1. Costing, Advocacy Strategies and Policy Transformation Jorge Romero Leon Accountability and Monitoring in Health Initiative Costing for Change Seminar Poiana - Brasov, Romania October 27th, 2011

2. Contents Transforming the model of care Elements of the transformation What is effective advocacy? Where does costing fit in? Costing and budgeting What is costing useful for? Costing definitions (minimal) Perspective of costing Information sources Not rocket science, but…

3. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing

4. Elements of the transformation Multiple transformations Of the legislation Of the institutional support for palliative care Of the model of care Of the budgetary allocations for supporting humane and up to standard policy alternatives Of the quality, reach and inclusion of services to the broadest possible number of affected persons

5. Elements of the transformation The transformation takes many years It requires standards, justification, evidence of feasible policy alternatives and leadership to engage different levels of stakeholders and decision makers. It requires increasingly effective advocacy and broad network support. The Public Health Program of the Open Society Foundations has a diverse strategy that considers a wealth of elements to promote transformation from below, from above, and through alliances.

6. What is effective advocacy? It identifies and addresses gaps. It identifies policy programs and activities that could address those gaps. It complements international standards and advocacy strategies with context specific activities. It engages stakeholders at every stage to inform strategy, to develop methodological choices and forge alliances to ‘shake’ things up, to ‘move’ towards the adoption of alternatives and ‘drive’ legal and institutional changes.

7. What is effective advocacy? It develops Knowledge Existing gaps Models of care and international standards Requirements for implementation under local constraints and in the local system Evidence Of existing systemic constraints Of viable alternatives Feasibility of policy choices and institutional support at different stages

8. What is effective advocacy? Justification On the basis of human cost and lagging conditions for development On the basis of Human Rights obligations On the basis of the legal and financial feasibility of transformation (identifies alternatives within reach) On the basis of analysis warranting cost-effectiveness of up to standard policies

9. What is effective advocacy? Finally, effective advocacy seeks to impact decision- makers to persuade, compel or coerce. It maps interests, power, allies, plausible support and instances of opposition. It develops proactive, not reactive strategies. It develops leverage.

10. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing

11. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing International standards and support Policy alternatives (drug policy, models of care, public financing of palliative care) Drug availability Education, mentoring, professional training, popular education and communication / dissemination strategies

12. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing International standards and support Policy alternatives (drug policy, models of care, public financing of palliative care) Drug availability Education, mentoring, professional training, popular education and communication / dissemination strategies

13. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing International standards and support Policy alternatives (drug policy, models of care, public financing of palliative care) Drug availability Education, mentoring, professional training, popular education and communication / dissemination strategies

14. Transformation of the model of care Status quo Limited access model of care, high cost, ineffective, limited access to pain relief, no national strategy and limited training Costing more effective, identifies GAPS Education, discussion of alternative models, changes in legislation to introduce access to essential medicines Policy changes, adoption of standards, adoption of variety of models; training and implementation of new policies Budget monitoring, cost comparison, auditing of implemented standards; costing of new activities Transformation and institutional adoption of new model of care Gradual implementation of effective, inclusive model of care with in-patient services, home and community care, increased coverage and exhaustive training Monitoring of allocation for advanced implementation, trend analysis and program auditing International standards and support Policy alternatives (drug policy, models of care, public financing of palliative care) Drug availability Education, mentoring, professional training, popular education and communication / dissemination strategies

15. Costing and Budgeting Costing - determining the expenditure required to purchase the resources needed to achieve an activity or strategy. Budgeting - the allocation of resources to match requirements. Once the cost of an activity is determined, the total number of desired activities will then determine the desired funding. The number of activities will be adjusted to fit the amount of funds allocated, which will become the budget. Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

16. What is costing useful for? Identifying a human rights gap in policy, e.g. lack of access, inadequacy of care, failure to meet essential standard or minimum core obligations Assessing efficiency in two “equivalent” programs -which one yields the greatest benefit with a given amount of resources? Identifying important cost issues for potential savings Strategic planning and budgeting for programs Together, costing and budgeting helps the planning process by ensuring that the goals are financially affordable. Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

17. Costing definitions In costing we identify and measure all the inputs and all the outputs. Costs are always related to the outcomes they produce. Outcomes can also be called benefits or output. There are intermediate and final outcomes. Some examples: HIV treatment programmes: cost per life year gained HIV prevention programmes: cost per HIV case prevented Immunisations: cost per Fully Immunised Child (FIC) Immunisations: cost per measles case prevented/death prevented Palliative care: Cost per patient per day in inpatient units Palliative care: Cost per outpatient visit At a very basic level, we often relate costs to certain activities, such as the cost of an inpatient day or the cost per outpatient visit Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

18. Perspective of costing From whose point of view is the costing being undertaken? Societal Perspective (the patient and the health system and any other relevant individuals); also known as societal costs Health-system Perspective (the health system only); also known as provider costs or health system costs Patient Perspective (the patient only or the patient and her caregiver); also known as patient or consumer costs The perspective will determine which costs are to be included and will affect the methodology Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

19. Information sources Literature review of published reports Expert opinion (Delphi panel) Data bases Prospective collection of the data Medical records Information of prices from the market Unit costs of as many ingredients as possible Programme budgets and expenditure records Clinical trials which provide outcomes Adapted from Guthrie, Teresa. Costing Health Interventions. CEGAA, South Africa, 2007.

20. Costing is not rocket science While we will see very sofisticated costing exercises, even the most basic exercises have succeded: Cost of HIV treatment Cost of emergency maternal care Cost of immunization in marginalized communities The onus of responsibility for addressing a human right violation or policy gap lies on the State. Basic costing can be enough to identify the gap, propose a feasible alternative and ‘get the ball rolling’.

21. Costing is not rocket science Every costing exercise is context depending, despite flexible methodologies available, due to information constraints, systemic characteristics of care and context specific environmental factors that will affect the costs for provision of services. Every costing exercise will be difficult. While it will never be ‘bullet proof’, it must be sound, warranted, fully justified and externally validated to have traction.