Presentation given by Meghan Bruce Kumar at the International Health Economics Association conference in 2017

1. The REACHOUT project is funded
by the European Union
1
Meghan Bruce Kumar
Liverpool School of Tropical Medicine
Meghan.brucekumar@lstmed.ac.uk
July 2017 - iHEA
Is quality affordable?
Costing capacity development in quality improvement for
community health managers in four countries

2. Disclaimer
• Preliminary results only
• Not for dissemination without permission
• Please contact the author with any queries
(meghan.brucekumar@lstmed.ac.uk)
The study presented in this paper is part of the REACHOUT programme. This
programme has received funding from the European Union Seventh Framework
Programme ([FP7/2007-2013] [FP7/2007-2011]) under grant agreement n°
306090.

3. Focus on quality improvement for
community health in low and middle-
income countries

4. Quality improvement
capacity development intervention
ImplementationPhase
Recurrent costs
Regular periodic
QI team meetingsStep5
QI team
interventions
Step6
Intermediate outcomes/
Resulting interventions
P
D
S
A QI
Improved
service quality
and health
outcomes
Ultimate
Outcomes
BenefitsTraining Phase
Capital costs
Development of global
QI curriculum
Training of program
Trainers (ToT) on QI
Adaptation of QI
curriculum to country
contexts
Development Phase
Capital costs
Step1Step2Step3
Training of QI teams
managing CHWs
Step4
Project Intervention:
capacity development forQI

5. Site description
• Ethiopia: HEWs, facility staff,
woreda (district) health officers
• Kenya: CHEWs, sub-county
health management teams,
facility staff
• Malawi: HSAs, district health
management teams,
environmental health officers,
facility staff
• Mozambique: APE
supervisors, district health
management teams

6. Implementation sites
Setting Remoteness
# of QI
teams
# of QI
team
members
# of CHWs
supervised
Catchment
population
Ethiopia Rural Medium 9 63 68 244489
Kenya Urban Low 3 29 1530 737460
Malawi Rural High 2 28 121 213206
Mozambique Rural Medium 2 23 68 214388

7. Research objectives
To assess the costs of Ministry of Health-led
quality improvement for district managers in
different healthcare systems
Specifically:
– Comparison of costs between countries
– Identification of key resource inputs or phases
– Address perceptions that quality improvement is ‘too
costly’ by looking at resource constraints

8. Approach to costing
Ingredients-based, bottom-up costing:
1. Project-led quality improvement:
Cost the intervention in ‘REACHOUT world’, i.e. what we did
in each country
2. Ministry of Health-led quality improvement:
Cost the intervention in the same sites in the post-REACHOUT
real world
– Global and country materials exist (sunk costs)
– Training conducted by local trainers with support
– Sensitivity analysis of best/worst case
3. Budget impact of Ministry of Health-led quality
improvement

9. • Ingredients: people-time, per diem, transport,
venue, food, communication
• Reporting year: 2016
• Discount rate: 3%
• Useful life of training: 4 years
• Inflation adjustment and annualization of
capital costs
Parameters and assumptions

10. Costs (€) of project-led
quality improvement: Kenya
Intervention
Economic costs Financial outlay Economic cost
by step by phase by step
per QI team
member
trained
per CTC
provider
supervised
per
catchment
population
Phase Step EUR % of total EUR % of total EUR
% of
economic
EUR EUR EUR
Development
1 6,090.00 5.4%
36,487.30 32.6%
6,090.00 100.0% 210.00 3.98 0.01
2 11,861.76 10.6% 11,861.76 100.0% 409.03 7.75 0.02
3 18,535.53 16.6% 15,102.85 81.5% 639.16 12.11 0.03
Training 4 63,947.07 57.2% 63,947.07 57.2% 23,669.82 37.0% 2,205.07 41.80 0.09
Implementation
5 2,865.96 2.6%
11,341.72 10.1%
904.76 31.6% 98.83 1.87 0.00
6 8,475.76 7.6% 6,787.09 80.1% 292.27 5.54 0.01
Total 111,776.09 100.0% 111,776.09 100.0% 64,416.28 57.6% 3,854.35 73.06 0.15

11. Costs (€) of Ministry of
Health-led quality improvement: Kenya
Intervention
Economic costs Financial outlay Economic cost
by step by phase by step
per QI team
member
trained
per CTC
provider
supervised
per
catchment
population
Phase Step EUR % of total EUR % of total EUR
% of
economic
EUR EUR EUR
Development
1 0.00 0.0%
0.00 0.0%
0.00 0.0% 0.00 0.00 0.00
2 0.00 0.0% 0.00 0.0% 0.00 0.00 0.00
3 0.00 0.0% 0.00 0.0% 0.00 0.00 0.00
Training 4 62,346.60 83.6% 62,346.60 83.6% 21,504.09 34.5% 2,149.88 40.75 0.08
Implementation
5 4,851.19 6.5%
12,251.84 16.4%
730.80 15.1% 167.28 3.17 0.01
6 7,400.66 9.9% 5,665.01 76.5% 255.20 4.84 0.01
Total (MoH-led) 74,598.44 100.0% 74,598.44 100.0% 27,899.90 37.4% 2,572.36 48.76 0.10

12. Costs (€) of Ministry of
Health-led quality improvement: Kenya
Intervention
Economic costs Financial outlay Economic cost
by step by phase by step
per QI team
member
trained
per CTC
provider
supervised
per
catchment
population
Phase Step EUR % of total EUR % of total EUR
% of
economic
EUR EUR EUR
Development
1 0.00 0.0%
0.00 0.0%
0.00 0.0% 0.00 0.00 0.00
2 0.00 0.0% 0.00 0.0% 0.00 0.00 0.00
3 0.00 0.0% 0.00 0.0% 0.00 0.00 0.00
Training 4 62,346.60 83.6% 62,346.60 83.6% 21,504.09 34.5% 2,149.88 40.75 0.08
Implementation
5 4,851.19 6.5%
12,251.84 16.4%
730.80 15.1% 167.28 3.17 0.01
6 7,400.66 9.9% 5,665.01 76.5% 255.20 4.84 0.01
Total (MoH-led) 74,598.44 100.0% 74,598.44 100.0% 27,899.90 37.4% 2,572.36 48.76 0.10
Total (project-led) 111,776.09 100.0% 111,776.09 100.0% 64,416.28 57.6% 3,854.35 73.06 0.15

13. Absolute costs of Ministry of
Health-led quality improvement
Country
Economic costs Financial outlay
EUR EUR
% of
economic
Ethiopia € 48,134.56 € 13,551.85 28%
Kenya € 74,598.44 € 27,899.90 37%
Malawi € 14,328.47 € 7,472.56 52%
Mozambique € 9,101.20 € 6,330.10 70%

14. Economic (unit) costs of
quality improvement approach
Currency: 2016EUR
Per QI team
trained
Per QI team
member trained
Per CHW
supervised
Per capita
catchment
population
Ethiopia € 3,984.85 € 569.26 € 527.41
(3600 pop/CHW)
€ 0.15
Kenya € 11,674.67 € 1,207.72 € 22.89
(500 pop/CHW)
€ 0.05
Malawi € 5,764.03 € 411.72 € 95.27
(1750 pop/CHW)
€ 0.05
Mozambique € 2,181.42 € 189.69 € 64.16
(3152 pop/CHW)
€ 0.02

15. Affordability of quality
improvement approach
Currency: 2016EUR Annualized economic costs per
capita
Total Health
Expenditure per
capita
C
B/C (%)
Project-led
A
MoH-led
B
Ethiopia €0.19 €0.15 €25.35 0.58%
Kenya €0.06 €0.05 €73.25 0.06%
Malawi €0.07 €0.05 €27.23 0.08%
Mozambique €0.04 €0.02 €39.44 0.05%

16. How does it compare to other
regularly funded interventions?
HIV testing per person in
LMICs:
€11.85
WHO guidelines on HIV testing services, 2015
MoH-led QI in Kenya
€0.05

17. Key findings
1. Contrary to perceptions, costs of quality
improvement for community health
programmes are low in absolute terms
2. Majority of costs of intervention are capital
training costs (financial outlay in year 1)
3. Recurrent costs of quality improvement are
driven by costs of people-time

18. Limitations in methodology
• Retrospective
• Handling time allocations
and labour costs for
unpaid workers
• Community health
programmes often not
government-funded –
who is decision-maker?
• Does not take economies
of scale/scope into
account

19. What about benefits?
• Acknowledge complexity: systems thinking approach
• Identify decision-makers and priorities
• More from Jason!