Costing of Integrated Community Case Management in Rwanda

Transcription

1 Costing of Integrated Community Case Management in Rwanda May 2013 Photo Credit Katherine Wright Z. Jarrah, A. Lee, K. Wright, K. Schulkers, D. Collins Management Sciences for Health

2 Contents Acknowledgements... iii Acronym List... iv Executive Summary... vi 1. Introduction Background and Country Context: Rwanda Methodology... 8 Tool Development... 8 Ethics Partner and Central Level Data Collection Facility and Village Clinic Data Collection Catchment Population Medicines Training Assumptions and Standard Data Input into the Model Population Figures ASC Availability and C-IMCI Service Delivery Assumptions Program and Coverage Assumptions Incidence Rates for the iccm Interventions Prices Standard Treatment Guidelines Analysis ASC Time on iccm Activities Utilization Costs Start-up Costs Recurrent Costs Conclusion References May 2013 Page i

3 Annexes Annex A. Districts and Health Centers Sampled Annex B. People Contacted Annex C. Questionnaire Templates for District, Health Facility, and Community Level Annex C1. Central Level Questionnaire Annex C2. District Hospital Questionnaire Annex C3. Health Center Questionnaire Annex C4. Community Level Questionnaire Annex C5. ASC Time Template Annex C6. Training/Meeting Template to Collect Information about Each of the Training Sessions Held at All Levels of the Health System That Binômes Are Expected to Attend Annex D. Sample ASC Reporting Form Annex E. Standard Treatment Guidelines Annex F. Total Costs of iccm Program in Rwandan Francs (RWF) Annex G. Glossary Tables Table 1. Costing of Rwanda s iccm program (USD)... vii Table 2. Costs per service (USD)... viii Table 3. Summary of additional community health worker tasks in Rwanda... 3 Table 4. Sources of costs used in the iccm tool Table 5. Summary of data collection Table 6. Population figures (2010) Table 7. Calculation of current percentage of service delivery coverage Table 8. Standard treatment guidelines Table 9. Number of iccm services and services per capita, target service delivery coverage scenario, Table 10. iccm and ASC figures for the target service delivery coverage scenario, Table 11. iccm program start-up costs for the target service delivery coverage scenario (USD) Table 12. Total recurrent costs for actual and 100% coverage scenarios, (USD) Table 13. Cost per service, iccm interventions, (USD) Figures Figure 1. Rwanda s Community Health Program... 5 Figure 2. Total recurrent costs by administrative level, (USD) Figure 3. Total recurrent costs attributed by iccm treatment areas, (USD) Figure 4. Average recurrent cost per iccm service (USD) Figure 5. Annual program cost by input, (USD) May 2013 Page ii

4 Acknowledgements This study was conducted by Management Sciences for Health, in collaboration with Rwanda s Ministry of Health (MOH) and the United States Agency for International Development (USAID) through the Translating Research into Action (TRAction) Project. The study was coordinated in close collaboration with Cathy Mugeni, head of the MOH s Community Health Desk (CHD) and the co-principal investigator for this study. Standards for integrated community case management (iccm) were developed in consultation with Mbombo Wathum, a Senior Program Associate with MSH s Strengthening Pharmaceutical Systems (SPS) project. Information was gathered in 2011 from 9 of Rwanda s 30 districts at the district, health center, and community levels; this was used to test the model. (See Annex A for the complete list of facilities and communities sampled.) The following partners and donors were consulted: National Malaria Control Program, Concern, International Rescue Committee, UNICEF, Partners in Health, Maternal and Child Health Integrated Program (MCHIP), and President s Malaria Initiative. These partners provide iccm support across the 30 districts in Rwanda. Thanks are also due to other people who contributed to the process and who are listed in Annex B. Zina Jarrah is a Technical Advisor; Angela C. Lee, Katherine D. Wright, are Senior Technical Officers, and Keriann Schulkers is a Technical Officer; and David Collins is a Senior Principal Technical Advisor at Management Sciences for Health (MSH). They are all based in Cambridge, Massachusetts. This report may be reproduced if credit is given to MSH and URC s TRAction Project. Please use the following citation: Jarrah, Z., Lee, A., Wright, K., Schulkers K, and D. Collins Costing of Integrated Community Case Management in Rwanda. Submitted to USAID by the TRAction Project: Management Sciences for Health. Information shown in the annexes may not be quoted or reproduced separate from the rest of the document without the written permission of Management Sciences for Health. Key Words: integrated community case management (iccm), community health workers (CHWs), malaria, diarrhea, pneumonia, costing, financing, Rwanda Disclaimer: The authors views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. May 2013 Page iii

5 Acronym List ASC ASM CAMERWA CBHI CCM CHD CHP CHW C-IMCI CIDA CMS C-PBF CTC DHO DHS DOTS GHI EIP HC HH HMIS HSSP iccm IHSSP IMCI MCHIP MDG MOH MSH ORS PBF PMI agent de santé communautaire (community health worker) animatrice de santé maternelle (maternal health community health worker) Centrale d Achats des Médicaments Essentiels du Rwanda community-based health insurance Community Case Management Community Health Desk Community Health Program community health worker Community-Based Integrated Management of Childhood Diseases Canadian International Development Agency Central Medical Stores community performance-based financing Community Therapeutic Care district health office Demographic Health Survey Directly Observed Treatment, Short Course Global Health Initiative Expanded Impact Project health center household Health Management Information System Health Sector Strategic Plan integrated community case management Integrated Health Systems Strengthening Project Integrated Management of Childhood Illness Maternal and Child Health Integrated Program Millennium Development Goal Ministry of Health Management Sciences for Health oral hydration salts performance-based financing President s Malaria Initiative May 2013 Page iv

6 PIH PSI RDT RNEC RMS RWF SPS STC SW TWG TB TRAction UNICEF USAID WHO WVI Partners in Health Population Services International rapid diagnostic test Rwandan National Ethics Committee Regional Medical Stores Rwandan francs Strengthening Pharmaceutical Systems Save the Children social worker technical working group tuberculosis Translating Research into Action, project funded by USAID United Nations Children's Fund United States Agency for International Development World Health Organization World Vision International May 2013 Page v

7 Executive Summary Integrated community case management (iccm) has proven to be an effective strategy for expanding the treatment of childhood diarrhea, pneumonia, and malaria, which are the leading causes of child mortality and result in nearly 44% of deaths worldwide in children under five years old. Through the Translating Research into Action (TRAction) project, funded by the United States Agency for International Development (USAID), Management Sciences for Health (MSH) has been awarded a subgrant to develop a costing and financing model for iccm. Countries considering implementing or expanding iccm programs will benefit from a comprehensive understanding of costs and financing. This understanding will help them advocate to donors and ministries of finance for necessary funding. It will also help them allocate sufficient funds to appropriate levels of the health system. This report describes the testing of the iccm Costing and Financing Tool in Rwanda, where community health activities were initiated in Rwanda is divided into 30 districts. In 2006 Rwanda s iccm program began with the home-based management of malaria in 6 districts. By then the country had expanded the Community Health Worker (CHW) mandate to include pneumonia and diarrhea, and in May 2009 Rwanda s national iccm program officially began training CHWs in the identification and treatment of uncomplicated malaria, diarrhea, and pneumonia. The iccm program also implemented the Integrated Management of Childhood Illness (IMCI) program in 7 pilot districts. Today Rwanda s Community Health Worker program covers all 30 districts and 100% of the requisite CHWs have been trained. Each of Rwanda s 30 districts comprises various administrative sectors, each sector comprises multiple cells, and each cell comprises multiple villages (umudugudu). Rwanda s Community Health Program (CHP) is organized into the following levels of care: referral hospital (central level), district hospital (district level), health center (sector level), and dispensary (cell and village level). The IMCI program currently exists at both the health center level (facility IMCI) and the community level, the Community-Based Management of Childhood Illnesses (C-IMCI) program. 1 The Ministry of Health (MOH) policy is that each village is covered by a total of four community health workers, each with well-defined tasks: two agents de santé communautaire (ASCs); one animatrice de santé maternelle (ASM) in charge of maternal health; and one social worker (SW) in charge of prevention, nutrition, and environmental health activities. 1 Republic of Rwanda, Ministry of Health, C-IMCI Rapid Evaluation Report 2010, draft (Kigali: June 2011); Republic of Rwanda, Ministry of Health, Community IMCI/CCM: Evaluation Report of Community Health Workers Performance (Kigali: 2009). May 2013 Page vi

8 The iccm Costing and Financing Tool was used to project the costs of Rwanda s iccm program from the baseline year of 2010 through The 2010 figures were based on the actual numbers of services provided, whereas the figures are projections based on illustrative targets set by the authors. The main purpose of this work was to test the tool, and a small sample of facilities and community health workers was used for that purpose. That sample is too small for the resulting data to be representative of the program as a whole, and the results of the modeling shown in this report should, therefore, be considered as illustrative. Nevertheless, we believe that these results can be useful to the MOH and its partners, and the figures used in the tool can be updated as desired. Because Rwanda s CHW program currently covers the entire country, there was no geographic scale-up calculated for this analysis. However, there was a large potential to scale up the coverage of services in areas already served by CHWs. The numbers of services per year were calculated based on prevalence rates of 3.00 episodes per child per year for diarrhea, 0.28 for pneumonia, and 0.56 for malaria. The actual number of services were used for 2010, a total of 716,871 for the three services. Based on the prevalence figures above, the services would increase to 2.9 million by 2015, assuming that Rwanda scaled up the Community Health Program to treat 30% of all diarrhea cases, 45% of pneumonia cases, and 85% of malaria cases in children under five. Note that all assumptions can be changed in the model to reflect more upto-date information and targets. Table 1 summarizes findings of the costing of Rwanda s iccm program. Table 1. Costing of Rwanda s iccm program (USD) 2010 Actual 2011 Projected 2012 Projected 2013 Projected 2014 Projected 2015 Projected Total recurrent cost 4,784,409 5,245,586 5,219,282 5,649,235 5,641,662 6,091,097 Total number of 716,871 1,274,074 1,653,960 2,054,808 2,477,514 2,923,009 services Average cost per service Average cost per capita (children 0 59 months) Average cost per capita (total population) The total recurrent costs over the entire period amounts to US$32.6 million. Adding start-up costs (training ASCs and other start-up activities) brings the grand total to US$44.9 million. Table 2 shows the costs per service for each program year. May 2013 Page vii

9 Table 2. Costs per service (USD) 2010 Actual 2011 Projected 2012 Projected 2013 Projected 2014 Projected 2015 Projected Diarrhea Pneumonia Malaria Due to economies of scale, the costs per service decrease from 2010 to 2015; although the direct costs (medicines) remain the same, the indirect costs, such as management and supervision, are divided over an increasing number of services. The utilization of iccm services in 2010 appears to be low compared with the projected numbers of cases for However, because of the low level of utilization and the resulting high unit costs of management and supervision, the actual costs for 2010 indicate that the program was expensive and inefficient. If this analysis is correct, increasing utilization levels, as well as exploring less costly ways of providing management and supervision, should be a priority. Information collected during the study indicates that it is important to analyze some possible constraints to increasing utilization in particular, stock-outs of medicines and supplies, ASC competencies, financial-access barriers related to user fees or insurance, and the application of performance-based incentives. The testing showed that the iccm Costing and Financing Tool could be used for the intended purposes. In general the tool fit Rwanda s needs well, although the testing led to some minor changes to both the tool and the data collection questionnaires. The tool was updated to include an ASC supervisory cadre, which provides direct iccm services but also plays an overall supervisory role. The questionnaires were updated to include more detailed templates for meeting and training costs, as well as a template to record ASC time usage over the previous week of service. May 2013 Page viii

10 1. Introduction Integrated community case management (iccm) has proven to be an effective strategy for expanding the provision of diarrhea, pneumonia, and malaria services and is accepted by international donors and developing countries as a key strategy to meet Millennium Development Goal (MDG) 4 on reducing child mortality. Furthermore, it is a pivotal strategy to achieve the Global Health Initiative (GHI) vision. Diarrhea, malaria, and pneumonia are leading causes of child mortality and cause nearly 44% of deaths worldwide in children under five years old. Community case management (CCM), the delivery of timely and low-cost interventions at the community level by community health workers (CHWs), is promoted by the World Health Organization (WHO), The United Nations Children's Fund (UNICEF), United States Agency for International Development (USAID), and the Global Health Initiative (GHI) as an effective strategy to deliver lifesaving interventions for these illnesses. Several developing countries have adopted and promoted policies and programs in which CHWs promote timely care by treating uncomplicated cases of diarrhea, pneumonia, and malaria and referring severe cases to health facilities. Despite the success of this strategy in several low-income countries, iccm programs in many other countries have yet to be implemented or expanded. This is partly due to concern or uncertainty about the costs and financing of iccm programs. A comprehensive understanding of costs and financing will help countries who are considering implementing or expanding iccm programs to advocate to donors and ministries of finance for necessary funding and to allocate sufficient funds to appropriate levels of the health system. It will also allow for costs to be better monitored and controlled, thus ensuring efficient use of scarce resources. Unfortunately, in many developing countries, there is a lack of skills necessary to analyze the cost and funding needs of such programs, as well as a need for simple, user-friendly tools with which to conduct this analysis. Moreover, the absence of a standardized analysis model means that even where cost and financing studies are done, they may not be accurate or complete and are not generally comparable across countries or over time. The purpose of this work is to develop a simple, user-friendly tool to determine the costs of starting up and expanding iccm programs. The work includes visits to three countries to help develop the tool, beginning with Malawi 2. This report outlines the results of testing the tool in the second research country, Rwanda. Testing the tool requires the use of only a small sample of facilities and CHWs. That sample is too small for the resulting data to be representative of the program as a whole, and the results of the modeling shown in this report should, therefore, be considered as illustrative. Nevertheless, we believe that these results can be useful to the Ministry of Health (MOH) and its partners, and the figures used in the tool can be updated as desired. 2 Jarrah, Z., Lee, A., Wright, K., Schulkers K, and D. Collins Costing of Integrated Community Case Management: Malawi. Submitted to USAID by the TRAction Project: Management Sciences for Health. May 2013 Page 1

11 2. Background and Country Context: Rwanda Rwanda s MOH initiated community-based health activities in In 2006 Rwanda s iccm program began with the start of home-based management of malaria in six districts: Gitwe (now in Ruhango District), Kibogora, and Kibilizi (now Gisagara District), Kirehe, Remera, Rukoma, and Nyanza. 4 In addition, the country began to establish a functional Integrated Management of Childhood Illness (IMCI) technical working group (TWG) and a strategic work plan. Rwanda also began to adapt international generic tools and trainings to the context in Rwanda. By then, the country had expanded the CHW mandate to include pneumonia and diarrhea. In May 2009 Rwanda s national iccm program officially began training CHWs in the identification and treatment of uncomplicated malaria, diarrhea, and pneumonia. Rwanda s MOH also implemented IMCI in seven pilot districts, 5 with technical support from partners like USAID/BASICS, Strengthening Pharmaceutical Systems (SPS) project, Expanded Impact Project (EIP), Twubakane project, and UNICEF. 6 Today Rwanda s CHW program covers all 30 districts, and 100% of the requisite CHWs have been trained. The MOH, through its Community Health Desk (CHD) and in collaboration with its Malaria Unit, is the lead institution managing, coordinating, and implementing iccm in Rwanda. The Community Health Desk coordinates iccm nationwide, including the following: training, adapting and revising protocols, approving tools, making medicines available, conducting midterm evaluations, and monitoring iccm indicators. The CHD is assisted by the IMCI s TWG, which is composed of a number of active partners. Funding partners include the Government of Rwanda, the Global Fund, the President s Malaria Initiative, USAID, the Canadian International Development Agency (CIDA), and a few foundations. Implementing partners include Partners in Health (PIH), Maternal and Child Health Integrated Program (MCHIP), John Snow Inc., Population Services International, UNICEF, Concern International, and the International Rescue Committee. Rwanda is divided into 30 districts, with each district comprising various administrative sectors, each sector comprising multiple cells, and each cell comprising multiple villages (umudugudu). Rwanda s Community Health Program is organized into the following levels of care: referral hospital (central level), district hospital (district level), health center (sector level) and cell (village and dispensary level). The IMCI program currently exists at both the health center level (facility IMCI) and at the community level (C-IMCI). 7 3 Republic of Rwanda, Ministry of Health, National Community Health Strategic Plan (Kigali: Date Unknown). 4 L. Barat et al. External Evaluation of the Pilot Phase of the Home-Based Management of Malaria Program in Rwanda: Final Report (Kigali: USAID/BASICS, USAID/RPM Plus, Integrated National Malaria Control Program, Rwanda: 2007). 5 Rwanda MOH, C-IMCI Rapid Evaluation Report Rwanda MOH, Community IMCI/CCM: Evaluation Report. 7 Rwanda MOH, C-IMCI Rapid Evaluation Report May 2013 Page 2

12 The MOH policy is that each village is covered by a total of four community health workers, each with well-defined tasks: two agents de santé communautaire (ASCs), partners (binôme) 8 one male and one female ASC, trained to treat the three main childhood diseases: malaria, diarrhea, and pneumonia one animatrice de santé maternelle (ASM) in charge of maternal health activities, such as providing in-home follow-up care and ensuring that women go to the health center (HC) for timely prenatal care and other necessary services one social worker (SW) in charge of prevention, nutrition, and environmental health activities In addition to performing their typical duties, CHWs also participate in a variety of other activities, based on their training and the community s needs (Table 3). Table 3. Summary of additional community health worker tasks in Rwanda Agents de santé communautaire Organization of Hygiene Clubs to promote clean water, sanitation, and behavioral change HIV/AIDS Animatrice de santé Maternelle Referral for institutional delivery, supervision of home delivery Referral for prenatal care and tetanus vaccination Social worker Outreach Health education, adult consultations Nutrition education Data management and utilization Birth spacing methods Tuberculosis Condom distribution and family planning education Immunization and vaccination Basic and advanced care on noncommunicable diseases Referral for antenatal care and tetanus toxoid Iron supplement distribution for pregnant women Vitamin A distribution Disability services Prenatal care Mental health services Source: Health Sector Strategic Plan (HSSP) II independent review. 8 PIH districts were found to have a range of 2 5 binômes per village, based on the population size. May 2013 Page 3

13 CHWs are elected into the position by members of their own community. While the ASM and SW are typically responsible for covering the whole village, the ASC binôme generally splits the village population, with each ASC covering half the households (HH). On average each village consists of households. Of the 60,000 CHWs in total in Rwanda, around 30,000 are binômes. In addition to the ASCs in the villages, each cell (which comprises 5 6 villages) has an ASC Coordinator. ASC Coordinators are responsible for overseeing all the ASC activities within their cell, such as collecting the ASCs monthly reports, compiling data at the cell level, and submitting the reports to the health center. ASC Coordinators play a dual role in that they also conduct regular ASC duties within their own villages. 9 ASC Coordinators are elected into the position by their peers on the basis of their level of experience and commitment. Rwanda s C-IMCI program is supported by routine management and supervision (Figure 1). Central level supervisors from the Community Health Desk supervise the In-Charge of Community Health at the district hospital once per quarter for one week. During that week two health centers in the district are selected at random, and the central-level supervisor accompanies the district hospital s In-Charge of Community Health to conduct the supervision. At each health center, two ASCs are selected at random to receive supportive supervision. The In-Charge of Community Health at the district hospital supervises the In-Charge of Community Health at the health center, typically once per quarter. The In-Charge of Community Health (in some cases working with the In-Charge of Environmental Health) at the health center supervises the CHWs, including the ASC Coordinator. The appropriate staff at the health center and district hospital receive training on supervision of the ASCs. The activities performed by the ASCs are recorded in a Health Management Information System (HMIS) database called SIScom, created specifically for community iccm. These activities include number of treatments delivered at the community level, drug management, and other indicators. The ASC Coordinator is responsible for collecting and collating the data monthly at the village level and then submitting this information during the monthly supervisory visits to the health centers. The health centers aggregate the data from their cells and send it to the district hospitals. The In-Charges at the district hospitals review and enter the data and send it to the central level database. This database is the foundation of the monitoring and evaluation of community-based services. Figure 1 shows this line of reporting. 9 Unlike most ASC Coordinators, those in PIH Districts do not also act as regular ASCs in their village. Their only role is as ASC Coordinators. May 2013 Page 4

14 Figure 1. Rwanda s Community Health Program Central Ministry of Health District District Hospital In-Charge of Community Health Sector Health Center Cooperative In-Charge of Community Health In-Charge of Hygiene and Environmental Cell ASC Coordinator Village Village Village Village Village ASC ASC ASC ASC ASC ASC ASC ASC ASC ASC ASM SW ASM SW ASM SW ASM SW ASM SW HH HH HH HH HH Key: = Physical structure = Binôme pair = Path of reporting/data = Staff = CHW = Path of supervision = Formal community group ( ) = Indicates working relationship Source: Authors. May 2013 Page 5

15 The Rwandan Community Health Program has identified several challenges, including a lack of regular supervision for ASCs; drug and supply stock-outs; the need to reinforce the competencies of ASCs; and the high cost of delivering services at the community level. Potential solutions to meet these challenges include recruiting additional supervisory staff; improving supply-chain management; continuous refresher training for ASCs; and adding a fee for service for families that are not enrolled in the community-based health insurance system (mutuelles). No previous studies have assessed the cost of community case management in Rwanda. ASCs in Rwanda are a cadre of volunteer workers who do not receive a salary from the MOH. However, community health activities were recently integrated into the national performancebased financing (PBF) scheme. ASCs were incorporated into the PBF scheme in 2006, and that scheme has undergone a number of iterations since then. The current community PBF scheme is intended to support existing efforts to accelerate progress toward the Millennium Development Goals and the Rwanda Vision ASCs receive incentives based on six key indicators: 11 mutuelle enrollment deliveries at health centers use of insecticide-treated bed nets management of dehydration from diarrhea among children under five personal hygiene reporting Under the original community PBF (C-PBF) scheme, payments were made directly to ASC cooperatives, and that money was invested in the income-generating activities of the cooperatives. It became clear that the delay between when ASCs were completing their work and when they were receiving their incentives was too long, so the MOH issued a ministerial order saying that 30% of the cooperative performance payment should be paid directly to the ASCs immediately after the cooperative received the PBF bonuses. These individual payments made to ASCs are known as "PBF primes" or PBF bonuses. Now ASCs receive a payment each quarter as a part of the C-PBF scheme. Of the 35 ASCs we interviewed for this study, the average PBF prime payment per quarter was US$12.00 or 7,374 Rwandan francs (RWF) (range: 0 20,000 RWF, median: 6,000 RWF) Republic of Rwanda, Ministry of Health, The National Community Performance-Based Financing and Conditional In- Kind Transfers Program Implementation Manual (Kigali: June 2011). 11 Republic of Rwanda, Ministry of Health, Community Performance-Based Financing User Guide (Kigali: January 2009). 12 An exchange rate of 604 RWF to 1 USD was used for all currency conversions in this report. May 2013 Page 6

16 In addition to the C-PBF scheme, Rwanda has a fairly advanced health insurance program, which includes a community-based health insurance (CBHI) scheme that provides health insurance coverage to those who are not covered by the formal sector (i.e., through another government insurance program or a private employer-based insurance program). The CBHI scheme is funded through premiums and co-payments, and it covers approximately 90% of those who are eligible to be enrolled in the program. Community-based treatments, including iccm, are provided for a fee of 200 RWF (US 0.35) for those patients enrolled in CBHI and 500 RWF (US 0.85) for those who are not enrolled. Patients are not turned away if they cannot afford to pay for the treatment, so some patients pay nothing and still receive services. Of the CHWs we interviewed, user fees averaging 868 RWF per ASC (range: 0 6,500 RWF, median: 400 RWF) were collected per quarter. May 2013 Page 7

17 3. Methodology Tool Development The Rwanda iccm costing model was developed from the prototype of the generic iccm costing tool. It covers all aspects of the vertical program, including service delivery costs at the community level and support, supervision, and management costs at all levels of the health system. Additionally, the tool has a financing element that can be used to show and project financing sources. The Rwanda model covers the three key iccm interventions: diarrhea, pneumonia, and malaria. At the service delivery level, it is largely a bottom-up, activity-based costing tool, in which costs are built up by type of resource (such as medicines) on the basis of estimated numbers of services. The tool estimates the number of CHWs required as well as anticipated support and supervision staffing needs. It takes into account constraints for example, the amount of time available for a CHW to provide services. It produces the cost per output, as well as aggregate costs for different levels of the health system (e.g., community, district, and national). The tool contains a need norms section that uses incidence rates to estimate the expected caseload for the specified catchment population. The user can also input assumptions into the tool about CHW availability, so that the number of projected services is constrained to the number of available CHW work hours. The tool then estimates the numbers of CHWs required and the anticipated cost of support and supervision staffing needs, based on assumptions entered by the user. The tool estimates the unit cost per service, as well as the aggregate costs for different levels of the health system (i.e., community, district, and national) and the total costs. In summary, the tool automatically produces different output costs that can be used to measure cost efficiency and effectiveness. These output costs include costs per capita, per contact, per disease type, and per resource type. More specifically, users of the model will be able to calculate the following: total program costs, baseline year and five-year cost projections; costs per capita, per contact, per disease type, and per resource type; incremental costs and incremental financing of the iccm programs (start-up and recurrent) as a whole and for each level (national, regional, district, facility, and community) over time; incremental costs to support each of the disease areas (diarrhea, malaria, and pneumonia) with the capability to include other iccm interventions; key drivers of costs and cost categories, as a percent of total costs; five-year projections of financing with sources of funding. These outputs can be used to: advocate for funding from the government or donors; develop government or donor budgets; measure cost efficiency and effectiveness; produce global and country financial iccm indicators, as developed by the iccm technical advisory group; May 2013 Page 8

18 develop what-if scenarios that were considered by researchers or program managers to improve program sustainability or reduce funding requirements. The tool allows the user to select an option for three different scenario questions, as follows: Scenario 1: Purpose of the Tool The user is asked to select between two options: (1) Scale-Up of Existing iccm Program and (2) Introduction of New iccm Program. Countries that currently have an iccm program in place should select the first option; countries that are considering starting up a new program should select the second option. The key difference between the two options for Scenario 1 is the use of baseline data. If a country selects the Scale-Up of Existing iccm Program option, the user is allowed to input baseline data in the Baseline Data worksheet of the model. This data can then be used in the subsequent two scenario questions (on geographic and service delivery coverage) to evaluate the current actual iccm coverage. However, if the user selects the Introduction of New iccm Program option under Scenario 1, the data cannot be used in conjunction with the Actual option in Scenarios 2 and 3. Scenario 2: Geographic Coverage The user is asked to select among three options: (1) Actual, (2) Full-Scale, and (3) Target Geographic Coverage. Geographic coverage is defined as the number of provinces, districts, and other administrative structures in which the iccm program is functional. Selecting the Actual option allows the user to input the current actual coverage of an existing iccm program for the baseline year. The user can select the Actual option only if "Scale-Up of Existing iccm program" was selected as the option under Scenario 1. The tool calculates the costs of providing iccm services at the actual coverage level for the first program year; the remaining years are based on calculations from the Target option. Selecting the Full-Scale option results in a scenario with geographic coverage of the entire country for all program years. The user is asked to input the total population and number of each geographic unit (province, district, village, etc.) in the country, and that information then drives the number of iccm services. Selecting the Target option allows the user to input a target coverage (expressed as a percentage of full-scale coverage) of the iccm Program. For example, if the iccm program is currently in the pilot phase in 5 out of 30 districts, the user can specify an increasing number of districts to be covered for each subsequent program year. The user must identify the population covered within those geographic areas for each program year, and that information then drives the number of iccm services. Scenario 3: Service Delivery Coverage The user is asked to select among three options: (1) Actual, (2) Full-Scale, and (3) Target Service Delivery Coverage. Service delivery coverage is defined as the number of diarrhea, pneumonia, and malaria cases treated through iccm, divided by the total number of expected cases within the designated geographic coverage area. May 2013 Page 9

19 Selecting the Actual option allows the user to input the actual total number of iccm treatments provided for the baseline year, as reported in the HMIS. The remaining years are based on calculations from the Target option. The user can select the Actual option only if "Scale-Up of Existing iccm Program" was selected as the option under Scenario 1. Selecting the Full-Scale option results in a scenario in which the total population defined within the geographic coverage areas of the iccm program is assumed to be treated through iccm. In this scenario the tool calculates the number of treatments by multiplying the total population under age five by the incidence rate for each iccm condition in the package. The user can specify the incidence rates for each program year in the model, although in the case of Rwanda, the same rates were used for each year. A country should choose this option only if it plans to treat pneumonia, diarrhea, and malaria exclusively at the community level. Selecting the Target option allows the user to input a target (expressed as a percentage of full-scale need) of iccm treatments provided to children in iccm-covered areas. The tool calculates the number of treatments based on the incidence rates for each iccm condition. The methodology is similar to the one used for the Full-Scale option; the key difference is the assumption that the target delivery coverage is less than the full need. This target is expressed as a percentage of the total expected caseload. The user enters a percentage for each treatment area and can change that percentage for each subsequent program year to model the cost implications of gradual scale-up. The Target option is most useful when the gap between actual and full-scale coverage is perceived to be too large to close immediately, or when the country still provides a percentage of treatments at the health center level. For each option under the two coverage scenarios, the tool calculates the cost data using a mix of actual and standard costs (see Table 2) 13. For example, the user inputs actual salaries to determine supervision costs, but the tool uses standard estimates for staff time spent on supervision, to arrive at a total supervision cost. The actual costs for trainings and meetings are applied to the normative number of each occurrence. For example, actual cost inputs for the monthly ASC meetings are determined and multiplied by 12, assuming that all monthly meetings occurred as planned. For the Actual options for the two coverage scenarios, the tool combines the actual number of iccm services with the standard costs of providing each service, to arrive at a total cost. 14 For this option the tool also uses the actual number of CHWs currently providing iccm services and multiplies this figure by the standard CHW salary allocated to iccm, if applicable. Costs for the Target and Full-Scale options for the two coverage scenarios are based on standard costs, using a methodology similar to the one used for the Actual option. For these coverage options the required number of CHWs is driven by demand (utilization). 13 Actual costs of the iccm program in Rwanda were not available to the necessary level of detail or breakdown by specific line item. Certain costs were available (e.g., from NGOs) for specific elements, such as training, but determining the total actual cost of the program was not possible. 14 Standard costs of a service (treatment) are determined by calculating the cost of drugs, supplies, staff time, and other resources required according to standard treatment guidelines. May 2013 Page 10

20 Table 4. Sources of costs used in the iccm model Element Source Comment ASC and iccm training ASC incentives Average of the actual unit costs of training from partners Actual unit costs of incentives (e.g., kits, bicycles) for ASC The actual unit cost was multiplied by the standard number of expected participants to arrive at total cost. The actual unit cost was multiplied by the total number of ASCs (assumed that they all received the incentives). iccm treatment Actual unit medicines and supply prices The standard quantities of medicines and supplies were multiplied by standard unit medicines prices. Health center, district health office, and central level salaries ASC meetings Actual 2010 salary costs provided by the CHD Unit of MOH Average of the actual unit costs for meetings for partners Actual salaries were multiplied by standard estimates for time spent on supervision to arrive at the total supervision cost. The actual unit cost was multiplied by the standard number of expected participants to arrive at total cost. Ethics All results presented in this report are based on the following scenario and option selections: Scenario 1, Scale-Up of an Existing iccm Program option; Scenario 2, Full-Scale geographical coverage option; and Scenario 3, Target service delivery coverage option. This study received approval from the Government of Rwanda, MOH. Oral consent was obtained in advance of all interviews with central, district, and health center staff and ASCs. This study was judged to have no risk to participants, and any personal data collected was deidentified at the time of analysis. Participants were allowed to terminate the interviews at any time for any reason, without personal detriment. In addition, the study protocol and questionnaires were submitted to the Rwandan National Ethics Committee (RNEC) for approval. Partner and Central Level Data Collection Partners (binômes) were interviewed to determine what support they provide for iccm implementation. We used a standard questionnaire, which was amended to reflect the degree of variation between each partner s activities. In the standard questionnaire, partners were asked to provide the following information: districts in which partner supports iccm implementation; training data for ASCs (including the number trained, total costs, and unit cost); supervision data (including total spent per year at each level central to facility, facility to community and the unit costs for supervision); costs and quantities of medicines /supplies provided to ASCs for iccm (including transport and storage costs); May 2013 Page 11

21 partner iccm program support costs (including supervision, mentoring, and reporting time provided directly from partner staff to IMCI unit or districts); budget/projections for future spending/commitment on iccm activities. To collect this information, the research team met with the iccm/child health focal staff at the following organizations, projects, and initiatives: National Malaria Control Program, Concern, the International Rescue Committee, UNICEF, PIH, MCHIP, and the President s Malaria Initiative. Together, these partners provide support for the national iccm program across 30 districts in Rwanda. Information collected at the central level includes the following: names of staff, salaries, and percentage of time spent on the iccm program (including percentage of time spent on supervision, trainings, and meetings); national treatment protocols for community case management of diarrhea, malaria, and pneumonia; national IMCI manual for ASCs; national iccm program start-up costs; historical program costs; caseload for all iccm services (diarrhea, malaria, and pneumonia) for 30 districts in Rwanda; medicines prices for required medicines and supplies that ASCs distribute from Centrale d Achats des Médicaments Essentiels du Rwanda (CAMERWA); reporting/supervision, data management, and drug/commodity flow relationships; training requirements for ASCs. Facility and Village Clinic Data Collection The iccm costing model described above uses both actual and standard expenditure and utilization data. To test the functionality of the assumptions, norms, and standards in the model, actual costs and revenues were analyzed for a small number of communities. The actual data collected were used to build a complete picture of the Rwanda Community Health Program. The sample for this study included a total of 9 out of the 30 total districts in Rwanda, supported by key partners, including the MOH, Save the Children, PIH, UNICEF, and the Global Fund. Within each district, data were collected at three levels of the health system: the district level (district hospital), the health center level, and the community level (via ASCs and ASC supervisors). At the district hospital data were collected from the district s In-Charge of Community Health Activities. At the health centers, the In-Charge of Community Health for the health center provided catchment population figures, utilization data, and expenditure figures for these facilities and the communities they serve. At the community level, ASCs provided population and utilization figures for their specific catchment areas. Additionally, the ASCs provided detailed information on their time usage, incentives, supervision, reporting, and meeting requirements. All data were collected by oral interviews, and information was captured electronically. Where possible, soft copies of documents were collected; if only hard copies existed, photographs were taken for subsequent data entry. A standard questionnaire and data collection checklist were applied at each level (see Annex C for questionnaire templates). May 2013 Page 12

22 In the nine selected districts sampled, nine health centers and 35 ASCs were selected for sampling (Table 5). Table 5. Summary of data collection District Visited Health Center Visited # of ASCs interviewed Partner organization supporting MOH Burera Gitare HC 4 PIH Gakenke Ruli HC 4 GF Gisagara Save HC 4 GF, Concern International Kamonyi Nyagihamba HC 4 GF, FHI Karongi Rubingera HC 4 GF, Strive Foundation, ICAP Kayonza Kabarondo HC 3 GF, PIH Kicukiro Masaka HC 4 MCHIP/JHPIEGO Ngororero Muramaba HC 4 GF, PSI Rwamagana Rwamagana HC 4 GF TOTAL 9 35 The rationale for choosing districts was to achieve geographical representation from each province North, East, South, West, and Mairie de la Ville de Kigali (MVK). Two districts were selected in each of the North, East, South and West provinces. One district was selected from MVK. In each of these districts, sampled health centers were selected based on proximity and accessibility to the district hospital. (See Annex A for details of actual facilities sampled.) Catchment Population The rationale for choosing districts was to achieve geographical representation from each province North, East, South, West, and Mairie de la Ville de Kigali (MVK). Two districts were selected in each of the North, East, South and West provinces. One district was selected from MVK. In each of these districts, sampled health centers were selected based on proximity and accessibility to the district hospital. (See Annex A for details of actual facilities sampled.) May 2013 Page 13

23 Medicines The essential medicines for iccm in Rwanda are oral rehydration salts (ORS), Zinc (10 mg), Amoxicillin (125 mg), Primo Red, and Primo Yellow. Primo Red and Primo Yellow are Lumefantrine Artemether (Coartem) reformulated and packaged by Population Services International (PSI) in the appropriate dosages for children six months to three years of age and three to five years of age, respectively. Each binôme takes its medicines stock card to its CHW coordinator every month. This coordinator completes a drug requisition form and takes it to the health center pharmacy during his or her monthly meeting with the health center s In-Charge of Community Health. Health center pharmacy managers validate the requisitions and prepare a requisition form for each cell (five to six cells per health center). This form is then sent to the district pharmacy. The district pharmacy requisitions CAMERWA for C-IMCI medicines. These drug orders are sent directly to each health center, where medicines are distributed during monthly CHW coordinator meetings. Training Training costs were collected from partner organizations, which finance trainings and support the MOH in their respective districts. In addition to receiving training in iccm provision, including the use of rapid diagnostic tests (RDTs) for malaria, ASCs are given annual refresher training. May 2013 Page 14

24 4. Assumptions and Standard Data Input into the Tool The following information was obtained through the various data collection methods described above and was input into the iccm tool: Population Figures Table 6 shows the population and geographic coverage assumptions input into the iccm tool for Rwanda. As noted earlier, all districts in Rwanda have functional ASCs providing iccm, so we have considered Rwanda as having full geographic coverage of the program. Table 6. Population figures (2010) Total population of Rwanda 10,412,820 Population under five years of age 1,686,877 Total districts in Rwanda providing iccm 30 Total health centers in Rwanda providing iccm 430 Annual population growth rate 2.9% Source: Republic of Rwanda, Ministry of Health and National Institute of Statistics, National Community Health Strategic Plan , Date Unknown. ASC Availability and C-IMCI Service Delivery Assumptions A total of 35 ASCs were interviewed for this study. Because ASCs are volunteers in Rwanda, and no standardized hours of operation are specified by the iccm policy, the average actual hours worked were entered into the model. The actual hours per week per ASC were based on a recall of the previous week s activities (see Annex C5 for template). This average amounted to four hours of work per day, six days a week. However, we found that only a very small percentage of this time was actually spent on iccm activities (only 1% of the overall ASC time). Instead of using the total actual iccm time, we assumed that ASCs could spend up to two thirds, or 67%, of their time on iccm treatments (which would come out to 16 hours per week). The iccm costing and financing tool uses the iccm time available per CHW to calculate the total number of CHWs required to deliver the total number of services in each scenario. However, the user can override this calculation by entering a maximum and minimum number of CHWs per village or community. Rwanda s community health policy stipulates that there must be two ASCs per village (the binôme described earlier in the background section). Therefore, the number of ASCs varies only by the number of villages covered by the iccm program. Program and Coverage Assumptions As described in the background section of this report, Rwanda is currently fully scaled up in terms of geographical iccm coverage all villages in the country contain ASCs trained in iccm. Thus, for Scenario 2, the Full-Scale geographic coverage option was selected. Although the country is fully covered in terms of villages that are able to provide iccm treatments, the current levels of treatment within the geographic coverage areas are not at full scale; as a result, for Scenario 2, the Target service delivery coverage option was selected. May 2013 Page 15

25 Table 7 shows how the target geographic coverage was calculated for We began with the total actual iccm treatments in that year, then divided this total by the number of expected cases for each iccm treatment area. The number of expected cases is calculated based on the incidence rate for each disease (see next section) multiplied by the total population of children 2 59 months of age. Table 7. Calculation of current percentage of service delivery coverage Number of actual iccm treatments (2010) Number of expected iccm cases full coverage % of expected iccm cases treated Diarrhea 86,297 5,060,631 2% Pneumonia 76, ,326 16% Malaria 553, ,651 59% For the remaining program years, the Service Delivery Coverage was gradually increased to the following targets: treating 30% of diarrhea cases by 2015; treating 45% of pneumonia cases by 2015; and treating 85% of malaria cases The final-year targets are based on incremental 5% annual increases from the initial level of service delivery coverage. These targets are based on assumptions of what could reasonably be achieved and are not based on MOH targets. All cases calculated based on these targets are assumed to be treated by ASCs through iccm. Incidence Rates for the iccm Interventions Prices According to Rwanda s 2011 Annual National Quantification Report, the incidence rate of diarrhea is 3 episodes per child per year. For the remaining treatment areas, we used internationally recognized incidence rates in sub-saharan Africa: 0.56 episodes per child per year for malaria 15 and 0.28 episodes per child per year for pneumonia. 16 These rates can be easily updated in the model if other figures become available. All data were collected for the baseline year 2010, including prices of medicines, salaries, and training. 17 Salaries in the model were increased on a yearly basis by 2% to reflect inflation. 15 Eline Korenromp, Arantxa Roca-Feltrer, and Ilona Carneiro, Malaria Incidence Estimates at Country Level for the Year 2004 (Geneva: World Health Organization, Roll Back Malaria, March 2005). 16 Eline Korenromp, Arantxa Roca-Feltrer, and Ilona Carneiro, Malaria Incidence Estimates at Country Level for the Year 2004 (Geneva: World Health Organization, Roll Back Malaria, March 2005). 17 The exchange rate of 604 RWF per 1 USD was used for all currency conversions. May 2013 Page 16

26 Standard Treatment Guidelines The model focuses on the three key iccm interventions provided by Rwanda s ASCs: for malaria, diarrhea, and pneumonia. Specifically, the model focuses on the curative services provided by the CHWs (i.e., the costs associated with treating these illnesses, such as the drug costs and salary costs on time spent per service) and does not include the costs associated with preventive services. There are two key reasons for not including preventive costs in the model. First, all CHW s, not just the binôme pair, provide preventive services as part of their normal job duties (see Table 1). As a result, these services are not included as a cost specific to the iccm program. Secondly, binôme pairs tend to focus on diagnosing and treating cases only when sought out by caregivers, and they typically provide general promotional and preventive services the rest of the time. Their diagnostic and treatment time is the time accounted for in the model; calculating the costs associated with preventive activities (such as encouraging breastfeeding to prevent diarrhea and providing bed nets to prevent malaria) is beyond the scope of the model. 18 We obtained the cost of one treatment per illness by consulting an expert group (see Table 8). Annex E provides further details on how we calculated the costs estimates, including the unit cost per drug (listed in both RWF and USD). Table 8. Standard treatment guidelines Average time to treat one patient (minutes) Medicines/supplies needed Diarrhea < 5 35 ORS (4 sachets) Zinc (10 mg) Pneumonia < 5 45 Amoxicillin (125 mg) (dosage varies by age/weight) Malaria < 5 55 PRIMO Red PRIMO Yellow RDT Average drug cost per episode (USD) On the basis of current assumptions input into the model, ASCs would have 1/3 or 33% of their total working time available for preventive and promotional activities. May 2013 Page 17

27 5. Analysis ASC Time on iccm Activities Utilization As reported in the previous section, we found that actual time spent by ASCs on iccm-specific activities was very low an average of about 0.2 hours per week, or 1% of the total time they spent on ASC work overall. This figure represents the actual time spent, but not the available time that could be spent, on providing iccm services. Therefore, we decided that it would not be appropriate to constrain the ASC s availability to deliver iccm services to 1% of their time. Instead, we made an assumption that two-thirds of the total time available for ASC activities could be spent on iccm-specific activities. This assumption results in an approximate iccm percentage allocation of 67%, which is applied to certain cost calculations in the model. For example, only a portion of general costs incurred for the community health program should be attributed to the iccm program; the model calculates a 67% allocation of general cost toward iccm. In another instance, the tool calculates the total amount received by the ASCs in quarterly PBF incentives, and then multiplies this figure by 67% to determine the portion that will be allocated to the iccm program cost. The iccm percentage allocation of 67% is based on our assumptions and can be easily updated in the model if the MOH develops standards for the amount of time ASCs should spend on iccm activities. A sensitivity analysis using an iccm percentage allocation of 50% shows that total iccm program costs and per-service costs decreased by approximately 7%, compared with the 67% scenario. As noted in the background section, the results shown in this report are based on full-scale geographic coverage and target service delivery coverage. Table 9 shows the actual figures for 2010 and the targets that were entered into the iccm costing and financing model for the three iccm interventions for the remaining years. These figures are illustrative targets developed by the authors. Based on these targets, in combination with the incidence rates and the population covered, the total number of cases is estimated for each program year. Finally, the table shows the total cases per capita (for children 2 59 months of age). May 2013 Page 18

28 Table 9. Number of iccm services and services per capita, target service delivery coverage scenario, Actual 2012 Projected iccm service delivery targets (% of total cases treated) 2013 Projected 2014 Projected 2015 Projected 2016 Projected Diarrhea 2% 10% 15% 20% 25% 30% Pneumonia 16% 25% 30% 35% 40% 45% Malaria 59% 65% 70% 75% 80% 85% Total number of iccm cases Diarrhea 86, , ,760 1,102,759 1,418,424 1,751,470 Pneumonia 76, , , , , ,206 Malaria 553, , , , , ,333 TOTAL 716,871 1,274,075 1,653,960 2,054,808 2,477,514 2,923,009 Number of iccm cases per capita (children 2 59 months) Diarrhea Pneumonia Malaria TOTAL The current National Community Health Policy of Rwanda stipulates that two ASCs should work in each village, providing iccm treatments in addition to preventive and promotional services. It has been reported that all villages in the country are currently covered with functional ASCs, so the total number of ASCs does not vary by program year. However, the iccm costing and financing tool shows the average number of services provided per ASC in each program year (Table 10). In the first program year, ASCs provide an average of 0.08 iccm services per day, amounting to approximately 1 service every two weeks, assuming a six-day work week. In the final year, because of higher utilization targets, this figure would increase to 0.32 services per day, averaging almost 2 services per day. These results suggest that ASCs may currently be underutilized and could provide more services. May 2013 Page 19

29 Table 10. iccm and ASC figures for the target service delivery coverage scenario, Total # ASCs 29,674 29,674 29,674 29,674 29,674 29,674 Total # of iccm cases 716,871 1,274,074 1,653,960 2,054,808 2,477,514 2,923,009 # annual iccm services per ASC # daily iccm services per ASC ASC/1,000 pop (<5) Costs Start-up Costs Although the Rwandan iccm program expanded to the national level in 2009 from the three iccm treatment areas, we have estimated the start-up costs required to train and equip all the ASCs to provide iccm services. These start-up costs are shown in Table 11 and are not included as part of the unit costs per service. The majority of start-up costs were generally incurred before the baseline program year (shown in the Start-Up column). The remaining program years still have some start-up costs because additional ASCs will need to be trained and equipped due to job attrition. Table 11. iccm program start-up costs for the target service delivery coverage scenario (USD) Start Up Number of villages covered 14,837 14,837 14,837 14,837 14,837 14,837 Total number of ASCs 29,674 29,674 29,674 29,674 29,674 29,674 required Number additional ASCs to be trained and equipped a Training cost of new ASCs 8,135, , , , , ,137 Equipment costs for new 3,171,286 31,713 31,713 31,713 31,713 31,713 ASCs TOTAL COST 11,307, , , , , ,850 a Additional ASCs required to cover loss due to attrition from previous year. 19 These figures decrease over the years because of population growth. May 2013 Page 20

30 Recurrent Costs Table 12 shows the total recurrent costs for the iccm program, based on the target service delivery scenario described above. Starting at approximately US$4.8 million in 2010, the program cost would increase to US$6.1 million by Overall, drug costs constitute the majority of iccm program expenditure, at an average of 27% of all costs over the life of the program. Training also absorbs a large portion of total costs, averaging 22% of the total, followed by ASC equipment costs at 14% of the total. Due to the flat number of ASCs per year, most recurrent costs do not change significantly medicines are the only costs that increase steadily from one year to the next, because of increased numbers of services. Drug costs are calculated based on the standard medicines required per iccm service multiplied by the total number of each iccm service. Although ASCs are not paid a salary, they receive incentives through the C-PBF system. These incentives are not specific to iccm, and therefore we applied the standard iccm percentage allocation of 67% to the total PBF incentives. The PBF incentives are further split between direct salary and indirect salary (incentives). Direct salary is calculated by multiplying the ASC salary per hour by the total number of hours spent directly treating iccm cases. The remaining portion of ASC salary is considered to be indirect salary. This amount constituted a high proportion of the total costs, representing an average of 18% of all recurrent costs. Management costs are generally defined as central level or partner organization salary costs for staff involved in managing the iccm program. This staff does not directly supervise ASCs, but rather provides support to the iccm program, such as organizing trainings, attending technical working group meetings, or overseeing drug supply chains. These costs are calculated by applying a percentage of time spent on iccm management to the total salary for each staff member. The percentage of time spent on iccm was based on each person s own estimate; in some cases, when this data were not available, we used the 67% iccm percentage allocation instead. We have adjusted all salaries for inflation for the projection years, assuming a 2% increase per year. Supervision costs are the costs of staff based in health centers and district hospitals who directly supervise ASCs. At each of these levels, there is an In-Charge of Community Health who conducts the supervisory visits. Because these visits are meant to supervise community health in general, we applied the 67% iccm percentage allocation to the In-Charge salary. We estimated meeting and training costs based on the average cost per ASC participant, plus other associated costs, from previous trainings and meetings supported by partner organizations. Each meeting or training session was specified as being either iccm-specific or general to ASCs. If the former, the full costs of the meeting or training session were included; if the latter, the 67% iccm percentage allocation was applied to the costs. Recurrent training costs made up a high proportion of the total costs (25% in the first year) due to the assumption that all ASCs received annual refresher training on iccm, at an average cost of US$40 per ASC per training session. We calculated the total cost of iccm equipment provided to ASCs by identifying each piece of equipment provided, its unit cost, and its replacement frequency throughout the life of the iccm project. Equipment costs fluctuate from year to year because some equipment is replaced on an annual basis, while other equipment is replaced every two to three years. May 2013 Page 21

31 Direct Costs Table 12. Total recurrent costs for actual and 100% coverage scenarios, (USD) Actual Services 2010 Target services 2011 Target services 2012 Target services 2013 Target services 2014 Target services 2015 medicines 1,042,758 1,249,232 1,414,677 1,588,667 1,771,560 1,963,723 % of total cost 22% 25% 29% 30% 33% 34% Direct salary (PBF incentives) 24,560 39,640 50,774 62,915 76,135 90,511 % of total cost 1% 1% 1% 1% 1% 2% Indirect Costs Indirect salary (PBF incentives) 941, , , , , ,114 % of total cost 20% 18% 18% 17% 17% 16% Management 512, , , , , ,096 % of total cost 11% 10% 10% 10% 10% 9% Supervision 79,449 81,038 82,659 84,312 85,998 87,718 % of total cost 2% 2% 2% 1% 2% 1% Meetings 343, , , , , ,904 % of total cost 7% 7% 7% 6% 6% 6% Training 1,190,989 1,190,989 1,190,989 1,190,989 1,190,989 1,190,989 % of total cost 25% 23% 23% 21% 21% 20% Equipment 648, , , , , ,042 % of total cost 14% 17% 12% 15% 11% 14% TOTAL 4,784,409 5,245,586 5,219,282 5,649,235 5,641,662 6,091,097 May 2013 Page 22

32 7,000,000 Figure 2 shows the total recurrent costs broken down by the administrative level at which they are incurred (central, province, district, sector, and community level). As expected, the majority of costs are spent at the community/village level, constituting an average of 63% of the total costs across the program years. However, there is also significant cost allocation at the provincial level, averaging 23% of the total costs, due to the annual refresher training sessions that are hosted for all ASCs in each province. Costs at the remaining levels are minimal by comparison. Note that NGO program management costs, in addition to the MOH/IMCI unit management costs, are also included at the central level. The fluctuation in costs from year to year at the community/village level is due to the changing cost of equipment; as noted above, certain items are replaced every two to three years. By contrast, the costs incurred at the central, provincial, district, and health center levels remain constant from program year to year, as they are indirect costs. Figure 2. Total recurrent costs by administrative level, (USD) 6,000,000 Community Level (Village) 5,000,000 4,000,000 3,000,000 2,000,000 Sector (Health Center) District Province 1,000,000 Central May 2013 Page 23

33 7,000,000 Figure 3 shows the total recurrent costs attributed to each of the three iccm treatment areas for the iccm program. Indirect recurrent costs were allocated to diarrhea, pneumonia, and malaria treatment based on the proportion of time required for treatment of each disease, divided by the total time required for all treatment. Overall, malaria is the most costly of the three interventions across all program years, accounting for approximately 64% of total recurrent costs over the life of the program. This large percentage is expected, because the current service delivery coverage for malaria is higher than for the other two iccm services. Diarrhea treatment accounts for 28% of total recurrent costs, while pneumonia treatment accounts for only 8%. Figure 3. Total recurrent costs attributed by iccm treatment areas, (USD) 6,000,000 5,000,000 4,000,000 3,000,000 Malaria <5 Pneumonia <5 2,000,000 1,000,000 Diarrhea < May 2013 Page 24

34 Table 13 shows the average cost per service for diarrhea, pneumonia and malaria by program year. Malaria was the most costly service, at an average of US$4.88 per treatment, compared with US$3.10 for pneumonia and US$2.06 for diarrhea. The main driver for the high malaria cost is the relatively higher drug costs due to antimalarials and RDTs. These per-service costs can be compared with our previous iccm costing study in Malawi, where we found average costs per service as follows: US$2.38 for malaria, US$1.70 for pneumonia, and US$2.44 for diarrhea. Note that the cost per malaria treatment is lower, probably because Malawi did not use RDTs for malaria diagnosis. By the final program year, 2015, the cost per service in Rwanda was US$1.27 for diarrhea, US$2.08 for pneumonia, and US$3.63 for malaria. Table 13. Cost per service, iccm interventions, (USD) AVERAGE Diarrhea Drug cost per service Direct salary (PBF incentive) cost per service Indirect cost per service Diarrhea < 5 cost per service Pneumonia Drug cost per service Direct salary (PBF incentive) cost per service Indirect cost per service Pneumonia < 5 cost per service Malaria Drug cost per service Direct salary (PBF incentive) cost per service Indirect cost per service Malaria < 5 cost per service May 2013 Page 25

35 Figure 4 shows the average recurrent cost per service for pneumonia, diarrhea, and malaria, broken down by major cost category medicines, direct salary, and indirect cost. Overall, indirect costs account for the majority of the cost per service, followed by medicines. ASCs are not paid a formal salary, but instead receive quarterly incentives from the C-PBF system in place. As previously mentioned, drug costs for malaria treatment are significantly higher than for the other two iccm services, mainly due to the use of antimalarials and RDTs. Figure 4. Average recurrent cost per iccm service (USD) Indirect Cost Direct Salary Drug Cost Diarrhea <5 Pneumonia <5 Malaria <5 May 2013 Page 26

36 Figure 5 shows the total comprehensive program costs for Rwanda s iccm program, based on full geographic coverage and an increasing target coverage level for each service that the ASC provides in the community. The estimated start-up costs for ASC and iccm training are shown separately. Figure 5. Annual program cost by input, (USD) 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000, START-UP Start-up Equipment Training Meetings Supervision Management Indirect Salary Direct Salary Drugs May 2013 Page 27

37 6. Conclusion Rwanda s iccm program spans the entirety of the country, covering all districts and villages with almost 30,000 trained CHWs. Unlike other countries iccm programs, which serve predominantly remote areas that do not otherwise have access to health facilities, Rwanda s program covers the country evenly, and the CHWs often serve as a direct relay between the village and the nearest health center. Due to the large network of health centers in Rwanda, a significant proportion of curative services are provided at the health center level, and not by CHWs. In 2010 health centers treated 67% of Rwanda s diarrhea cases, versus 33% that were treated by CHWs. Likewise, health centers treated 66% of pneumonia cases. However, the vast majority of malaria cases (80%) were treated by CHWs in the community. Even with the high number of treatments at health centers and by CHWs, there remains a gap between what is currently being treated and what should be treated, according to incidence norms for the three main childhood diseases. Overall, only 2% of the predicted number of diarrhea cases for children under five were treated, whether by CHWs or at a health center. Only 16% of expected pneumonia cases were treated, and 59% of expected malaria cases were treated. Our model shows that CHWs in Rwanda are currently operating at a very low level of utilization (0.08 treatments per day, amounting to about 1 case treated every two weeks). Therefore, there is room to increase the uptake of curative cases at the community level and thereby narrow the gap between the current utilization and the expected utilization. As there is already a system in place of trained CHWs, increasing the number of services provided by CHWs could lead to substantial gains. A second issue that our costing model identified is the high indirect costs per service for the iccm program. This issue is linked to the first issue: as utilization increases indirect costs decrease on a perservice basis. On average, indirect costs consume 93% of the cost of a diarrhea service, 78% of a pneumonia service, and 60% of a malaria service. Much of the indirect costs are training and equipment costs. In addition, the cost of CHWs idle capacity was another significant contributor to these high indirect costs. We calculated idle capacity as the salary cost (or in Rwanda s case, PBF incentive cost) paid to CHWs when they were not directly providing services. Once again, as the number of curative cases provided by CHWs increases, this idle capacity cost will decrease because the workers will be more productive. If this analysis is indeed correct, increasing utilization levels, as well as exploring less costly ways to provide management and supervision should be priorities. Information collected during this study, however, indicates that it is important to analyze some possible constraints to increasing utilization in particular, stock-outs of medicines and supplies, ASC competencies, financial access barriers related to user fees and insurance, and the use of performance-based incentives. The main purpose of this work was to test the tool, and a small sample of facilities and community health workers was used for that purpose. That sample was too small for the resulting data to be representative of the program as a whole; consequently, the results of the modeling described in this report should be considered merely illustrative. Nevertheless, we believe that these results can be useful to the MOH and its partners, and the figures in the tool can be updated as desired. May 2013 Page 28

38 The testing of the iccm Costing and Financing Tool showed that it can be used to analyze a number of alternative scenarios, such as increased utilization, to determine how a country s iccm program can be best used to achieve national targets and goals. In general, the tool fit Rwanda s needs well, although some minor changes were made to the tool and data collection questionnaires as a result of this test. The questionnaires were updated to include more detailed templates for meeting and training costs, as well as a template for ASC time usage over the past week of service provision (see Annex C for detailed questionnaires). The iccm tool was updated to include room for an ASC supervisory cadre, which provides iccm services but also plays an overall supervisory role. As Rwanda s situation changes and improved data are made available, the figures in the tool can be updated to provide more accurate projections of iccm program costs. May 2013 Page 29

39 References 1. Jarrah, Z., Lee, A., Wright, K., Schulkers K, and D. Collins Costing of Integrated Community Case Management: Malawi. Submitted to USAID by the TRAction Project: Management Sciences for Health. 2. Barat, L. et al. External Evaluation of the Pilot Phase of the Home-Based Management of Malaria Program in Rwanda: Final Report. Kigali: USAID/BASICS, USAID/RPM Plus, Integrated National Malaria Control Program, Rwanda: Korenromp, Eline, Arantxa Roca-Feltrer, and Ilona Carneiro, Malaria Incidence Estimates at Country Level for the Year Geneva: World Health Organization, Roll Back Malaria, March Accessed from: 4. Republic of Rwanda, Ministry of Health. C-IMCI Rapid Evaluation Report Draft. Kigali: June Community IMCI/CCM: Evaluation Report of Community Health Workers Performance. Kigali: Community Performance-Based Financing User Guide. Kigali: January National Community Health Strategic Plan Kigali: Date Unknown. 8.. The National Community Performance-Based Financing and Conditional In-Kind Transfers Program Implementation Manual. Kigali: June Rudan, Igor, Cynthia Boschi-Pinto, Zrinka Biloglav, Kim Mulholland, and Harry Campbell. Epidemiology and Etiology of Childhood Pneumonia. Bulletin of the World Health Organization 86 (May 2008): The Earth Institute. One Million Community Health Workers: Technical Task Force Report. New York: The Earth Institute, Columbia University, May 2013 Page 30

40 Annexes Annex A. Districts and Health Centers Sampled Annex B. People Contacted Annex C. Questionnaire Templates for District, Health Facility, and Community Level Annex C1. Central Level Questionnaire Annex C2. District Hospital Questionnaire Annex C3. Health Center Questionnaire Annex C4. Community Level Questionnaire Annex C5. ASC Time Template Annex C6. Training/Meeting Template to Collect Information about Each of the Training Sessions Held at All Levels of the Health System That Binômes Are Expected to Attend Annex D. Sample ASC Reporting Form Annex E. Standard Treatment Guidelines Annex F. Total Costs of iccm Program in Rwandan Francs (RWF) May 2013 Page 31

41 Annex A. Districts and Health Centers Sampled District Health Center (HC) HC catchment # of cells in HC catchment area # of villages in HC catchment area Average population per village surveyed (range) Average population per ASC per village surveyed (range) Average # of house-holds per village surveyed Average # of house-holds per ASC Average # of hours per day ASC works (range) Average # of days per week ASC works (range) Burera Gitare HC 18, ( ) Gakenke Ruli HC 17, ( ) n/a (3 8) ( ) a (3 6) 5 (3 7) 4.3 (2 7) Gisagara Save HC 27, ( ) 194 ( ) (2 4) 6.3 (4 7) Kamonyi Nyagihamba HC 23, ( ) 241 ( ) (2 3 ) 6.5 (6 7) Karongi Rubingera HC 22, ( ) 397 ( ) (1 6) 5 (1 7) Kayonza Kabarondo HC 26, ( ) 238 ( ) (4 8) 7 (7) Kicukiro Masaka HC 28, ( ) 184 b ( ) (1 4) 7 (7) Ngororero Muramaba HC 13, ( ) 617 ( ) (1 4) 5.8 (2 7) Rwamagana Rwamagana HC 34, ( ) 289 ( ) (2 4) 7 (7) TOTAL AVERAGE 23, c RANGE 13,531 34, a In one village in Gakenke, ASCs shared the target population (e.g., they did not split the population by the total # of ASCs). Therefore, the average population per ASC is equivalent to the total population in the village. b Villages in Kicukiro District reported the average population per ASC for children under five years of age, not the total population (e.g., whole village). c Does not include Kicukiro District because population was reported only for children under five years of age. May 2013 Page 32

42 Annex B. People Contacted PARTNER ORGANIZATIONS CAMERWA Ignace Ndekezi, In Charge of Procurement Concern International Rose Luz, Health Team Leader Global Fund Simeon Munyambaraga, Global Fund Manager, Community Health Desk IHSSP Pierre-Corneille Namahoro, Deputy Chief of Party Eric Kalisa Salongo, Contracts Specialist, MSH Cedric Ndizeye, Senior Advisor for PBF and M&E Mbombo Wathum, Senior Program Associate Randy Wilson, Senior HMIS Advisor Alice Kalisa, CBHI Technical Specialist Job Nkulikiyinka, Operations Manager Felix Nzitatira, Logistics Assistant Peace Munezero, Logistics Coordinator Josephine Bucagu, Program Coordinator Bernard Bizumuremyi, Senior Accountant Staney Gahamanyi, Fleet Coordinator IRC Sarah Cohen, Health Coordinator Eliane Ndererimana, Health Manager MCHIP Dr. Christopher Mazimba, Sr. Technical Advisor Dr. William Twahirwa, M&E Advisor Jean Modeste Harerimana, IMCI/Pediatric HIV Technical officer Dr. Ahoranayezu Jean Bosco, Child Health Team Leader Jean Baptiste Musafili, CCM/RDT Technical Officer Anne Marie Mutegwaraba, CCM/RDT Technical Officer National Malaria Control Program Corine Karema, Director Partners in Health Didi Bertrand, Director, Community Health Department Tisha Mitsunaga, Community Health Research Assistant PMI Patrick Condo, Malaria Program and Other Infectious Disease Specialist Eric Tongren, CDC Resident Advisor UNICEF Rwanda Denise Ilibagiza, Health Officer Deguene Fall, Deputy Representative Dr. Friday Nwaigwe, Chief of Health and Nutrition Program May 2013 Page 33

43 Annex C. Questionnaire Templates for District, Health Facility, and Community Level May 2013 Page 34

44 Annex C1. Central Level Questionnaire CENTRAL LEVEL COLLECTION QUESTIONNAIRE Date of interview: Name of interviewer: Location of interview: Name of district: Name of person interviewed: Title: Contact information Phone Number DOCUMENTS National IMCI Policy/Strategic Plan CHW job description policy document General job description for all CHWs Specific job description for CHWs involved in IMCI (ASCs) List of activities expected to be carried out by CHWs Hours/month spent on travel Hours/month spent on supervision meetings Hours/month spent on other meetings Hours/month spent on training Hours/month spent on reporting, etc. Hours/month spent on other activities What health services are CHWs expected to provide? In addition to IMCI services, do CHWs provide additional community services? (health promotion, immunization, family planning, water & sanitation activities, etc). Is the package of services different depending on the cadre of CHWs? CHW reporting structure CCM reporting forms List of drugs and supplies given to CHWs During start-up (one time, start supplies) Ongoing and recurring drugs and supplies Are CHWs expected to have a certain time allocation for their range of activities? How much time are they expected to spend on individual activities throughout the course of a week, month, year (calendar)? May 2013 Page 35

45 IMCI PROGRAM BACKGROUND What is/are the cadre(s) of health care workers providing CCM services in Rwanda? Where do these health care workers work from? (facilities or communities) Who is the direct supervisor of the CHWs? Describe the reporting structure from the CHW to the Director of Community Services at the MOH. How do the services provided by CHWs get recorded and reported to the HMIS? Can we obtain a soft copy of the CCM HMIS? Can we obtain copies of all CCM reporting forms? Is there a standard form that they fill out? If so, where does it get submitted to? And how is it reported in the national HMIS information? Are facility-based and community services aggregated in reporting? What are the drugs and supplies provided to each CHW providing CCM services? What is the process in which CHWs request restocking of drugs? What is the process in which CHWs receive drugs and supplies? What is the desired CHW-to-population ratio? What is the rationale for the ratio? What is the expected number of people/households/villages in each CHW's catchment population? What is the actual average catchment population that one CHW serves? What percent of the country is covered by CHWs? (What % of the total population is served by CHWs?) Current coverage rates Desired coverage rates Key partners in the IMCI program (government, NGOs, civil society, major donors) What are their roles/what sorts of inputs do they provide to the IMCI program? What is the 5-year financing strategy for the IMCI program? What coordinating mechanisms are in place at the central level to avoid duplication of efforts and leverage of resources for the CCM program? HEALTH CARE PROFESSIONALS INVOLVED IN IMCI What staff are involved in Rwanda's IMCI program? What level do they work at? (central, district, health center, village, community) What roles to they play at each level? (IMCI service provision, supervision, training) What are the salaries and sources of funding for each of these individuals? What percent time do these individuals spend supervising CHWs? May 2013 Page 36

46 IMCI PROGRAM TRAINING Describe the training that individuals must undergo in order to become a CHW. (This includes one- time trainings and any recurrent trainings that are expected for CHWs.) Are there additional trainings to provide IMCI services? Describe ongoing/follow-up/refresher trainings that are expected for CHWs. For each training identified, describe the following: Number of people trained per training Trainers cadre and number per training Additional attendees (supervisors, mentors, government officials) Costs associated with training Facility rental Per diems Transport Fuel costs Supplies Refreshments Location of training Who paid/sponsored the training Number trained to date in each training IMCI PROGRAM MEETINGS Describe the meetings that individual CHWs are expected to attend. (This includes supervisory meetings, district level meetings, national meetings on IMCI.) For each meeting identified, describe the following: Number of people trained per training Trainers cadre and number per training Additional attendees (supervisors, mentors, government officials) Costs associated with training Facility Rental Per diems Transport Fuel costs Supplies Refreshments Location of meeting Who paid/sponsored the meeting May 2013 Page 37

47 IMCI PROGRAM SUPERVISION Who is the direct supervisor for the CHWs? What are the range of meetings that CHWs are expected to have with their supervisor? For each supervisory meeting, please describe the following: At what level does that meeting occur? Who attends that meeting? Length of meetings Associated meeting costs travel, per diems, food, etc. IMCI STATISTICS National population size National population growth rate Target population sizes Children under 5 Children under 1 Pregnant women Number of IMCI services provided at the community level Malaria Diarrhea Pneumonia Number of IMCI services provided at the health center level Malaria Diarrhea Pneumonia Incidence/prevalence of target conditions Malaria Diarrhea Pneumonia May 2013 Page 38

48 CHW TIME AVAILBILITY & SALARY INFORMATION Do they get national holidays off? If so, how many national holidays? What is the sick/vacation policy? Do CHWs get paid for sick/vacation? How many hours a day do they work? How many days/week? What is the average salary? Describe any bonus/top up/pbf incentive that CHWs receive. What is the average % wage increase? (annual) Do CHWs receive incentives? If so, what items and what are the costs? Is there any essential equipment for the job that they receive? If so, what is the cost? What is the annual CHW attrition rate per year? ADDITIONAL INFORMATION What are the standard treatment guidelines for the services provided by CHWs? What are the historical costs for the IMCI program? Are there established costs/budgets for years going forward? What are the start-up costs related to the IMCI program in Rwanda? Total number of districts in Rwanda Total number of health facilities in Rwanda What is the source of the PBF prime to the health centers? MOH account? District hospital accounts? Where did that money originate? Partners? Rwanda's own revenue? May 2013 Page 39

49 Annex C2. District Hospital Questionnaire DISTRICT QUESTIONNAIRE Date of interview: Name of interviewer: Location of interview: Name of district: Name of person interviewed: Title: Contact number: Health center: Health center contact information What time did the interviewer begin this interview? Period of analysis: Start Date (MM/YY) End Date (MM/YY) District hospital information 1) Location of district (rural, urban) 2) Catchment population 3) How many health centers report to this district hospital? 4) What is the name of the selected health center? 5) How many cells are in the sector of the selected health center? 6) How many villages are in the sector (of the selected health center)? 7) What partners support C-IMCI at this district hospital? Staff background information Who at the District Hospital is involved in the community health program? (C- 1) IMCI) If staff is not working full-time on community health, estimate days per week 1a) working on C-IMCI. 2) What grade are each of the above-named staff? 3) What is the source of funding for the staff salary? 4) What is the total monthly salary (including allowances, PBF prime, etc.) of the above-named staff? 5) What is the start and end time of your working day at the district hospital? 6) How many days per week? 7) What is the approximate number of days taken for sick/vacation in the past year? May 2013 Page 40

50 Training/meetings 1) List (on the template) the community health training or meeting sessions that were held by the district hospital in the past year. 2) Complete the Training/Meeting template for each relevant training (C-IMCI). Supervision 1) Title of staff who conduct supervision for C-IMCI 2) Confirm if supervision is only for C-IMCI or for broader community services (i.e. maternal, HIV, TB). 3) Where do the supervision visits take place? District hospital, HC, or village? 4) How often are supervision meetings? How many hours does each supervision visit last (including travel, if 5) applicable)? Reporting 1) Who completes the reporting for C-IMCI? 2) How much time do the staff spend on reporting per month? Expenditure 1) Does this district hospital provide any other financial support for C-IMCI? (yes/no) (i.e., ASC appreciation day, t-shirts) 2) If so, what support and in what amounts? What was the source of the financial support? (Partners, MOH, hospital's own 3) revenue) User Fees 1) Does this district hospital receive user fees from ASCs for treatment in the community? (yes or no) 2) If yes, how often were these user fees collected? 3) How much was collected per month? Per quarter? 4) How does the district hospital use these user fees? What time did the interviewer conclude the interview? How long (minutes/hours) was this interview? May 2013 Page 41

51 Annex C3. Health Center Questionnaire HEALTH CENTER QUESTIONNAIRE Date of interview: Name of interviewer: Location of interview: Name of district: Name of person interviewed: Title: Contact number: Name of District: Name of sector: Name of health center: What time did the interviewer begin this interview? Period of analysis: Start Date (MM/YY) End Date (MM/YY) Health center information 1) What partners support C-IMCI at this health center? 2) Location of health center (rural, urban) 3) Catchment population of this health center 4) Number of cells in sector (of this health center) 5) Number of villages in sector (of this health center) Staff background information 1) List of staff that supervise ASCs 2) In addition to C-IMCI, what other activities do you participate in at the HC? 3) Estimate what percentage of your time you spend on C-IMCI. (days per week) 4) Does the secondary supervisor provide supervision related to C-IMCI? (ONLY if yes, continue with all questions below for that staff.) 5) What is the total monthly salary (including allowances, PBF prime, etc.) of the above-named staff? 6) What is the grade of the above-named staff? 7) What is the start and end time of your work day? 8) How many days do you work per week? 9) What is the approximate number of days taken for sick/vacation in the past year? May 2013 Page 42

52 Training/Meetings 1) How many ASC/C-IMCI (general) training sessions held by the health center in the past year? 2) For each training, please refer to the Training/Meeting template and ask to see training records kept at HC. Supervision 1) If two staff provide supervision, do both participate in all supervisions at HC and villages? (yes/no) 2) How often do ASCs come to the health center for supervision? 3) How many hours does each supervision visit at the health center last? 4) How often do staff go to the villages for supervision visits? 5) How many hours does each supervision visit in the village last (including travel)? Reporting 1) Who completes the C-IMCI reporting at this health center? 2) How many hours per month are spent compiling reports from ASCs in all villages? Expenditure 1) Does this health center provide any other financial support for C-IMCI? 2) If so, what support and in what amounts? What is the source of this financial support? (Partners, MOH, or HC-generated 3) revenue) User Fees Does this health center receive user fees from ASCs for treatment in the 1) community? 2) If yes, how often were these user fees collected? 3) How much was collected per month? Per quarter? 4) How does the health center use these user fees? What time did the interviewer conclude the interview? How long (minutes/hours) was this interview? May 2013 Page 43

53 Annex C4. Community Level Questionnaire AGENT DE SANTÉ COMMUNAUTAIRE QUESTIONNAIRE Date of interview: Name of interviewer: Location of interview: Name of person interviewed: Title: Sex (M/F): District: Sector: Cell: Name of umudugudu/village: Supervising health center: Month/year when ASC began providing C-IMCI: What time did the interviewer begin this interview? Period of analysis: Start Date (MM/YY) End Date (MM/YY) A) Catchment area served 1) Catchment population (zone de rayonnement), village 2) Catchment population (zone de rayonnement), per ASC 3) Total number of households (village) 4) Total number of households (per ASC) 5) What is the number of households covered by this ASC? B) Time availability and contacts 1) How many hours per day do you spend working as an ASC? 2) How many days per week? 3) How many days are you sick and not working, or away from the village? 5) Fill out ASC time template. C) Supervision 1) With what frequency do you travel to the HC for supervision visits and picking up drugs? 2) Do you spend the entire day on the supervision visit and travel? May 2013 Page 44

54 D) Training/Meetings 1) Refer to the Training/Meeting template, but complete only the first four columns. E) Reporting 1) Estimate the number of days per month you spend compiling your monthly report. F) IMCI time per service List each type of service provided and approximate time spent per case 1) CCM, diarrhea 2) CCM, pneumonia 3) CCM, malaria G) Periodic ASC activities 1) Do you participate in additional periodic events, such as vaccination campaigns, bed net distributions, etc? 2) List each event, length of time, frequency, etc. H) Drugs, supplies, and equipment 1) For the following drugs, did you receive the drug each month of the last quarter, and did you have any stock-outs? a) Oral contraceptive pills b) Cycle beads c) Condoms d) Injectables (DMPA) e) Misoprostol f) PRIMO red g) PRIMO yellow h) Zinc i) ORS j) Amoxicillin k) Mebendazole l) RDTs m) Insecticide treated bed nets (LLINs) n) Any other drugs? Received (yes/no) Stockouts (yes/no) May 2013 Page 45

55 2) Did you receive these supplies when you began your work as an ASC? Received (yes/no) a) Drug box b) Timer c) MUAC tape d) Scale e) Other? F) Fees for service 1) Do you collect fees for service? 2) Do you collect different fees depending on the client's participation in mutuelles? 3) For each below service, what was standard fee collected? a) Malaria b) Diarrhea c) Pneumonia 4) Who is the final recipient of the fee (ASC, HC, co-op, etc)? 5) What is the average total amount collected from user fees monthly? G) Pay 1) How much was the PBF prime you received in the last quarter? 2) Do you receive any in-kind incentives? a) If yes, what kinds of in-kind incentives? b) If yes, from whom? COMMUNITY LEVEL CHECKLIST FOR DATA COLLECTORS Take one photo of: Register #2 Monthly reports for July, August, September 2011 If CHW Coordinator, also get photo for other selected ASCs. Sample Activity Report/Calendar and/or Action Plan (if available) Get sample drugs and accounts register What time did the interviewer conclude the interview? How long (minutes/hours) was this interview? May 2013 Page 46

56 Annex C5. ASC Time Template Ask ASC how many hours he or she spent on each of the activities below for every day in the past week. Suggested format for asking about the activities below: 1) Think about the activities that you do as an ASC. 3) How many hours did you spend on each activity? 2) What did you do on Monday? Tuesday? *Note: Total hours should be between 14 and 19. ASC Name: Monday Tuesday Wednesday Thursday Friday Saturday Sunday 1) Supervision meetings 2) 3) All other meetings (i.e., at co-op, etc.) Household visits health promotion 4) Travel to and from households 6) Family planning 7a) household 7b) CHW point of service 8) Nutrition 8a) household 8b) CHW point of service 9) CCM 9a) household 9b) CHW point of service 10) Reporting 11) Patient follow-up for C-IMCI 12) 13) Other health activity (i.e., HIV, TB, nonofficial HC visit, etc.) Other work/activity (non-asc work) May 2013 Page 47

57 Annex C6. Training/Meeting Template to Collect Information about Each of the Training Sessions Held at All Levels of the Health System That Binômes Are Expected to Attend Description of training or meeting Source of funding Frequency of training or meeting Length of session (days) # supervisors per per # trainers session session # trainees (ASCs) per session Total # participants per session Per diem, etc. for supervisor Per diem, etc. for trainer Per diem, etc. for trainees Rental cost per session Other costs per participant Other fixed costs TOTAL SESSION COSTS Actual expenditure on training session START-UP TRAINING* RECURRENT/REFRESH ER TRAINING** MEETINGS*** * Start-up training is considered to be any initial training required to prepare a volunteer for work as an ASC who performs IMCI. These trainings should be a one-off for each individual. ** Recurrent/refresher training is considered to be any subsequent training provided to an ASC providing IMCI. If these trainings are periodic (i.e., yearly), this should be noted. Also note that these trainings should be directly related to provision of IMCI for example, training on TB-DOTS should NOT be included. *** Note that all meetings should pertain to general supervision of ASCs and to IMCI in particular. May 2013 Page 48

58 Annex D. Sample ASC Reporting Form May 2013 Page 49

59 Annex E. Standard Treatment Guidelines The following standard treatment guidelines were developed in consultation with MSH SPS Senior Program Associate Mbombo Wathum. Drug Diarrhea Number of times/day Number of days % of cases treated Units per dose Oral rehydration salts (ORS), powder sachet % 0.25 for 1,000 ml Zinc (10 mg) tablet % 1.00 Zinc (10 mg) tablet % 1.00 Pneumonia Amoxicillin (125 mg) tablet % 1.00 Amoxicillin (125 mg) tablet % 1.00 Amoxicillin (125 mg) tablet % 1.00 Amoxicillin (125 mg) tablet % 1.00 Malaria PRIMO Red (6 tablets) % 0.17 PRIMO Yellow (12 tablets) % 0.08 Rapid Diagnostic Test (RDT) % 1.00 May 2013 Page 50

60 Annex F. Total Costs of iccm Program in Rwandan Francs (RWF) Total recurrent costs 2,889,783,262 3,168,334,227 3,152,446,582 3,412,137,651 3,407,563,628 3,679,022,612 Average cost per 4, , , , , , service Average cost per capita 1, , , , , , (children 0 59 months) Average cost per capita (total population) Direct costs Drugs 629,825, ,536, ,464, ,555,154 1,070,021,953 1,186,088,842 % of total cost 22% 24% 27% 28% 31% 32% Direct salary 14,833,984 23,942,665 30,667,690 38,000,713 45,985,492 54,668,629 % of total cost 1% 1% 1% 1% 1% 1% Indirect costs Indirect salary 568,675, ,237, ,415, ,224, ,623, ,573,048 % of total cost 20% 18% 18% 17% 17% 16% Management 309,689, ,882, ,200, ,644, ,217, ,921,731 % of total cost 11% 10% 10% 10% 10% 9% Supervision 47,987,207 48,946,951 49,925,890 50,924,408 51,942,896 52,981,754 % of total cost 2% 2% 2% 1% 2% 1% Meetings 207,718, ,718, ,718, ,718, ,718, ,718,000 % of total cost 7% 7% 7% 6% 6% 6% Training 719,357, ,357, ,357, ,357, ,357, ,357,108 % of total cost 25% 23% 23% 21% 21% 20% Equipment 391,696, ,713, ,696, ,713, ,696, ,713,500 % of total cost 14% 17% 12% 15% 11% 14% Cost per service Diarrhea 2, , , , Pneumonia 3, , , , , , Malaria 4, , , , , , May 2013 Page 51

61 Annex G. Glossary Capital expenditure: Cost benefit analysis: Cost effectiveness analysis: Costing: Direct cost: Depreciation: Economies of Scale: Fixed cost: Indirect costs: the cost for resources that last more than one year, such as building, vehicles, computers, pre service training. Sometime a price ceiling is also defined (usually $US100), below which costs are considered as recurrent. The cost of capital equipment is net of depreciation. Also called investment or non recurrent cost/expenditure. (World Health Organization - Health Systems Strengthening Glossary: a comparison of costs and achieved benefits, where both costs and benefits are expressed in monetary terms. (ibid) a form of economic evaluation where costs are expressed in money terms but consequences are expressed in physical units. It is used to compare different ways of achieving the same objective. (ibid) (i) the estimation of a specific strategy or intervention, or of an overall national policy, strategy or plan. (ii) the estimation of the cost of different scenarios, corresponding to different priorities or strategies, in the short, medium or long term. (ibid) (i) internal cost of an activity or decision including cost of labor, other goods and services, capital (usually considered as a rental value) and consumables. Direct cost excludes external costs, productivity costs, uncompensated forgone earnings and elements of cost that may be undervalued by market prices.42 (ii) all the goods, services and other resources that are consumed in the provision of a particular service or area (e.g. hospital supplies), including medical costs (e.g. payments to providers, material) and non medical costs (e.g. transportation to hospital). (ibid) the reduction in value of a capital asset through wear and tear. (ibid) the decline in average cost of each unit produced as output increases, due to the distribution of production costs and other fixed costs across a higher number of units. (ibid) A cost that does not change with variations in output. For example, the rent of a clinic building does not change with the number of patients treated (until the capacity of the clinic is reached. total sum of morbidity costs (goods and services not produced by the patient because of the illness), mortality costs (goods and services the person could have produced had the illness not been incurred and the person not died prematurely), and productivity cost (related to lost productivity incurred by an employee who leaves work to provide care for the patient). (World Health Organization - Health Systems Strengthening Glossary: May 2013 Page 52

62 Marginal cost: Opportunity cost: Recurrent expenditures costs: Variable cost: Semi-Variable Cost: Step-variable cost: the change in total cost that results from a unit increase in output. (ibid) "the value of the next best alternative forgone as a result of the decision made." (ibid) costs that refer to inputs which last less than one year and are regularly purchased for continuing an activity, such as salaries, drugs and supplies, repair maintenance, and others. (ibid) A cost that is directly proportional to the number of outputs produced. For example, in a clinic the cost of drugs can be regarded as varying directly with the number of patients treated. A cost which has a fixed element and a variable element and which varies to some degree with the volume of outputs produced. An example would be the cost of a training course which has a fixed element (the rent of the room) and a variable element (materials for the students). A cost which is fixed up to a certain volume of outputs. An example would be a nurse at a clinic who can see up to 30 patients per day. Her salary is a fixed cost when the volume is up to 30 patients. When there are 31 patients another nurse has to be hired and the salary cost increases to that of two nurses. Presented graphically these costs look like steps. May 2013 Page 53