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Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Comprehensive WHO Cervical Cancer Control Costing and
Planning (C4P) tool: findings from African countries
Comprehensive WHO Cervical Cancer Control Costing and
Planning (C4P) tool: findings from African countries
Raymond Hutubessy PhD
Initiative for Vaccine Research (IVR) team
Immunization, Vaccines and Biological (IVB) department
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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OutlineOutline
General description of the comprehensive WHO Cervical Cancer Prevention and Control Costing (C4P) tool
Country examples:– Tanzania – 5-years planned scaling up costs of HPV vaccines– Rwanda – 1 year retrospective national costs of HPV vaccines
Lessons learned
Conclusions
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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IntroductionIntroduction
Tool was developed for Tanzania in response to vaccine donation – Local economists, MoHSW*, WHO Tanzania & HQ*, consultants involved– 4 Country visits to collect data/interviews and workshops required
Tool addresses costing and planning issues– Economic and financial perspective– Input for Cost-Effectiveness Analysis and Financial Analysis
Excel-based model– Choice of inputs on strategies and assumptions– Spreadsheets with data on population and infrastructure: – Summary Page on Total Costs
Two modules of the generic tool– HPV Vaccine Module (version 1.0 available)– Cervical Cancer Screening and Treatment Module (available 2Q2013)
*Including representatives from EPI and Reproductive Health
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Purpose of Costing and Planning ToolPurpose of Costing and Planning Tool
Assist planners to:
– Estimate the cost of introducing a cervical cancerprevention and control programme in a country.
– Understand the cost implications of adopting various alternatives of cervical cancer prevention and controlapproaches and strategies.
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Designed for:Designed for:
Programme Managers:– Ministries of Health
– Reproductive Health
– Maternal and Child Health
– Immunization
•Policy Makers•Donors
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Users get a prospective 5-year cost estimate in exchange for their inputs.Users get a prospective 5-year cost
estimate in exchange for their inputs.Programme Cost Estimate Summary
– Financial vs. Economic Costs– 5-year costs by year– Activity cost breakdowns by:
1. Procurement2. Training3. Service Delivery4. Social Mobilisation and IEC5. Monitoring and Evaluation6. Other
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Approach to CostingApproach to Costing
Ingredients Approach
Government perspective
Financial versus Economic analysis
Multi-level: national, regional, district, community
Incremental cost to existing reproductive health services
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Costs represent the value of resources used for cervical cancer prevention and control
Costs represent the value of resources used for cervical cancer prevention and control
– Financial costs represent the actual expenditure on goods and services purchased.
• Use for financial analysis (affordability, budget allocation)• Perspective of individual payers e.g. MoH
– Economic costs Recognize that cost of using resources also means that these resources are then unavailable for productive use elsewhere and effectively being tied-up
• Concept of opportunity costs, which is the lost opportunity involved in using resources in one place rather than another
• Use for cost-effectiveness analysis (value for money, sustainability)• Perspective of the society
*WHO Guidelines for estimating costs of introducing new vaccines into the national immunization systemhttp://whqlibdoc.who.int/hq/2002/WHO_V&B_02.11.pdf
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Three types of CostsThree types of Costs
Introduction (Start-up) Costs– Micro planning– Training– Social Mobilization and IEC
Recurrent (Operational) Costs– Vaccine and Injection Supplies– Service Delivery
• Per Diems, Transport, communications– Supervision, Monitoring and Evaluation– Other (e.g. waste management)
Capital Costs– Cold chain equipment
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Pillars of Tanzania’s CxCa strategic planPillars of Tanzania’s CxCa strategic plan
Vaccination of adolescent girls (P4) before they become sexually active
Screening of women aged 30 to 50 years and treatment of precancerous lesions
Diagnosis, care and treatment including palliative care for cervical cancer patients
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Objectives and assumptions of planned HPV vaccination for Tanzania
Objectives and assumptions of planned HPV vaccination for Tanzania
Objective: to estimate and project incremental costs to health system of introducing HPV vaccine
– Assess the financial and economic costs of resources required for delivering a new vaccine to a non-traditional population using different delivery strategies
Assumptions– Scaling-up: 1st year 3 regions; 2nd year 10 regions; 3 yr all 26 regions– Girls aged 10 years will be vaccinated– Vaccine:
• Financial analysis: vaccines donated• Economic analysis: unit costs of $5 (maximum GAVI price) • 5% wastage and 25% buffer stock
– Projected cost over five years– Assume no capital good are needed since already available for other vaccines
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Summary of expected outputs of introducing HPV vaccines in Tanzania, 2011-2015
Summary of expected outputs of introducing HPV vaccines in Tanzania, 2011-2015
Output20112012201320142015TotalTarget population80,290349,349646,936672,833694,6662,444,074
Doses useda181,878791,3621,471,3081,524,1351,573,5915,542,274
Fully immunized girls52,209227,164422,345437,510451,7061,590,934
Health workers trained
1,4723,5965,0700010,138
Health facilities mobilized
7361,7982,535005,069
School vaccination sites added
2,0986,3337,7270016,158
Schools sensitized2,0986,3337,7270016,158
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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2011 2012 2013 2014 2015
02
46
81
01
2
School-based delivery
Fin
an
cia
l co
st (
US
$m
)
Waste managementVaccineTrainingSocial mobilisation/IECService deliverySupervisionMonitoring/evaluation
Note: Assuming vaccine purchase price of $5/dose; does not include costs of reaching girls that are not in school.
2011 2012 2013 2014 2015
02
46
81
0
Facility-based delivery
Fin
an
cia
l co
st (
US
$m
)
Waste managementVaccineTrainingSocial mobilisation/IECService deliverySupervisionMonitoring/evaluation
School vs health facility basedSchool vs health facility based
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Five-year average cost per dose and Fully Immunized Girl (FIG) - Tanzania
Five-year average cost per dose and Fully Immunized Girl (FIG) - Tanzania
Financial CostEconomic Cost
Total cost per dose$5.68$10.62
Delivery cost per dose (without vaccine)
$1.66$3.56
Total cost per FIG$19.79$37.01
Delivery cost per FIG (without vaccine)
$5.77$12.40
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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HPV introduction in Rwanda in 2011HPV introduction in Rwanda in 2011
HPV donation Merck
3 national campaigns
School-based (P6 girls) and facility based (12yrs girls)
Assumptions
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Annual costs Rwanda – preliminary resultsAnnual costs Rwanda – preliminary results
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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One-year average cost per dose and Fully Immunized Girl (FIG) - Rwanda
One-year average cost per dose and Fully Immunized Girl (FIG) - Rwanda
Financial CostEconomic Cost
Total cost per dose$3.82$11.59
Delivery cost per dose (without vaccine)
$3.26$4.60
Total cost per FIG$11.69$35.49
Delivery cost per FIG (without vaccine)
$9.97$14.09
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Lessons learnedLessons learned
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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HPV vaccine price vs delivery costsHPV vaccine price vs delivery costs
Indicative HPV vaccine price for GAVI countries is 5 US$ (a 64% reduction on the lowest public price)
In addition, countries would need to secure about $3-5 per girl for 1st year start-up costs and $4-6 per fully immunized girl for operational costs of vaccine delivery
Source: Hutubessy et al. A case study using The United Republic of Tanzania: Costing nationwide HPV vaccine delivery using the WHO Cervical Cancer Prevention and Control Costing Too (2012). BMC Medicine ( in publication)
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Non-Vaccine (Delivery) Cost per Infant Varies by Region (%)
Non-Vaccine (Delivery) Cost per Infant Varies by Region (%)
Source: Brenzel, L. et al (2012)
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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HICsMICsLICs
Vaccine costs
Delivery costs
Global trends on relative vaccine vs delivery costs
Global trends on relative vaccine vs delivery costs
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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C4P and other WHO economic tools and initatives
C4P and other WHO economic tools and initatives
cMYP Costing and Financing tool– Consistent costing methods and approaches– C4P provides adds-on and more details on HPV vaccination introduction and
recurrent costs over 5 year planning period– Integration in cMYP in future?
OneHealth Tool* –– For the first time, planners have a single framework for planning, costing, impact
analysis, budgeting and financing of strategies for all major diseases and health system components.
– Integration of C4P tool including a Cost-Effectiveness component (PRIME)
International Working Group (IWG) ProVac– C4P workshop organized in AFR and WPR in 2013 as part of capacity building
on using economic tools and information for vaccine introduction decisions *http://www.internationalhealthpartnership.net/en/tools/one-health-tool/
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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•Field tested in Tanzania and Rwanda and validated with PATH demonstration projects.
•C4P workshop in July 2011 in Dar es Salaam to inform national budget for HPV introduction.
•Costing and CEA workshops in regional WHO meetings in EUR (Oct11), AMR (Nov11), WPR (End Nov11), AFR (June 2012)
•C4P tool use and development workshop in 6-7 December 2011, WHO-HQ, Geneva with participants from 5 WHO regions and partners – 2 representatives from AFR
•2012 :Vaccination module reviewed and endorsed by WHO Advisory Committee on implementation research (IVIR).
WHO C4P applications up to nowWHO C4P applications up to now
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Vaccination Module in BMC MedicineVaccination Module in BMC Medicine
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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ConclusionConclusion
WHO C4P Costing tool– Allow calculation of costs of various scenarios of cervical cancer
prevention and control• Calculate total costs for budgetary purposes • Compare costs of various strategies: e.g. school-based vs. campaigns,
treatment options by level • Compare average costs across local levels, different strategies
Increase sense of ownership of process and output
Provide greater transparency, validity, and reliability in planning and costing of program tasks
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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Detailed national delivery cost information from LMICs are lacking – to address national program affordability and sustainability this information is crucial, also for resource mobilization
In MIC (non-GAVI eligible countries) both vaccine procurement and delivery program costs may be a barrier
HPV vaccines may be cost-effective but not affordable in LMICs
Overall conclusionsOverall conclusions
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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AcknowledgmentsAcknowledgments
MoHSW Tanzania– Dafrossa Lyimo – Safina Yuma– Mariam Ally
MOH Rwanda– Fidele Ngabo– Maurice Gatera
WHO Consultants– Ann Levin (Indep. Consult.)– Winn Morgan (Indep. Consult.)– Mark Jit (HPA, UK)
WHO Tanzania– Theopista John – Chris Kamugisha
WHO AFR– Carol Tevi Benissan– Richard Mihigo
WHO Geneva– Nathalie Broutet (WHO/RHR)– Susan Wang (WHO/IVB)
Financial support by GAVI Alliance
Annual Regional Conference on Immunization (ARCI)10-12 December 2012, Dar es Salaam, Tanzania
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THANK YOUTHANK YOU
More information:
Raymond Hutubessy, WHO IVB Geneva, Switzerland hutubessyr@who.int
Tool including user guide soon available on WHO NUVI HPV website http://www.who.int/nuvi/hpv/resources/en/index.html
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