Analyses of Costs and Financing of the Routine Immunization Program and New Vaccine Introduction in the Republic of Moldova Gotsadze G., Goguadze K., Chikovani I., Maceira D. November, 2014 www.curatiofoundation.org
• This study was conducted as part of a multi-country analysis of the costing and financing of routine immunization and new vaccines (EPIC) supported by the Bill & Melinda Gates Foundation. • This presentation is based on research funded by the Bill & Melinda Gates Foundation. The findings and conclusions contained within are those of the authors and do not necessarily reflect positions or policies of the Bill & Melinda Gates Foundation. • The methods were derived from a Common Approach developed for this exercise
Country Context • Population: 3,559,500 • Area: 33,846 km 2 • GDP P/C (PPP) : $3,415 (2012) Health Spending (2011) • THE-% GDP: 11.7% • GGHE-%THE: 45.8% • P/C THE (PPP) : $350
Introduction Organization of immunization services-Facility Taxonomy • FMC - Family Medicine Centres serve a population ranging from 40,000 to 80,000 inhabitants • HC - Health Centres usually established for 4,500 inhabitants • OFD – Office of a Family Doctor serve between 900-3,000 inhabitants • HO - Health Offices serve up to 900 residents In all primary health care facilities immunization is delivered as a fixed strategy, no outreach activities are being carried out
Methods : Selection of facilities: Multi-stage stratified random sampling I stage: selection of districts • Districts were stratified into three groups by number of total doses delivered in 2011 (Low, medium and high doses administered) • In each stratum two districts were chosen by a simple random sampling approach In total 6 districts out of 37 : 2 with low doses, 2 medium and 2 high doses
Methods : Selection of facilities: • II stage: selection of facilities • Proportions of urban/peri-urban and rural facilities from the total number of facilities in the sampled districts were estimated • These proportions were applied to calculate the number of rural and urban/peri-urban facilities to be included in the sample • One peri-urban facility was chosen in each sampled district and three urban facilities were randomly selected in the capital city • If more than one peri-urban facility existed in a district, simple random sampling approach was used • Rural facilities were selected using systematic random sampling In total 50 PHC facilities: 8 urban/peri-urban and 42 rural facilities 5 FMCs, 10 HCs, 23 OFDs and 12 HOs
Methods: Summary of facility selection Total Urban % of total Total Rural % of total Sample Facilities in urban Sampled Facilities in rural District d Urban a facilities Rural a facilities facilities District/Mun sampled facilities District/Muni sampled icipality cipality Briceni 1 2 50% 7 31 22% 1 1 100% 8 35 22% Calarasi Chisinau 3 26 11% 2 9 22% Leova 1 2 50% 7 32 21% Ungheni 1 2 50% 17 70 24% Vulcanes 1 1 100% 1 4 25% ti Total 8 34 24% 42 181 23%
Methods : Data collection Duration: October 3 rd 2012 to January 14 th 2013 • • Structured questionnaires • Questionnaires were field-tested and adjustments incorporated • Data collection methods: • Key informant interviews • Facility observation • Record review
EPI Costing
Cost analysis • Costs were calculated retrospectively for 2011 • Ingredient costing approach • Financial and Economic costs • Financial cost -capital costs were annualized using straight line depreciation method • Economic cost- capital costs were annualized using a 3% discount rate • Country specific useful life years for different capital items were applied
Cost analysis Different cost allocation methods: • Labour cost- percentage of staff time spent on immunization in a given facility • Cost of vehicles and vehicle maintenance costs - proportion of km travelled for routine immunization out of total km travelled in 2011 • Building costs - proportion of square meters designated for routine immunization (where vaccines are administered, stored) out of total facility space .
Cost analysis Unit costs: • Total Unit Cost (TUC)- includes salaries for shared labour • Unit Costs (UC) - without salaries • Cost per dose delivered • Cost per FIC • FIC-child < 1, who received DTP 3 doses • Cost per Infant • Cost per capita • Total Delivery Unit Cost- Total Unit Cost without vaccines and injection supplies • Delivery Unit cost- Unit Cost without vaccines and injection supplies •
Results Total facility costs and their variation
Weighted average total facility economic costs and delivery costs by facility type $2011 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 Total for FMC HC OFD HO all facilities Total Cost US$ 57,869 11,849 4,298 1,881 6,964 Total, Non-HR Cost US$ 17,448 3,151 1,264 728 2,066 Delivery Cost US$ 49,132 10,715 3,875 1,715 6,160 Total, Non-HR Delivery 8,711 2,017 841 562 1,263 Cost US$ The average total facility level immunization cost varied between 1,881$US and 57,869 $US; mean – 6, 964 $US
Distribution of total facility level economic costs by line item Labour cost is a main cost driver-immunization is labour intensive in Moldova Vaccines are the second largest component of the immunization cost
Distribution of total routine immunization economic costs by activity - Routine Facility-Based Service Delivery - Record-Keeping/HMIS - Supervision - Social mobilization - Cold chain maintenance - Vaccine collection and distribution 0.3% 3.6% 16.9% 3.2% 47.6% 1.6% 11.8% 2.0% 13.0% Main portion of the costs comes to the facility based service delivery (47.6%), followed by program management (16.9%) and HMIS (13%)
Total economic costs by facility type and average DTP3 coverage (%) Total EPI cost on a Facility Level Mean by Facility Type DPT3 Coverage (%) 120 120,000 Family 100 100,000 Medicine DPT3 Coverage Rate (%) Centers 80 80,000 Total Cost $US 60 60,000 Health Centers 40 40,000 Offices of Family Doctors Health 20 20,000 Offices 0 - 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 • Total facility cost varied by facility type, size of the facility and number of infants • Total facility level costs grew from HOs that are the smallest to FMCs that are the largest • HCs and OFDs achieve the highest DTP3 coverage rate , HOs has poorest performance
Facility staffing and communities where facilities operate Facility # of infants in Population in Staffing type catchment area catchment area FMCs 430 (95%CI: 372-487) 32,616 Doctors and Nurses HCs 47 (95%CI: 39-54) 3,737 Doctors and Nurses 17 (95%CI: 16.1 – OFDs 1,555 Doctors and 18.3) Nurses 7 (95%CI: 6.7-7.9) 535 HOs Only nurses
Results Unit cost structure
Unit Cost Structure by facility type 100 0.19 2.27 0.77 4.61 90 80 13.46 7.68 8.2 70 60 7.71 50 40 73.25 70.48 68.11 30 54.42 20 10 0 FMC HC OFD HO Salaried Labor Vaccines Utilities and communications Printing Other recurrent Building Cold chain equipment Other capital costs
Results Unit Cost Structure by facility type and scale Recurrent cost Capital cost Recurrent cost Capital cost 77.2 22.8 HO 9.3 90.7 High Facility scale Facility Type 85.4 14.6 OFD 12.3 87.7 Medium 88.7 11.3 HC 23.1 76.9 Low 89.7 10.3 FMC 100% 90% 80% 70% 70% 80% 90% 100% • Share of recurrent and capital costs vary across type of providers and by facility scale • Share of capital costs in a unit cost of FMCs is lowest and highest in HOs, lowest in high scale facilities and highest in low scale facilities
Results Unit costs and their variation
Economic cost per FIC by facility Economic cost per dose by type facility type FMC HC OFD HO Total FMC HC OFD HO Total 25.0 400.0 347.2 19.4 332.2 328.8 350.0 20.0 18.7 18.5 317.1 17.8 301.6 303.8 17.1 16.9 300.0 18.3 332.3 15.0 250.0 303.5 16.8 200.0 10.4 155.1 152.4 8.9 10.0 8.5 132.6 150.0 124.1 113.0 7.0 89.9 5.9 82.9 100.0 5.2 62.7 4.3 5.0 3.6 45.9 117.8 3.1 50.0 6.4 23.4 88.9 1.6 4.8 0.0 0.0 Cost per FIC Cost per FIC Delivery cost Delivery cost Cost per dose Cost per dose Delivery cost per Delivery cost per without labor per FIC per FIC without without labor dose dose without labor labor • Unit costs increase when facility size declines- statistically significant only when shared labour costs are removed • Mean costs in HCs and OFDs are in the same range and almost two times higher compared to unit costs in FMCs. • Contribution of labour costs in the unit cost declines in smaller facilities
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