Costing of Integrated Community Case Management in Rwanda

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

Contents Acknowledgements... iii Acronym List... iv Executive Summary... vi 1. Introduction... 1 2. Background and Country Context: Rwanda... 2 3. Methodology... 8 Tool Development... 8 Ethics... 11 Partner and Central Level Data Collection... 11 Facility and Village Clinic Data Collection... 12 Catchment Population... 13 Medicines... 14 Training... 14 4. Assumptions and Standard Data Input into the Model... 15 Population Figures... 15 ASC Availability and C-IMCI Service Delivery Assumptions... 15 Program and Coverage Assumptions... 15 Incidence Rates for the iccm Interventions... 16 Prices... 16 Standard Treatment Guidelines... 17 5. Analysis... 18 ASC Time on iccm Activities... 18 Utilization... 18 Costs... 20 Start-up Costs... 20 Recurrent Costs... 21 6. Conclusion... 28 References... 30 May 2013 Page i

Annexes... 31 Annex A. Districts and Health Centers Sampled... 32 Annex B. People Contacted... 33 Annex C. Questionnaire Templates for District, Health Facility, and Community Level... 34 Annex C1. Central Level Questionnaire... 35 Annex C2. District Hospital Questionnaire... 40 Annex C3. Health Center Questionnaire... 42 Annex C4. Community Level Questionnaire... 44 Annex C5. ASC Time Template... 47 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... 48 Annex D. Sample ASC Reporting Form... 49 Annex E. Standard Treatment Guidelines... 50 Annex F. Total Costs of iccm Program in Rwandan Francs (RWF)... 51 Annex G. Glossary... 52 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... 11 Table 5. Summary of data collection... 13 Table 6. Population figures (2010)... 15 Table 7. Calculation of current percentage of service delivery coverage... 16 Table 8. Standard treatment guidelines... 17 Table 9. Number of iccm services and services per capita, target service delivery coverage scenario, 2011 2016... 19 Table 10. iccm and ASC figures for the target service delivery coverage scenario, 2011 2015... 20 Table 11. iccm program start-up costs for the target service delivery coverage scenario (USD)... 20 Table 12. Total recurrent costs for actual and 100% coverage scenarios, 2010 2015 (USD)... 22 Table 13. Cost per service, iccm interventions, 2010 2015 (USD)... 25 Figures Figure 1. Rwanda s Community Health Program... 5 Figure 2. Total recurrent costs by administrative level, 2010 2015 (USD)... 23 Figure 3. Total recurrent costs attributed by iccm treatment areas, 2010 2015 (USD)... 24 Figure 4. Average recurrent cost per iccm service (USD)... 26 Figure 5. Annual program cost by input, 2010 2015 (USD)... 27 May 2013 Page ii

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 2013. 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

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

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

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 1995. 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

The iccm Costing and Financing Tool was used to project the costs of Rwanda s iccm program from the baseline year of 2010 through 2015. The 2010 figures were based on the actual numbers of services provided, whereas the 2011 2015 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 6.67 4.12 3.16 2.75 2.28 2.08 service Average cost per 2.84 3.02 2.92 3.07 2.98 3.13 capita (children 0 59 months) Average cost per capita (total population) 0.46 0.49 0.47 0.50 0.48 0.51 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

Table 2. Costs per service (USD) 2010 Actual 2011 Projected 2012 Projected 2013 Projected 2014 Projected 2015 Projected Diarrhea 3.64 2.49 1.91 1.69 1.38 1.27 Pneumonia 5.13 3.65 2.91 2.63 2.22 2.08 Malaria 7.36 5.55 4.64 4.29 3.80 3.63 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 2011 2015. 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

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 2013. Costing of Integrated Community Case Management: Malawi. Submitted to USAID by the TRAction Project: Management Sciences for Health. May 2013 Page 1

2. Background and Country Context: Rwanda Rwanda s MOH initiated community-based health activities in 1995. 3 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 2010 2012 (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 2010. 6 Rwanda MOH, Community IMCI/CCM: Evaluation Report. 7 Rwanda MOH, C-IMCI Rapid Evaluation Report 2010. May 2013 Page 2

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

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 100 150 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

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 100 150 HH 100 150 HH 10 150 HH 100 150 HH 100 150 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

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 2020. 10 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) 12. 10 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

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

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

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

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

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

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

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

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

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 2010 2012, 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