Costing, Advocacy Strategies and Policy Transformation

Jorge Romero LeonAccountability and Monitoring in Health

InitiativeCosting for Change Seminar

Poiana - Brasov, RomaniaOctober 27th, 2011

Contents

Transforming the model of careElements of the transformationWhat is effective advocacy?Where does costing fit in?Costing and budgetingWhat is costing useful for?Costing definitions (minimal)Perspective of costingInformation sourcesNot rocket science, but…

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

Elements of the transformation

Multiple transformations

Of the legislationOf the institutional support for palliative careOf the model of careOf the budgetary allocations for supporting humane and up to standard policy alternativesOf the quality, reach and inclusion of services to the broadest possible number of affected persons

Elements of the transformation

The transformation takes many yearsIt requires standards, justification, evidence of feasible policy alternatives and leadership to engage different levels of stakeholders and decision makers.It requires increasingly effective advocacy and broad network support.

The Public Health Program of the Open Society Foundations has a diverse strategy that considers a wealth of elements to promote transformation from below, from above, and through alliances.

What is effective advocacy?

It identifies and addresses gaps.It identifies policy programs and activities that could address those gaps.It complements international standards and advocacy strategies with context specific activities.It engages stakeholders at every stage to inform strategy, to develop methodological choices and forge alliances to ‘shake’ things up, to ‘move’ towards the adoption of alternatives and ‘drive’ legal and institutional changes.

What is effective advocacy?

It develops Knowledge

Existing gapsModels of care and international standardsRequirements for implementation under local constraints and in the local system

Evidence

Of existing systemic constraintsOf viable alternativesFeasibility of policy choices and institutional support at different stages

What is effective advocacy?

Justification

On the basis of human cost and lagging conditions for developmentOn the basis of Human Rights obligationsOn the basis of the legal and financial feasibility of transformation (identifies alternatives within reach)On the basis of analysis warranting cost-effectiveness of up to standard policies

What is effective advocacy?

Finally, effective advocacy seeks to impact decision-makers to persuade, compel or coerce.

It maps interests, power, allies, plausible support and instances of opposition.

It develops proactive, not reactive strategies.

It develops leverage.

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

International standards and support

Policy alternatives (drug policy, models of care, public financing of palliative care)

Drug availability

Education, mentoring, professional training, popular education and communication / dissemination strategies

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

International standards and support

Policy alternatives (drug policy, models of care, public financing of palliative care)

Drug availability

Education, mentoring, professional training, popular education and communication / dissemination strategies

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

International standards and support

Policy alternatives (drug policy, models of care, public financing of palliative care)

Drug availability

Education, mentoring, professional training, popular education and communication / dissemination strategies

Transformation of the model of care

Status quo

Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more

effective, identifies GAPS

Education, discussion of alternative models, changes in legislation to introduce access to essential medicines

Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies

Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities

Transformation and institutional adoption of new model of care

Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training

Monitoring of allocation for advanced implementation, trend analysis and program auditing

International standards and support

Policy alternatives (drug policy, models of care, public financing of palliative care)

Drug availability

Education, mentoring, professional training, popular education and communication / dissemination strategies

Costing and Budgeting

Costing - determining the expenditure required to purchase the resources needed to achieve an activity or strategy.

Budgeting - the allocation of resources to match requirements.

Once the cost of an activity is determined, the total number of desired activities will then determine the desired funding. The number of activities will be adjusted to fit the amount of funds allocated, which will become the budget.

Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

What is costing useful for?

Identifying a human rights gap in policy, e.g. lack of access, inadequacy of care, failure to meet essential standard or minimum core obligations

Assessing efficiency in two “equivalent” programs -which one yields the greatest benefit with a given amount of resources?

Identifying important cost issues for potential savings

Strategic planning and budgeting for programs

Together, costing and budgeting helps the planning process by ensuring that the goals are financially affordable.

Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

Costing definitions

In costing we identify and measure all the inputs and all the outputs.

Costs are always related to the outcomes they produce. Outcomes can also be called benefits or output. There are intermediate and final outcomes.

Some examples:HIV treatment programmes: cost per life year gainedHIV prevention programmes: cost per HIV case preventedImmunisations: cost per Fully Immunised Child (FIC)Immunisations: cost per measles case prevented/death prevented Palliative care: Cost per patient per day in inpatient unitsPalliative care: Cost per outpatient visit

At a very basic level, we often relate costs to certain activities, such as the cost of an inpatient day or the cost per outpatient visit

Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

Perspective of costing

From whose point of view is the costing being undertaken?Societal Perspective (the patient and the health system

and any other relevant individuals); also known as societal costs

Health-system Perspective (the health system only); also known as provider costs or health system costs

Patient Perspective (the patient only or the patient and her caregiver); also known as patient or consumer costs

The perspective will determine which costs are to be included and will affect the methodology

Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

Information sources

Literature review of published reportsExpert opinion (Delphi panel)Data basesProspective collection of the dataMedical recordsInformation of prices from the marketUnit costs of as many ingredients as possibleProgramme budgets and expenditure recordsClinical trials which provide outcomes

Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

Costing is not rocket science

While we will see very sofisticated costing exercises, even the most basic exercises have succeded:

Cost of HIV treatment

Cost of emergency maternal care

Cost of immunization in marginalized communities

The onus of responsibility for addressing a human right violation or policy gap lies on the State. Basic costing can be enough to identify the gap, propose a feasible alternative and ‘get the ball rolling’.

Costing is not rocket science

Every costing exercise is context depending, despite flexible methodologies available, due to information constraints, systemic characteristics of care and context specific environmental factors that will affect the costs for provision of services.

Every costing exercise will be difficult. While it will never be ‘bullet proof’, it must be sound, warranted, fully justified and externally validated to have traction.