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Contextualizing Case Management Costs in OVC Programs

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This webinar presented findings from an activity assessing the cost of case management in orphans and vulnerable children (OVC) programs across six countries.

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Contextualizing Case Management Costs in OVC Programs

  1. 1. Contextualizing Case Management Costs in OVC Programs Results Presentation Stacie Gobin, MPH, Senior Health Economist Shaylen Foley, MPH, MEL Specialist MEASURE Evaluation Palladium May 2018 © 2017 Uganda, Shaylen Foley
  2. 2. Global, five-year, $232M cooperative agreement 6 partners, led by the University of North Carolina at Chapel Hill Strategic objective: Strengthen capacity in developing countries to gather, interpret, and use data to improve health
  3. 3. • Prime: UNC-CH and partners: • ICF • John Snow, Inc. • Management Sciences for Health • Palladium • Tulane University • MEASURE Evaluation works with more than 72 smaller sub-awardees in over 27 countries • Over 26 percent of project funding goes back to minor sub-awardees Local partners and capacity building are key
  4. 4. Global Footprint (more than 40 countries)
  5. 5. Outline of the Webinar 1. Overview 2. Program Features 3. Case Worker Context 4. Case Management Costs 5. Conclusions © 2016 Riccardo Gangale/VectorWorks , Photoshare
  6. 6. Overview
  7. 7. Objective To provide cost estimates of OVC case management, as defined by 4Children To explore the context of case worker costs Purpose To improve understanding of OVC expenditures going towards case management and its relative components, supported by contextual data on case worker experiences To assist Missions with utilizing OVC cost data for planning and resource allocation Study Overview
  8. 8. Methodology Mixed-methods cost analysis • Selected programs in six countries: Nigeria, Rwanda, South Africa, Tanzania, Uganda, and Zambia • Collected financial data • Conducted 184 qualitative interviews • Qualitative content analysis • Determination of cost elements and allocation of costs © 2006 Babafunke Fagbemi, Photoshare
  9. 9. OVC Case Management Cross-Cutting Case Management Program Features Supervision cascades Government involvement Case worker (CW) context: CW education / qualification CW training Caseload CW compensation
  10. 10. Program Features
  11. 11. Program Features Rwanda Tanzania Uganda South Africa Zambia Nigeria Program Name Turengere Abana Kizazi Kipya Better Outcomes GCBS Zamfam STEER Implementing Mechanism Program Structure FXB Rwanda No partners / CSOs Pact 5 Partners & 48 CSOs World Education 4 Partners & 7 CSOs Pact Support Dep. of Social Devel. ECR 3 Partners & 73 CBOs Save the Children 2 Partners & 58 CSOs Beneficiaries (OVC & CG) 16,401 493,743 110,484 215,000 111,569 328,045 Setting Rural Both Rural Both Both Both
  12. 12. Big-Picture Differences • Supervision cascade • Government involvement • Case worker attributes © 2016 Simi Vijay, Photoshare
  13. 13. Supervision Cascade Rwanda: Turengere Abana National Office •Administrative/Leadership positions •M&E support Regional Offices •Regional managers: Supportive supervision, training cascade support Field •Field facilitators: direct supervision of PSW (case workers), cascade training, case file and document management •PSW: home visits, ISLG leadership Program Structure
  14. 14. Supervision Cascade Uganda: Better Outcomes National Level • Case management oversight • Administrative support Regional Level • Regional support roles District Level • Indirect CW supervisors County level • Direct CW supervisors Subcounty • Case workers • CW counterparts District: DCDO County: Probation Officer Subcounty: CDO Government CounterpartsProgram Structure
  15. 15. Government Involvement • Much variation in role and degree of government involvement • All had some kind of engagement at the local or regional/national level • Identification of beneficiaries • Selection of case workers • Referrals to government resources • Training support • Case worker supervision
  16. 16. Case Worker Context
  17. 17. Contextual Findings Case Worker Education 0 2 4 6 8 10 12 14 16 18 20 Grade 1-7 Grade 8-9 Grade 10-12 Certificate Bachelors NumberofCaseWorkers Education Level by Country/Program Rwanda Tanzania Uganda South Africa Zambia Nigeria
  18. 18. Contextual Findings Case Worker Qualifications Rwanda Tanzania Uganda South Africa Zambia Nigeria CW Requirements Read/write Selected by peers in savings group Read/write Less than 55 Primary education Pass interview Read/write Chosen by local council Read/write None (most can read and write) Assessment/ interview Identified by peers Read/write Pass written exam & interview
  19. 19. Rwanda Tanzania Uganda South Africa Zambia Nigeria Monetary and non-monetary compensation (monthly) Unpaid Intangible benefits (and receive beneficiary services) Stipend ($21 USD) Materials (not yet received) Stipend ($5.50 USD) Materials Stipend ($120 USD*) *paid by government Unpaid Materials Training certification Salary ($55 USD) Contextual Findings CW Compensation CW Perception of Compensation: • Payment or increased pay would provide motivation • Help cover costs of the role (communication, transport, beneficiary needs) • Enable case workers to spend more time (and less time on other work)
  20. 20. Contextual Findings CW Training Various training approaches were observed: • In-service/supervision (Rwanda) • Cascaded ToT trainings (Tanzania, Zambia) • Mixture of formal trainings and in-service trainings (Uganda, Nigeria, South Africa)
  21. 21. Contextual Findings CW Tools • All programs used paper tools • Number of case worker tools ranged from three forms (Uganda) to seven forms (Tanzania and Zambia) • Challenges were not frequently reported with using the tools but refresher trainings commonly requested
  22. 22. Contextual Findings CW Caseloads Rwanda Tanzania Uganda South Africa Zambia Nigeria Avg. # of HH Range 21.7 HH 10-30 HH 18.1 HH 5-40 HH 12.2 HH 8-16 HH 32.6 HH 10 – 53 HH 9.8 HH 4-25 HH 30.9 HH 26-42 HH Avg. # of beneficiaries 49.2 (est.) 39.2 (est.) 72.2 (est.) 71.3 (report) 22.2 (report) 117.2 (report) CW Perception of Caseload: • Reporting/defining caseload was challenging; found large regional variation • Caseload burden is related to time spent at households, travel time, and visit frequency • Severe cases added to perceived burden when reported
  23. 23. Contextual Findings CW Supervision Rwanda Tanzania Uganda South Africa Zambia Nigeria Supervision Ratio 17.8 88.7 36.0 Not reported Not reported 4.3 Frequency of Contact Monthly (formal) Weekly (informal) Monthly (formal) Monthly (formal) Weekly (informal, with government supervisor) Weekly (formal) Monthly (formal) Monthly (formal) Biweekly or weekly (informal)
  24. 24. Case Management Costs
  25. 25. Case Management Costs Cost Categories Supervision Direct supervisor salaries Indirect supervisor salaries (supervision cascade) Training Case worker case management training costs Staff training case management costs Transport Travel costs for supportive supervision Vehicle or motorbike expenses CW Support CW stipends and materials/supplies Monthly meeting costs Mobile phone/communication costs Printing of CM tools/forms General Personnel Administrative staff costs Office Costs Recurrent office expenses Office supply costs M&E M&E costs related to case management
  26. 26. Rwanda Tanzania Uganda Zambia South Africa Nigeria Study time period Oct 2015 to May 2017 4.7 YEARS Oct 2016 to Sept 2017 1 YEAR April 2015 to Sept 2017 2.5 YEARS Jan 2015 to Dec 2017 2 YEARS Oct 2016 - Sept 2017 1 YEAR Sept 2013 to Sept 2017 4 YEARS Financial data Expenditure data Expenditure & budgetary data Budgetary data Budgetary data Expenditure data Expenditure data Outcome measure Total served count OVC_SERV* Total served count Total served count OVC-SERV* Sum of newly enrolled beneficiaries Case Management Costs Data Characteristics *per MER 2.0 Guidance, only Q4 counts were used for OVC_SERV
  27. 27. Case Management Costs Rwanda, Turengere Abana Supervision, 44.7% Training, 8.9% Transport ation, 22.4% CW Support, 1.2% General Personnel, 21.2% Office Support, 1.1% M&E, 0.5%Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $76,621 22% $21.96
  28. 28. Supervision, 5.1% Training, 56.8%Transport ation, 5.5% CW Support, 14.0% General Personnel, 9.0% Office Support, 9.2% M&E, 0.4% Case Management Costs Tanzania, Kizazi Kipya Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $8,061,375 42% $15.98
  29. 29. Supervision, 10.4% Training, 8.4% Transportation, 5.4% CW Support, 35.6% General Personnel, 25.2% Office Support, 10.2% M&E, 4.8% Case Management Costs Uganda, Better Outcomes Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $2,093,697 55% $47.38
  30. 30. Case Management Costs South Africa, GCBS Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $1,796,006 5% $8.35 Supervision, 27.7% Training, 6.8% Transportation, 3.0%CW Support, 2.2% General Personnel, 52.8% Office Support, 4.1% M&E, 1.6%
  31. 31. Supervisi on, 16.5% Training, 32.9% Transportation, 4.9% CW Support, 14.2% General Personnel , 22.3% Office Support, 3.0% M&E, 6.3% Case Management Costs Zambia, ZamFam Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $2,784,349 %22% $50.41
  32. 32. Case Management Costs Nigeria, STEER Annualized Cost of Case Management % of Total Program Cost Cost per Beneficiary $1,782,441 %33% $21.73 Supervision, 34.6% Training, 5.5% Transport ation, 4.0% CW Support, 19.4% General Personnel, 27.7% Office Support, 6.5% M&E, 2.3%
  33. 33. Rwanda Turengere Abana Expenditure Category Costs from FXB Total % Supervision $ 160,948 44.7% Direct Supervision $ 100,504 Supervision Cascade $ 60,4424 Training $ 32,092 8.9% CW Training $ 28,907 Staff Training $ 3,185 Training Support Travel/Transportation $ 80,682 22.4% Field Staff and CW $ 19,851 Other Travel/Supervision Cascade $ 47,642 M&E Travel $ 13,189 CW Support $ 4,144 1.2% CW Stipends and Materials Printing of Tools $ 4,148 Monthly Meeting costs Communication Costs Other Costs $ 80,479 22.3% M&E Support $ 1,776 Labor and Personnel General $ 76,366 Non-CM Specific Office Support $ 4,112 Total Cost of Case Management $ 360,120 22% Annualized Cost (4.75 years) $ 76,621 Cost per Beneficiary $ 21.96
  34. 34. Tanzania Kizazi Kipya Expenditure Category Pact HQ JSI Pact CBOs Total % Supervision $ 401,097 5.1% Direct Supervision $ 123,596 Supervision Cascade $ 131,270 $ 146,231 CM & Related Training $ 4,482,213 56.8% CW Training $ 3,608,149 $ 212,786 Staff Training $ 49,773 $ 154,528 $ 319,178 Training Support $ 116,138 $ 21,661 Travel/Transportation $ 432,646 5.5% Field Staff and CW $ 94,952 Other Travel/Supervision Cascade $ 229,824 $ 107,871 CM and CW Support $ 1,103,369 14.0% CW Stipends and Materials $ 782,850 Printing of Tools $ 25,082 $ 104,968 $ 67,296 Monthly Meeting costs $ 3,134 CW Identification Costs $ 73,872 Beneficiary Identification Costs $ 8,631 Communication Costs $ 37,537 Other Costs $ 1,468,364 18.6% M&E Support $ 33,942 Labor and Personnel General $ 465,901 $ 243,719 Non-CM Specific Office Support $ 195,030 $ 529,773 Total Cost of Case Management $ 7,887,689 41.1% Annualized Cost (1 year) NA Cost per Beneficiary $ 15.98
  35. 35. Uganda Better Outcomes Expenditure Category Cost from WEI Costs from Partners Costs from CSOs Total % Supervision $ 545,848 10.4% Direct Supervision $ 14,621 $ 80,303 $ 88,934 Supervision Cascade $ 210,054 $ 86,063 $ 65,873 CM & Related Training $ 437,834 8% CW Training $ 101,707 $ 274,928 $ 3,012 Staff Training $ 20,296 $ 1,289 Training Support $ 7,868 $ 22,641 $ 6,092 Travel/Transportation $ 284,448 5.4% Field Staff and CW $ 95,449 $ 51,305 Other Travel/Supervision Cascade $ 137,694 CM and CW Support $ 1,863,816 35.6% CW Stipends and Materials $ 124,182 $ 120,558 $ 191,578 Printing of Tools $ 15,922 $ 6,610 $ 19,822 Monthly Meeting costs $ 121,600 $ 3,904 $ 4,529 Identification Costs $ 671,598 $ 3,612 Referral Costs $ 49,175 $ 124,232 $ 302,332 Communication Costs $ 79,557 $ 17,127 $ 7,478 Other Costs $ 2,102,297 40.2% M&E Support $ 135,363 $ 45,783 $ 67,833 Labor and Personnel General $ 606,708 $ 553,321 $ 157,477 Non-CM Specific Office Support $ 412,264 $ 66,314 $ 57,234 Total Cost of Case Management $ 5,234,244 55% Annualized Cost (2.5 years) $ 2,093,697 Cost per Beneficiary $ 47.38
  36. 36. Case Management Costs • Cost per beneficiary range from $9 to $50 • Large portion of program expenses contribute to case management (except in SA GCBS) • Distribution of expenditures reflect program structure and approach Summary
  37. 37. 4Children Definition Costing the CM process RWANDA Identification Assessment/ Enrollment/ Case Plan Development Implementation/ Monitoring Graduation 21% 25% 35% 19%
  38. 38. Conclusions
  39. 39. Findings Summary • Case management viewed as integral to program delivery, but challenging to define costs and activities attributable to CM • High staff reported LOE estimates contributing towards CM, even at above-field level • 22% - 55% of total expenditures on CM • Supervision and training structure reflected in cost distribution, ie. Rwanda & Tanzania • High CW demand for in-service training, especially in programs with pre-service training focus • Supervision marked by informal communication not reflected in expenses
  40. 40. Findings Summary • Direct case worker expenditures mostly cover printing of tools, meeting costs, & compensation • Case worker pay is low relative to other staffing costs • Stipends used to cover out-of-pocket expenses on travel, emergency cases, direct beneficiary assistance, & communication • When tangible material benefits are provided, they are often perceived as poor quality (i.e. bags) or poor fit for case worker needs (i.e. oversized record books) • Challenges with balancing caseload and supervisor ratios
  41. 41. Implications • Case management approach reflected in costs – highlighting need for activity based budgeting • Clarification of the definition of case management as an intervention is needed, using 4Children process definition as foundation • Case worker costs should be reviewed to assess adequacy of compensation for covering CW expenses, particularly for transportation and emergency cases
  42. 42. Conclusions • Investment in OVC programs requires high quality and accessible case management • Engagement with national and international stakeholders to: Support OVC strategic objectives Prioritize cost-effective services • Focus on domestic resource mobilization in light of the PEPFAR shift to epidemic control
  43. 43. Questions? © 2013 Sushil Kanta Dasgupta, Photoshare Please submit all questions to the Q&A box on your screen.
  44. 44. This presentation was produced with the support of the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation cooperative agreement AID-OAA-L-14-00004. MEASURE Evaluation is implemented by the Carolina Population Center, University of North Carolina at Chapel Hill in partnershipwith ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed are not necessarily those of USAID or the United States government. www.measureevaluation.org

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