Measuring Costs of Pilot Interventions Measuring Costs of Pilot Interventions

John H. BrattJohn H. BrattSeptember 29, 2009September 29, 2009

Outline

How costing pilot interventions differs from costing services Phases of pilot interventions From phases to resources Converting resources into costs Data sources Example: Introducing CBD of DMPA

Average Costs of Health Services

•Health facility represents a production process (inputs-processes-outputs)•Defined outputs produced•Measured and costed all resources used to produce these outputs•Result: average cost per service

ART

CT

PMTCTOther

Program Costs

Incremental Costs Associated with Interventions

•Many health interventions begin as small pilot projects•Pilot projects often carried out within an existing program•Which costs should we consider?

Program Costs

Incremental Costs

Costs of a Pilot Project

Inputs OutputsProcesses (activities)

•Labor•Supplies•Capital

•Planning the intervention•Implementing the plan•Carrying out new service delivery

Increased or improved provision of services

Outcomes

•Higher use of ARVs•Improved Adherence •Higher PMTCT coverage

Economic Taxonomy of a Pilot Project

• Pilot Project– Phase

Phases of a Pilot Project

• Planning• Implementing the Plan• Initial service delivery

Economic Taxonomy of a Pilot Project

Pilot ProjectPhase

• Activity

Phase 1: Planning

Examples of objectives/activities in the planning phase:

Work sessions to create curricula and job aids

Design training materials

Meetings with MoH, community leaders, service providers, etc.

Build stakeholder support

Work sessions to decide on intervention size and scope

Design Intervention

Phase 2: Implementing the Plan

Examples of objectives/activities in the “implementing the plan” phase:

Consultations with supervisors to explain changes in system

Improve supervision system

Workshops to introduce the intervention to providers

Train providers

Workshops to form cadres of trainers Train ToTs

Phase 3: Initial service delivery

Additional time spent by supervisors

Increased use of supplies and commodities

Additional time spent with clients

New / improved service provision

Examples of objective/activities in the “service delivery” phase:

Economic Taxonomy of a Pilot Project

Pilot ProjectPhase

• Activity– Resource

» Cost

Approach to Costing

Identify resources used for each activity– Labor– Supplies– Capital

Approach to Costing, cont’

Measure resources in natural units– hours, items, days of per-diem

Assign Unit Value to each resource– wage rate, unit cost

Cost calculation for activity– Σ (quantity of resource x unit cost)

Costing a planning activity: MoH stakeholder meeting

Resource Quantity Unit Cost Total

Facilitator time 3 person-hours $18/hr $54

Facilitator travel 1 RT taxi $6/RT $6

Tea/snack 8 portions $2/portion $16

Grand Total $76

Costing an implementation activity: workshop for clinic staff

Resource Quantity Unit Cost Total

Trainer time 5 person-days $120/day $600

Lodging/food 24 person-days $80/day $1,920

Venue fee 3 days $60/day $180

Trainee time 21 person-days $8/day $168

Grand Total $2,868

Costing a service delivery activity: increased supervision visits

Resource Quantity Unit Cost Total

Supervisor time 3 person-days $80/day $240

Lodging 2 nights $50/night $100

Per-diem 3 days $60/day $180

Transport 3 days $100/day $300

Grand Total $820

How and where do we obtain data to cost out a pilot project?

Retrospective vs. Prospective

• Retrospective data collection is the only option if the intervention has already been carried out

• Quality of data highly variable; depends on financial systems and reporting requirements of implementing agency

• Best case – worst case

Prospective is Preferred

• The Ideal: build economic component into pilot project from beginning

• Assess routine financial reporting of implementing agency• Build on existing systems for financial reporting • Introduce forms to intervention staff • Monitor. Monitor. Monitor.

Example: CBD of DMPA

What is DMPA?• Progestin-only injectable contraceptive• Highly effective (99%) when timely injections given over the first

year• Administered as an intramuscular Injection (IM) • Fertility resumes after 4 months

Facilitating Factors

• Government support is essential• An active, strong CBD program• Existing demand for injectables • State-of–the art service guidelines• Effective commodity logistics system

Planning Phase for CBD of DMPA: Building Stakeholder Consensus

• Gauge support among national health authorities• Create advocacy strategy• Establish national core team• Conduct sensitization meetings with various stakeholder

groups

Costing a planning activity: MoH stakeholder meeting

Resource Quantity Unit Cost Total

Facilitator time 3 person-hours $18/hr $54

Facilitator travel 1 RT taxi $6/RT $6

Tea/snack 8 portions $2/portion $16

Grand Total $76

Total Costs of Building Stakeholder Consensus

Activity Quantity Unit Cost Total

MOH Meetings 4 meetings $76 $304

Sensitization meetings

8 meetings $140 $1,120

Advocacy Strategy 2 meetings $50 $100

Subtotal $1,524

Planning Phase for CBD of DMPA: Designing the Intervention

• Develop training curriculum• Design supervision system• Develop messaging strategy

Total Costs of Designing the Intervention

Activity Quantity Unit Cost Total

Training Curriculum 15 consultantdays

$200/day $3,000

Supervision System 5 consultant days $180/day $900

Messaging Strategy 1 package $1,600 $1,600

Subtotal $5,500

Planning Phase: Total Costs

Stakeholder consensus $1,524

+ Intervention Design $5,500

= Total Planning Cost $7,024

Implementation of Plan:CBD of DMPA• Intervention staff conduct TOT• Trainers train CBAs in central location • Improve supervision system• Improve logistics system for commodities

Costing an implementation activity: workshop for CBAs

Resource Quantity Unit Cost Total

Trainer time 5 person-days $120/day $600

Food/Lodging 24 person-days $80/day $1,920

Venue fee 3 days $60/day $180

Trainee time 21 person-days $8/day $168

Grand Total $2,868

Total Costs of Implementing the Plan

Activity Quantity Unit Cost Total

ToT workshop 1 $1,880 $1,880

CBA workshop 3 $2,868 $8,604

Supervisor training 3 $200 $600

Logistics upgrade 3 $85 $255

Total cost of “implementing the plan” $11,339

Initial Service Delivery Phase for CBD of DMPA• More DMPA provided (maybe fewer OCs?)• Increased supervision visits/content• CBAs spend more time with clients

Total Costs of Initial Service Delivery (6 months)

Activity Quantity Unit Cost Total

DMPA commodity 420 units $0.92 $386

Supervisor visits 3 visits $250 $750

Additional CBA time with clients

4200 minutes $0 $0

Total cost of initial service delivery $1,136