Cambodia
In Cambodia, the project developed a custom mobile reporting app, the Malaria Case Surveillance App (MCS), for providers to be able to report cases directly to DHIS2 through a mobile smartphone device. The project procured and equipped 585 of 710 private providers with smartphones, trained providers to report cases through the mobile app, and provided monthly data packages to the private providers to support us $263,224 annually. Economic costs included the estimated value of private provider time on the intervention and the value of DHIS2 software, a global public good supported by the University of Oslo that makes the software freely available[1] as well as private provider time spent on training and electronic and paper reporting. The costs to the payer (financial costs) are higher for mobile reporting than for introduction of electronic surveillance with DHIS2. This is due to the cost of the mobile phones and the monthly data packages. However, both costs are similar for economic costs when the value of the ‘free’ DHIS2 software are taken into account.
The largest share of financial total costs went for recurrent costs (54%), followed by start-up activities and capital goods (24% and 23%, respectively), due to the cost of the monthly mobile data packages and other costs of implementation. The largest share for economic costs was also for recurrent (48%) (see Figure 1b), followed by startup (37%).
Table 3. Financial and Economic Costs of Cambodia Electronic Surveillance Intervention and Provider Mobile Reporting Intervention
Cost Category
|
Total
Cost
|
%
|
|
|
|
Start-up
|
|
|
|
System Design and Configuration (DHIS2)
|
$ 52,933
|
12.1%
|
|
Piloting (DHIS2)
|
$ 11,545
|
2.3%
|
|
Training (DHIS2)
|
$ 7,847
|
1.5%
|
|
MCS App Design and Development
|
$24,817
|
4.9%
|
|
MCS App Piloting
|
$9,475
|
1.9%
|
|
MCS App Training
|
$8,054
|
1.6%
|
|
Surveillance Bulletin Design
|
$2,366
|
0.5%
|
|
Server Set-up
|
$150
|
0.0%
|
|
Sub-total Start-up
|
$120,616
|
23.6%
|
|
Capital
|
|
|
|
Equipment (desktops)
|
$4,800
|
0.9%
|
|
Equipment (mobile devices)
|
$112,155
|
21.9%
|
|
Sub-total Capital
|
$116,955
|
22.9%
|
|
Recurrent
|
|
|
|
DHIS2 Maintenance & Routine Upgrades
|
$22,592
|
5.1%
|
|
DHIS2 Software upgrades
|
-
|
0.0%
|
|
Data Entry
|
$71,070
|
13.9%
|
|
Server hosting
|
$7,620
|
1.5%
|
|
MCS App Maintenance & Routine Upgrades
|
$32,182
|
6.3%
|
|
Procure electronic report: Monthly mobile data packages
|
$104,580
|
20.5%
|
|
Provider Social and Behavioral Change Communication (SBCC) & Supervision
|
$35,569
|
7.0%
|
|
Sub-total Recurrent
|
$273,612
|
53.5%
|
|
Total costs
|
$511,183
|
100%
|
|
Annual Costs
|
$170,394
|
N/A
|
|
Annual Cost per mobile reporting provider (n=585 providers)
|
$291
|
N/A
|
|
Annual cost per provider (n=710 providers)
|
$240
|
N/A
|
|
Economic Costs
|
|
Start-up Costs
|
|
|
|
System Design (DHIS2)
|
$218,782
|
27.7%
|
|
Piloting (DHIS2)
|
$12,242
|
1.6%
|
|
Training (DHIS2)
|
$12,891
|
2.4%
|
|
MCS App Design and Development
|
$26,317
|
3.3%
|
|
MCS App Piloting
|
$10,048
|
1.3%
|
|
MCS App Training
|
$10,800
|
1.1%
|
|
Surveillance Bulletin Design
|
$2,508
|
0.3%
|
|
Server Set-up
|
$159
|
0.0%
|
|
Sub-total Start-up
|
$297,703
|
37.7%
|
|
Capital
|
|
|
|
Equipment (desktops)
|
$5,090
|
0.6%
|
|
Equipment (mobile devices)
|
$118,934
|
15.1%
|
|
Sub-total Capital
|
$124,024
|
15.7%
|
|
Recurrent
|
|
|
|
DHIS2 Maintenance & Routine Upgrades
|
$22,592
|
2.9%
|
|
DHIS2 Software upgrades
|
$30,000
|
3.8%
|
|
Paper-based and Electronic Data Entry
|
$110,498
|
14.0%
|
|
Server hosting
|
$7,620
|
1.0%
|
|
MCS App Maintenance & Routine Upgrades
|
$32,182
|
4.1%
|
|
Procure electronic report: Monthly mobile data packages
|
$129,483
|
16.4%
|
|
Provider Social and Behavioral Change Communication (SBCC) & Supervision
|
$35,569
|
4.5%
|
|
Sub-total Recurrent
|
$367,944
|
46.6%
|
|
Total costs
|
$789,671
|
100%
|
|
Annual Costs
|
$263,224
|
N/A
|
|
Annual Cost per mobile reporting provider (n=585 providers)
|
$450
|
N/A
|
|
Annual cost per provider (n=710 providers)
|
$371
|
N/A
|
|
|
|
|
|
|
|
Figure 1 shows a bar chart for the financial and economic costs for electronic surveillance and mobile reporting in Cambodia.
Lao Electronic Surveillance
Table 4 shows that total financial costs for the Lao intervention were $160,323, while annual costs were $53,441. Total economic costs were $399,699 while annual costs were $136,169. Economic costs also accounted for the value of the DHIS2 software and the estimated cost of providers’ personal mobile devices as in Cambodia and private provider time. For financial costs, the largest share of total costs was for recurrent costs (56%) due to the high cost of supervision (28%). Among economic costs, start-up costs had the highest share (58%) due to the inclusion of the value of DHIS2 software (42.1%). Similar to Cambodia, the financial cost of mobile reporting is higher than that of electronic surveillance.
Table 4. Financial and Economic Costs of Lao PDR Electronic Surveillance Intervention and Provider Mobile Reporting Intervention
Cost Category
|
Total Costs
|
%
|
Financial Costs
|
|
|
Start-up
|
|
|
System Design and Configuration (DHIS2)
|
$5,768
|
5.5%
|
Piloting (DHIS2)
|
$595
|
0.4%
|
Training (DHIS2)
|
$7,473
|
4.7%
|
Server Set-up
|
$150
|
0.1%
|
Surveillance Bulletin Design
|
$5,107
|
3.2%
|
MCS App Design and Development
|
$27,362
|
16.9%
|
MCS App Piloting
|
$5,659
|
3.5%
|
MCS App Training for Providers
|
$8,281
|
5.2%
|
Sub-total Start-up
|
$63,250
|
39.5%
|
Capital
|
|
|
Hardware (desktops)
|
$2,400
|
1.5%
|
Equipment (tablets for field officers)
|
$4,800
|
3.0%
|
Sub-total Capital
|
$7,200
|
4.5%
|
Recurrent
|
|
DHIS2 Maintenance & Routine Upgrades
|
$ 8,245
|
5.1%
|
Server hosting
|
$ 5,976
|
3.7%
|
MCS App Maintenance & Routine Upgrades
|
$ 12,877
|
8.0%
|
Monthly mobile data packages
|
$8,640
|
5.4%
|
Paper-based data entry
|
$7,445
|
4.6%
|
Provider BCC & Supervision
|
$44,490
|
28.0%
|
Monitoring and Evaluation
|
$ 1,750
|
1.1%
|
Sub-total Recurrent
|
$89,873
|
56.1%
|
Total costs
|
$160,323
|
100%
|
Annual Costs
|
$53,441
|
N/A
|
Annual cost per private provider (n=432)
|
$124
|
N/A
|
Annual cost per private provider reporting by mobile (n=250)
|
$214
|
N/A
|
Economic Costs
|
Startup Cost
|
|
|
System Design and Configuration (DHIS2)
|
$168,446
|
36.8%
|
Piloting (DHIS2)
|
$631
|
0.1%
|
Training (DHIS2)
|
$13,243
|
2.9%
|
Server Set-up
|
$159
|
0.0%
|
Surveillance Bulletin Design
|
$5,415
|
1.2%
|
MCS App Design and Development
|
$28,781
|
6.2%
|
MCS App Piloting
|
$6,001
|
1.3%
|
MCS App Training for Providers
|
$10,156
|
2.2%
|
Sub-Total Startup
|
$ 232,833
|
50.8%
|
Capital
|
|
|
Hardware (desktops)
|
$2,545
|
0.6%
|
Equipment (tablets for field officers)
|
$5,090
|
1.1%
|
Equipment (provider smartphones)
|
$ 39,767
|
8.7%
|
Sub-total Capital (annual)
|
$ 47,402
|
10.3%
|
Recurrent
|
|
|
DHIS2 Maintenance & Routine Upgrades
|
$ 8,245
|
1.8%
|
DHIS2 Software Upgrades
|
$30,000
|
6.5%
|
Server hosting
|
$ 5,976
|
1.3%
|
MCS App Maintenance & Routine Upgrades
|
$ 12,877
|
2.8%
|
Monthly mobile data packages
|
$12,177
|
2.7%
|
Paper-based and Electronic Data Entry
|
$62,215
|
13.6%
|
Provider BCC & Supervision
|
$ 44,940
|
9.8%
|
Monitoring and Evaluation
|
$ 1,750
|
0.4%
|
Sub-total Recurrent
|
$ 178,179
|
38.9%
|
Total Costs
|
$458,414
|
100%
|
Annual Costs
|
$152,805
|
N/A
|
Annual cost per private provider (n=432)
|
$354
|
N/A
|
Annual cost per private provider reporting by mobile (n=250)
|
$611
|
N/A
|
Figure 1 shows a bar chart for the financial and economic costs for electronic surveillance and mobile reporting in Lao PDR.
Figure 2. Financial Cost of Lao PDR Electronic Surveillance and Mobile Reporting by Category
Myanmar Electronic Surveillance
Table 5 shows the financial and economic costs of introducing electronic surveillance and mobile reporting in Myanmar. The mobile reporting model employed in Myanmar is different from Cambodia and Lao PDR since 200 field officers employed by PSI Myanmar reported electronically to DHIS2 with tablets when they visited providers monthly rather than providers using smartphones to report directly. Providers maintained paper records for primary reporting. Further, PSI Myanmar did not design or develop a customized mobile application for reporting. Instead, PSI Myanmar used a free generic, open-source DHIS2 reporting app made.
Total financial costs for the Myanmar intervention were $1,316,379, while annual financial costs were $437,954. Total economic costs were $3,988,621 and $1,310,912 annualized. Economic costs also accounted for the value of private provider time and DHIS2 software as in the other two countries. The economic cost of the custom app was $25,979, with no financial costs incurred by the program for development. The annual financial and economic costs per provider were $27 and $49, respectively.
Recurrent costs represented 88% of the total share of financial costs. The cost driver was monthly supportive supervision to providers for capturing surveillance data from paper records. For economic costs, recurrent costs also had the largest share of total costs (69%) due to the value of private provider time spent on data entry and cost of supervision.
Table 5. Financial and Economic Costs of Myanmar Electronic Surveillance Intervention and Mobile Reporting Intervention among Field-based Supervisors
Cost Category
|
Total Cost
|
%
|
Financial Costs
|
|
|
Start-up
|
|
|
System Design and Configuration (DHIS2)
|
$39,363
|
3.0%
|
Piloting (DHIS2)
|
$4,832
|
0.4%
|
Training (DHIS2)
|
$9,361
|
0.7%
|
Server setup
|
$300
|
0.0%
|
Surveillance Bulletin design
|
$2,443
|
0.2%
|
App piloting
|
$4,178
|
0.3%
|
App training for field officers
|
$12,672
|
1.0%
|
Sub-total Start-up
|
$73,149
|
5.6%
|
Capital
|
|
|
Tablets (for mobile reporting)
|
$80,200
|
6.1%
|
Hardware (desktops)
|
$9,600
|
0.7%
|
Sub-total capital (annual)
|
$89,800
|
6.8%
|
Recurrent
|
|
|
DHIS2 Maintenance & Routine Upgrades
|
$10,070
|
0.8%
|
Server hosting
|
$13,680
|
1.0%
|
Provider Social and Behavior Change Communication and Supervision
|
$1,093,680
|
83.1%
|
Mobile data packages
|
$36,000
|
2.7%
|
Sub-total Recurrent
|
$1,153,430
|
87.6%
|
Total costs
|
$1,316,379
|
100%
|
Annual Costs
|
$437,954
|
N/A
|
Cost per provider (16,000 providers)
|
$27
|
N/A
|
Economic Costs
|
Startup Costs
|
|
|
System Design and Configuration (DHIS2)
|
$200,809
|
5.1%
|
Piloting (DHIS2)
|
$5,124
|
0.1%
|
Training (DHIS2)
|
$875,760
|
22.0%
|
Server setup
|
$318
|
0.0%
|
Surveillance Bulletin design
|
$2,590
|
0.1%
|
App piloting
|
$4,430
|
0.1%
|
App training for field officers
|
$13,438
|
0.3%
|
App development
|
$27,549
|
0.7%
|
Sub-total Start-up
|
$1,130,019
|
28.3%
|
Capital
|
Tablets (for mobile reporting)
|
$85,048
|
2.1%
|
Hardware (desktops)
|
$10,180
|
0.3%
|
Sub-total capital (annual)
|
$95,228
|
2.4%
|
Recurrent
|
|
|
DHIS2 Maintenance & Routine Upgrades
|
$40,070
|
1.0%
|
Paper and Electronic Data Entry
|
$1,555,200
|
39.0%
|
Server hosting
|
$13,680
|
0.3%
|
Provider Social and Behavior Change Communication and Supervision
|
$1,093,680
|
27.4%
|
Mobile data packages
|
$38,244
|
1.0%
|
App maintenance
|
$22,500
|
0.6%
|
Sub-total Recurrent
|
$2,763,374
|
69.3%
|
Total costs
|
$3,939,268
|
100%
|
Annual Costs
|
$1,310,912
|
N/A
|
Cost per provider (16,000 providers)
|
$82
|
N/A
|
Figure 3. Cost of Myanmar Electronic Surveillance with Generic DHIS2 app
Sensitivity Analysis
Table 6 shows the impact of varying variables with uncertainty on annual economic cost in thousands for USD: discount rate, value of provider time, and % supervisor time spent on visits. The impact is greatest when the value of provider time is varied.
Table 6. Annual Economic (000s USD) of Electronic Surveillance when Key factors are varied
|
Discount Rate
|
Value of Provider Time
|
% Supervisor Time spent on Visits
|
|
0%
|
5%
|
Minimum Wage
|
General Practitioner/Clerk Salary
|
-25%
|
+25%
|
Cambodia
|
$255
|
$277
|
$267
|
$310
|
$262
|
$273
|
Lao PDR
|
$148
|
$156
|
$153
|
$202
|
$149
|
$158
|
Myanmar
|
$3,863
|
$3,978
|
$1,311
|
$2,536
|
$1,220
|
$1,402
|
Comparison of Electronic Surveillance Costs in Cambodia, Laos, and Myanmar
Cost structure varied across the three countries depending on the cost drivers, the size of the networks and the manner in which electronic reporting was implemented, i.e. individual provider level in Cambodia and Lao PDR and supervisor level in Myanmar. Myanmar’s coverage was national with a large number of providers covered (16,000) that resulted in a high annual economic cost ($1,310,912), primarily due to the cost of supervision, but a low annual cost-per-provider covered ($82) (Table 4). The numbers of providers covered in Lao PDR was much smaller (n=432), leading to a lower annual economic cost ($152,805), but a higher cost-per-provider ($611) (Table 3). Cambodia had a network size (710) closer to Lao PDR’s and thus a similar annual economic cost-per-provider covered ($354). However, because the project in Cambodia developed the mobile app and purchased smartphones and data packages for all the providers, the annual economic costs were higher ($251,035) (Table 5).
Neither Myanmar or Lao PDR developed a mobile app or purchased smartphones for their providers. Thus, supervision was the primary cost driver for financial cost.
Economic costs were compared to the annual national malaria strategic plans’ (NMSP) budgets in all three countries, and to the proportion specifically budgeted for surveillance in Lao PDR and Myanmar (there was no surveillance budget in the Cambodian NMSP). The total annual cost of PSI’s electronic surveillance intervention in the three countries comprised 0.5-1.5% of the total annual NMSP budget, and 6.8-20.5% of the total NMSP surveillance budget in Lao PDR and Myanmar (Table 7).
Table 7. Comparisons of Estimated Annual Costs of Electronic Surveillance with National Malaria Program
|
Economic Cost of Electronic Surveillance
|
Estimated Annual Costs National Malaria Strategic Plan
|
Estimated Cost of Surveillance in NMSP
|
% Electronic Surveillance to Annual Program Cost
|
% Electronic Surveillance to Estimated surveillance Budget
|
Cambodia
|
$263,224 (14 out of 25 provinces)
|
$50,354,592
|
N/A
|
0.5%
|
N/A
|
Lao PDR
|
$152,805 (5 out of 17 provinces)
|
$14,557,696
|
$2,260,000
|
1.0%
|
6.8%
|
Myanmar
|
$1,310,912 (entire country)
|
$92,600,000
|
$6,400,000
|
1.5%
|
20.5%
|
Note: It should be noted that Myanmar used a different model of electronic surveillance (tablets with monthly reporting by NGO workers) than in Cambodia and Lao PDR where smartphones were used.
[1] It was estimated that supporting a new software for the system would cost $150,000 in in total or $50,000 per year; and routine maintenance upgrades to the software were valued at $30,000 total and $10,000 per year.