1. Setting Standards for Global Health Costing
Anna Vassall, LSHTM,
on behalf the GHCC consortium

2. Why set standards in costing?
Improving the nature and extent of use of cost data:
Systematic reviews of costs suggest a wide variety of costing methods and metrics
Poor quality may lead to poor decisions - but how to judge poor quality
Improving the production of cost data
Inefficiency – what is important?
Limited use of current guidelines
Limited capacity in costing

3. "Data that is comprehensive" would have been a good additional option.
What do you value most in cost data?
Overall Rank
Item
Score
Total Respondents 1
Data that is transparent
180 35 2
Data that is accurate
166 32 3
Data that is relevant
145 34 4
Data that is reliable
142 31 5
Data that is timely
123 6
Data that is robust
101 29 7
Data that is precise 69 27
It is artificial to have to order them, as I value and require all of the above
"Data that is comprehensive" would have been a good additional option.

4. The approach What is a ‘reference case’?
The aim of a reference case is to provide guidance on a set of standardised set of principles, methods and reporting standards
US panels on Cost-Effectiveness in Health and Medicine
iDSi reference case for economic evaluations
Country specific reference cases
Tool for both users and producers

5. Reference Case content
Set of ‘acceptable’ principles
Methodological guidance on how to achieve those principles (theory and evidence based)
Reporting standards
Standardisation for specific interventions with additional guidance where available
=> Reference case compatible guidelines/tools

6. I don't think one can or should be developed
What would be the greatest benefit of adopting a Reference Case for collecting cost data in LMIC?
I don't think one can or should be developed
To ensure consistency of methods and comparability of results across different studies/ settings/ time as well as to improve the quality of costing studies.
Ensuring cost data was transparent so that users could apply it correctly to decision makers
Increase understandability and comparability of data. Encourage efficiency of costing.

7. What would be the greatest risk of adopting a Reference Case for collecting cost data in LMIC?
Limited acceptability for future innovative approaches to cost data collection and analysis
Could put additional burden on researchers (both with and without capacity/skills) and increase costs of data collection.
It would become quickly outdated. If too general, it is not useful, and if too specific it may too long and overwhelming for non-academics.
Ensuring relevancy across country contexts (e.g., reflecting differences between LICs and MICs)
Hard to provide guidance to address all possible questions-- might not get used to the extent we wish

8. What would be your top suggestions for a reference case to make cost data useful to decision makers at the country level?
Cannot be seen as a "one-off" that is primarily an exercise carried out by outsiders; in order to ensure that data are used, local authorities must "buy in" and own the process and results.
I am unclear at the moment if a 'reference case' logically makes sense. Decision makers need to understand that how their program operates will drive costs, so costs will logically vary across time and space (countries).
Determining what added value the reference case would have in relation to existing guidance/tools Providing clear guidance on interpreting results

9. Don't think a reference case will make data cost useful
What would be your top suggestions for a reference case to make cost data useful to decision makers at the country level?
Have a general section that is applicable across countries/diseases, then allow for (and suggest) country/disease-specific supplemental modules
Clearly specify methods (and if possible have an adaptable MS Excel spreadsheet to aid collection) Specify minimum reporting standards (and if possible use a Drummond et al-like checklist)
Don't think a reference case will make data cost useful

10. What do we want to achieve?
What is a ‘good enough’ standard in costing?
Costing is a process of estimation
Example characteristics of a good estimate:
Precision
Accuracy
But how accurate and precise is good enough?
Cost of getting it right compared to the cost of getting it wrong

11. Other ‘desirable’ characteristics
Generalisability
Can we apply the cost to other settings?
More important to be relevant to context?
Comparability and standardisation
Are cost estimates comparable with on another?
Innovation?
Reliablilty

12. Our aim
To improve the relevance, use and quality of cost estimates by: Ensuring that the process of cost estimation is transparent, so that those using the data can apply estimates widely and appropriately Framework for producers of cost data to consider how their methodological choices influence the quality and relevance of their estimates, and present data in way that maximises the extent of use

13. Principles for purpose
Many purposes
Economic evaluation and priority setting
Medium term planning
Budgeting
Price setting
Efficiency analyses
Study design and valuation methods differ
Tolerance for uncertainty may differ

14. Please indicate the areas below for which you (or your organization) use cost data? (tick all that apply)
Value
Percent
Count
Budgeting
45.5% 15
Medium / long-term resource needs estimates
60.6% 20
Priority setting
63.6% 21
Investment case
51.5% 17
Sustainability planning
48.5% 16
Technical efficiency analysis
Health Technology Assessment
30.3% 10
Economic Evaluation (eg. cost-effectiveness analysis)
93.9% 31
Equity and poverty analyses
27.3% 9
Other
6.1% 2
Other
Count
HIV allocative efficiency and scenario analysis mathematical modelling 1
price negotiation
Total 2

15. For what purpose(s) are you currently producing cost data
For what purpose(s) are you currently producing cost data? (tick all that apply)
Value
Percent
Count
Budgeting
51.6% 16
Medium / long-term resource needs estimates
54.8% 17
Priority setting
61.3% 19
Investment case
41.9% 13
Sustainability planning
45.2% 14
Technical efficiency analysis
Health Technology Assessment
16.1% 5
Economic Evaluation (eg. cost-effectiveness analysis)
83.9% 26
Equity and poverty analyses
25.8% 8
Other (please describe)
Other (please describe)
Count
Insurance 1
Mathematical modelling to improve HIV and TB allocative efficiency
Performance improvement
decision analysis
price negotiation
Total 5

16. Scope of the reference case
‘Unit costs’ and/or cost functions estimated using ‘research’ approaches, but also can be used to think about strengths and weaknesses of routine cost data Does not include guidance on cost analysis, such as estimating investment case costs Currently, focuses on provision costs (service and above service), not access (time and transport)

17. Terminology and definitions
Intervention, episode, components and service/output units, activities and inputs
An m-health intervention to reduce default amongst patients with TB
Cost per person successfully treated
Cost per patient receiving the intervention
Cost for first line treatment
Cost per person followed up with SMS’s
Cost per visit

18. Other challenges Gross or micro costing Top down or bottom up
Activity based costing
Indirect costs
Resource use vs Service use
Do we just select one, where currently used differently?

19. Questions
How can the reference case best meet the needs of users and producers of cost data? What would be its main benefits? What are the main risks?

20. Questions
Is the current scope sufficient? Could the form be improved? Process for tomorrow

21. Study Design 1
Cost estimates should be communicated transparently to enable the decision-maker(s) to interpret and use the results. 2
The type of the cost estimated should be defined in terms of economic vs financial, gross vs micro, real world vs per protocol, and incremental vs full cost, and justified relevant to purpose. 3
The population, intervention, perspective and scope (extent of the resource use of the intervention captured) of the cost estimation should be stated and justified relevant to purpose. 4
The time horizon should be of sufficient length to capture all costs relevant to purpose, and consideration should be given to disaggregating costs into separate time periods where they vary over time. 5
The ‘units’ in the unit costs for interventions, episodes of care and service use should be relevant for the costing purpose and generalizable.

22. Resource use measurement6
The selection of the data source for estimating service use should be described, with potential biases reported in the study limitations 7
The use of ‘top-down’ or ‘bottom-up’ resource measurement methods should be stated by input 8
The sampling strategy should be determined by the precision demanded by the costing purpose and designed to minimise bias. 9
Consideration should be given to the timing of data collection to minimise recall bias and, where relevant the impact of seasonality and other differences over time. 10
Above site costs should be considered, and where excluded potential biases reported in the study limitations 11
Methods for capturing human resource use should be reported, and where relevant, limitations and biases reported in the study limitations 12
Research costs should be reported separately and excluded from intervention costs, where relevant to the purpose of the costing.

23. Valuation and pricing 13
The sources for price data should be listed by input, and clear delineation should be made between local and international price data sources 14
Capital costs should be appropriately annuitized or depreciated to reflect the expected life of capital inputs 15
Where relevant an appropriate discount rate, inflation and exchange rates should be used, and clearly stated. 16
The use and source of shadow prices, for goods and for the opportunity cost of time, should be reported.

24. Reporting results 17
The total costs, number of units and unit costs of the intervention should be reported, including where relevant any component (eg. service) unit costs. 18
All total and unit costs should be disaggregated, by input category (e.g., capital/ recurrent, personnel, supplies), tradable/ non-tradable inputs, and where relevant by activity and site 19
The cost of the intervention for sub-populations, and other areas of heterogeneity should be explored 20
The uncertainty associated with cost estimates should be appropriately characterised.

25. Possible additions
Guidance around cost functions Quality adjusted units Societal costs Unrelated costs

26. Methodological specifications
The population, intervention, perspective and scope (extent of the resource use incurred by the intervention) of the cost estimation should be stated and justified as is relevant for purpose. The full production process of an intervention should be considered in the first instance. Exclusions to scope can be made based on purpose, type of cost and the costs of data collection. The direction and likely extent of any bias should be transparent

27. Reporting standards
Cost estimates should be communicated transparently to enable the decision-maker(s) to interpret and use the results
The purpose should be stated, clearly identifying:
The relevance for health practice and policy decisions
The aim of any cost analysis where relevant
The intended user (s) of the cost estimate
The intervention and context of the intervention being costed should be clearly outlined, describing:
Main activities/technologies involved
Target population
Coverage level or phase (pilot, implementation, post scale up)
Delivery mechanism (health system level/ facility types/community/ownership/ where relevant integration with other services)
Epidemiological context (incidence/prevalence of the illness being addressed)

28. Specific reporting standards
Intervention
Sub-intervention
Population
Unit cost
TB Treatment - intensive phase
New
Retreatment drugs
MDR
Pre –XDR
XDR
Other
Children
Community
Contacts
General
Prisons
Facility attendees
High risk
Cost per person (or person month) treated in intensive phase”
Intervention
Service use units (and unit costs)
TB Treatment - intensive phase
Inpatient bed-days
Outpatient visits
Community observation visits
Drugs regimen
Microscopy
TB Treatment - continuation phase

29. The approach Set of ‘acceptable’ principles
Methodological guidance on how to achieve those principles (theory and evidence based)
Standardisation for specific interventions with additional guidance where available
Reporting standards

30. Process

31. Scope of the reference case
‘Unit costs’ estimated using ‘research’ approaches, but also can be used to think about strengths and weaknesses of routine cost data Does not include guidance on cost analysis, such as estimating investment case costs Focuses on provider costs

32. What do we want to achieve?
Costing is a process of estimation
Two characteristics of a good estimate:
Precision
Accuracy
But how accurate and precise is good enough?
Depends on the decision to be made using the cost

33. Other characteristics
Generalisability
Can we apply the cost to other settings?
More important to be relevant to context?
Comparability
Are cost estimates comparable with on another?
Standards or standardisation?

34. Cost functions vs unit costs

35. Limited empricial validation of measurement tools/ approaches

36. First challenge – cost for purpose a cost is not a cost
First a caveat, principles for purpose
Economic evaluation and priority setting
Medium term planning
Budgeting
Price setting
Efficiency analyses
Study design and valuation methods differ

37. Common terminology and definitions
Intervention, episode and service/output units – activities and inputs
An m-health intervention to reduce default amongst patients with TB
Cost per patient receiving the intervention
Cost for first line treatment
Cost per person followed up with SMS’s
Cost per visit

38. Standardisation of interventions/ inputs
Intervention, episode and service/output units – activities and inputs
An m-health intervention to reduce default amongst patients with TB
Cost per patient receiving the intervention
Cost for first line treatment
Cost per person followed up with SMS’s
Cost per visit

39. Other challenges Gross or micro costing Top down or bottom up
Activity based costing
Indirect costs
Resource use vs Service use

40. Scope of costs

41. Suv

42. Study Design 1
Cost estimates should be communicated transparently to enable the decision-maker(s) to interpret and use the results. 2
The type of the cost estimated should be defined in terms of economic vs financial, gross vs micro, real world vs per protocol, and incremental vs full cost, and justified relevant to purpose. 3
The population, intervention, perspective and scope (extent of the resource use of the intervention captured) of the cost estimation should be stated and justified relevant to purpose. 4
The time horizon should be of sufficient length to capture all costs relevant to purpose, and consideration should be given to disaggregating costs into separate time periods where they vary over time. 5
The ‘units’ in the unit costs for interventions, episodes of care and service use should be relevant for the costing purpose and generalizable.

43. Resource use measurement6
The selection of the data source for estimating service use should be described, with potential biases reported in the study limitations 7
The use of ‘top-down’ or ‘bottom-up’ resource measurement methods should be stated by input 8
The sampling strategy should be determined by the precision demanded by the costing purpose and designed to minimise bias. 9
Consideration should be given to the timing of data collection to minimise recall bias and, where relevant the impact of seasonality and other differences over time. 10
Above site costs should be considered, and where excluded potential biases reported in the study limitations 11
Methods for capturing human resource use should be reported, and where relevant, limitations and biases reported in the study limitations 12
Research costs should be reported separately and excluded from intervention costs, where relevant to the purpose of the costing.

44. Valuation and pricing 13
The sources for price data should be listed by input, and clear delineation should be made between local and international price data sources 14
Capital costs should be appropriately annuitized or depreciated to reflect the expected life of capital inputs 15
Where relevant an appropriate discount rate, inflation and exchange rates should be used, and clearly stated. 16
The use and source of shadow prices, for goods and for the opportunity cost of time, should be reported.

45. Reporting results 17
The total costs, number of units and unit costs of the intervention should be reported, including where relevant any component (eg. service) unit costs. 18
All total and unit costs should be disaggregated, by input category (e.g., capital/ recurrent, personnel, supplies), tradable/ non-tradable inputs, and where relevant by activity and site 19
The cost of the intervention for sub-populations, and other areas of heterogeneity should be explored 20
The uncertainty associated with cost estimates should be appropriately characterised.

46. Reporting standards
Cost estimates should be communicated transparently to enable the decision-maker(s) to interpret and use the results
The purpose should be stated, clearly identifying:
The relevance for health practice and policy decisions
The aim of any cost analysis where relevant
The intended user (s) of the cost estimate
The intervention and context of the intervention being costed should be clearly outlined, describing:
Main activities/technologies involved
Target population
Coverage level or phase (pilot, implementation, post scale up)
Delivery mechanism (health system level/ facility types/community/ownership/ where relevant integration with other services)
Epidemiological context (incidence/prevalence of the illness being addressed)

47. Additional and complementary activities?
Support the TB Taskforce and develop principles and methods around access costs, including income measurement, sampling methods, inclusion and exclusion
TB provider costing study in 5 countries will enable us to pilot and apply methods
iDSi work to hold workshop to link reference case (s) to modelling work
TB MAC work on unit costs and cost functions in resource allocation models (linking to analytics)

48. Going forward - Questions for TAG
Reference case
How can we engage funders to encourage adoption?
Are there important constituencies we should include beyond those coming this week?
How do we best link to other efforts?
Are there other methods areas?
How can GHCC stimulate methods work to advance the reference case in other areas?

49. Next steps