
Figure 2. South Sudan BHI. Cost by programme for each scenario for the second year in US $.
The total direct and indirect cost of each curative service in 2019 with 100% coverage would be US$ 1.22 for malaria testing (RDT), US$ 2.60 for malaria treatment, US$ 2.76 for pneumonia treatment and US$ 2.81 for diarrhea treatment. And the highest cost medicines and supplies in 2019 for 100% coverage would be US$ 3.4 million for male condoms, followed by US$ 1.0 million for malaria RDTs and US$ 0.5 for malaria medicines.
A comparison of the annual numbers of services and total costs for the four different scenarios can be seen in Table 3. The cost of 50% coverage in Year 2 would be half that of 100% coverage.
Table 3. South Sudan BHI. Total number of services and costs per year.
|Year 1||Year 2||Year 3||Year 4||Year 5|
Impact on health: The Lives Saved Tool (LiST) was used to model the impact of increasing CHS coverage on infant and maternal mortality rates over a period of ten years. The results demonstrate the return on investment in terms of the decline in mortality associated with different levels of coverage of high-impact health interventions. Based on the projected increases in coverage of the initial package, it is estimated that by year five of the program a total of more than 36,000 deaths could be averted in the 100 per cent coverage scenario compared to the baseline coverage scenario. The vast majority of these would be deaths among children under five years old with the under-five mortality rate reducing from 96 deaths to 73 deaths per 1,000 live births after five years in all coverage scenarios. This scenario would cost an average of US$ 33 million per year (Table 3). These figures only represent the benefits in terms of estimated lives saved and do not take into account reductions in morbidity which would have a beneficial impact on areas like education and economic productivity.
Bottleneck analysis: Current and potential future bottlenecks were identified by a discussion panel meeting. It was not possible to determine solutions for the removal of the bottlenecks and the costs of those solutions due to time and resource constraints. It was also not possible to quantify the effect of the bottlenecks on targeted coverage rates. The key bottlenecks are:
- Lack of qualified CHW candidates - lack of formal education, low levels of literacy and gender barriers.
- Insufficient remuneration for CHWs - in some cases, the proposed salary and incentives may be less than are currently paid by NGOs.
- Shortages of medicines and supplies and equipment - poor management, insecurity, high distribution costs, inadequate storage, weak logistics and transport systems.
- Limited capacity and numbers of MOH supervisors and weak linkages between CHWs and health facilities;
- Low acceptance of community health services. Insufficient buy-in by community leaders, poor community understanding due to misinformation, and insufficient numbers of female CHWs.
The implementation of the BHI will help to resolve some of these bottlenecks, such as the provision of sufficient funding for medicines, supplies and equipment and the training of CHWs on supply chain management. However, additional funding may be required to engage more CHWs and to strengthen supervision and to promote community health services in the communities. The degree to which the bottlenecks are removed will affect the achievement of the targets, for example if they are not removed perhaps only the 30% or 50% scenarios will be feasible.
The tool and user guides are presently being updated based on feedback from users and English and French versions should be ready by September 2019.
For more information or to request a copy of the tool please contact David Collins or Colin Gilmartin via firstname.lastname@example.org.