1. Measuring the cost-effectiveness of providing Family Planning and MNCH services as part of the basic package of health services in Cambodia David Collins (dcollins@msh.org) USAID’s Extending Service Delivery Project Management Sciences for Health Progress Made and Lessons Learned in Scaling-Up FP-MNCH Best Practices in Asia and the Middle East Bangkok, March 2010

2. Health System Performance FP/MNCH services are generally provided as part of integrated service packages at community, health centre and hospital levels Scaling up these services to national levels is therefore heavily dependant on a well- performing health system and this can only be achieved if adequate resources are generated, and if those resources are used cost-effectively 9/17/20152David Collins

3. Control knobs In a resource-constrained environment one of the main control knobs is the selection of the key health problems to tackle, and the choice of interventions and service delivery mechanisms to use. Another control knob which is important for influencing health system performance is finance, for example in resource generation and allocation, and in the use of incentives 9/17/20153David Collins

4. Using cost information An understanding of costs is a critical element in deciding how best to use these control knobs and in measuring their effectiveness For example an understanding of costs is vital for setting user fees as a source of revenue, for deciding how to allocate resources equitably across provinces, and for deciding how much to pay in incentives. 9/17/20154David Collins

5. Cambodia cost modeling In Cambodia the cost of scaling up has been modeled extensively by USAID’s BASICS Project To be of maximum use for the MOH and donors and to have a more accurate and realistic estimation of costs the whole package of services was costed – at community, health centre and district hospital levels. Next - three examples of the use of the cost information 9/17/20155David Collins

6. Example 1: the impact of incentives on the numbers and costs of services Under a performance-based finance project, incentive payments were targeted at key FP/MNCH services but also included an indicator for total curative services to ensure that increases in key services did not substitute for others An analysis of a sample of facilities indicated that the payment of incentives resulted in 44% more services in total, including significantly higher numbers of key FP/MNCH services 9/17/20156David Collins

7. The impact of incentives on FP/MNCH services for a sample of health centres 9/17/20157David Collins

8. The impact of the incentives on costs To fund the 44% more services provided, the contracted health centres used more resources as shown in a higher cost per capita of $2.05 compared with $1.63 at the other health centres. This additional 25% in cost is proportionally less than the additional number of services because efficiency was much greater at the contracted health centres. This was due to greater staff productivity and more than offset the additional cost of the incentives paid to the staff. 9/17/20158David Collins

9. Example 2: the cost effectiveness of shifting tasks to community volunteers The second example involves an analysis to see if it was more cost effective to have unpaid volunteers provide certain services in the community under health centre supervision instead of having health professionals provide the services at the health centre. 9/17/20159David Collins

10. Task shifting cost savings Excluding drug costs, which would be the same wherever the service is provided, the model showed that a contact for treatment of a child with upper ARI would only cost $0.31 in the community versus $1.11 in the health centre And if the health centre shifted appropriate services to the community volunteers it could manage with one less staff even after assigning one staff full time to supervising the volunteers. 9/17/201510David Collins

11. Example 3: scale up costs The models showed that to achieve full coverage (90%) of the basic package a health centre would need to provide 2.49 services per capita, a big increase from 1.00 services per capita at non-contracted health centres. They also showed that full coverage would require an average funding of $4.43 per capita, much more than the $1.63 spent at the non-contracted health centres. 9/17/2015David Collins11

12. Conclusions Without a clear understanding of costs the use of the finance control knobs is unlikely to result in the appropriate generation, allocation and use of resources, and the full scale up of key services to national levels is unlikely to happen. Furthermore, without a clear understanding of costs the long-term sustainability of those services is questionable. 9/17/2015David Collins12