HSSP outputs and outcomes using the Malawi cost model
HSSP outputs and outcomes using the Malawi cost model
Introduction
The cost model of the Essential Health Package (EHP) was developed by the Ministry of Health in 2002-3 prior to the Programme of Work and the
first SWAp for health. It has been checked, modified, re-costed and improved for the HSSP. Other models are being developed such as the United
Nations OneHealth Costing Tool. This paper describes how the Malawi cost model can be used to calculate the overall cost-effectiveness of the
EHP and targets based on activity for each year.
Methods
The MOH cost model used for the first EHP has been adapted by the Ministry of Health (MOH) for EHP2. The costs have been revised. Staff
numbers have been revised to accommodate recent revisions of the staff establishment. A number of assumptions have been used to derive the
activity estimated from the model under different funding scenarios. They are:1. The model has been calibrated using 2009/10 activity based on HMIS data and 2010/11 estimated costs. The model over-predicts costs by
27%. This is due to drug and staff costs being less than predicted by the model because of staff absences and drug stock-outs. The effect is
that activity over-predicts beneficial effect by some 20%. The model has been re-calibrated to take this into account.
2. The core scenario used is based on the MOH resource based estimate of budgets in 2011/12 and 2015/6. It is assumed that 33% of the
MOH budget in 2011/2 is used to fund non-EHP activity and 66% to fund EHP activity. This reduces to 25% in 2015/6 as more services
become part of the EHP as part of the HSSP. Two versions are available, one assuming direct donor funding falls throughout the HSSP to
$110.9m per year as compared to $185m in 2010/11. The second version assumes direct donor funding remains at $185m a year.
3. Staff levels and costs are based on actual budget plans. Direct costs, which include those for drugs and equipment are assumed to increase by
3% a year due to inflation. Earmarked funded activities are those such as ARTs which have funding specifically earmarked for that activity.
Malaria, EPI and HIV/AIDS are the main sets of such activities. Pooled funded activities are the remainder, such as RH and ARI treatment.
4. By 2016 the effectiveness of patient care is assumed to have increased from 80% to 90% for well resourced EHP as facilities are better staffed
and stock outs are less. An ideal scenario has also been modelled to estimate activity and effect on the burden of disease using the activity to
meet all targets and the resources required to do this. The ideal scenario will achieve 100% staffing and no stock outs.
Prevention interventions
Various assumptions were used to estimate the burden of disease that has already been prevented by prevention interventions such as immunisations
as to stop these would have the effect of increasing these diseases in future. To gauge what would happen if immunisations were reduced, the SubSaharan incidence rates of vaccine preventable diseases have been used to calculate the effect of a suboptimal immunisation programme, adjusted by
the estimated levels of disease pre-immunisation era.
Professor C Bowie
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HSSP outputs and outcomes using the Malawi cost model
Clinical treatments
For those interventions involving clinical treatment 2009/10 HMIS data have been used, being the most recent year of currently available data.
Treatments have been adjusted in two ways; by a factor for treatment effectiveness (as an example, antibiotics work in 84% of times for pneumonia in
children); and by a factor measuring the affected population (as an example, 50% of adults and 70% of children registered in HMIS as malaria are not,
so only half or less of the number treated will benefit from antimalarial drugs). Treatment effectiveness factors are taken from recent authoritative
sources and referenced in the table.
Summation of benefits of the EHP
The burden of disease calculated in DALYS for each intervention for 2011 (and succeeding years) can be summed to provide an overall estimate of
burden averted by the programme. As the costs are also contained in the EHP model it is possible to measure the cost effectiveness of each and all
interventions combined at the levels of activity agreed once funding is known.
Results
Three scenarios are provided. The top scenario assumes the budgets as found in the HSSP. The second scenario assumes the assumption of direct
donor funding of $110.9m is pessimistic and uses the level estimated in 2010/11 of $185m. The third scenario shows what would occur if the EHP
was completely funded and all targets achieved. The table shows the burden of disease averted by the HSSP in each year, the cost-effectiveness of the
EHP and the proportion of planned activity which will be achieved.
A baseline for 2010/11 is also shown. From previous research approximately 70% of earmarked funded activity and 40% of pooled funded activity
was achieved at a cost of $389m. The package was cost effective at $170 per DALY. Anything less than $350 per DALY is thought to be affordable
for a country such as Malawi with a Gross National Product of $350 per capita.
To achieve all targets (ideal based scenario) would require $438m in 2011/2 rising to $727m in 2015/6. This assumes full staffing of established posts
by the end of the programme.
The current resource based budget, which includes a pessimistic assumption about the level of direct donor funding of EHP activity of $110.9m a
year, will reach 63% of earmarked activity and targets and 32% of pooled activity. This is a little less activity than last year because of the increase in
size of the population and the extra activity, raised targets and pessimistic funding assumptions.
The more optimistic assumption about direct donor funding being as found at $185m in 2010/11 increases the proportion of activity and targets
likely to be met at 90% for earmarked activity and 81% for pooled activity. The targets reduce with each year because of the flat level of donor
funding assumed, the population growth, inflation and a funded staff establishment of 55% of the gap between staff in 2011 and the establishment.
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HSSP outputs and outcomes using the Malawi cost model
Professor C Bowie
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HSSP outputs and outcomes using the Malawi cost model
Discussion
The results are based on a number of assumptions that can be modified after discussion and further research. The model still has some inaccuracies
in the data on which it relies. It needs to be validated by an expert team from the MOH, who can look at the financial assumptions, the activity and
target assumptions and the model itself. A number of improvements would make the model more useful and these will not need a huge amount of
investment – probably a full time researcher in the Planning Department for a year. In the meantime the results can be used for planning purposes
now.
The results highlight the effect of underfunding. The marginal benefit of additional funds is substantial as shown by the different in activity found if
less pessimistic assumptions about overall funding are used. The results, which demonstrate the overall cost-effectiveness of the proposed plan and
the marginal benefit of additional funding, can be used to encourage government and donors to find more money for the EHP.
Conclusion
The appropriate technical working group can consider these results and recommend possible modifications to targets and activity in Year 1 of the
plan. They might also consider seeking some support to improve the model for future use and collaborate with the United Nations OneHealth
Costing Tool team.
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