Raymond Hutubessy PhD Initiative for Vaccine Research (IVR) team

1. Comprehensive WHO Cervical Cancer Control Costing and Planning (C4P) tool: findings from African countries Raymond Hutubessy PhD Initiative for Vaccine Research (IVR) team Immunization, Vaccines and Biological (IVB) department

2. Outline • General description of the comprehensive WHO Cervical Cancer Prevention and Control Costing (C4P) tool • Country examples: • Tanzania – 5-years planned scaling up costs of HPV vaccines • Rwanda – 1 year retrospective national costs of HPV vaccines • Lessons learned • Conclusions

3. Introduction • Tool was developed for Tanzania in response to vaccine donation • Local economists, MoHSW*, WHO Tanzania & HQ*, consultants involved • 4 Country visits to collect data/interviews and workshops required • Tool addresses costing and planning issues • Economic and financial perspective • Input for Cost-Effectiveness Analysis and Financial Analysis • Excel-based model • Choice of inputs on strategies and assumptions • Spreadsheets with data on population and infrastructure: • Summary Page on Total Costs • Two modules of the generic tool • HPV Vaccine Module (version 1.0 available) • Cervical Cancer Screening and Treatment Module (available 2Q2013) * Including representatives from EPI and Reproductive Health

4. Purpose of Costing and Planning Tool • Assist planners to: • Estimate the cost of introducing a cervical cancerprevention and control programme in a country. • Understand the cost implications of adopting various alternatives of cervical cancer prevention and controlapproaches and strategies.

5. Designed for: • Programme Managers: • Ministries of Health • Reproductive Health • Maternal and Child Health • Immunization • Policy Makers • Donors

6. Users get a prospective 5-year cost estimate in exchange for their inputs. • Programme Cost Estimate Summary • Financial vs. Economic Costs • 5-year costs by year • Activity cost breakdowns by: • Procurement • Training • Service Delivery • Social Mobilisation and IEC • Monitoring and Evaluation • Other

7. Approach to Costing • Ingredients Approach • Government perspective • Financial versus Economic analysis • Multi-level: national, regional, district, community • Incremental cost to existing reproductive health services

8. Costs represent the value of resources used for cervical cancer prevention and control • Financial costs represent the actual expenditure on goods and services purchased. • Use for financial analysis (affordability, budget allocation) • Perspective of individual payers e.g. MoH • Economic costs Recognize that cost of using resources also means that these resources are then unavailable for productive use elsewhere and effectively being tied-up • Concept of opportunity costs, which is the lost opportunity involved in using resources in one place rather than another • Use for cost-effectiveness analysis (value for money, sustainability) • Perspective of the society * WHO Guidelines for estimating costs of introducing new vaccines into the national immunization system http://whqlibdoc.who.int/hq/2002/WHO_V&B_02.11.pdf

9. Three types of Costs • Introduction (Start-up) Costs • Micro planning • Training • Social Mobilization and IEC • Recurrent (Operational) Costs • Vaccine and Injection Supplies • Service Delivery • Per Diems, Transport, communications • Supervision, Monitoring and Evaluation • Other (e.g. waste management) • Capital Costs • Cold chain equipment

10. Pillars of Tanzania’s CxCa strategic plan • Vaccination of adolescent girls (P4) before they become sexually active • Screening of women aged 30 to 50 years and treatment of precancerous lesions • Diagnosis, care and treatment including palliative care for cervical cancer patients

11. Objectives and assumptions of planned HPV vaccination for Tanzania • Objective: to estimate and project incremental costs to health system of introducing HPV vaccine • Assess the financial and economic costs of resources required for delivering a new vaccine to a non-traditional population using different delivery strategies • Assumptions • Scaling-up: 1st year 3 regions; 2nd year 10 regions; 3 yr all 26 regions • Girls aged 10 years will be vaccinated • Vaccine: • Financial analysis: vaccines donated • Economic analysis: unit costs of $5 (maximum GAVI price) • 5% wastage and 25% buffer stock • Projected cost over five years • Assume no capital good are needed since already available for other vaccines

12. Summary of expected outputs of introducing HPV vaccines in Tanzania, 2011-2015

13. School vs health facility based

14. Five-year average cost per dose and Fully Immunized Girl (FIG) - Tanzania

15. HPV introduction in Rwanda in 2011 • HPV donation Merck • 3 national campaigns • School-based (P6 girls) and facility based (12yrs girls) • Assumptions

16. Annual costs Rwanda – preliminary results

17. One-year average cost per dose and Fully Immunized Girl (FIG) - Rwanda

18. Lessons learned

19. HPV vaccine price vs delivery costs • Indicative HPV vaccine price for GAVI countries is 5 US$ (a 64% reduction on the lowest public price) • In addition, countries would need to secure about $3-5per girl for 1st year start-up costs and $4-6 per fully immunized girl for operational costs of vaccine delivery Source: Hutubessy et al. A case study using The United Republic of Tanzania: Costing nationwide HPV vaccine delivery using the WHO Cervical Cancer Prevention and Control Costing Too (2012). BMC Medicine (in publication)

20. Non-Vaccine (Delivery) Cost per Infant Varies by Region (%) Source: Brenzel, L. et al (2012)

21. Global trends on relative vaccinevsdeliverycosts

22. C4P and other WHO economic tools and initatives • cMYP Costing and Financing tool • Consistent costing methods and approaches • C4P provides adds-on and more details on HPV vaccination introduction and recurrent costs over 5 year planning period • Integration in cMYP in future? • OneHealth Tool* – • For the first time, planners have a single framework for planning, costing, impact analysis, budgeting and financing of strategies for all major diseases and health system components. • Integration of C4P tool including a Cost-Effectiveness component (PRIME) • International Working Group (IWG) ProVac • C4P workshop organized in AFR and WPR in 2013 as part of capacity building on using economic tools and information for vaccine introduction decisions * http://www.internationalhealthpartnership.net/en/tools/one-health-tool/

23. WHO C4P applications up to now • Field tested in Tanzania and Rwanda and validated with PATH demonstration projects. • C4P workshop in July 2011 in Dar es Salaam to inform national budget for HPV introduction. • Costing and CEA workshops in regional WHO meetings in EUR (Oct11), AMR (Nov11), WPR (End Nov11), AFR (June 2012) • C4P tool use and development workshop in 6-7 December 2011, WHO-HQ, Geneva with participants from 5 WHO regions and partners – 2 representatives from AFR • 2012: Vaccination module reviewed and endorsed by WHO Advisory Committee on implementation research (IVIR).

24. Vaccination Module in BMC Medicine

25. Conclusion • WHO C4P Costing tool • Allow calculation of costs of various scenarios of cervical cancer prevention and control • Calculate total costs for budgetary purposes • Compare costs of various strategies: e.g. school-based vs. campaigns, treatment options by level • Compare average costs across local levels, different strategies • Increase sense of ownership of process and output • Provide greater transparency, validity, and reliability in planning and costing of program tasks

26. Overall conclusions • Detailed national delivery cost information from LMICs are lacking – to address national program affordability and sustainability this information is crucial, also for resource mobilization • In MIC (non-GAVI eligible countries) both vaccine procurement and delivery program costs may be a barrier • HPV vaccines may be cost-effective but not affordable in LMICs

27. Acknowledgments • MoHSW Tanzania • DafrossaLyimo • Safina Yuma • Mariam Ally • MOH Rwanda • FideleNgabo • Maurice Gatera • WHO Consultants • Ann Levin (Indep. Consult.) • Winn Morgan (Indep. Consult.) • Mark Jit(HPA, UK) • WHO Tanzania • Theopista John • Chris Kamugisha • WHO AFR • Carol Tevi Benissan • Richard Mihigo • WHO Geneva • Nathalie Broutet (WHO/RHR) • Susan Wang (WHO/IVB) • Financial support by GAVI Alliance

28. THANK YOU More information: • Raymond Hutubessy, WHO IVB Geneva, Switzerland hutubessyr@who.int • Tool including user guide soon available on WHO NUVI HPV website http://www.who.int/nuvi/hpv/resources/en/index.html