Karin Stenberg WHO Health Systems Financing Department (WHO/HSF)

1. Workshop on Country Perspectives on Decision Making for control of chronic diseases Institute of Medicine of the National Academies July 19-21, 2011 OneHealth for Strategic Planning and Costing A tool developed by the UN Inter-Agency Working Group on Costing Karin Stenberg WHO Health Systems Financing Department (WHO/HSF)

2. To date UN agencies have supported the development of numerous costing tools for health programmes. Inter-Agency Working Group on Costing established in 2008 (WHO, UNICEF, WB, UNAIDS, UNFPA, UNDP) A User's meeting in Senegal reviewed 13 commonly used tools.  Recommendations from countries (users): Request for standardised approaches across UN agencies Request for joint UN tools for MDG planning Harmonised technical support UN costing tools: Background

3. Context Challenge: the need to address health systems strengthening as part of national planning processes • Health systems: composed of interacting subsystems; health systems development takes time. • High Level Taskforce on Innovative International Financing for Health Systems (2009)

4. Context Asynchronous disease programme planning: Review of national health plans show asynchronous disease programme planning; uneven development of health system • Uneven attention to health system components within national plans (ongoing research, forthcoming) Source: WHO planning cycle data base

5. OneHealth: purpose and audience • A tool to support processes for medium term (3-10 years) health systems to planning at country level • Covers the national health sector, with focus on public sector health interventions. Allows for incorporating activities in private sector and costing of selected non-health sector activities that may have health impacts. • Intended audience: • Health Sector planners (department of planning, Ministry of Health) • Disease-specific programme planners (e.g. EPI, Malaria) , Health System component (e.g., Human Resource Department in MoH) • NGOs and other agencies in countries • Donors, academe and UN agencies

6. OneHealth development process Wide stakeholder engagement process • Inter-Agency Working Group on Costing (IAWG-COSTING) established in 2008 (WHO, UNICEF, WB, UNAIDS, UNFPA, UNDP) . • The Global Fund to fight Aids, TB and Malaria, The Global Health Workforce Alliance, The Health Metrics Network, Bilateral agencies, IHP+, have provided funding and technical support; other partners: UNIFEM and projects like USAID deliver, Optimize provide technical inputs • Health Planners in Country Reference Group provide technical and user related inputs into model development (Burkina Faso, Cap Vert, Ghana, Mali, Mauretania).

7. HS4. Health Information HS5. Governance and Leadership HS6. Financing Policies • National Disease Programmes • Hospital • Health Centre …NCDs… WASH HIV Child Health Nutrition Reproductive Health Immunization Malaria TB • Outreach • Community HS1. Infrastructure and Equipment HS2. Human Resources HS3. Logistics

8. OneHealth : what is new and better? #1 • Unified model in 3 aspects: • Planning, Costing, Budgeting, impact analysis, financial space analysis. • Bringing disease programme planning and health systems planning together • One UN • Aligned with Joint Assessment of National Strategies (JANS) principles on situation analysis, informed priority setting, and financial sustainability considerations. • Incorporates UN epidemiology impact models to demonstrate the achievable health gains, e.g., Lives Saved Tool (LiST), AIM; with new modules developed where there was previously a gap, e.g., TB impact. • Programme planning is carried out within a framework of: • Health system capacity assessment • Financial sustainability assessment

9. OneHealth : what is new and better? #2 • User friendly interface closely resembles the formats and structures of existing tools, thus allowing transfer of skills from old tools • The tool is modular in format and can easily be adapted to different country contexts • Allowing for flexibility within a structure and language that corresponds to the ways in which real world health care system planning is performed. • User can choose the level of detail for planning, down to ingredients based, population-based costing; provided with default values from UN health statistics databases • Software updated on a regular basis including recent updates of epidemiology impact models. • Direct links and checks are built in between different modules, allowing for real time integrated planning discussions.

10. A flexible approach that emphasizes integration and inter-relationships between Disease/ Program/ Level-specific Planning Planning by programmes Nutrition Child Health Immunization Maternal and Reproductive Health Malaria TB HIV/AIDS WASH + (user defined) + NCDs (forthcoming) Planning by levels National District Hospital Facility Outreach Community Planning for systems • Human Resources for Health • Infrastructure, Equipment and Vehicles • Logistics • Health Information Systems • Governance • Health Financing Policy Gender, Equity and the Private Sector as cross-cutting considerations

11. Selected questions answered by OneHealth • What set of interventions will lead to what impact? • What are the overall health systems constraints that need to be addressed in order for me to scale-up? Given the existing health system, what would be the feasibility of scaling up using different approaches (e.g., community-based vs. outreach based)? • How much funds will I need for my programme budget? • What demands on the system would my programme training goals have and how could I better integrate my training with other MOH programmes? • Compare different scenarios – cost, impact and financing implications

12. Specify ingredients for intervention costing Detailed sheet for drugs and commodities, as well as the human resource requirements – by level of service delivery.

13. Some NCD interventions already included in default list

14. Bottom-up detailed estimation of cost for activities to support the national programme Programme-Specific staff Training Supervision Monitoring & Evaluation Infrastructure & Equipment Transport Communication, Media & Outreach Demand generation Advocacy General Programme Management Technical Assistance

15. Example of activity costing: Training

16. Health system modules Example: Logistics Supply Chain Costs Quantity of drugs derived bottom-up from program plans Inventory $ Transport $ Warehousing $ Transport $ Inventory $ Warehousing $ Procurement $ $ per unit delivered product Central WH Regional WHs SDPs

17. Assessing impact on health systems and opportunities for integration

18. Program planning takes into account systemic constraints Programme-specific plans are compared against Health System capacity • Example: Child health /Nutrition programme sets target to scale up Complementary feeding counselling to 90% coverage by 2015 • …Child health /Nutrition programme revises target to a more realistic level in line with the planned system investments – for example 70%. • Human Resource Planning indicates that sufficient Human Resources will not be available to allow for reaching 90% target • Based on the HRH plan 2010-2020 for educating and hiring health personnel Costs and predicted health impact is adjusted to align with new target

19. Outputs: consolidating implications of programme plans to facilitate discussions on priority setting and integration

21. Mapping costs to the national budget classification

22. Up to 7 budget classifications can be implemented simultaneously

23. Detailed budget mapping per item

24. Looking at financial sustainability and opportunities for increasing financial (and fiscal) space

26. Strengths and Opportunities: utility for policy makers • Giving national programmes a common platform where consistent methods are used across programme areas • Ensuring that health system capacity is driving the planning process,  set realistic goals • Health impact and other criteria to drive priority setting process • Provides a check list function, promote comprehensiveness and inclusiveness • Bringing NCDs into the mainstream planning process for national strategic health plans

27. Challenges • Data requirements • Strengthening health information systems • Building capacity to use strategic planning tools to inform the decision making process

28. Next steps: roll out and capacity building (a) Desk review; test application on costed national health plans (ongoing) (b) Roll out of OneHealth version 1.0 September 2011 • MDG programme planning • HSS modules for HRH, Infrastructure, Logistics + some financing and HIS • Budgeting and financial space • Health impact (c) Early Implementation (3 countries) (d) Roll out of OneHealth version 2.0 October/November 2011 • Added modules for NCD costing, Health Information Systems (e) Further development expected (2012 onwards) - Model to be continuously refined as new evidence available - Develop models for projecting health gains from NCDs, adult malaria

29. Summary recommendations for designing and applying a costing model as part of an NCD tool kit • Design: be clear on the specific policy question(s) to be answered; how the tool(s) will be used and by whom. • Design: opting out of a silo approach: consider broader health sector planning processes and how to cost integration across programmes. • Need to invest as much in training, application, validation, proof of concept studies, communication and advocacy as in development of tools; to ensure their use for the intended purpose.

30. Thank you