Yuba Raj Khatiwada United Nations Development Programme Regional Centre in Colombo Serving Asia and the Pacific

1. MDG Needs Assessment and Costing Approach Health Sector Needs Assessment Yuba Raj Khatiwada United Nations Development Programme Regional Centre in Colombo Serving Asia and the Pacific

2. Overview IntegratedHealth Tool: Key Features Components of Integrated Health Tool Health MDG Needs Assessment Choosing Interventions defining Setting Coverage targets Estimating Resource Needs Checking Results Excel Sheet Demonstrations Contents

3. Health MDG goals to be achieved by 2015 from the level of 1990: reduction of child (U5) mortality by two-thirds, reduction of maternal mortality by three-fourth, combating HIV, TB, Malaria and other major diseases –halting the spread and beginning to reverse the incidence Reaching the MDGs will require investing in a health system that can deliver quality essential health services to all of the population Such a health system includes prevention and treatment activities carried out in community, clinic and up to district/ referral hospital. Overview (1)

4. Individual disease-focused programs (such as malaria, TB and HIV control) cannot be viewed on a stand-alone basis but should be considered as part of a larger basket of essential health services. Estimating resource needs, therefore, requires not only an assessment of individual-level inputs but a rigorous evaluation of the costs of establishing and maintaining a district and referral level health system and the costs of public health activities. Overview (2)

5. While technically possible to deliver interventions vertically, successful scale-up and utilization of a broad range of health interventions requires a functioning health system. Estimating health system costs difficult due to differences in the structure of health systems in countries; MP tools attempt to getting a rough estimate of potential health system costs with main components of a functioning health system. Overview (3)

6. Main components of a functioning health system-- Scaling up system-wide health HR (including clinical and administrative staff), facilities and infrastructure. Improving the system’s ability to plan, finance, and deliver high-quality health services: strengthening management capacity improving M&E and quality assurance. enhancing community demand for and access to essential interventions. building capacity for health research and development. Overview (4)

7. Integrated Health Tool: Key Features • Planning and Budgeting Tool • Goal-based • Anchored in Health System (Facilities) • Addresses Supply and Demand Side • Flexible, transparent • Accounts for some synergies • Builds on Important Costing Work by Other UN Agencies

8. Components of Integrated Health Tool • Health System • Commodity Supply System • Maternal and Reproductive Health • Child Health • Malaria Prevention and Treatment • Tuberculosis Treatment • HIV Prevention and Treatment

9. Choosing interventions Defining and setting targets Estimating resource needs Checking results Health MDG Needs Assessment Approach

10. Interventions should be seen not as isolated programs but as an integrated set of health services provided through a strengthened system of health care delivery. Health MDG Needs Assessment 1. Choosing Interventions (1)

11. Health MDG Needs Assessment 1. Choosing Interventions (2) • New infrastructure and O&M of existing infrastructure at district & referral level • Adequate health personnel salaries • Pre- and in-service training • Community demand interventions • Management systems and M &E • Research and development Health System Commodity Supply System • Vehicles for transportation of goods • Storage facilities and equipment • Equipment for communication & monitoring • HR for transport and monitoring

12. Health MDG Needs Assessment 1. Choosing Interventions (3) • IMCI package, Immunization • Neonatal package, Antenatal care • Skilled attendance and clean delivery • Emergency obstetric care (EmOC) • Contraception & family planning services • Safe abortions & care of abortion complications Child Health, Maternal Health, and Reproductive Health • Antiretroviral therapy • UNAIDS HIV prevention and care package • Artemisinin combination treatment for malaria • Insecticide treated nets and IRS (other vector control as appropriate) • DOTS and DOTS Plus (as required) Infectious Diseases

13. Some health MDGs have quantified targets, such as the goal on child mortality Others allow for interpretation of targets, such as HIV/AIDS Each country will need to adopt specific numeric outcome targets to guide its MDG health strategy. Health MDGs offer no specific guidance on coverage levels for health services. Overall aim should be to achieve universal coverage of essential health services (or “essential health package”). Health MDG Needs Assessment 2. Defining and Setting Targets

14. Health MDG Needs Assessment 3. Estimating Resource Needs (1) To assist countries in undertaking a Needs Assessment, the Millennium Project suggests the following four-point approach: • Direct intervention costs • Human resources • Infrastructure • Health systems strengthening

15. Health MDG Needs Assessment 3. Estimating Resource Needs (2) • Recurrent costs for the essential health interventions in the areas of maternal health, child health, HIV/AIDS, TB, and malaria include: • Drugs • Supplies • Hospital beds • Diagnostic tests

16. Health MDG Needs Assessment 3. Estimating Resource Needs (2) • Capital costs for the essential health interventions in the areas of maternal health, child health, HIV/AIDS, TB, and malaria include: • Building construction • Equipments and machines • Long term pre service and in service training • Vehicles, etc Costs for each area of health are calculated as follows: • Total cost = Unit cost X Population in need.

17. Country epidemiological data Country demographic data • Unit costs of components • Drugs • Hospital bed and food • Laboratory costs • Other supplies Target coverage rates Health MDG Needs Assessment 3. Estimating Resource Needs (3)Direct Intervention Costs NO. OF CASES TOTAL COSTS Intervention components and quantities COST PER CASE

18. Countries need to calculate the number and cost of health workers at all levels of the health system needed to deliver the interventions at scale. Health workers include (among others): Doctors Nurses and midwives Clinical officers Lab technicians and technologists Pharmacists and pharmacy technicians Community health workers Health managers Health MDG Needs Assessment 3. Estimating Resource Needs (4)Human Resources

19. Human resource cost categories include: Salary and benefits In-service training Pre-service training Retention and distribution incentives Human resource needs have to be carefully estimated by each country for the desired level of service coverage. Health MDG Needs Assessment 3. Estimating Resource Needs (5) Human Resources

20. Health MDG Needs Assessment 3. Estimating Resource Needs (6) Human Resources • Suggested costing methods • Health workers per facilities • Doctor or nurse to population ratio • Conducting a comprehensive human resources needs survey

21. Health MDG Needs Assessment 3. Estimating Resource Needs (7)Infrastructure Number and cost of building or refurbishing health facilities from health posts to first level referral hospitals (including capital costs, maintenance, and overhead).

22. Health MDG Needs Assessment 3. Estimating Resource Needs (8)Health Systems Strengthening • Two methods: • Bottom-up costing of health system components • Costs of managers at all levels (training & pay) • Quality control and audit systems • Basic financial and accounting systems • Health information systems (and required ICT) • Public health functions (such as epidemiologic surveillance) • Enhancing community demand for services (health education and community mobilization)

23. Health MDG Needs Assessment 3. Estimating Resource Needs (9)Health Systems Strengthening • Overhead mark-up to direct cost of services • Estimate a % of direct cost of services as:

24. Health MDG Needs Assessment 3. Estimating Resource Needs (10)Health Systems Strengthening Example: If the costs of interventions, infrastructure, salaries, and community education equal $30 per capita annually, the additional three health systems “overhead” items would add another 37% percent of that total or $11.1 per capita for a total health system cost of $41.1 per capita.

25. Health MDG Needs Assessment 3. Estimating Resource Needs (11)Adding it All Up Direct costs of all interventions Costs of health system strengthening Infrastructure and HRH costs + + Total health costs

26. Health MDG Needs Assessment 4. Checking Results Review all results to ensure that numbers are robust. Sample costs (in US $) from Mongolia and Bhutan:

27. Excel Sheet Illustrations