1. Cost of the Skilled Care Initiative in
Kenya and Tanzania
Stephanie Boulenger
Women Deliver – Global Conference
London, 19 October 2007
2. Study objectives
Kenya (Homabay and Migori) and Tanzania (Igunga)
1. Assess the SCI implementation costs
• What were the costs for FCI?
2. Determine the SCI maintenance costs
• What it will cost in the future to maintain the SCI?
3. Establish the SCI replication costs
• What it would cost to implement the SCI in other districts?
3. Methodology (1/3)
• Includes Incremental costs from the point of view of a
government
– Excludes health personnel, supplies, and infrastructures
already in place
• Types of costs
– Fees; Equipment; Renovation; Maintenance and repair;
Fuel cost; Licensing fees for the referral system equipment;
Printing; Meetings and trainings; Travel.
4. Methodology (2/3)
• Data collection for unit costs and inputs
– Retrospective analysis of budgets, reports, and all available
documents from FCI headquarters, and the field offices in
Kenya and Tanzania.
– Per activity: Activity 1 to 5 of Intervention 1 OR Activity 1
and 2 of Intervention 2
– Per cost type: Implementation OR Maintenance OR both
• Average monthly exchange rate: Converted into US
• Inflation rate = 2.67%
5. Methodology (3/3)
• Intervention 1: Health Sector Strengthening
– Activity 1: Strengthening health services management and
introducing quality improvement approaches
– Activity 2: Making structural improvements to health facilities
– Activity 3: Providing maternal health equipment and consumables
– Activity 4: Strengthening communication and referral system
– Activity 5: Strengthening provider skills and competencies
• Intervention 2: Behavior Change Communication (BCC)
– Activity 1: Developing BCC messages/materials
– Activity 2: Implementing BCC campaign
6. Results: Implementation costs
Total cost
(US$)
2002-06
Cost per
delivery with
SBA/year
(US$)
Cost per
capita (US$)
Per capita
THE (average
exchange
rate US$)*
Igunga 559,095 15.0 1.7 12
Homabay 364,469 10.6 0.6 20
Migori 277,140 10.6 0.6 20
* Source: World Health Organization. WHO Statistical Information System. 2004
7. Results: Implementation costs
Igunga
(US$)
Homabay
(US$)
Migori
(US$)
Activity 1: Strengthening HS
management and introducing quality
improvement approaches
23,158.6 16,010.2 18,420.0
Activity 2: Structural improvements 17,861.6 75,206.1 99,866.5
Activity 3: MH equipment and consum. 67,413.2 56,037.1 94,773.4
Activity 4: Strengthening communication
and referral system
105,715.2 11,097.2 9,511.9
Activity 5: Strengthening provider skills
and competencies
191,893.4 58,554.2 54,568.3
BCC Intervention 153,052.0 147,564.6 -
Total 559,094.9 364,469.4 277,140.1
8. Results: Maintenance costs
• Main items
– Equipment and consumables
– Educational materials for BCC campaign
– LSS and PAC trainings
Year 3
(US$)
Year 4
(US$)
Year 5
(US$)
Year 6
(US$)
Igunga 8,256.92 64,945.40 42,059.31 75,117.54
Homabay 304.29 3,007.22 52,621.58 50,346.01
Migori 128.44 3,180.69 34,124.20 29,718.72
9. Results: Maintenance costs
• Example:
– The cost of re-purchasing and maintaining maternal health
equipment in Igunga for 29 facilities is as follows:
2004 2005 2006 2007 2008
5,220.3 5,414.8 7,913.2 5,841.8 52,748.9
– For 1 facility:
2004 2005 2006 2007 2008
190.4 186.7 272.9 201.4 1,818.9
10. Results: Replication costs
• Example 1: If MOH wants to train health personnel in LSS,
it would cost about 1,534 US$ per trained person in
Tanzania and, on average, 820 US$ per trained person in
Kenya.
• Example 2: Equipping health facilities with medical and
maternal health equipment would cost, per facility, about
2,010 US$ in Tanzania and 2,753 US$ in Kenya.
• Opportunities for economies of scale
11. Conclusions
• Additional investments required
– Example: recruitment and deployment of additional SBA cadres,
upgrading of health facilities
• Spillover effect of investments in MCH
– Poverty
– Child survival
– Non-obstetric benefits
• Documenting the total and marginal cost of MH interventions
• Data for evidence-based decision making,
– Better planning, Help budgeting process and advocacy.
Cost items were each assigned to an activity (activity 1 to 5 of intervention 1, activity 1 and 2 of intervention 2) and it was determined whether each item was part of the implementation costs or the maintenance costs, or both.
The inflation rate used was 2.67%. It represents the average inflation rate between 2001 and 2006 in the United States.
As I said earlier, the cost items were each assigned an activity. List the different activities.
Explain if necessary what each activity includes – see Annex 1 of report.
To give an order of magnitude, the per capita Total Health Expenditure (at average exchange rate) was 12US$ in Tanzania and 20 US$ in Kenya
In Igunga, the most expensive set of activities was: Activity 5 for strengthening provider skills and competencies (LSS and PAC trainings, a gestational pregnancy wheel, and the development and distribution of an obstetric job aide) followed by the BCC campaign.
- Activity 5 was more expensive in the Tanzania district because (1) the training course is 3 weeks, not 2 weeks; (2) the training site is farther from the intervention district, meaning more costs getting people to the site; (3) the trainers are national resource persons who are quite costly as consultants, whereas in Kenya fewer such national experts were used and more local trainers were used.
In Homabay, the activity with the highest cost was the BCC campaign. The main cost items were the production of promotional materials, such as khangas, bags, and tee shirts, and educational materials, including leaflets, booklets, and flipcharts.
In Migori, structural improvements to health facilities (Activity 2) required the most financial resources: renovating 10 health facilities, and on equipping 32 facilities with solar power systems and water supply systems.
The costs of the interventions in Tanzania and Kenya differ because they did not focus on the same activities, depending on needs and priorities identified:
In Igunga, the need for strengthening the communication and referral system (Activity 4) was greater than in both districts in Kenya. Ambulance
In Kenya FCI opted to purchase cell phones for the health facilities rather than a radio call system, because the annual radio licensing fee was prohibitively expensive.
The maintenance costs are driven or determined by the activities that would need to be re-conducted to make sure that the SCI is maintained over time. This includes re-printing some materials, supervision and follow-up of activities, maintenance of equipment, re-purchasing of equipment, re-training (either to refresh the skills and notions acquired during the implementation phase or to train new staff), Behavior Change Communication: Educational materials and their distribution (and promotional activities)
BUT some activities that only needed to be done prior to the implementation were excluded such as: postpartum care registers development, pre-test of postpartum care register, Community Health Fund study, ambulance manuals, radio call books, referral forms, clinical flowcharts, district health management team (DHMT) orientation, BCC qualitative study, BCC launch, BCC materials preparation, BCC traditional leaders study and BCC feedback meeting.
The MC are measured for 10 years from the onset of the SCI
The main cost items to consider for the MC are: Equipment and consumables, Educational materials for BCC campaign and LSS and PAC trainings.
The report provides for each item the unit cost so it is easy to estimate how much it would cost to apply the SCI to other districts.
Why are costs of maintenance so different in the three districts?
Timing of equipment purchase and trainings (bought earlier in Igunga than in Kenya, and thus need to be replaced faster/sooner.
More expensive Strengthening communication and referral system (ambulance and walkie-talkie) in TZ
BCC campaign slitely more expensive in TZ
This is an example of what you can find in the report and how the data produced can be used.
The tables with the detailed replication costs can be found in the hand outs.
Repeat what replication costs are and what they mean.
For example, if the Ministry of Health wanted to train its health personnel in LSS, it would cost about 1,534 US$ per trained person in Tanzania and, on average, 820 US$ per trained person in Kenya. The significant difference in costs is related to the fact that the (1) training in TZ lasted 3 weeks (versus 2 in Kenya) and (2) the fact that there was only a limited pool of national resource persons available to lead such training, which contributes to high costs.
Similarly, equipping health facilities with medical and maternal health equipment would cost, per facility, about 2,010 US$ in Tanzania and 2,753 US$ in Kenya. It is important to note that these costs are based on the experience working in these particular districts (which may have been better or worse off than other districts in each country). For example, the equipment costs appear higher for Kenya because of the much greater gaps that we found had to be addressed, based on the districts where we were working. It may be that there are other districts in Kenya that are better off and costs would be lower. Similarly, for Tanzania, it may be that there are other districts where the gaps would be greater and replication costs would be higher.
It should be noted that as the replication scale increases, there are opportunities for economies of scale. This means that as the number of trained personnel or quantity of goods and materials purchased or produced increases, their unit costs could potentially decrease. For example, the unit cost of equipment will become cheaper as the quantities purchased increases. So as the government replicates the SCI intervention at a national scale or to a greater number of districts, the costs evaluated could in fact be lower.
Scaling up the SCI intervention will require some additional investments on the part of governments to ensure effectiveness and sustainability of the intervention, such as EXAMPLE ON SLIDE
It is critical to recognize and acknowledge that investments made in maternal health extend far beyond the sole area of maternal health, such as poverty, child survival, and other health care services provided in facilities.
POVERTY: Reducing maternal and perinatal mortality can help reduce poverty by freeing up resources otherwise diverted to health crises, which in turn stimulates economic activity and can feed back into improvements in maternal and perinatal health, and can be a means of achieving wider health service improvements.
CHILD SURVIVAL: Investing in MH is directly linked to improving child survival : complications during labor are a determinant of fetal and neonatal survival and health, intrapartum risk factors are associated with greater increases in risk of neonatal death than those identified during pregnancy, obstructed labor and malpresentation carry the highest risk of neonatal death and require skilled intervention.
NOB: among the benefits that were not measured and captured in the cost of the intervention and which could potentially reduce the overall costs of the SCI are the NOB. The SCI also benefits other medical specialties in a health facility because the equipment purchased or skills acquired can be used for other services than the ones related to MH or obstetric care. Example:
blood pressure machines can be used for interventions other than deliveries; the same goes for stethoscopes and scales.
availability of equipment can improve the quality of care, increase the availability of care, and improve the working conditions of the health personnel.
Training received had an impact on other services than OC.
These factors in turn have an impact on the use of care. A patient is more likely to return or seek care from a health facility that has equipment available and high-quality service. But further research is needed to assess the impact of maternal health packages on broader health systems.
DOCUMENT: The findings of this report will contribute to documenting the cost of MH interventions and the marginal costs of implementing packages similar to the SCI. The data provided can be used to inform evidence-based decision making, can help in better planning for maternal health services, can help the budgeting process for health, and can be used for advocating for funding for these services.
