MDG Needs Assessment Training Workshop May 9-12, 2005 Health Module

2 To present the Millennium Project approach to conducting a health needs assessment Purpose

3 1.Choosing interventions 2.Defining and setting targets 3.Estimating resource needs 4.Checking results MDG Needs Assessment Approach

4 Interventions should be seen not as isolated programs but as an integrated set of health services provided through a strengthened system of health care delivery. 1. Choosing Interventions

Choosing Interventions Infectious Diseases Child Health, Maternal Health, and Reproductive Health IMCI package Immunization Neonatal package Antenatal care Skilled attendance and clean delivery Emergency obstetric care (EmOC) Contraception and family planning services Safe abortions and care of complications of abortion Antiretroviral therapy UNAIDS HIV prevention and care package Artemisinin combination treatment for malaria (as appropriate) Insecticide treated nets and IRS as appropriate (other vector control as appropriate) DOTS and DOTS Plus (as required)

Choosing Interventions New infrastructure and O&M of existing infrastructure at district level Adequate health personnel salaries Pre- and in-service training Community demand interventions Management systems and monitoring & evaluation Research and development Health System Interventions to ensure availability, e.g.: Incentives to direct research and development Establishment of national essential medicines lists, including preventive, curative, and reproductive health commodities, equipment, and supplies Ensuring reliable procurement and distribution systems Interventions to ensure affordability, e.g.: Equity pricing Reduction of tariffs and duties Reduction of mark-ups Interventions to ensure appropriate use, e.g.: Programs to improve the way drugs are prescribed, dispensed, and used Public media campaigns and education of providers Access to Essential Medicines

Choosing Interventions: More Detail on MCH and SRH

Choosing Interventions: More Detail on HIV/AIDS

Choosing Interventions: More Detail on TB, Malaria

Choosing interventions 2.Defining and setting targets 3.Estimating resource needs 4.Checking results MDG Needs Assessment Approach

11 Some health MDGs have quantified targets, e.g.: –Child Mortality: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate –Maternal Health: Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio Others allow for interpretation of targets, e.g.: –HIV/AIDS: Have halted and begun to reverse the spread of HIV/AIDS –Malaria and other major diseases: Have halted and begun to reverse the incidence of malaria and other major diseases 2. Defining and Setting Targets: Outcome Targets Each country will need to adopt specific numeric outcome targets to guide its MDG health strategy.

12 Health MDGs offer no specific guidance on coverage levels for health services. Overall aim should be to achieve universal coverage of essential health services (or “essential health package”) 2. Defining and Setting Targets: Coverage Targets

Choosing interventions 2.Defining and setting targets 3.Estimating resource needs 4.Checking results MDG Needs Assessment Approach

Estimating Resource Needs To assist countries in undertaking a Needs Assessment, the Millennium Project suggests the following four-point approach: A.Direct intervention costs B.Human resources C.Infrastructure D.Health systems strengthening

Estimating Resource Needs: A. Direct Intervention Costs Recurrent costs for the essential health interventions in the areas of maternal health, child health, HIV/AIDS, TB, and malaria include:  Drugs  Supplies  Hospital beds  Diagnostic tests Costs for each area of health are calculated as follows:  Total cost = Unit cost X Population in need Note, that drug costs will not usually need to be inputted as international drug prices for essential drugs are coded into the models.

16 NO. OF CASES COST PER CASE Country epidemiological data Country demographic data Target coverage rates Intervention components and quantities Unit costs of components Drugs Hospital bed and food Laboratory costs Other supplies TOTAL COSTS 3. Estimating Resource Needs: A. Direct Intervention Costs

Estimating Resource Needs: B. Human Resources Countries need to calculate the number and cost of health workers at all levels of the health system needed to deliver the interventions at scale. Health workers include (among others): doctors nurses and midwives clinical officers lab technicians and technologists pharmacists and pharmacy technicians community health workers health managers

Estimating Resource Needs: B. Human Resources Human resource cost categories include salary and benefits in-service training pre-service training retention and distribution incentives Human resource needs should be carefully estimated by each country for the desired level of service coverage

Estimating Resource Needs: B. Human Resources Suggested costing methods Health workers per facilities Doctor or nurse to population ratio Conducting a comprehensive human resources needs survey Country example: Yemen Human Resources Needs, 2015

Estimating Resource Needs: C. Infrastructure Number and cost of building or refurbishing health facilities from health posts to first level referral hospitals (including capital costs, maintenance, and overhead). Country example: Ethiopia Infrastructure Needs, 2015

Estimating Resource Needs: D. Health Systems Strengthening Two methods: 1.Bottom-up costing of health system components Costs of managers at all levels (training and salaries) Quality control and audit systems Basic financial and accounting systems Health information systems (and required ICT) Public health functions (such as epidemiologic surveillance) Enhancing community demand for services (health education and community mobilization)

Estimating Resource Needs: D. Health Systems Strengthening 2.Overhead mark-up to direct cost of services Estimate a percentage of direct cost of services as follows: Strengthening management systems (including financial management) 20% of direct health costs including salaries Improving monitoring, evaluation, and quality assurance 15% of direct health costs including salaries Building capacity for basic research and development 2% of direct health costs including salaries

Estimating Resource Needs: D. Health Systems Strengthening Example: If the costs of interventions, infrastructure, salaries, and community education equal $30 per capita annually, the additional three health systems “overhead” items would add another 37% percent of that total or $11.1 per capita for a total health system cost of $41.1 per capita.

Estimating Resource Needs: Adding it All Up Direct costs of all interventions + Infrastructure and HRH costs Costs of health system strengthening + Total health costs

Checking Results Review all results to ensure that numbers are robust. Here are some sample health costs from Tanzania:

Checking Results Sample health costs from Uganda:

Checking Results Sample health costs from Ghana: