3.1 RESULTS
The project was implemented through a participatory consultative approach with establishment of a technical working Group (TWG). The TWG comprised representation of nine (9) senior management staff from the hospital and the UON Fellow. Specific departments represented included procurement, human resource, HIV program, laboratory, pharmacy, in/out patient and finance. The TWG members participated in the whole process of development, training and dissemination of the tool while the mentor (Chief Executive Officer) helped to align the project to the needs of the hospital and offered overall guidance as per the defined roles and responsibilities.
An initial sensitization meeting was held with the appointed project TWG who were sensitized on the project, its objectives and deliverables. The TWG developed terms of engagement including frequency of meetings, clarifications on the roles and responsibilities, and the communication processes.
The second TWG meeting was also critical in identifying the programme from which information was to be used to develop the cost effectiveness analysis tool. The adult ART program was identified and an indicator collection tools were developed for collecting cost as well as program outcome indicators.
The adult ART programme offers various services to HIV clients form the entry point of HIV testing and counseling, to enrollment into care, treatment, and treatment monitoring. Resource inputs (costs) and outputs (outcomes) information were therefore collected using an indicator collection tool to act as dummy data for use in developing the cost effectiveness analysis tool for the hospital.
Diagnosis services includes HIV testing and counselling, routine laboratory tests and baseline tests,
Treatment comprises of universal prophylaxis, enrollment into ART and clinical management of HIV as well as counselling on adherence to medication. Other aspects include sexual and reproductive health support services e.g. prevention and management of sexually transmitted illnesses (prevention with positives), provision of as well as education on correct and consistent use of condoms, treatment of opportunistic infections, nutrition services that include assessments, counselling, supplementation and nutrition treatment.
Treatment monitoring include laboratory testing, routine lab services to monitor clients receiving treatment and diagnosis of opportunistic Infections (OIs), viral load and CD4 monitoring, drug monitoring, drug resistance testing, drug toxicity monitoring, organ functions assessments etc. There are also other services that include medical records services (from initial client capture, identification and continual/long term client management including digitalization processes. Other services identified included hospital inpatient care (inpatients due to HIV), management of malignancies, blood transfusions, specialized consultant reviews, linkages and referral services (linkages from testing to treatment within facility departments and outside the facility, support services to care & treatment clients (support groups, direct financial support from the hospital to HIV clients (e.g. transport, allowances to clients, Income Generating Activities (IGAs), youth friendly services, defaulter tracing, client education, communication, behaviors change messages, campaigns and materials including time allocated; palliative care and pain management; family care, psychosocial counselling, community based care as well as voluntary male medical circumcision. All services were comprehensively identified and service delivery points listed to facilitate comprehensive collection of all cost inputs and outcomes. Indicator collection templates were developed to collect the various type of information required.
Thereafter, a series of working meetings were held throughout the project implementation period. Meetings involved various activities all geared towards project implementation. This included learning, giving feedback on collected indicators, discussions on collected indicators, and reaching consensus on information collected as well as practicing on the draft sections of the tool as they were prepared. The TWG members gave feedback on the tool which helped in making improvements. Continuous learning was necessary to communicate health economics information to members of the TWG. This was done through power point presentations.
The output of the successful process include an excel tool with inbuilt instructions, a training report and a dissemination report. The TWG members appointment letter, indicator collection tools, minutes and participants lists to the series of meetings held are as presented in Appendixes.
3.2 Excel Based Cost Effectiveness Analysis Tool (Presented in form of a Compact Disc (CD).
The excel-based tool and inbuilt instructions remain the single most output of this project. The tool consists of several excel sheet sections which are described in details below:
3.2.1 The Table of Content Section
This is the section from which all other sections are accessed. Other sections are opened by simply clicking on the section name. Sections opened allow for moving back to the table of content page by clicking the BACK icon. The section of content page is protected from deletions or additions of any other information.
3.2.2 The Cover Page
The cover page contains the Bomu Logo, the author and affiliate institutions through which this tool was developed. The section allows for back and forward movement to other sections but it is protected from deletions or additions of any other information.
3.2.3 The Introduction page
This section briefly describes the background from which the tool was conceived and developed. This section also defines the responsible persons. The section allows for back and forward movement to other sections but it is protected from deletions or additions of any other information
3.2.4 Intervention Outcomes Page
The intervention outcomes page provides for identification of the intervention outcome(s) of interest before embarking on cost effectiveness analysis. The outcome to be used in the cost effectiveness analysis must be identified and determined in advance. The outcome must be similar for interventions being compared and must be ones that can be measured accurately. Where no two similar programs or intervention be identified, Cost Effectiveness Thresh holds are utilized. WHO defines an outcome as a "change in the health of an individual, group of people, or population that is attributable to an intervention or a series of interventions"
3.2.5 Cost Elements Page.
This section identifies and lists various departments within a hospital from which costing process can be applied. The departments are listed separately into to administrative and service delivery departments for easy of selection. It is important to assign costs to specific departments or units in the hospital so that we can then assign costs to cost objects.
The section further identifies, categorizes and lists costs under four main categories for purposes of costing. The four main categories include Capital Costs, Overheads, Labor and Consumables/materials. This is the most important step in costing exercise and the purpose is to account for all costs incurred in full. Cost inputs and financial requirements for different interventions can vary widely in different facilities depending on the settings and the manner in which the services are designed and offered. Attempts have been made to further list several examples of cost elements under each cost category in detail for purpose of guiding the user. This section allows for additional cost elements to be added in each cost category so as to be as comprehensive as possible not to underestimate costs.
- Capital costs broken down to land, building, equipment.
- Equipment sub divided into general equipment and equipment specific to service delivery in both out and in patient settings
- Overheads
- Labour sub divided into administration and labour specific to service delivery
- Consumables which mainly include medicines, medical supplies and laboratory products are sub divided further into various classes for ease of relating to specific services and costing purposes e.g. HIV medicines, TB medicines, Malaria medicines, general medicines (tablets, injectable, oral liquids and external use medicines), nutrition supplements, vaccines, reproductive health products, laboratory reagents as well as non-pharmaceuticals.
The page allows for back and forward movement to other sections while being protected from deletions or any other manipulation other than addition of cost elements as may be required.
3.2.6 Generating Units Costs Page
The section allows for generation of unit costs through selection of various cost elements from a drop down list. This section draws information form the cost elements page linked through excel formulas.
- Drop down list allows ease of navigation and selection
- Allows quick search
- Acts as a guide
- Easy to add new elements on need
Generation of unit costs
Regardless of source of funds all costs that hospital expended or used for the day to day functioning in carrying out its operations were gathered. Two approaches were utilized in generating units costs; the top down approach and the bottom up approach.
Top-down approach
The top down approach was utilized in generating unit costs for indirect costs that could not be directly linked to the intervention. It involved summing up all annual expenditures per cost category and dividing by the number of clients served during the period giving average costs per client.
- Its less technical
- Less time consuming
- It is direct once total expenditure and total clients served are known
- Assumes all costs are the same
- Useful for calculating costs that may not be estimated in any other way
- Was utilized for capital costs, overheads and administrative labor costs
Bottom-up approach
The bottom up approach method was utilized for consumables especially medicines, medical supplies and laboratory reagents. It involves mapping and relating the expenditure to a certain treatment or test process for purposes of comprehensively identifying each individual item utilized. Usually, standard operating procedures and treatment or testing guidelines laid down are of great use here. An example is HIV testing where the process of testing include wearing of gloves, use of wipes for cleaning the skin, pricking for blood withdrawal, use of kit, wiping pricked area, use of buffer on withdrawn sample. The various items utilized are costed for and summed to constitute the cost per test.
- More technical and tedious
- Time consuming
- Gives more comprehensive and most accurate cost estimate
- Very useful for costing case specific costs for various treatments as it allows for direct individual client consumption costs such as medicines.
The method is important as it allows one to understand the process fully, can improve quality, impacts greatly on patient care
However, the method may not account for duplicate tests which is a great short coming. The challenge of consumables consumed in quality control e.g. proficiency testing are factored as a percentage.
The costs associated with economic evaluation methods are derived from many different sources and include both direct and indirect costs, some of which are difficult to measure or estimate. The approach utilizing both the top down and bottom up costs measurement methods was considered more useful despite its short comings.
Discounting and depreciation of capital asset costs
Capital assets are those items acquired in one period but used not consumed all at once rather they are expended over several years. They include building, equipment, vehicles and land. Their full cost is thus spread over the useful life years while noting that they depreciate over time and also bearing in mind the present value of money. Useful life is the number of years a piece of asset can operate and is used to calculate the present value of future benefits which also helps accounts for inflation and aging. Present value (PV) annuity Factor is given by the formula
The interest rate r is used to discount the annuity. The Present value annuity is then used to calculate. Annuity Due.
Annuity Due =
This formula relies on the concept of time value of money. Time value of money is the concept that a dollar received at a future date is worth less than if the same amount is received today. Though Annuity due tables are available, the formula was incorporated in the tool to avoid need to enter annuity values all times and only asset life years are required to be entered.
The section makes a summation of indirect costs per clients treated and allows viewing of the various indirect costs and their contribution to the total cost per client.
3.2.8 Diagnosis Page
The tool allows costing consumables for several independent tests from a bottom up approach. It also makes provision for costing laboratory equipment, personal time and laboratory consumables to get total costs of a test. The tool allows for diagnostic processes made by other personnel to be costed e.g. a medical personnel may use a spirometer to diagnose asthmatic cases or in the case of diagnosing a psychiatric patient by a specialist where no lab tests may be made.
3.2.9 Treatment Page
Costs for individual medicines are relatively easier to generate. Both program and non-program commodities have been costed. Provision was also been made to cost various disease conditions where more than one drug is used. This helps to give an average treatment cost per condition. Only medications and non-pharmaceuticals were considered under treatment.
3.2.10 Treatment monitoring Page
The section made provision for costing routine as well as targeted treatment monitoring. Both staff and equipment costs are accounted for. It also enables costing for both in and out-patient services. Hospitalization was assumed to be a monitoring process and was included in this section.
3.2.11 Outcomes Page
WHO defines an outcome as a "change in the health of an individual, group of people, or population that is attributable to an intervention or a series of interventions“. The tool identifies three main possible outcomes namely:
- Cure or achievement of desired outcome
- Treatment failure and
- Death
In addition, clients completing treatment/intervention, failing to complete treatment/intervention, defaulting and transferring out are accounted for in the effectiveness analysis. It will be necessary to carry out health outcomes research to clearly inform outcomes for interventions being compared.
3.2.12 Cost Effectiveness Analysis Page
Cost effectiveness analysis is the ratio of the cost of the intervention to a relevant measure of its effect. The tool calculated the measure of effect to cost for two interventions being assessed for effectiveness. In the absence of similar interventions that can be compared, Cost Effectiveness Thresholds may be employed. These are costs where policy makers have specified an explicit standard or thresh hold for what should be considered cost-effective and above which interventions are rejected on considered non-cost effective. WHO has based cost–effectiveness thresholds on a country’s per-capita gross domestic product (GDP). The tool made provision for both
3.2.13 Additional information pages
Several excel sheets have been used to provide the user with more information about various terms used in the tool or sources of information. The user is able to access this information by clicking on instruction for “read more about”. More sections utilized in consolidating calculations have also been hidden including key formulas:
3.3 Sensitivity analysis.
This is the process of characterizing uncertainty to enable decision makers make an informed decision. Examples of uncertainties
- Uncertainty over treatment effects (outcomes); e.g. confidence intervals around estimates
- Methodological uncertainty e.g. rates of discounting used
- Uncertainty of data inputs e.g. costs and or
- Assumptions made
The inputs utilized in the cost effectiveness analysis and analyzed data is subjected to a sensitivity analysis to compensate for uncertainty. The process looks at "what if" to test the assumptions or estimates made within the process when precise input values could not be acquired. This is because values used and assumptions made are subject to change and error. Sensitivity analysis (SA), seeks to investigate these potential changes and errors and their impacts on conclusions. Basically, assumption values are varied in a sensitivity analysis and see how analyzed costs change while unresponsive parameters and scenarios are exclude from further analysis. The results are summarized for each key decision variable, while the values of a sensitivity index for all parameters and discrete scenarios are calculated and ranked by absolute value. This information was provided.
3.4 Excel Based Cost Effectiveness Analysis Tool Instructions Manual
The instructions were inbuilt within the tool. This was important to make reference easier during concurrent entry of data and interpretation of results.
3.5 Excel Based Cost Effectiveness Analysis Tool Training Report
Learning took place throughout the project implementation. Power point presentations were made during TWG working meetings for knowledge sharing. Additionally, a series of continuous medical education (CMEs) were prepared and incorporated into the institution CME schedule for purposes of sensitizing all staff. The learning process culminated in a two day training workshop where twenty three (23) Bomu Hospital staff were trained.
3.1.4 Excel Based Cost Effectiveness Analysis Tool Dissemination Report
A half day dissemination meeting was held in Mombasa County pooling membership from the County Health Department. Individual hospitals in Mombasa County were also represented.
3.2 Discussion
The project was a success and increased knowledge and skills among the staff on costing procedures and cost evaluation. The process will also impact on budgeting. Specifically,
- The implementation process fostered an environment for sustainability (involvement of CEO and TWG members)
- With regular use of the tool, implementation of cost effective interventions will enhance wide accessibility of HIV and other services to clients
- The tool will enhance cost savings. The hospital will be able to carry out own costing & and cost evaluations rather than outsourcing for the same
- Excel based tool allows cost and intervention outcome data entry for healthcare workers with basic excel knowledge while outputs are automatically computed. Can be used by personnel with basic Information technology (IT), excel, research and data analysis backgrounds.
- Has features such as simple to use instructions, systematic listing of cost elements and a drop down option to allow selection as required.
- Allows additional cost elements to be added thus increasing scope of use
- The tool separates the various costs and sub-costs in a manner that allows cost drivers to be known precisely.
- The tool attempts to estimate different costs separately to the lowest detail possible.
- It is acknowledged that results from accosting process may only be acceptable and implemented where the method used to derive costs is clear, convincing and practical. The tool makes this possible as each process is clear.
- The tool makes it possible for one to cost a certain cost and ignore another where it may not be necessary e.g., one may cost for personnel costs associated with a certain intervention while leaving the others costs out. Similarly, one may cost for consumables only, overheads only and vice versa. This takes into consideration that “true costs” of a service may be almost impossible to define because of complexities involved necessitating one to clearly indicate costs involved in every costing done (what is involved, what is excluded and all assumptions done).
- By listing various cost categories and sub categories, and use of drop down lists with pre-populated costs, this enables user to clearly categories costs and thus avoid double costing.eg consumables.
- Transferability: This tool can be in other health facilities
- Level of dissemination: The can be replicated in all hospitals within the country, in private, public and non – governmental organizations.
Lessons learnt
- Importance of stakeholder participation in the process
- Time management and effective communication is critical
- Opportunity to work in private sector setting
Challenges
- Information gap: Generally, concerns related to hospital level data have long been recognized as a major obstacle to any costing process. There was no prior collection of economic analysis data which had implication on the accuracy of results. In most areas assumptions were made and apportioning to departments as majority of cost information was consolidated together as hospital costs and not specific to departments.
- The current format in which information is kept at the hospital level was not optimal for analyzing and monitoring cost of services and or for costing purposes.
- Information was also not available to the level of detail needed for costing purposes requiring working backwards or making estimates for the required cost information. Administrative/financial information was more available and accurate than clinical records.
- Enabling the tool to cost and analyze effectiveness for varying interventions.
- Delayed approval and funding of project. This led to the need to extend the project time beyond the anticipated work plan.
- Availability of staff (staff work schedules). The project was implemented by a TWG comprising senior management staff who also performed their routine tasks.