annual regional conference on immunization (arci) 10-12 december 2012, dar es salaam, tanzania 1 |1...

Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania

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Comprehensive WHO Cervical Cancer Control Costing and

Planning (C4P) tool: findings from African countries

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


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OutlineOutline

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


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IntroductionIntroduction

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


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Purpose of Costing and Planning ToolPurpose 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.


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Designed for:Designed for:

Programme Managers:– Ministries of Health

– Reproductive Health

– Maternal and Child Health

– Immunization

•Policy Makers•Donors


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Users get a prospective 5-year cost estimate in exchange for their inputs.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:

1. Procurement2. Training3. Service Delivery4. Social Mobilisation and IEC5. Monitoring and Evaluation6. Other


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Approach to CostingApproach to Costing

Ingredients Approach

Government perspective

Financial versus Economic analysis

Multi-level: national, regional, district, community

Incremental cost to existing reproductive health services


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Costs represent the value of resources used for cervical cancer prevention and control

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 systemhttp://whqlibdoc.who.int/hq/2002/WHO_V&B_02.11.pdf


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Three types of CostsThree 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


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Pillars of Tanzania’s CxCa strategic planPillars 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


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Objectives and assumptions of planned HPV vaccination for Tanzania

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


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

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

Output20112012201320142015TotalTarget population80,290349,349646,936672,833694,6662,444,074

Doses useda181,878791,3621,471,3081,524,1351,573,5915,542,274

Fully immunized girls52,209227,164422,345437,510451,7061,590,934

Health workers trained

1,4723,5965,0700010,138

Health facilities mobilized

7361,7982,535005,069

School vaccination sites added

2,0986,3337,7270016,158

Schools sensitized2,0986,3337,7270016,158


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2011 2012 2013 2014 2015

02

46

81

01

2

School-based delivery

Fin

an

cia

l co

st (

US

$m

)

Waste managementVaccineTrainingSocial mobilisation/IECService deliverySupervisionMonitoring/evaluation

Note: Assuming vaccine purchase price of $5/dose; does not include costs of reaching girls that are not in school.

2011 2012 2013 2014 2015

02

46

81

0

Facility-based delivery

Fin

an

cia

l co

st (

US

$m

)

Waste managementVaccineTrainingSocial mobilisation/IECService deliverySupervisionMonitoring/evaluation

School vs health facility basedSchool vs health facility based


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

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

Financial CostEconomic Cost

Total cost per dose$5.68$10.62

Delivery cost per dose (without vaccine)

$1.66$3.56

Total cost per FIG$19.79$37.01

Delivery cost per FIG (without vaccine)

$5.77$12.40


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HPV introduction in Rwanda in 2011HPV introduction in Rwanda in 2011

HPV donation Merck

3 national campaigns

School-based (P6 girls) and facility based (12yrs girls)

Assumptions


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Annual costs Rwanda – preliminary resultsAnnual costs Rwanda – preliminary results


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

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

Financial CostEconomic Cost

Total cost per dose$3.82$11.59

Delivery cost per dose (without vaccine)

$3.26$4.60

Total cost per FIG$11.69$35.49

Delivery cost per FIG (without vaccine)

$9.97$14.09


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Lessons learnedLessons learned


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HPV vaccine price vs delivery costsHPV 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 $3-5 per 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)


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Non-Vaccine (Delivery) Cost per Infant Varies by Region (%)

Non-Vaccine (Delivery) Cost per Infant Varies by Region (%)

Source: Brenzel, L. et al (2012)


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HICsMICsLICs

Vaccine costs

Delivery costs

Global trends on relative vaccine vs delivery costs

Global trends on relative vaccine vs delivery costs


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C4P and other WHO economic tools and initatives

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/


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•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).

WHO C4P applications up to nowWHO C4P applications up to now


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Vaccination Module in BMC MedicineVaccination Module in BMC Medicine


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ConclusionConclusion

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


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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

Overall conclusionsOverall conclusions


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AcknowledgmentsAcknowledgments

MoHSW Tanzania– Dafrossa Lyimo – Safina Yuma– Mariam Ally

MOH Rwanda– Fidele Ngabo– 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


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THANK YOUTHANK YOU

More information:

Raymond Hutubessy, WHO IVB Geneva, Switzerland [email protected]

Tool including user guide soon available on WHO NUVI HPV website http://www.who.int/nuvi/hpv/resources/en/index.html

annual regional conference on immunization (arci) 10-12 december 2012, dar es salaam, tanzania 1 |1...

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