tab 1 draft 6
TRANSCRIPT
PLEASE NOTE – ALL PREVIOUS SHADING HAS BEEN REMOVED. CURRENT SHADING IF FOR CHANGES FROM 1 JUNE ONWARDS
TAB ONE Introduction
(Costing, budgeting, resource forecasting, planning and reporting – what is it and why bother?)
Chapter one: Financial planning
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What is financial planning?
Financial planning is a process that allows you to manage your program finances. As program objectives cannot be reached without adequate, timely and reliable finances, financial planning is crucial to the success of your immunisation program.
Financial planning helps you to analyse, manage and mobilise your programs finances because it:
Identifies the costs and resources requirements of your program Identifies the gap between your resource requirements and the amount of funds you
expect to receive for the program Identifies risks to future funding of the program Highlights program inefficiencies Assists in the development of strategies to overcome the funding gap, reduce funding
risks and address program inefficiencies.
In short, is assists you to strategically plan and efficiently use your finances. Financial planning is therefore an important aspect of program planning and management [page 5] and long-term financial sustainability [page 33] .
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[page 2]
Financial planning is a process
Financial planning is similar to any planning process. It:
fits into an overall planning framework [page 3] ; and is governed by a set of principles [page 4]
The document that results from the planning process is called a Financial Plan. To produce a Financial Plan you will need to access a range of information and data [page 11] about your health system, health policy environment, previous program expenditure, and government and donor contributions. You will also need to be to be familiar with some economic and financial concepts [page 15] and terms [page 31] .
Getting started [page 9]
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[page 3]
A ‘financial planning’ framework
Financial planning is always ongoing and, like any planning exercise and strong management, involves a cycle of key stages. These are:
Establish your current financial situation [TAB 3] Project or Forecast your future needs and resources [TAB 4] Analyse the results of the projections [TAB 4] Assess the policy and program context; identify opportunities and challenges to
financial sustainability [TAB 5] Develop and prioritise strategies and actions for achieving your financial objectives
[TAB 5] Implement strategies [TAB 5] Monitor and report progress
By continuing the cycle of assessing, forecasting, prioritizing, implementing and reporting, financial planning becomes an important tool for program planning and management [page 5].
More information? [Link to expanded version]
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[page 4]
Financial Planning principles
Good planning requires good information about a program’s financial status and performance. A financial plan needs to be well presented so all stakeholders can understand the process and the results. Therefore, some key principles of financial planning are: Know your own program – what it costs, what it needs and why Involve relevant stakeholders in the planning process Keep detailed, transparent and accessible financial records Use quality data – is it consistent with other documents? does it make ‘sense’? Base your financial projections on a Multi Year Plan reflecting your overall
programmatic objectives Provide detailed information of how you calculated your costs and projections Interpret results for stakeholders ANALYSE ANALYSE ANALYSE everything! Set and explain priority areas for funding Use the budget as a management tool - compare actual expenditure against the
budget and analyse any discrepancies
And most importantly - Be realistic!
If these principles are adhered to, the financial planning process will be credible, reliable and therefore useful. Your financial plan will be a practical instrument for dialogue, planning and action among key players.
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[page 5]
How is financial planning linked to program planning?
‘Immunisation programs can improve the health of children only when there is adequate and reliable funding’ (1)
Along with political, technical, administrative and logistical considerations, financial analysis and planning is an important and (powerful) tool for program decision making.
The immunisation program will reach its objectives only if resources can be counted on to support these efforts. Yet, program objectives must take into account financial realities. For example, if a major donor terminates or greatly reduces support and no alternative arrangement can be made, there may be no choice but to slow down planned expansion. Therefore, setting program objectives and determining the right financing strategy are both part of the same process of program planning.
Financial planning actions are most likely to be implemented if they are an integral part of managing the immunisation program. Therefore the key strategies and actions in a Financial Plan must also be included as part of the Multi Year Plan.
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Why is financial planning important?
Precisely because it is a key factor in program planning.
Program objectives and financial planning are interdependent – they are a ‘two way street’ (1)
EXERCISE ONE [Link Box 1] QUIZ
Funding availability and strategies are based on program objectives
1. Before seeking funding, you must know what your objectives are. You can’t go to your government or a donor to ask for funds without saying what they are for.
Program objectives are constrained by financial realities
Before you finalise your Multi Year Plan, you must know what resources are available in order to set realistic program objectives. You would not have a program objective of introducing a new vaccine if there is no hope of funding this introduction.
Good financial planning helps to balance program objectives and priorities with financial realities. It plays a key role in securing adequate, timely, and reliable funding so that it becomes possible to achieve your program objectives. It also shows WHAT program objectives are realistic and achievable.
Understanding and managing your finances is a fundamental component of your overall program management.
Not convinced? Financial planning has a number of other advantages [page 14].
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What are the challenges?
Financial planning will take your time and commitment if it is to be useful. Program managers who have undertaken a financial planning exercise note that some of the main challenges include:
Lack of time Lack of experience Problems with data collection
Identifying sources of data, especially if the data is in another Ministry or agency
Generating accurate costs and expenditures at district level
Predicting future costs
Collecting future commitments from government and donors
Discrepancies with data Analysis can be more complex and difficult than expected
These should not put you ‘off’. If you are aware of these constraints, then you can plan to overcome them. You may want to draw up a timetable [Link to suggested timetable, from FSP docs] to guide the process. It is strongly encouraged that you also include people from departments of planning and finance in your financial planning team from the beginning.
The first time is always the hardest. The same program managers also said they found the financial planning process extremely useful.
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Financial planning is not ‘rocket science’
It is important to remember that financial planning is a process that, with some background information and training, everyone can understand. It does not have to be complicated or undertaken by a specialist (such as a health economist). In fact, as its plays an important part in the overall planning and management of your immunisation program, it should remain clear and accessible to all members of your team, whether they are management or technical people.
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OK, how do I get started?
Step one – raising the issueThe first step is to begin raising the issue of financial planning with your colleagues and program stakeholders, if they aren’t already thinking about this. Familiarise yourself with what financial planning is and what the advantages of a writing a financial plan are. You will need to argue the importance undertaking a planning process if people are to be involved and committed to the idea.
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Step two – guidance questions
You need to start considering the following key questions: How much does it cost to achieve your program objectives? How much funding is available? How do the funds flow from the source to the eventual use? How are do you allocate funds within the program? Is there a prioritisation process?
These will guide your thinking and direct you to the information you need to collect.
You also need to think about your program objectives and which components will have the most impact on your finances. For example:
Certain components, such as vaccines (which account for 25-55% of program costs) are extremely important for financial planning.
What changes are planned? For example improvements such as: expanding coverage, cold chain replacement, purchase of vehicles, introduction of safe injection policy and surveillance will all demand significant extra resources
Case Study [Link] – Example of cost implications for expanding coverage
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[page 11]
Step three – identifying information sources
You will need information on:
Program objectives Program finances: past expenditure, future costs, past and future government and
donor contributions The health sector: the current system, policies, financial management processes and
any changes that are taking place – or are planned to take place National macro economic context and policies
Collecting this information may prove frustrating and time consuming. You will need to ask the right people and search in the right places.
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[page 12]
Where is the information?
Data collection is totally dependent upon people, people, people. You won’t get anywhere unless you TALK to people. People will direct you to the right places, the right documents and other people. It might take a while, but you will get there!
Which people? Which documents? (some examples)
Ministry of Health
1. EPI Team and Procurement,
Logistics, Surveillance, IEC units
2. Department of Finance, Planning
1. Program Documents
Multi year Plan, annual reports
Reviews or assessments
Budgets and expenditure reports
2. Health sector documents
Five Year Plan and Annual Plan of Action
Annual Ministry of Health budget and expenditure report, district
budgets and expenditure reports in decentralized systems
National financial management reports/procedures, budgets and
expenditure reports
Health reform and/or decentralization reports/plans eg Sector wide
Approach reports/plans
Ministry of Finance or Planning National planning documents: e.g. Medium Term Expenditure Framework
(MTEF), Poverty Reduction Strategy Paper (PRSP)
Partner Organisations
WHO, UNICEF, The World Bank,
Bilateral donors (these may all be
together in the ICC)
Immunization funding, activity or expenditure reports
Planning documents
Tip! Be systematic about data collection. Make a list of all the documents you need and the people you should see. Make a plan. The process will be iterative – as you analyse the information you collect, you will find there are gaps, and you will need to go back to fill them.
Remember! Always maintain high standards – your financial strategies will only be as good as the data that you use to develop them. Ensure information is up to date and of good quality.
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Step four – forming a team
Putting together a good team is very important. You need the: Right people
Right skills Right amount of time
You also need a focused and manageable group of people – so it’s good to start with a core group of 4-6 people. You also need to consider who will lead and who will coordinate the team. An example of how you might make up a team is:
Ministry of Health, Budget or Finance Department - LEAD EPI manager - COORDINATE Ministry of Health, Policy and Planning Department Ministry of Finance, Health representative Key representative from a partner organisation (if your country has a donor
coordination mechanism, such as an Interagency Coordinating Committee, the representative ideally be a member of this group)
Remember! Always make sure roles and responsibilities are clear and always keep your EPI team fully informed of progress.
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Chapter two: Financial planning advantages
How does financial planning strengthen my immunisation program?
Financial planning has a number of advantages, which help to strengthen your immunisation program. It:
Improves your understanding of the cost and financing challenges facing your program over the short, medium and long term.
Monitors costs and improves overall program efficiency by identifying potential cost savings
Improves program planning, by helping to set realistic program objectives Develops relevant, and realistic strategies [TAB 5] for addressing financial concerns
Helps to prevent funding shortfalls, which interrupt service delivery
Reduces ‘crisis management’ of funding problems, which is time consuming and inefficient.
Provides a strong advocacy tool [page 41] for mobilising additional resources. Contributes to the broader planning processes within the health sector [TAB 5] (for
example, what is the cost of achieving immunisation goals within the Poverty Reduction Strategy?)
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Chapter three: Economic and financial concepts
Financing and economics – what’s the difference?
The difference between finance and economics is one of money.
Financing focuses on how much money you will need for an activity or program, and where you are going to get it. It therefore involves processes such as budgeting and resource mobilization.
Economics, on the other hand, focuses on the total value of a good or service. Although often expressed in money terms, it places a value on things that are not being bought or sold. It looks at both the financial and non-financial elements of a good or service. For example, an economic evaluation of a program would take into account someone’s volunteer time, but a financing analysis would not, because there is no money involved. Because economic evaluation is based on valuing something – it takes a look at the ‘bigger picture’ and therefore is often used to prioritise activities or programs.
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Economic evaluation
The aim of economic evaluation in health care is to:
Ensure that the benefits from health care programs are greater than the costs of implementing such programs
Maximise the amount of well-being (or good health) for society for the minimum cost
The process of economic evaluation is a comparative exercise and to be meaningful it should
involve assessment of at least two alternative strategies. It can be used to compare:
Alternative objectives within a single program (should I improve coverage or introduce a new vaccine?)
Alternative strategies to achieve the same objective within a single program (should I improve coverage through outreach or campaigns?)
Alternative health programs (should I start an immunisation program or a malaria program?)
It does this by comparing the costs and consequences of each action. By doing so, an economic
evaluation can assist in decision making about the allocation of resources and priority setting.
It can also be used to improve program efficiency and equity.
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What are the key steps? (2)
All methods of economic evaluation put a value on the costs and consequences of an intervention by using the same three steps:
Identify inputs and consequences; Measure inputs and consequences using appropriate physical units (eg hours of time,
consumable items used); and Place a value on inputs and consequences (eg, each hour of someone’s time is worth
$5).
Problems are encountered in all three phases. Some items are difficult to identify as some health care interventions have hidden or unknown costs and consequences. Not all costs and consequences can be measured in appropriate physical units as some interventions have intangible consequences such the reduction of pain or the increase of the quality of one's social performance. Valuing inputs and consequences is the most difficult aspect of conducting an economic evaluation as in reality the only readily available measures of value (prices) exists only where there are true markets, and these cover only a minority of health inputs and consequences.
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The difference between economic and financial costs (3)
Costs are defined as the value of resources used to produce a good or a service. The value is usually expressed in monetary terms. However there are two main ways these resources can be measured:
Financial costs, which are the actual amount of money spent on a good or a service. For example the financial cost of human resources in an immunisation program would be the amount of salaries paid to health workers. The financial cost is usually equal to the price of a good.
Economic costs are the value of resources (financial and non-financial) used in a program. For example, the economic cost of human resources in an immunisation program would be the amount of salaries paid (the financial cost) plus the value of any volunteer work undertaken (such as in a campaign) plus the cost of the parents time to bring their children to the clinic (this time could otherwise have been used to earn a salary, or produce food).
Financial costs are important when forecasting a budget and determining what funding (money) you will need. Financial costs are used in a Financial Plan. Economic costs are important when setting priorities and determining the efficiency or cost-effectiveness of a service.
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Costing, budgeting and expenditure
These are three terms that are often confused in financial planning, although they have quite different meanings – and uses.
Costing (4): The costing of an immunisation program is the estimate of the actual value of resources (goods or services) used. For example, a costing analysis would include the value of the ‘overhead and maintenance costs’ of the building in which vaccinations take place, even though the program may never actually pay money for these.
Program costing [TAB 3] can provide useful information for cost effectiveness and benefit
analyses. It can be used to: Assess the most efficient strategies for improving coverage, or introducing a new vaccine
Evaluate different options for program improvement
Identify potential cost savings within the program (to improve efficiency)
It is also provides the basis upon which you develop a program budget.
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Budgeting (5): A budget is a detailed plan for the future showing what financial resources
will be needed, how these resources will be obtained and how they will be used during a
specific time period. It is calculated and shown in money terms: it shows the amount of money
that will be needed so that program objectives can be met. Budgeting is the process of
drawing up this plan.
For a budget to be useful you must report against it at the end of the time period. What
money did you actually receive and how did you spend it? What were the major discrepancies?
How will this change the budget next time?
A budget [TAB 4] provides useful information on: Financial requirements for the future (usually from 1-5 years)
Funding sources and levels for the future
The size of the gap between requirements and expected funding
What does a budget look like? [Link to FSP-Guidelines Annex II_Tables for section 4. Cost projections sheet].PAULINE HAVE YOU GOT THIS?
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Expenditure (4): is the amount of money actually spent in a particular timeframe. For example, the amount spent on vaccines in one year, or the amount spent on per diems is ‘expenditure’.
3.
‘Expenditure’ is different to ‘cost’. For example, assume $1000 was spent on vaccines in a year, but this was actually enough to cover vaccines needs for two years. So, in the first year $500 worth of the vaccines was actually used to vaccinate children (the remainder stayed in the warehouse). In this case, the ‘expenditure’ would be $1000, because that is what money was paid. However, the ‘cost’ (or the value of vaccines actually used) was $500.
Expenditure (amount actually spent) may be different from the budget (plan of resources required). This can happen if there was, for example:
Insufficient funding (expenditure will be less than the budget) A lack of supplies (expenditure will be less than the budget) Unforseen purchases were made, because of an epidemic (expenditure will be more
than the budget).
Despite this, expenditure is often used as the basis for forecasting the next year’s budget.
An analysis of expenditure provides useful information on: Fluctuations in spending (and possible fluctuations in donor contributions)
Regularity of funding flows (highlighting where ‘funding bottlenecks’ might occur)
Actual funds likely to be available the following year
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Which comes first?
Costing, budgeting and expenditure reporting are not independent of each other. They are part of a cycle where information from one process can be used to guide another. For example, a costing study can provide information for planning your resource needs (budgeting), expenditure reporting when compared against your budget, will identify areas where budgeting can be improved.
Costing and Financing Cycles
EXERCISE THREE [Link] - test your understanding of the differences between costing, budgeting and expenditure.
A. Knowing the definitions
Costing: A costing is the value of all resources (both financial and non-financial) used in a program.
Budget: A budget is a plan for the future showing what money will be spent during a specific time period.
Expenditure: Program expenditure is the amount of money actually spent in a particular timeframe.
B. Applying your knowledge
Background:
Planning in 2001
In 2001, your immunization program planned to purchase $300,000 of vaccines, $100,000 of syringes and four vehicles (which were priced at $15,000 each) for the routine program. The funds were to come from the government in 2002.
Costing
(valuing)
Budgeting
(planning)
Expenditure
(reporting)
Usually a one-year
cycle (financial
Usually a 5-10 year cycle
In addition, you estimated the National Immunization Day for polio would cost $100,000 in vaccines, and operational costs, such as per diem and fuel. A donor agreed to give you $80,000 in cash for the campaign, on the condition that you organised local communities and businesses to provide support to the campaign. After some advocacy work, a national advertising agency agreed to promote the campaign free of charge. The manager of the business told you this contribution is worth $30,000.
Fifteen districts agreed to provide 10 volunteer vaccinators each. Vaccinators would be required to work for 1 day. Vaccinators employed by the Department of Health are normally paid $10 per day.
You need to run a workshop to train vaccinators and estimate it will cost $300.
Implementation in 2002
In 2002, you received more government funds than you expected. You therefore purchased $400,000 of vaccines, although you only ended up using $250,000 during the year.
After checking the syringe stock levels, you decided that you only needed to buy $80,000 of stock. All of these were used during the year. You only purchased two vehicles, as the supplier did not have four in stock. These vehicles have a ‘useful life’ [page 36] of 5 years and therefore the ‘annual average cost’ [page 36] is $3,000.
The polio campaign went according to plan and all funds were fully used.
Question
In the above story, what amounts would be used in a:
Program costing Program budget Program expenditure report
Answer
Classification Items Explanation
Costing
(annual)
1. Vaccines $250,000
2. Syringes $80,000
3. Vehicles $30,000
4. National Immunization Day $111,800
Vaccines and operational costs
$80,000
National advertising agency
contribution, worth $30,000
Volunteer vaccinators, worth
$1,500
Workshop $300
1. Although $300,000 of vaccines was budgeted, and
$400,000 was purchased, $250,000 was the value
actually used during the year.
2. $80,000 is the value of syringes actually used
during the year. ($100,000 of syringes was
budgeted, and $80,000 of syringes was purchased.)
3. The average annual cost of vehicles is $3,000. The
budgeted amount for vehicles was $60,000 and
expenditure was $30,000.
4. The full value of the National Immunization Day
includes both financial and non-financial costs. This
means the monetary equivalent of donations or
volunteer time must be shown in a costing. The
total cost value equals $111,800. Both the
budgeted and expenditure amount is $80,300
Budget 1. Vaccines $300,000
2. Syringes $100,000
3. Vehicles, four @ $15,000 = $60,000
4. National Immunization Day for polio
$80,300
Vaccines and operational costs $80,000
Workshop $300
1. $300,000 of vaccines was budgeted. $400,000 was
purchased, while $250,000 was the value actually
used during the year.
2. $100,000 of syringes was budgeted for.
Expenditure was $80,000 of syringes as was the
value (or cost) of syringes actually used during the
year.
3. The budgeted amount for vehicles was $60,000 and
expenditure was $30,000. The average annual cost
of vehicles is $3,000.
4. Both the budgeted and expenditure amount is
$80,300. The total cost of the National Immunization
Day includes both financial and non-financial costs.
This means the monetary equivalent of donations or
volunteer time must be shown. This equals
$111,800.
Expenditure
report
1. Vaccines $400,000
2. Syringes $80,000
3. Vehicles two @ $15,000 = $30,000
4. National Immunization Day for polio
$80,300
Vaccines and operational costs
$80,000
Workshop $300
1. $400,000 was purchased and must be shown as
expenditure. $300,000 of vaccines was budgeted
and $250,000 was the value actually used during
the year.
2. Although $100,000 of syringes was budgeted,
expenditure (or the amount of money actually
spent) was $80,000. The value (or cost) of syringes
actually used during the year was also $80,000.
3. Expenditure on vehicles was $30,000, even though
the budgeted amount was $60,000 and the average
annual cost of vehicles is $3,000.
4. Both the budgeted and expenditure amount is
$80,300. The total cost of the National Immunization
Day includes both financial and non-financial costs.
This means the monetary equivalent of donations or
volunteer time must be shown. This equals
$111,800.
Pauline – suggest that you have a box they can enter the amounts in. So in the second column, there are already heading for Vaccines, syringes, etc…. the correct answer prompts a tick and ‘correct!’ and the explanation….and incorrect one prompts an ‘ try again’. Also, regarding the explanation – I give the answers away in the first part of the exercise. Not sure that it really matters if the explanation doesn’t stay on the screen…what do you think?
More information? [Link to Bibliography]
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Cost effectiveness and cost benefit analysis
Cost effectiveness and cost benefit analyses are the most common form of analyses used in immunisation programs, BUT are used for different purposes. These analyses are time consuming and cost money so before undertaking any study, you should be clear about what question you are asking – and whether a costing study is the right tool to use.
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Cost effectiveness analysis
A cost effectiveness analysis takes the objective as given (such as improved coverage) and seeks to identify the least expensive way of achieving this objective (through outreach teams, or campaigns?). It compares different ways of achieving the same objective. Cost effectiveness is measured using one dimension – such as number of lives saved, or number of children vaccinated.
One of the best ways to use a cost-effectiveness study is linked to the concept of marginal analysis [page 36]. This means that you examine the cost-effectiveness of additional (or marginal) changes you would make if you had more or less resources. For example, if you were offered more money for your program, you would identify what extra things you could do with it. You would then calculate the cost of each of addition and what program improvement each change would have. You then compare the results to make a decision.
Cost effectiveness studies cannot answer whether an overall program itself is worth implementing, or continuing.
A cost effectiveness analysis can provide answers to the following questions (6):
Which strategy for a particular objective provides the best ‘value for money’?
Which type or combination of services provides the best value from the budget available?
How can additional funds best improve a program’s performance?
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Cost-benefit analysis
A cost-benefit analysis seeks to value and compare all costs and benefits (both private and social costs [page 36]) that result from alternative interventions (5). It is used to compare two different health programs – such as malaria control and immunisation to see which provides the most benefits. Therefore, it is used for comparisons to see which programs offer the most efficient use of resources.
Cost-benefit analyses are complex and costly and it is unusual for them to be undertaken on an immunisation program.
EXERCISE FOUR [Link Box 2] - test your understanding of the uses of cost effectiveness analysis and cost-benefit analysis.
This will be a multiple choice quiz where the user will assign each situation with the appropriate analysis - cost-benefit or cost-effectiveness.
1. Q: If you received an additional $500,000 for your program, what type of study would help to show you the best way to use that money?
A: Cost effectiveness analysis: A cost effectiveness analysis can provide guidance on how extra funds are best used to improve your program’s performance. You would a) define your objective - such as number of children vaccinated and b) compare the outcome for 2 or more different strategies that should achieve this objective.
2. Q: If the Ministry of Health needed to cut two of its ten vertical health programs, and wanted an economic evaluation to help make the decision, which analysis would it use?
A: Cost benefit analysis: A cost benefit analysis can be used to compare two different health programs – such as malaria control and immunisation to see which provides the most benefits – for the least cost.
3. Q: You have a budget that will not change, but you want to improve coverage. Which study will help you do this?
A: Cost effectiveness analysis: A cost effectiveness analysis can provide guidance on which strategy is the most efficient way of achieving your objective – within a given budget. For example, you may be using a mobile team to provide immunization to remote areas and this costs $100,000 per year. However, you think it may be more useful to spend these funds on a social mobilisation and IEC campaign to encourage parents to bring their children into town on market day to be immunized at the health center. A cost effectiveness analysis could help you decide whether it is best to stay with the mobile team or use that money for the campaign.
4. Q: If you were asked to cut $1,000,000 from your budget, where would you start?
A: Cost effectiveness analysis: In the same way that a cost effectiveness analysis can provide guidance on how to best spend additional funds – it is also useful for determining where to cut costs. i.e. of the activities that you might have to suspend which one is the least cost effective?
5. Q: You have a set of health programs – all of which would benefit the community – but you don’t have enough money to implement them all. What study would help you prioritise your spending?
A: Cost benefit analysis: When there are competing health needs and limited funds, the most appropriate study is a cost benefit analysis. This analysis can show which program uses resources most efficiently. However, it won’t show which programs are most equitable.
Remember! An economic analysis is a tool to assist decision making. There are a number of other factors that also need to be considered. For example:
Will the public support the program? Or the new intervention (eg introduction of new vaccine?)
Does a program or new activity have political support? What is the sustainability of program funding? Is there sufficient human resource capacity to manage the new program or
intervention? What are the consequences of the disease the intervention is aimed at? Does it create
fear in the public? Would they prefer to use funds to prevent even one incidence of a severe disease rather than reduce prevalence of a less severe disease?
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How can a cost effectiveness analysis strengthen my program?
A cost effectiveness analysis can:
Help program decision-making by providing an economic comparison of alternative activities;
Identify inefficiencies in your program; Provide information to calculate the cost per fully immunised child; and Identify resources needed for program objectives.
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What are the constraints of costing analyses? (8):
Whilst costing studies are useful for planning and management, they do have limitations. These include:
Decisions are not based solely on economics – political, technical, administrative and logistical considerations often have more influence on the final choice of strategies
Cost effectiveness studies mostly look at the cost of providing EPI services, and don’t include the cost to the families of seeking immunisation services (travel, waiting time etc)
Interventions can often contribute to other positive health outcomes. For example, measles immunisation helps to reduce ARI and diarrheal disease. A costing analysis should take into account these benefits – but it is impossible to account for all the health outcomes of a strategy
It is difficult to quantify intangible benefits (what is a good measurement of ‘quality of life’?).
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Efficiency, effectiveness and equity
Efficiency
A program is efficient if it achieves its objectives for the least cost.
There are two dimensions of efficiency. The first type is called allocative efficiency. This looks at how to maximise overall health benefits with available resources within the health sector. For example, which health program, malaria control or immunisation, is the cheapest way to save lives? And how much should be given to that program? Because an immunisation program is extremely cost effective, funding an immunisation program reflects allocative efficiency.
The second is known as technical efficiency, which looks at how to achieve a particular program objective at least cost, in other words, most effectively. For example, a program manager should want to know that most technically efficient way to improve coverage (that is, what is the cheapest way to increase coverage from 80-90%?).
As an immunisation program manager, you need to look at the technical efficiency of your program. For example, some factors that influence efficiency include: quality vaccine procurement; low vaccine wastage; good stock management; or preventive maintenance on cold chain and vehicles.
EXERCISE FIVE [Link] – What key immunisation program components are most often inefficient? Why?
Pauline – you requested a full list of program management areas and then those that are ‘traditionally’ inefficient (as per my original statement). Unfortunately when I thought it through, there is very little evidence about what areas are more inefficient than others or what is ‘traditionally’ inefficient – they all are to some degree or other (other than campaigns). However, there are areas that will have a greater impact on overall program efficiency: and these areas tend to be focused on in program assessments. These are the ones I’ve highlighted. Not sure whether this will work well – await your feedback.
PART A: Program components
Program planning and management, especially at sub national level
Vaccine management
Cold chain management
Vehicle management
Service delivery
Resource mobilisation
Logistic systems
Financial management
Surveillance systems
Training
Supplemental immunization activities (campaigns)
Safe injection management
Social mobilisation and IEC development and distribution
PART B: Areas that are ‘traditionally’ inefficient and have can have a significant impact on overall program efficiency
Program management areas What might cause inefficiencies?
Planning and management, especially at sub
national level
Lack of micro-planning and/or communication
between national and sub-national levels
Limited management skills or understanding,
especially in financial planning
Limited financial and accountability systems.
Limited resources
Poor co-ordination between immunization
stakeholders
Vaccine management Poor stock management including:
- Forecasting methodology and skills
- Inappropriate storage and distribution practices;
Unnecessarily high wastage, often caused by:
Lack of systematic assessment and monitoring
of sources of waste;
Lack of policies (such as multi dose vial policy)
and equipment (such as vaccine vial monitors)
that would reduce wastage;
Poor cold chain management;
Inefficient delivery services; and
Inappropriate immunization schedule
Year to year procurement contracts (instead of multi
year contracts)
Cold chain management Lack of inventory and monitoring systems
Limited understanding, especially at sub-national
level about cold chain management
Poor preventative maintenance regimes
Inadequate repairs and maintenance capability or
capacity (both human resources and budget)
Vehicle management Lack of inventory and monitoring systems
Inadequate repairs and maintenance capability or
capacity (both human resources and budget)
Poor preventative maintenance
Limited or poor driver skills
Lack of co-ordination with other programs that use
vehicles
Logistic systems Lack of centralised and rationalised equipment
procurement system
Inefficient transportation services
Service delivery Inefficient outreach sessions caused by:
Poor attendance of children
Limited social mobilisation
Lack of budget for operational expenses
Unmotivated health workers
Poor supervision and training
Poor planning, especially at the sub-national level
(micro planning)
Limited public demand
Financial management Lack of transparency of funding flows
Corruption
Poor co-ordination between immunization
stakeholders
Extreme bureaucracy
Resource mobilisation Lack of multi year financial planning and planning
for sustainability
Changing government preferences and limited
government budgets
Short funding periods (and preferences) of donors
Constraints on donor funding (funding is often only
provided for specific activities or equipment)
Limited advocacy skills
What are some strategies to improve efficiency? [LINK to Dimensions Table – TAB 5]
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Effectiveness
Effectiveness is the degree to which an activity or a program achieves it objectives. An effective program will be successful in achieving its goal. A highly effective vaccine, will for example, confer immunity on over 90% of those vaccinated. A highly effective polio program will eliminate polio from the country. An ineffective program will not decrease the prevalence of polio.
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Equity
Basically, equity means the fair distribution of health care resources and overall health benefits across a population. It does not necessarily mean equal distribution. If some parts of the population have greater health needs, they should be allocated greater health resources.
For an immunisation program, equity means that all children regardless of socio-economic status should have access to, use and benefit from immunisation services. For example, it is important that children in remote areas or urban slums get are immunised, despite additional costs that might be incurred to reach them.
EXERCISE SIX [Link] – Are equity and efficiency compatible? Check the box + linked to CASE STUDY
YES Correct! Equity and efficiency can be compatible - but not always. See the case study, [LINK] which shows how there is often a trade-off between the two objectives. The trick is to make equity as efficient as possible!
NO Correct! Equity and efficiency are not always compatible. Sometimes the most efficient means of implementing a program means that equity is compromised. See the case study, [LINK] which shows that you can, nonetheless, find a balance between the two. The trick is to make equity as efficient as possible!
Sometimes Correct! Equity and efficiency can be compatible. It is good to remember that equity can be efficient, and promoting efficiency does not always compromise equity. See the case study, [LINK] which illustrates this point.
Don’t know Balancing equity and efficiency is difficult – and there is no clear answer. See the case study, [LINK] which illustrates this point.
CASE STUDY
Part A: Background
You are the EPI Manager of your country’s immunization program. A donor has approached you with the offer to contribute $100,000 to your program. The donor has recently seen a review of the program and concluded that it is inefficient. They want their funds to be used to improve program efficiency and suggest that a user fee system could be established with the funds, as this will decrease costs.
DPT3 coverage in your country is 70%. However, the majority of the rural population has only 40% coverage. The highest priority in your multi-year plan is to improve coverage to these vulnerable populations. This priority reflects a commitment to improving equitable access to immunization services. You really need the money to increase coverage. But! a recent costing showed that although the national average cost per fully immunized child is $10, the cost of reaching children in rural areas would increase this to approximately $14, appearing to make the program less efficient.
You want equity and the donor wants efficiency. Can the two objectives be reconciled?
What do you think? How would you present your thoughts to the donor?
Part B: Meeting with donor
You: Good morning, thank you for coming today, and your offer to provide assistance to our program.
Donor: Good morning. My government would like to support your program, but I think we have a problem. Your priority is to improve coverage for the poorer rural population, but this will increase the cost per fully immunized child and makes the program less efficient.
My government believes that overall program efficiency is best. That is, getting the most benefits for the least cost without worrying so much about the distribution of these benefits. Therefore, we want our contribution to be used to improve program efficiency through increased urban coverage and cost reduction strategies. For example, we would be very interested in the introduction of a user fees system.
You: Certainly, it does appear we have competing objectives – equity versus efficiency. A clear example of this is that improved coverage through more outreach services will mean our vaccine wastage rate is likely to increase. We just won’t be getting as many children per session as we currently get through our fixed facilities. Equitable access will mean higher costs.
As for user fees, in line with international opinion we are opposed to user fees for immunization. This has been shown to place an unfair burden on the poor, and there is solid evidence that it discourages the poor from seeking vaccination services. As importantly, additional costs are usually incurred to manage such a system, undermining any apparent efficiency benefits. Therefore, user fees are neither equitable nor efficient!
If you would like more information on user fees, I suggest you look at the information sheet on user fees [LINK to Vaccine briefcase info sheet on user fees] provided by the Global Alliance for Vaccines and Immunization (GAVI).
Donor: Why don’t you just increase coverage in urban settings? This will increase overall coverage and keep costs down.
You: Increasing urban coverage means the benefits of immunization are not fairly distributed to poorer children in rural areas and this is inequitable. It is neither fair nor just.
It is true – equity and efficiency are not always compatible – there is often a trade-off between the two. The price of equity can be an increase in costs and/or a decrease in program efficiency– and sometimes we need to agree this is the price worth paying.
However! I do think we can come to an agreeable compromise.
Donor: Please tell me – I am all ears!
You: We agree with the need to improve efficiency – just not at the expense of equity. I believe that the solution is to use your funds to increase coverage – or to improve equity - in the most efficient way. To do this, we need to assess the cost effectiveness of alternate strategies to improve coverage. For example, we may find it is more efficient to pay a small incentive to parents to bring their children to health centers rather than using mobile teams (which was our plan). We could use your money to undertake this study.
We could also use your money to assess the causes of vaccine wastage and introduce measures to address these causes. Reducing wastage would improve efficiency. As you know our wastage rate is high – but we are not sure why. I suspect it is because of major problems in our stock management system. If thiswere the case, and we could address these problems any increase in wastage through increased coverage to rural areas would be relatively minimal to the overall savings we could make. Hopefully, this would be acceptable to your government.
Any remaining funds can be used to implement the increased coverage strategy. This will mean we can’t use all your funds to increase coverage as I had hoped but at least we could use some. Also, in the longer term, savings we make through improved program efficiency can be directed towards improving coverage. We can use efficiency to promote equity.
Donor: That’s sounds like a good balance between our two objectives. The money is yours!
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Chapter five: Basic terms
Understanding the following terms will help when discussing the financial aspects of you program. Being conversant in economic and financial language supports your advocacy efforts, especially when talking to representatives from Finance and Planning Ministries and Departments, and donor agencies. This section is divided into two: Main terms, which are the most important, and Extras, which would be useful to know, but are not critical.
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Main terms
Financial sustainability
Although self-sufficiency is the ultimate goal, in the nearer term sustainable financing is the
ability of a country to mobilise and efficiently use domestic and supplementary external
resources on a reliable basis to achieve current and future levels of immunisation
performance in terms of access, utilisation, quality, safety and equity.
The key points are: The responsibility is shared between government and development partners Financing needs to match (realistic) program objectives Financial resources must be adequate and reliable. That is, there must be enough of
them and they must reach the right levels in sufficient time to be useful It relates to mobilisation and efficient use of resources.
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Costs
There are three key sets of costs:
1. All costs can be divided into either capital or operational (9)
Capital costs are also known as non-recurrent costs. Any items that last longer than a year are classified as capital costs. For immunisation services, important capital costs are cold chain equipment and vehicles.
Operational, or recurrent costs are those that must be paid every year. They include vaccines, personal salaries, fuel, equipment maintenance and per diems. It is usually the annual operational costs that are of most interest to financial planners because they represent between 75-90% of the overall total cost of the program. As they are such a large part of the costs, considerable emphasis should be given to the accuracy in assessing these types of expenses since small inaccuracies can mean large discrepancies of the total cost.
In a Financial Plan, costs are always classified as either capital or operational.
Why is the difference important? [Link to new window]
NEW WINDOWSo two different sets of information can be shown:
The yearly cost of a program The yearly budget of a program – or how much cash is needed in a particular year
Remember – the ‘cost’ of a program (which is the economic value) is different to the ‘budget’ (which is the amount of money you need).
Program cost
To assess the yearly cost (or ‘value’) of the program, the operational costs are presented in total but the capital costs are reflected as a ‘cost per year’. To arrive at the cost per year, you divide the purchase price of the capital item, by the number of years you think the item will last (this length of time is also known as the ‘useful life’). For example, a car with a purchase price of $10,000, which will last for 5 years, has an equivalent ‘cost per year’ of $2,000 per year. This method of division is called ‘straight line depreciation’ and simply means that the total cost can be averaged over the number of years the item will be used. It shows that although the car was purchased in one year, it is being used over five years.
The table below shows how this would be presented, with the following example:
Between 2003-2007, country X spends: $1000 on vaccines
$500 on AD syringes
$600 on staff salaries
In 2003 country X also buys a vehicle worth $20,000, which is expected to last 5 years. This means that the car has a ‘straight line depreciation’ of $4,000.
Program cost
Cost 2003 2004 2005 2006 2007 TOTAL
Operational Costs
Vaccines 1,000 1,000 1,000 1,000 1,000 5,000
Syringes 500 500 500 500 500 2,500
Salaries 600 600 600 600 600 3,000
Capital Cost
Vehicle 4,000 4,000 4,000 4,000 4,000 20,000
TOTAL $6,100 $6,100 $6,100 $6,100 $6,100 $30,500
Program budget
A budget reflects financial costs, and so is more straight forward. It shows the amount of cash needed per year. Therefore, using the example above, the budget will look like this:
Cost 2003 2004 2005 2006 2007 TOTAL
Operational Costs
Vaccines 1,000 1,000 1,000 1,000 1,000 5,000
Syringes 500 500 500 500 500 2,500
Salaries 600 600 600 600 600 3,000
Capital Cost
Vehicle 20,000 20,000
TOTAL $22,100 $2,100 $2,100 $2,100 $2,100 $30,500
Summary
Both totals are the same, although the tables show different information. The first one shows the average cost per year of the program, whilst the second one shows how much money is needed per year. Both are important for financial planning.
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2. Fixed and variable costs (7)
Fixed costs are those that do not vary with fluctuations in volume, frequency, or activity. For example, administrative salaries will remain the same regardless of whether 100 or 200 children are vaccinated (unlike the cost of vaccines, which will increase).
Variable costs are those costs that vary directly or proportionally with changes in volume or activity. For example, the cost of outreach transportation or syringes increases depending on the number of children that will be vaccinated.
It is important to note that this distinction is only really valid for one year, as in the long-term all costs are variable. Also, most costs are fixed only in tiers. That is, at some point the increased number of vaccinations will demand a change in a fixed cost (at some point if the number of children continues to increase you will have to buy a new refrigerator to house all the extra vaccines). Finally, don’t confuse capital costs and fixed costs. Fixed costs can be either capital or operational.
When looking to improve the efficiency of your program through cost savings, it is best to start with variable costs as these are something you more likely to be able to influence.
Why is the difference important? [Link to new window]
NEW WINDOWThe difference between fixed and variable costs is useful when analysing the results of a costing exercise. For example, because fixed costs are incurred independent of number of children vaccinated, it allows managers to determine the minimum level of funds required to implement a service – or to expand a service. At the same time, when expanding a service, the manager can seek funds to cover variable costs based on the number of expected children to be vaccinated.
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3. Direct and indirect costs1
Direct costs are those relating to the provision of a service, such as vaccines and syringes. Indirect costs are those that support a service but are not directly involved in service provision. For example, electricity or building maintenance are indirect costs.
3. Shared and program -specific costs (4)
Shared or joint costs are those costs that are shared by more than one service. For example, the salaries of health workers who provide other health services (such as midwifery or reproductive health advice) is a shared cost. Shared costs often represent the largest part of a government’s contribution to the immunization program and are essential to the delivery of immunization services. They can however, be difficult to measure.
Program specific costs are those costs that are specific to the delivery of immunization services. They include items such as social mobilisation, in-service training, direct program management costs, vaccines and refrigerators (if used only for vaccines). They can be either capital or operational costs.
When looking to improve the efficiency of your program through cost savings, start first with program
specific costs – and how you might decrease these (without compromising service quality!). They are
often much easier to influence than shared costs.
Why is the difference important? [Link to new window]
NEW WINDOW
Including shared costs allows the full cost of the program to be known. As the government
usually pays for shared costs, it also reflects the true contribution of the Government to the
immunization program.
More information? [Link to specific bibliography]
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Extras!
Depreciation and annualization
‘Depreciation’ is the term used to show:
Average annual cost of a capital item. Although a capital item (such as a car) will be purchased in one year, it will be used for several years. The length they are used is called the ‘useful life’. To present the average cost of an immunization program, capital costs need to be shown as ‘cost per year’. To do this, the full purchase price is converted to an annual equivalent cost by dividing by the ‘useful life’. This process is called ‘annualization’ and the method of division is called ‘straight line depreciation’.
1
The value of a capital item over time, and/or with use. By calculating the depreciation of a capital item, you can also work out the value of that item during the years it is being used. For example, a country buys a vehicle that is expected to last 5 years and is worth $20,000. Using ‘straight line depreciation’, the car has an average annual cost of $4,000. Therefore, at the end of the second year, the car has a value of:
$20,000 - $4,000 (year 1 depreciation) - $4,000 (year 2 depreciation) = $12,000.
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Marginal Cost and Analysis
The marginal cost of an activity is the increase in cost that accompanies a unit increase in output. For example, the marginal cost of immunising an additional 1,000 children in an existing fixed health facility would take into account the cost of the extra vaccines, syringes and staff time required. The marginal cost is any new cost incurred as a result of vaccinating more children. This is different to calculating what the new average cost per child would be, which would include all existing costs.
Marginal costs are important when undertaking a marginal analysis. A marginal analysis looks at the costs and benefits of making changes on the ‘margins’ or edges of a program. For example, looking at the costs and benefits of adding a vaccine to an immunization program rather than assessing all of the costs and benefits of the immunization program when determining whether to add a vaccine. This is a pragmatic way of analysing where to put additional funds.
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Opportunity Cost
This is the cost of a foregone opportunity. The opportunity cost to a country of producing a unit more of a good, such as for export or to replace an import, is the value of some other good that could have been produced instead.
The concept of opportunity cost is always important to consider when making decisions about your program. You should ask: ‘if I follow this course of action – what does this mean that I now can not do?’ For example, if I spend additional funds on social mobilisation, this means that I can’t spend it on repairs and maintenance for the cold chain. Or if I spend my time developing a financial plan today that means that I can’t be at the workshop to train vaccinators. The opportunity cost of doing the plan is the training of the vaccinators. Is this a good trade-off? Is it the best trade-off?
Anything and everything you do will incur an opportunity cost - because you have lost the opportunity to take an alternative course of action. The trick is to minimise the opportunity cost – making sure your decision to do something or spend money provides the maximum benefit compared to the alternative course of action.
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Public good
A public good is one that, when provided, is used by the public as a whole, not individuals. For example, national defence is a collective public good, as it provides security for everyone, not one person in particular. Also, because one person enjoys the benefits of it, it doesn’t stop someone else from enjoying it as well.
Immunization is an important public good. Vaccination against pertussis, for example, provides a benefit to the individual who receives it, but it also provides benefits to the unimmunized population due the ‘herd immunity’ effect. This benefit to the public is also known as a ‘positive externality’ (13).
This overall benefit of immunization to the public means there is a very strong argument for the free provision of vaccination services to individuals. That is, because the benefit goes to the public, so public funds (i.e. government or donor) should pay for the service.
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Social costs
A social cost from an event, action, or policy change is one that costs society as a whole. For example, poor air pollution caused by a energy factory is a cost paid for (through ill health) by the whole community, not by the factory owners. This would be considered social cost. For immunization, the negative consequences for the national economy caused by high vaccine preventable disease prevalence (which means people can’t work either because they are sick themselves, or must look after someone who is sick or are a burden on a public health system) would be considered a social cost.
The social cost of a population that is not immunized is another strong argument for the public funds to be used to finance an immunization service. The public reaps both the benefits of an immunization program but also the costs of NOT having one.
EXERCISE 7.5: QUIZ
Definitions:
Social cost: The non-financial cost of an activity that is distributed across the community.
Public good: A benefit that the public collectively receives from a service, often provided by the government.
Opportunity cost: The cost of choosing one alternative over another.
Depreciation: The process by which the annual average cost, or the changing value (over time) of a capital item is determined.
Financial sustainability: The reliable, adequate and efficient use of domestic and external resources.
Costing: The value of all resources (both financial and non-financial) used in a program.
Budget: A plan for the future showing what money will be spent during a specific time period.
Expenditure: A report showing the amount of money actually spent in a particular timeframe.
Pauline – two questions:
1. Were you thinking definitions for operational / capital, direct / indirect etc? i.e. I’m not clear if definitions for all terms required.
2. You wanted examples to match to the definitions. This is causing me some grief! i.e. how do you write an example of financial sustainability without being obvious about what it is (especially relative to other definitions)? Unfortunately examples are not as straight forward for the more conceptual definitions as they are for the straight cost definitions (eg operational vs capital costs). Is there something else we can do for part B of this exercise? Or shall we just leave it at matching definitions? And if so, is this enough?
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Chapter six - Advocacy NAVIGATION TITLE
Chapter six – Advocacy: mobilising support and resources CONTENT TITLE
What is advocacy?
Advocacy is about generating and maintaining support for vaccination programs. It is not a financial sustainability or resource mobilization strategy. It is however a very powerful tool that can be used to implement financial sustainability strategies.
Advocacy is about presenting an argument (backed by good information) that persuades people to support what you are doing. It requires strong communication skills. It is an ongoing process (a one-off presentation is rarely enough to convince people to support you), which demands attention to relationship building.
To be a strong advocate for financial sustainability you must thoroughly understand the cost and financial needs of your program, know the people (or organisations) that you want to persuade – and most importantly know what will persuade them (and give it to them!).
Remember! Advocacy is NOT a ‘magic bullet’. It is takes time, is hard work, results in the short term are unusual and many times it doesn’t work at all.
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How can financial planning be used in advocacy?
Costing analyses and the financial planning process can be a powerful tool for mobilising adequate and reliable funds. For example, they can:
Raise awareness and understanding of the EPI program and its financing concerns among stakeholders;
Provide information to decision makers on the cost (and effectiveness) of programs so that continued allocation of resources is justified; and
Increase confidence of donors in the financial management capability of the program. Programs that manage funds well and have good procedures for accounting and auditing are more likely to attract commitment from financing partners
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How do I get started?
To be a successful advocate you must carefully plan your approach. Key steps are:
Define the desired action or goal Identify the primary actor(s) Describe what needs to happen before this person can or will take action Define who will influence or catalyze the primary actor into taking action Outline the motivations and barriers of getting this done
Show me an example [LINK, below]
Realistic goal Primary actor What actions need
to happen for actor
to take action
Who can influence
them?
What are
opportunities and
challenges to
getting this done?
Increase in the
allocation of the
health budget to EPI
Minister of Health Organize meeting
with Minister
Have Financial Plan
prepared
Have clear
argument for WHY
it should be
increased
Deputy Minister for
Preventative Care
Opportunities
Prime Minister has
health as a election
priority
Challenges
Competing health
priorities
Elections
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How should information be presented?
Information can be presented through a number of different mechanisms:
You
The most important part of any presentation is YOU. Unless you are fully prepared and understand your subject matter, no amount of graphs, power point presentations or pictures can help.
As an advocate you should:
Be prepared: know what you are asking for Organise your discussion points in advance Be focused: state you main point early in the discussion and repeat them at the end Show how the person you are presenting might benefit.
Put yourself in the their shoes and think about what matters to them – what other demands must they respond to – how does immunization fit into this?
Think about ways that help them to rationalise an investment in immunization and make them feel enthusiastic about immunization.
And! BE ENTHUSIASTIC AND PASSIONATE ABOUT IMMUNIZATION!
Immunization partners
It is crucial that you recruit key immunization partners (such as WHO, UNICEF and bilateral
donors) to undertake advocacy on behalf of the program. Partners can be used to, and are very
effective at, influencing their peers and also the government.
Other forums
Other ways of communicating information besides personal meetings and presentations are: Newsletter or email updates Workshops and conferences
DO WE HAVE ANY EVIDENCE RE WHAT COMMUNICATION MEDIUM IS THE MOST INFLUENTIAL?
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How to present information visually
Discuss best ways to presentation visually eg graphs etc etc
As per comments in my email – shall we wait on more info from the Advocacy Taskforce and /
or group or just complete with info we have at the moment?
If we continue, can include Pauline’s suggestion to use Tufte material here, or I can develop
some graphs etc that are normally used - or we can link to TAB 3 and 4 graphs….Comments?
DO WE HAVE ANY EVIDENCE RE WHAT TYPE OF PRESENTATION IS THE MOST INFLUENTIAL?
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What information is the most powerful?
It all depends on who you are trying to persuade – and what you are trying to persuade them to do.
DO WE HAVE ANY EVIDENCE RE WHAT IMMUNIZATION INFORMATION IS THE MOST PERSUASIVE – IS IT REALLY COST PER FIC AND EFFECTIVENESS?? OR IS IT, FOR EXAMPLE, DEMONSTRATING PUBLIC DEMAND (SEEMS TO ME, A POLITICIAN IS MORE LIKELY TO BE PERSUADED BY THIS).
More information? [Link to GAVI Immunization Advocacy Resource Kit, and other documents
as per Uganda CD]