Development Of An Excel-Based Cost Effectiveness Analysis Tool For Ascertaining Value For Money In Implementation Of Hiv And Other Health Interventions At Bomu Hospital, Kenya


 An Organization Capacity Assessment done in Bomu hospital in April 2015 with an aim to strengthen the local institution’s capacity for sustainable fight against HIV Aids pandemic led to the development of this excel-based cost effectiveness analysis tool. Objective: The specific objectives were to develop a cost-effectiveness analysis excel tool complete with instruction manual for use in costing, determining prices of services and carrying out economic evaluations. Method: A technical working team (TWG) comprising of senior management of the hospital and the University of Nairobi Fellow was formed. The TWG identified program where cost indicators would be derived, developed cost indicators collection tools, collected costing data and build necessary consensus and assumptions. The data was used to design the tool complete with working instructions. Results: The tool comprises of processes, instructions, excel data entry provisions and inbuilt formulae in excel sheets. The unique tool features include; simple to use instructions, systematic listing of cost elements with a drop down option to allow selection as required, allows additional cost elements to be added thus increasing scope of use . The tool also separates costs and sub-costs in a manner that allows cost drivers to be known precisely as well as avoid double costing among others. Conclusion: The tool is transferable to other facilities and can be replicated in all hospitals within the country, in private, public and non – governmental organizations. Its regular review, improvements and utilization will be important for the health sector to fully benefit from its use. It will be necessary to sensitize health facilities to address information gaps and also ensure that data is available in form and detail necessary for costing purposes. Key words: Economic evaluation, Costing, Resources, Treatment outcomes

Introduction And Background 1

.0 Introduction
The organizational capacity assessment (OCA) carried out in Bomu hospital in April 2015 identified various gaps under health economics requiring strengthening. The OCA process utilised a participatory approach and established that costing of services to inform pricing of services as well as health economic evaluations were not conducted on a regular basis at the hospital. This project will facilitate the process by developing a cost effectiveness analysis excel based tool that will be utilized by the hospital on a regular basis.

Background
Escalating expenditures on health and limited health care budgets have highlighted the need to use resources effectively and efficiently and the desire has arisen to implement evidence-based policy decisions. Health economics and economic evaluation have thus acquired greater prominence among decision makers, who need to know which interventions represent 'value for money', (WHO 2008).
It has been observed that a lot of spending in health is as a result of advances in medicine, improved The current 90-90-90 United Nations strategy on HIV/AIDs to get HIV epidemic under control and based on the principle of universal testing and treating requires more financial investments from both donors and respective governments. In addition, declining donor funding for the health sector in a county that relies heavily on donor funding requires that conscious efforts are made to utilize every available resource effectively.
Health economics and application of economic evaluations for health interventions can thus be made an integral component of the routine practices in our health institutions to address the need for maximizing output for every available resource. This is based on the fact that resources are scarce and at no one time shall we have all that we require to meet all our public health needs. It attempts to apply the theories, concepts and techniques of economics to the institutions, actors and activities that affect health, (Ann & Kenneth, 1993).
Cost effectiveness analysis is one of the methods that can be utilized to undertake economic evaluations. The method specifically involves assessing the gains (effectiveness) and resource input requirements (costs) of alternative ways of achieving a specified objective usually expressed in terms of cost per unit of effectiveness for each alternative, (Andrew C. & David P. 1994). It involves showing how costs and effectiveness could be combined to derive measure of efficiency. Efficiency is related to cost-effectiveness. It is a term used to define the relationship between outputs and inputs, (Lorna & Virginia 2011). There is both technical efficiency (carrying out agreed activities using the least possible resources) and allocative efficiency (directing resources to their most productive use) (Sophie W. et al 2000). The method will be utilized as it is relatively easy and simple to conduct.

Bomu
Bomu Hospital is a 'not for profit 'organization established is the late 1970s as a clinic by a group of philanthropists to provide accessible, affordable, and quality healthcare services in Mombasa. The Orphan and Vulnerable Children, Nutrition, and screening and treatment of TB. These services are supported by a strong community program operating with over 100 community health workers. The program's success is evident with a mother -to -child HIV transmission rate of less than 2%. 95% of adults and 100% of the paediatric clients receive life -saving antiretroviral medicines and treatment of opportunistic infections at no cost. Supportive services such as laboratory monitoring and Gene Xpert for TB is also provided free of charge to the patient. Currently, the facility is a fully fledged level 4 Hospital that has also achieved ISO 9001:2008 certification including the accreditation of its medical laboratory to ISO 15189:2012.

Problem statement
Bomu's growth has been solid and transparent with good governance which has resulted to sustained donor funding (BMC-SP 2010-2015. The hospital has various supporting partners who have supported its tremendous growth. Despite this, the OCA reported conducted in Bomu hospital identified various gaps in health economics where economic evaluations were not conducted regularly. This is mainly due to lack of expertize and skills especially with the involvement of cost measurement where prior accurate and reliable data to inform economic evaluation hinders the process. There is also no substantive staff in charge of health economics. In addition, and due to lack of evidence based economic research, the hospital relies on external market forces in the costing of services. This was also done through comparison with other hospitals for both quality and costs.
Though Bomu has been able to mobilize resources, resources are not normally adequate given the competing health needs or institutional needs. Therefore, Bomu Hospital must prioritize its HIV activities and to do this successfully, they need to understand the costs and the health benefits of various interventions.
Secondly, there are varying HIV interventions within the HIV Programme geared towards prevention of infections and treatment of those that are already HIV positive. Bomu needs to estimate the costs of various interventions and also track the effectiveness (benefits) of each intervention with the view of implementing the interventions that will give the greatest benefit at a reasonable cost.
Thirdly, HIV interventions are life-long in nature; Bomu Hospital needs financial sustainability in order to ensure the long-term provision of HIV services. One way of increasing financial sustainability is through increasing savings by employing cost saving initiatives. Cost effectiveness analysis findings would enable Bomu to make the right decisions.
Fourthly, in the need for value for money assessment, the hospital should be able to assess if they are using the resources both monetary and non-monetary (human resources, infrastructure, commodities etc.) in the most efficient way possible and getting the greatest health benefit achievable. Are there areas in which the hospital can get the same output at a lower cost or more output at the same cost or better output at a higher cost? These are questions that the management struggles with every day and yet cost effectiveness analysis can provide some of the answers.
For purposes of such informed decision making it is important then for the hospital to strengthen health economics in order support health care financing and planning. A cost effectiveness analysis tool will thus be developed to facilitate conduction of cost evaluations at the hospital. The tool, which will address aspects of costing for services as well as evaluation for effectiveness of health interventions will be the first of its kind at the hospital to inform health care financing, budgeting and costing decisions.
The main goal of this project is to develop of a cost-effectiveness analysis tool for ascertaining value for money in implementation of HIV programs and interventions at Bomu Hospital. This will contribute towards maximizing human welfare and utility by employing scarce health resources cost-effectively.

Purpose
The purpose is to facilitate regular conduction of economic evaluations on HIV programs and health interventions at the hospital through development of a cost-effectiveness analysis tool.

1.
To develop a cost-effectiveness analysis excel tool 2.
To develop a cost-effectiveness analysis manual/instructions

3.
To pre-test the tool

4.
To train on the use of the tool and disseminate lessons learnt

JUSTIFICATION/ SIGNIFICANCE
Bomu has many supporting partners and the call for evidence of interventions and value for money is a reality. Prioritization of services in the light of scarce resources and the competing needs is thus an important goal in an institution seeking to address the dire lack of accessible and affordable health care service for all without excluding the poor. The application of economic evaluation will therefore help to determine how resources can give the greatest benefit as well as help the hospital in promoting efficiency and equity during service delivery. There is also an increasing demand for going beyond accountability and transparency with the need for further evaluations of economic feasibility of health interventions even before they are implemented.
Few health institutions are able to perform economic evaluations for their health interventions. The major setback lies in lack of expertize and skills which is also the case in Bomu hospital. The project therefore aims to develop a tool that the institution will utilize regularly to carry out cost-effectiveness analysis on its HIV programs and health interventions. This will be a simple tool that is easy to use.
Secondly, the process will build capacity of the hospital staff to appreciate the need to continuous economic evaluation at the hospital and use of the tool. Thirdly, the informed decision making role of economic evaluation in health care will be clearly captured.

Project Implementation Methods And Management Plan 2.1 Methodology
The project was implemented through a participatory approach through establishment of a technical working team (TWG) to participate in the project implementation. The key institutional issues for consideration included senior management involvement and commitment as well as the co-ordination of activities, oversight and transparency. Secondly provision of incentives, training and supervision of staff involved was done for motivation and to maintain morale.  Monthly reports to UNITID were submitted through emails. All matters regarding the project implementation was communicated, shared and discussed by the project TWG and escalated to the CEO/mentor and supervisor as necessary through meetings and email communications.

Communication strategies/plans/processes
The TWG held regular meetings to deliberate on activities and the implementation. Timely communication and follow ups were very important. The final outcomes of the project was shared in a dissemination forum for Mombasa County health department.

Documentation
All information gathered was documented and presented in notes to discussions, minutes of meetings as well as in monthly progress and feedback reports. Specific tools were developed for indicators collection e.g. indicators on costs and intervention outcomes. All information was documented and kept for reference.
Assumptions were made where cost indicators were not be readily available. This required consensus meetings and all discussions taken into consideration before reaching a final decision. Adjustments of the cost indicators and discounting for assumptions were clearly stated.

Risks and assumptions
Accurate information availability on cost indicators at the facility remained the main assumption of the project. This was found to be true as though information was available, it was not present in the manner it could be utilized for costing.

Sustainability plan
The legal framework for economic evaluation of health interventions is currently embedded in the national health policy (MOH, Kenya Health Policy 2012-2030). This will be an important document where all health managers intending to carry out economic evaluations on health products, health technologies and health interventions will be anchored. It creates a support towards investing in economic evaluations by health facilities which is important for future sustainability.
Secondly, involving decision makers in the project helped ensure future sustainability in that it is relevant to their needs. The mentor at the hospital (CEO) and members of the technical/project multidisciplinary team directly participated in the project to ensure capacity was built in them for carrying out of similar tasks in future. Further to this, carrying out economic evaluations become embedded in the facilities health intervention programming through establishment of an economic evaluation team.
Lastly, at least two champions within the hospital were capacity built for hands on skills to carry out cost-effectiveness analysis to enhance future sustainability. A total of 22 members of staff comprising of departmental heads and managers were trained on the use of the tool and the team will continue to sustain the project in future.

Data sources
The cost indicators (costs of various items) came from the accounts and finance department, and various user departments including existing program information. Additional information was gathered for assessment of the benefits against costs of HIV and other health interventions. For example; number HIV positive patients are on ART, of these how many adhered or were retained on treatment? How many transferred out?, How many were lost to follow up?, How many died?, Etc.
These were a few areas that were utilized to build and develop a cost effectiveness analysis tool.

Expected Outcomes and Deliverables Project Deliverables
Project deliverables included an excel-based tool and instructions manual for carrying out costeffectiveness analysis at BOMU Hospital. The document will act as both a reference point as well as a working tool during cost-effectiveness analysis. Its regular review, improvements and utilization will be important for the hospital to fully benefit from the project and future activities. Further a training report and a dissemination report were generated.

Project Outcomes
The immediate outcome of the project included a general buy in and sensitization of the hospital staff towards use of economic evaluations for health interventions and its importance. All participants gained practical knowledge generated by and during the implementation of project. Capacity to carry out economic evaluations in the future was built into the staff including for two staff undertaking medium term courses who gained hands on experience. The capacitated staff henceforth became cost-effective conscious during laying out health interventions by making sure scarce health resources are employed optimally. Specifically, the project led to an increased understanding on the application of economic concepts and principals of economics in decision making for health. It also increased the understanding of the different methods of carrying out economic evaluations, handling uncertainties and making realistic assumptions during economic evaluation processes.
In addition, the staff not only showed competence but also confidence in planning for, carrying out and utilizing basic economic evaluation analysis during planning, budgeting, costing and implementation of health interventions at the hospital. Though the project was implemented at the hospital level, was necessary that the project outcomes and knowledge learnt be cascaded to other stakeholders in health. To support this, the project results and lessons learnt was shared with Mombasa County Health department stakeholders through a dissemination meeting.

Project Impact
The long term outcome will be availability of evidence based data to inform health care planning, budgeting, informed allocation of resources, costing and charging for services and an overall enhanced service delivery. This will contribute towards promoting equity and efficiency in the overall use of scarce health resources.

Project Monitoring and Evaluation
The progress of the project was monitored and evaluated for efficiency and alignment to the work plan. The work plan completion time for every activity remained a standing agenda in all meetings.
Regular meetings and timely communication helped to maintain progress and to ensure activities were on course. Monthly reports were drawn and all reports submitted clearly indicated the progress of the project as per the work plan at all times.  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. 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.

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.

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

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"

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 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.

3.2.7
Indirect costs Page 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.

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.

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.

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.

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.

Cost Effectiveness Analysis Page
Cost effectiveness analysis is the ratio of the cost of the intervention to a relevant measure of its

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.

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.

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.

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.

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.

Conclusion And Recommendations
In spite of data gap challenges, it was possible to utilize the available information collected to develop the excel-based tool. Making the tool as generic as possible remained the single most challenge all.
This was overcame by creating what if scenarios and especially by making provision where information is not specific to a certain condition. The tool makes provision for case-based costing while being flexible enough for calculation of program costs. Its unique ability for transferability will help different facilities using the tool be able to compare their resource input in relation to outcomes and this forms a basis for comparing different health facilities performance, sharing best practices and offering possibility for standardization. Hospitals may use the tool to improve financial management.
The results of costing studies and cost effectiveness analysis will used as a basis for identifying areas of inefficiencies by comparing the costs and outputs with those of similar interventions or similar facilities etc. This is also useful in setting up or revising existing service charges for various interventions. It is however important to note that the analysis will be as accurate as the numbers entered. Health facilities attempting to use the tool must collect all costs and outcomes comprehensively and accurately.
It is highly recommended that economic evaluations be made a routine practice within the hospital.
Institution are now in a position to participate in shaping decision making in financial allocations to health that could go a long way in informing health sector funding reforms. Facility may utilize the tool to inform outcome research studies. These are very useful in assessing clear health care services end points. Facilities need to embed economic evaluations in their strategic plans, health intervention programming and other working documents. This ensures that funds are formally allocated to the course. The tool's regular review, improvements and utilization will be important for facilities to fully benefit from the project.

Declarations
Ethical approvals and consent to participate: The proposal developed in collaboration with Bomu hospitals and Supervisor was submitted to CDC through the University of Nairobi Institute of Tropical and Infectious Diseases. Upon approval, the students were given go ahead to proceed with implementation.

Consent for publication:
The Bomu CEO Dr. Aabid Ahmed whose hospital provided the information utilized in development of the Excel based Cost Effectiveness Analysis Tool provided consent for publication and he is a Co-Author.

Availability of data and materials:
The Excel based Cost-Effectiveness Analysis Tool has been submitted alongside this manuscript. Data, including capital costs data such as equipment (medical and non-medical), overhead costs, labor, consumables and patients numbers and various outcomes utilized during this study are included in this published article as supplementary information files.

Competing interests: None
Funding: The Centre for Disease Control met the full cost of study (school fees at the University of Nairobi and the project implementation costs upon approval of the proposal.) Author's contributions: Specifically, the following individuals who played a key role towards the overall success of the project are acknowledged for their immense contributions.

TWG Members
Dr