comprehensive Multi-Year Planning (cmyp) A Tool and User Guide for cmyp Costing and Financing

Transcription

1 WHO/IVB/14.06 comprehensive Multi-Year Planning (cmyp) A Tool and User Guide for cmyp Costing and Financing Update 2014 DEPARTMENT OF IMMUNIZATION, VACCINES AND BIOLOGICALS Family, Women s and Children s Health (FWC)

2 WHO/IVB/14.06 comprehensive Multi-Year Planning (cmyp) A Tool and User Guide for cmyp Costing and Financing Update 2014 DEPARTMENT OF IMMUNIZATION, VACCINES AND BIOLOGICALS Family, Women s and Children s Health (FWC)

3 The Department of Immunization, Vaccines and Biologicals thanks the donors whose unspecified financial support has made the production of this document possible. This document was produced by the Expanded Programme on Immunization of the Department of Immunization, Vaccines and Biologicals Ordering code: WHO/IVB/14.06 Printed: April 2014 This publication revises the original publication (WHO/IVB/06.15) published in December 2006 This publication is available on the Internet at: Copies of this document as well as additional materials on immunization, vaccines and biologicals may be requested from: World Health Organization Department of Immunization, Vaccines and Biologicals CH-1211 Geneva 27, Switzerland Fax: vaccines@who.int World Health Organization 2014 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: ; fax: ; bookorders@who.int). Requests for permission to reproduce or translate WHO publications whether for sale or for noncommercial distribution should be addressed to WHO Press, at the above address (fax: ; permissions@who.int). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed by the WHO Document Production Services, Geneva, Switzerland ii

4 Contents Abbreviations and acronyms...v Acknowledgments... vii Introduction...ix 1. Strategic planning for immunization with costing A revised approach to planning for immunization Why cost a cmyp? What are the costing linkages in the cmyp guidelines? What are the cmyp linkages with broader health sector costing exercises? Overview of the cmyp Costing and Financing Tool Description of the worksheets in the cmyp Tool Can the cmyp Tool be used in a decentralized setting? Can the cmyp Tool be damaged? What is the cmyp Tool not designed to do? Where to send feedback and seek technical support Some principles and suggestions on procedure Important concepts, methodologies and terms What to cost in a cmyp What is the difference between a cost and a resource requirement? What are the basic costing methodologies used? What are some methodological differences and limitations? Using the cmyp Costing and Financing Tool Overview of the Data Entry worksheet Review of each data table contained in the Data Entry worksheet Costing results and tables Overview of the financing and financing projections worksheets Steps to complete the Financing worksheet Steps to complete the Co-financing worksheet Analysis of results Analysis of past costing and financing (baseline) Analysis of future resource requirements, financing and gaps : Analysis of immunization strategies : Sustainability analysis Dashboard...83 iii

5 7. Scenario building Types of Scenarios Using the cmyp Tool for scenario building Annual monitoring using the cmyp Costing and Financing Tool Annual planning and financial resources Review of key assumptions on the costing Financial management and trends on immunization financing Reporting requirements Other uses of the cmyp Costing and Financing Tool information Linkages to other costing tools WHO Vaccine Forecasting Tool WHO UNICEF Joint Reporting Form WHO Cervical Cancer Prevention and Control Costing Tool (C4P)...91 Annex I: Summary table of data needs and sources...92 Annex II: Glossary of important cmyp costing terms...99 iv

6 Abbreviations and acronyms AD APR BCG CBAW CEA cmyp cmyp Tool DFID DTP EPI FIC GAVI GDP GHE GIVS GVAP HepB Hib HIPC ICC IEC IMF IMR JICA JRF LCU auto-disable syringe annual progress report bacille Calmette-Guérin (tuberculosis vaccine) childbearing age women cost-effectiveness analysis comprehensive Multi-Year Plan (for immunization) cmyp Costing and Financing Tool Department for International Development (United Kingdom) diphtheria-tetanus-pertussis (vaccine) Expanded Programme on Immunization fully immunized children the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation) gross domestic product government health expenditure Global Immunization Vision and Strategy Global Vaccine Action Plan hepatitis B (vaccine) Haemophilus Influenzae type B (vaccine) highly indebted poor country inter-agency coordinating committee information, education and communication International Monetary Fund infant mortality rate Japan International Cooperation Agency WHO UNICEF Joint Reporting Form local currency units v

7 MDG MDRI MoF MoH MTEF MYP NHA NIP OPV PRSP SIA SWAp TB THE TT U1P ULY UNICEF US$ USAID WHO Millennium Development Goal multilateral debt relief initiative ministry of finance ministry of health medium-term expenditure framework multi-year plan (for immunization) national health accounts national immunization programme oral polio vaccine poverty reduction strategy papers supplemental immunization activities (campaigns) sector-wide approach tuberculosis total health expenditure tetanus toxoid (vaccine) under one population useful life years United Nations Children s Fund United States dollars United States Agency for International Development World Health Organization vi

8 Acknowledgments This document has been revised by the World Health Organization (WHO) and the United Nations Children s Fund (UNICEF), with the support of other immunization partners, to reflect the updated version of the cmyp Costing and Financing Tool. The revised document replaces the previous publication, Immunization costing & financing: a tool and user guide for comprehensive Multi-Year Planning (cmyp) (2006, WHO/IVB/06.15). The original contributors to the document are partners of the GAVI Alliance: the Bill & Melinda Gates Foundation, the Centre for Global Development, the Children s Vaccine Programme at PATH, UNICEF, the United States Agency for International Development (USAID), the World Bank and WHO. The revisions were made by Claudio Politi, Michael Hinsch (WHO Headquarters) and Ann Levin, independent consultant. We would like to express our gratitude to Jean-Bernard Le Gargasson (Agence de Médecine Préventive), William Meaney and Viktor Galayda (independent consultants) who reviewed the document. Our special thanks go to the numerous national EPI Managers and colleagues from WHO and UNICEF regional and country offices and immunization partners who contributed to the review. vii

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10 Introduction Responding to global immunization challenges, including the need to protect more people and introduce new vaccines, and in consultation with their other partners, the World Health Organization (WHO) and the United Nations Children s Fund (UNICEF) developed the Global Immunization Vision and Strategy (GIVS) for the period , followed by the Global Vaccine Action Plan (GVAP) for the period GVAP is a framework that offers policy-makers and stakeholders a unified vision of immunization and a set of strategies from which countries can select those most suited to their specific needs. In conjunction with GVAP, and as a way of implementing GVAP at national level, countries are encouraged to develop their own comprehensive multi-year plans (cmyp) for immunization. In 2005, in conjunction with their GAVI Alliance partners, WHO and UNICEF developed the WHO UNICEF guidelines for developing a comprehensive multiyear plan (cmyp) * as a means of providing support for countries to improve their immunization planning. This new approach was guided by the need to simplify and harmonize the proliferation of varied immunization planning activities at the national level, which in turn had led to duplication of effort, high transaction costs, and a lack of alignment with national systems. The cmyp process is expected to streamline the immunization planning process at national level into a single comprehensive and costed plan. With the GVAP initiative and framework, the cmyp guidelines and tools have been revised, taking into account the countries experience on developing multi-year planning during the GIVS period. In the development of these user guides, it was broadly recognized that strategic planning for immunization requires credible information about how much was currently being spent, what it was spent on, from what source the funding came, and how much future funding would be needed to reach programme objectives. Analysing the costing and financing of a cmyp is therefore a key step in the planning process of a national immunization programme (NIP). * The 2005 publication was recently revised under a slightly different title: World Health Organization (WHO), United Nations Children s Fund (UNICEF). WHO UNICEF guidelines for comprehensive multi-year planning for immunization: update September Geneva: WHO; 2014 (WHO/IVB/14.01; accessed 27 May 2014). ix

11 To help undertake the costing and financing elements of a cmyp, a Microsoft Excel-based tool was developed the cmyp Costing and Financing Tool to make it easy to estimate past costs and financing for immunization, to aid in making future projections of resources requirements and financing, and for analysing the corresponding financing gaps in reaching immunization programme objectives. The cmyp Costing and Financing Tool (the cmyp Tool) is accompanied by this comprehensive User Guide, which provides an overview of important concepts, methodologies and definitions. It also provides step-by-step instruction on how to use the cmyp Tool, guidance on sources of information, and results analysis, as well as guidance on interpretation of findings. The User Guide is structured as follows: introduction to strategic planning for immunization and costing overview of the costing and financing tool suggestions on procedures basic concepts, methodologies and terms how to use the costing and financing tool how to analyse the results and interpret findings how to develop alternative scenarios for costing and financing how to use the tool for annual monitoring other uses of the information from the costing and financing tool annexes: (1) reference summary table of data needs and sources; (2) glossary of terms. While the cmyp Tool and User Guide are principally targeted at national immunization programme managers developing comprehensive multi-year plans, the documents can also be used by researchers, consultants, international donors and other health planners in developing countries. No prior experience or formal training in health economics is necessary in implementing the cmyp Tool and understanding its User Guide. The intention is that these materials will be continually be improved and updated. We therefore recommend that users regularly visit the website to obtain the latest versionsǂ. ǂ Available at: x

12 W 1. Strategic planning for immunization with costing 1.1 A revised approach to planning for immunization Responding to global immunization challenges, including the need to protect more people and introduce new vaccines, WHO and UNICEF, in consultation with other partners, have developed the Global Vaccine Action Plan for the period GVAP is a framework that offers policy-makers and stakeholders a unified vision of immunization and a set of strategies from which countries can select those most suited to their specific needs. In conjunction with GVAP, countries are encouraged to develop a cmyp for immunization. Yet to date, the planning experience at country level for immunization has revealed many shortcomings. Plans are based upon a review of past achievements and problems; they are not sufficiently forward-looking; there are separate plans for each initiative or target disease; plans may be developed to fit particular funding proposals rather than reflecting country priorities; plans are not well costed to identify clear funding needs and resources gaps, and many plans have very little connection with the broader health sector or macroeconomic context. This experience has taught us that planning needs to reflect country priorities and align with country planning cycles. The planning process must be simplified and harmonized. To address these issues, the WHO and UNICEF cmyp process for immunization began in 2005, with the formulation of new guidelines and tools. Through the GVAP initiative, the cmyp Guidelines and Tool have been revised to streamline the immunization planning process at country level into a single comprehensive and costed plan aligned with the new framework. In summary, the WHO UNICEF guidelines for comprehensive multi-year planning for immunization 1 provides a new approach to planning that: ensures that the strategies in the plan are sufficiently comprehensive; integrates and consolidates activities with other health interventions and within the immunization programme to solve shared problems; plans by immunization system components rather than by disease or initiative; evaluates the costs and financing of the cmyp to ensure improved financial management sustainability of the programme; links annual workplans to the multi-year plan; links to the broader health sector planning and budgeting processes. 1 WHO and UNICEF, 2014 (see footnote 1, page 1) HO/IVB/

13 1.2 Why cost a cmyp? It is broadly recognized that strategic planning for immunization requires credible information about cost to achieve the programme objectives, estimate available funding, allocate funds within the programme, and avoid funding shortfalls. For this reason, analysing the costing and financing of a cmyp is a key step in the planning process. The costing of a cmyp is thought to have a number of benefits. It strengthens national budgeting and planning for immunization and helps to answer the fundamental questions of how much it will cost to reach programme objectives, who will pay for these needs, and how to prioritize activities based on available funding. It helps in decision-making about programme improvements, for example, understanding the cost implication of introducing new vaccines. A baseline costing of the programme would enable the development of scenarios for improvements, and understanding the incremental costs of such improvements. It generates information that will help advocacy and mobilize the resources needed for vaccination and immunization. A solid understanding of the funding gaps can facilitate discussion with ministries and donors on how to mobilize the resources required for the programme. 1.3 What are the costing linkages in the cmyp guidelines? The WHO UNICEF guidelines for comprehensive multi-year planning for immunization provide a series of steps to develop a comprehensive plan. Step 6 of these guidelines relates to analysing the costs, financing, and financial gaps in a cmyp. Note that the basis of the costing should be the programmatic objectives and milestones defined during steps 1 to 3 (see Figure 1). 2 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

14 W Figure 1: Costing linkages in cmyp guidelines Step 1 Situation analysis Step 6 Step 7 Putting cymp into action Cost & financing & resource mobilization 1. Health sector analysis 2. Estimating costing and financing of the cmyp 3. Scenario building using the costing tool 4. Interpreting costs, financing and gap results 5. Developing financial sustainability strategies 6. Financial sustainability indicators and targets Step 2 Objectives & milestones Step 3 Planning strategies Step 5 Activity timeline, monitoring & evaluation Step 4 Links to national, regional and international goals Step 6 has six components to it. Step 6(1) is to undertake a diagnosis of the macroeconomic and health sector environment in which the immunization programme operates. This diagnosis recommends exploring three areas: (a) trends in government financing of health services; (b) the planning and budgeting processes for the health sector; (c) current or potential reforms which may have an impact on the immunization programme. Such a diagnosis will strengthen any projections of future financing for immunization, and assessment of the reliability of future funding. Steps 6(2) and 6(3) are to estimate the baseline costing and financing of the immunization programme, making future projections of resource requirements based on the programmatic objectives defined under steps 1 to 3 of the cmyp, and to develop alternative scenarios for resource requirements and financing. Step 6(4) is to analyse the results and interpret the findings, particularly with regard to the financing gaps for immunization. Lastly steps 6(5) and 6(6) are to identify strategies and indicators that will help you move towards financial sustainability. HO/IVB/

15 1.4 What are the cmyp linkages with broader health sector costing exercises? Neither strategic planning for immunization, nor its costing, have ever been easy processes. The immunization programme is one of many components of a country s health system. It is supported by a broad range of national and international partners and actors that can have differing objectives and needs, and might view planning for immunization within a different context (see Figure 2). Figure 2: Reconciling v a r i o u s objectives when planning for immunization Poverty Reduction (MDG, PRSP, MTEF...) MoF Priorities MoH Policy Health Sector Planning, integration, SWAp... World Bank EPI Objectives GAVI Polio, measles, campaigns, outbreaks, surveillance... New vaccine introduction, increasing coverage... The ministry of finance (MoF), for example, might view immunization in the context of the Millennium Development Goals (MDGs), or how it can contribute to poverty reduction. Thus, any strategic planning for immunization should fit with these broader objectives as laid out in the MDGs, and any budgeting for immunization would need to appear in the relevant national budgeting processes such as a medium-term expenditure framework (MTEF). The ministry of health (MoH), on the other hand, would view immunization in the context of the broader objectives and planning process. The national immunization programme may have its own specific planning and budgeting objectives, and these can be different from those of international agencies and initiatives supporting the programme. 4 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

16 W Although the different planning processes and objectives are not necessarily in competition, reconciling all these in the context of a strategic plan for immunization is not an easy task, and it is therefore important that objectives and priorities are aligned. Similarly, the costing information generated through the cmyp development should link to the relevant consolidated costing and budgeting plan for the health sector. If applicable, it can be useful to link various ongoing exercises such as: poverty reduction strategy papers (PRSP); health sector and public expenditure reviews; budgeting, allocation, and expenditure (MTEF, NHA); and external support and resource mobilization processes (such as donor round tables, SWAp, etc.). This has the effect of increasing the visibility of immunization during health sector planning processes and can increase the chances of mobilizing the resources needed for the programme. Because the relevant planning cycles and costing/budgeting exercises for the health sector differ between countries, and budgeting formats can also vary from one country to the next, it is not possible to develop a costing template that will fit into every existing situation. To reconcile this difficulty, the cmyp Costing and Financing Tool includes a costing table that provides the most disaggregated level of costing possible. This facilitates how specific budget lines in the cmyp costing table can be linked and matched to budget lines in another. (More on the costing table is available in part 5.3). Also, the period covered by resource estimation should be set for five years, as with a longer time frame, more assumptions need to be made for future projections, and estimates become unreliable. Maximum five-year projections therefore seem useful, especially when linked to annual operational plans and allocations. HO/IVB/

17 2. Overview of the cmyp Costing and Financing Tool The cmyp Costing and Financing Tool (referred to as the cmyp Tool throughout the remainder of this User Guide) is a Microsoft Excel-based template. 2.1 Description of the worksheets in the cmyp Tool The cmyp Tool contains the following worksheets: Home page Style Checklist Dashboard Data Entry Costing Financing Gaps & Indicators Graphs Sustainability Co-financing Vaccine Prices Annual Workplan Index The Home worksheet is where you can find shortcuts to important sections, and a schematic of the main activities required to complete the cmyp. Clicking the shortcut icons along the upper bar take the user to the Checklist, Co-financing worksheet, and Graphs worksheet. Every other worksheet will have similar shortcuts leading back to the home page and the checklist. Shortcuts on the home page, located next to START HERE, take you to the three worksheets that require data input and the three review worksheets. The Style worksheet contains descriptions of different styles, formats and colours used for text and numbers in the cmyp Tool. 6 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

18 W The Checklist contains a checklist of all the necessary data inputs. As you enter data, you should keep track of what you have done by double clicking the appropriate boxes on the checklist. This will help you monitor progress during the data entry and remind you of what additional data entry is required. The Dashboard contains a summary of the costing and financing situation and a summary of baseline annual expenditures. It also has a table with the financing information of the baseline year, which is useful for the financing indicators on the Joint Reporting Form. The summaries will automatically update as data are entered into the cmyp Tool. Start by selecting Enter/edit costing data on the Home worksheet. The Data Entry worksheet is where you need to enter all the data for the costing and resources requirements projections. The worksheet contains a series of data entry tables for the calculations of vaccines, injection supplies, personnel, vehicles and transport, cold chain and maintenance, supplemental immunization activities, other recurrent and capital costs, and other costs not specified elsewhere. Given the importance of this worksheet, parts 5.1 and 5.2 of this User Guide are dedicated to explaining how to complete the worksheet and find the required data. Go back and select Enter/edit financing data on the Home worksheet. Data on past and future financing are entered in the Financing worksheet. Some suggestions on procedures to collect financing information are provided in parts 5.4 and 5.5 of the User Guide and in Annex I. Go back and select Enter/edit co-financing data on the Home worksheet. The data on GAVI co-financing are entered in the Co-financing worksheet. Some suggestions on procedures to collect co-financing information are provided in part 5.6 of the User Guide. HO/IVB/

19 Figure 3: Screen shots of the cmyp Costing and Financing Tool (illustration only) 1. Data Entry Worksheet 2. Costing Worksheet 3. Gaps & Indicators worksheet 4. Graphs The remaining worksheets are automatically generated based on the information entered in the Data Entry, Financing and Co-financing worksheets. The Calculations worksheet consolidates the formulas that convert the information and data provided in the Data Entry worksheet into the costing and estimates for resource requirements. The broad underlying methodology used in the Calculations worksheet is described in part 4 of the User Guide. This worksheet is hidden and is available for developers. The Costing worksheet is linked to the Calculations worksheet and presents the results by means of various costing tables. These costing tables are described in part 5.3 of the User Guide. The Gaps & Indicators worksheet is linked to the Financing worksheet and generates a summary table of costs, future resource requirements, financing and gaps needed for complete financial diagnosis of the cmyp. This worksheet automatically calculates a range of indicators that should be used in the analyses. It contains several tables presenting year-to-year variation of secure and probable financing, and makes overall estimates for the financing gaps and how they will evolve over time. These indicators are explained in parts 6.1 and 6.2 and in the Annex to the User Guide. 8 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

20 W The Graphs worksheet is linked to numerous other worksheets in the cmyp Tool and contains a number of automatically generated charts and graphs needed for analyses. This worksheet contains charts that plot the future resource requirement profiles and the future financing and gap profiles. These help clarify the level of resource requirements needed by the NIP, and also what financing will be available in the future. More information is available in parts 6.1 and 6.3 of the User Guide. The Sustainability worksheet is linked to numerous other worksheets in the cmyp Tool and contains a number of automatically generated macroeconomic and financial sustainability indicators that can be used for your analyses. More information is available in part 6.4 of the User Guide. The Vaccine Prices worksheet contains detailed information on numerous vaccines and vaccine supplies. On this sheet you will find the following information about each item: vaccine, vaccine code, formulation, mode of administration, recommended schedule, doses per vial, and price per vial. The following information is provided for vaccine supplies: injection supplies/equipment, references, units per box, cost per box, freight cost, and total cost. The Annual Plan worksheet contains a template to be used for listing the main activities to be carried out during each year of the planning period. The template is structured in a way that allows regular updating of implementation rates according to the timeline expected. The Index contains a list of the worksheets and a summary of the content of each worksheet. In addition, the worksheets that require user input are indicated. Note that all the worksheets in the cmyp Tool are printer friendly. HO/IVB/

21 Figure 4: Design of the cmyp Tool 1. Enter/Edit Costing data Review sustainability analysis (autogenerated) Review costing report (autogenerated) 3. Enter/Edit Costing data 2. Enter/Edit Financing data Review gaps & indicators report (autogenerated) 2.2 Can the cmyp Tool be used in a decentralized setting? It is important to note that the cmyp Tool allows for a generalized approach but can be customized to fit a particular country situation or context. For instance, it is not restricted to any particular country administrative level. In a decentralized setting, different sections of the cmyp Tool may need to be used at different levels of the system (subnationally). This may be of particular relevance in large country settings and where data collection needs to be undertaken at lower levels in the system or where subnational (e.g. provincial) planning and budgeting is required to implement the immunization programme activities. 10 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

22 W 2.3 Can the cmyp Tool be damaged? Owing to its intricate linkages and formulas, the cmyp Tool is very sensitive to any formatting changes (adding or deleting cells, rows or columns) and editing (cut, copy and standard pasting of information from different sources). In order to protect it from any damage caused by formatting or editing changes, certain protective measures have been put in place and the worksheets are also password protected. More detailed information about cmyp Tool protection and passwords is provided in part 5.1 of this User Guide. 2.4 What is the cmyp Tool not designed to do? The main purpose of the cmyp Tool is to facilitate costing and finance estimation of a cmyp, and to make projections of future resource requirements and financing to achieve programme objectives. However, the cmyp Tool currently has three areas of limitation. 1) The first is that it was not designed for cost effectiveness analysis (CEA), which can assist in evaluation and comparison for alternative uses of scarce resources. Although defining programme objectives and strategies during the development of a cmyp should be based on cost effectiveness considerations (particularly in relation to new vaccine introduction), the cmyp Tool, in its current design, is ill-equipped to strengthen such a priority-setting exercise. Likewise, the cmyp Tool is not designed to determine allocative efficiency. A critical consideration in any planning and budgeting exercise must be the efficient use of funds. 2) The second limitation is that in its current format, the cmyp Tool does not automatically factor in any scale effect. Ideally, costs would vary as the scale of immunization interventions changes. For instance, with economies of scale, costs would decrease as the scale (such as coverage) increases, as fixed inputs (such as buildings) are used more efficiently. There could, however, also be diseconomies of scale, whereby costs increase proportionally if the last people to be reached and immunized live in areas that are difficult to access. There can even be economies of scope, when combining intervention results in cost savings. While techniques and methodologies are rapidly becoming available for global level costing exercises, where scale up effects can be included, these have not yet been assimilated into the cmyp Tool. In the meantime, any scale effect needs to be done manually. 3) Finally, the cmyp Tool is immunization specific, and is therefore not adapted to include the costing of other health interventions. Moreover, it has limited linkage with other existing tools available for costing health interventions, programmes and packages of services. Work to improve the cmyp Tool and to overcome these limitations is continuing HO/IVB/

23 2.5 Where to send feedback and seek technical support We welcome questions and comments on the cmyp Tool and User Guide. While we have tried to identify any inconsistencies in the system, if you discover any errors, encounter any problems, or have any suggestions on how to improve these materials, we encourage you to bring these to our attention. Please direct your comments to: The World Health Organization Department of Immunization, Vaccines and Biologicals Expanded Programme on Immunization 20 Avenue Appia CH 1211, Geneva 27 Switzerland For questions, comments and technical assistance related to the development of a cmyp, please contact your regional offices. For general information on submitting the cmyp as part of a GAVI funding application, visit the GAVI website at More general information on immunization planning and financing is available at: 12 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

24 W 3. Some principles and suggestions on procedure Before starting the cmyp costing and financing exercise, several principles should be noted. The first is the importance of creation of leadership and ownership of the cmyp development process within the immunization department of your MoH. It is equally important to inspire commitment and buy-in to the process, priorities and strategies for immunization from the stakeholders represented on the Inter-agency Coordinating Committee (ICC). Because any costing and financing resource requirement projection exercise will invariably be based on many assumptions, limited data and future uncertainties mean that these assumptions need to be agreed upon in close cooperation and agreement with all stakeholders so that the final estimations for the cmyp will be credible, acceptable, and useful. Unfortunately, there is no blueprint for the process and therefore considerable time can be taken up tailoring the cmyp costing and financing exercise to each individual country. The exercise cannot be done in isolation and will need the collaboration of colleagues in the MoH and the MoF, as well as all development partners supporting immunization, for data collection, analysis, feedback and review. The second principle is the importance of putting together a good team to work on the cmyp costing and financing exercise. The team will need to be composed of the right people, with the right skills, and they will need the right amount of time to complete the exercise. A focused and manageable group of no more than three people is required. It will be important to decide on who will lead and who will coordinate the team. Below are some suggestions on steps and procedures for the team. 1) The cmyp development team should read the WHO UNICEF guidelines for comprehensive multi-year planning for immunization, 2 paying particular attention to step 6: Analysing the costs, financing, and financial gaps in the cmyp. Discuss the steps so that the group fully understands the task at hand, how the costing steps of the cmyp development will inform the overall financial sustainability planning for the NIP, and also what needs to be done to achieve these objectives. 2) Read the User Guide to understand the methodologies, key concepts and terms needed, and to obtain step-by-step instructions on how to use the cmyp Tool and where to obtain the necessary data. The latest versions of the cmyp Tool and User Guide are available for download. 3 Because these materials will be constantly improved and updated, it is important to visit the website regularly 2 WHO and UNICEF, 2014 (see footnote 1, page 1) 3 Available at: cmyp/en/ HO/IVB/

25 to obtain the latest version. 3) Review the objectives, strategies, and macroeconomic/health sector context developed for your cmyp, and determine what will constitute your baseline scenario for the costing. For example, the baseline scenario needs to include the same actual coverage achieved, immunization schedule and expansion, and the same timing of specific campaigns as those defined in your cmyp. Also, activities that are specified in the cmyp should be budgeted for in the cmyp Tool (e.g. expanding the cold chain, strengthening outreach services, etc.). 4) Review the Data Entry worksheet of the cmyp Tool to determine what data is needed and how best to collect it. Collecting and synthesizing data can be difficult since information sharing among external development agencies involved in health, and the different ministries and their internal departments, may be weak. It may be more useful to print the entire worksheet to use as a data collection instrument. This way the different data tables can be distributed to those people that will be collecting the data or who will be providing the information. Refer to Annex I of this User Guide for suggestions as to where to find data for the costing, or techniques for estimating some data needs. 5) A checklist is available on the Checklist worksheet to assist the user in keeping track of completed sections. 6) Once all the data on inputs and activities has been collected, these should be entered in the appropriate tables of the Data Entry worksheet of the tool. Review this worksheet carefully for any errors in data entry, or any omissions or oversights of data needs for the tables. Remember that the cmyp Tool is password protected and data should not be pasted into the Data Entry worksheet from another Excel file. This could damage formulas, provide wrong results, or render the cmyp Tool useless. 7) Review the results of the costing in the Costing worksheet. Close inspection of the tables may yield strange results. This could be due to errors in the data or data entry into the cmyp Tool, or omissions of required data inputs. These should be reviewed. It can happen that costing results do not appear in the costing table. If this is the case, it could be due to important information not having been entered into the Data Entry worksheet. 8) Double-check the work as often as you think necessary. Remember to save the work frequently. This updates your file and helps to ensure that you do not lose significant amounts of data once it is entered in the cmyp Tool. 9) After completion of data entry in the Data Entry worksheet, a first analysis should be made of the results obtained. Parts 6.1 to 6.4 of this User Guide offer suggestions on how to analyse the findings. Ensure review of the Gaps & Indicators and Graphs worksheets of the cmyp Tool. It is important to make a first analysis so that the team can present the results and validate them with a broader group, such as the ICC. 10) Once the costing of the cmyp is finalized, and estimates have been made for future resource requirements, the team will need to collect information on past and future financing. This information should be entered in the Financing worksheets. For future financing, it is important to classify the funding according to its level of risk secure versus probable. Suggestion on how to collect financing data is developed in parts 5.4 and 5.5 of the User Guide. 14 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

26 W 11) After finalization of the financing of the cmyp, the team will need to collect information on co-financing requirements for GAVI vaccines. This information should be entered in the Co-financing worksheet. Instructions for using this worksheet can be found in part 5.6 of the User Guide. 12) Once the financing data is entered in the cmyp Tool, the work should be doublechecked for any mistakes or results. To identify errors, it can be helpful to review the Gaps & Indicators and Graphs worksheets. Once the team is satisfied with the results and these have been double-checked for errors, the cmyp Tool can be saved as the baseline scenario. 13) A second analysis of the results should compare the estimated resource requirements and available funding, to identify the gap in funding needed to meet desired programme objectives. Again, it can be helpful to review the Gaps & Indicators and Graphs worksheets in the analysis. A summary of the results is available on the Dashboard worksheet. 14) Using the baseline scenario, the team may be interested in exploring alternatives to evaluate what impact a change in cmyp objective may have on projected resource requirements, financing and gaps. Various scenarios can be developed, and guidance on this is provided in parts 7.1 and 7.2 of this User Guide. 15) The final step is filling in the Annual Plan worksheet where the main activities for each year of the planning period should be listed with timeline. Their implementation should be monitored during the year. HO/IVB/

27 4. Important concepts, methodologies and terms Part 4 of the User Guide provides important background information on basic costing concepts, methodologies and terms. Before starting the cmyp costing and financing exercise, it is essential to become familiar with these terms. Figure 5: Broad elements to cost in a cmyp cmyp Objectives Strategies Inputs (e.g. vaccines) Activities (e.g. training) 4.1 What to cost in a cmyp The costing exercise needs to account for all the inputs and activities designed to carry out the strategies needed to reach the programme objectives, as defined in the cmyp. Table 1 illustrates the types of inputs and activities that are usual in an immunization programme. They are linked to the health system components defined in the WHO UNICEF guidelines for comprehensive multi-year planning for immunization. 4 4 WHO and UNICEF, 2014 (see footnote 1, page 1) 16 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

28 W Table 1. Health system components to cost in a cmyp Health system components Inputs Activities Leadership & governance Health workforce Programme management, computers and office equipment Human resources/salaries, outreach per diems Meetings, planning, research, data management, expanded programme on immunization (EPI) reviews, cold chain assessment, etc. Supervision, training, workshops, etc. Finance Financial resources Budgeting and monitoring expenditures Medical product and technology Service delivery Information Vaccines, auto-disable (AD) syringes, safety boxes, other injection supplies, cold-chain equipment vaccines, cold chain and logistics Transport, operational cost for routine immunization and campaigns Information, education and communication (IEC) materials, such as posters, etc.; surveillance and laboratory equipment Vaccine procurement and storage; monitoring; vaccine stock management activities Operations for immunization delivery Social mobilization, IEC, development of advocacy and communication plan, surveillance The cmyp Tool is designed around this framework and requires the necessary data entry to calculate the costs and resource requirements for inputs and activities relevant to your immunization programme. This is described in greater depth in parts 5.1 to 5.5 of this User Guide. At a minimum, it is important to estimate the costs, financing and future resource requirements of your cmyp for all immunization-specific inputs and activities. All inputs and activities that are shared with other programmes, such as personnel, transportation and buildings are optional. HO/IVB/

29 What is the difference between an immunization-specific input and a shared input? Immunization-specific costs include the value of inputs and activities undertaken specifically for immunization. In other words, their utilization is 100% for the NIP. Typically, immunization-specific recurrent inputs include: vaccines; injections supplies; full time immunization personnel (including those who conduct outreach and supplemental immunization activities); the transport costs incurred by the NIP (e.g. fuel and maintenance cost of the vehicles owned by the NIP); training activities; social mobilization; surveillance activities, etc. On the other hand, immunization-specific capital inputs can include vehicles and cold-chain equipment to be used specifically for the NIP, together with other inputs used specifically by the programme (e.g. waste disposal, etc.). The complete listing and definition of the immunizationspecific inputs can be found in Annex II at the end of this User Guide. Shared costs include the value of inputs that are not specific to immunization and which are used by different programmes or activities in the health sector, i.e. their utilization for the NIP is less than 100%. For instance, a nurse working in a district health centre is likely to be providing immunization services as well as other curative and preventive services. Only a portion of that nurse s salary and time can be attributable to immunization. Lik ewise, a vehicle in a district health centre (such as a four-wheel drive) may be used by staff working for programmes other than immunization, such as malaria or tuberculosis (TB) programmes. Therefore, only a portion of the fuel and maintenance cost of these vehicles will be borne by the NIP. The remaining portion will be borne by the budget of the district health administration. This makes it difficult to separate out the portion of these inputs that can be attributed to immunization. These inputs are classified as shared costs. Other typically shared inputs are health centres, cold chain storage buildings and the use of some cold-chain equipment. Given the relative difficulty in collecting information on shared costs in a programme and that these costs are not tied to funding that is specifically set aside for immunization (the most relevant for the cmyp costing and financing exercise), the estimation of shared costs is optional. However, we strongly recommend that these shared costs are taken into account, since in most countries shared inputs are likely to be quite significant. In some countries, there might not even be any specific funding for immunization at subnational level. The added investment in time will result in a more accurate costing exercise. 5 If shared inputs are excluded, the analysis will: (a) underestimate the true government contribution to immunization, since many of the shared inputs tend to be funded from national resources (especially for personnel costs); (b) underestimate the total cost and resource requirements of the programme if other inputs (such as vehicles) are frequently shared with other programmes. The cmyp Tool has been set-up to allow for the calculation of shared inputs, if so desired. The process whereby the portion of a shared cost is separated out is known as cost allocation. Its main method is to allocate shared inputs to a programme based on the percentage time spent on immunization. The various cost allocation methods will be explained in the sections of this User Guide that introduce categories of shared costs, such as personnel, vehicles and buildings. 5 We recommend also to liaise with National Health Account teams in countries which adopted the methodology to report health expenditure. See also: 18 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

30 W Finally, estimations of costs, financing and future resource requirements should be done for a particular set of years or time period. One past year. The rationale for looking at a past year is to have a baseline reference year from which comparisons can be made between how much the programme currently costs, and what will be the future resources required. Between three and five future ye ars. This is considered the standard period for making future projections of costs and resource requirements in a cmyp, especially if this is linked to the annual operational plans. Optional forecast (beyond five years). In some instances, it may be useful to forecast the costs and resource requirements for the programme beyond the 3 5 year planning cycle of the cmyp. This is explained in greater depth in parts 7.1 and 7.2 of the User Guide. Note that in the case of a longer time frame, more assumptions have to be made regarding the possible unpredictability of future trends and estimates. 4.2 What is the difference between a cost and a resource requirement? So far, the term cost and resource requirement have been used interchangeably, but it is important to clarify the difference between them. Generally speaking, a costing exercise is associated with a retrospective analysis (past year), whereas, resource requirements are associated with a prospective analysis of future projections (3 5 future years). In the cmyp Tool, the distinction between the term cost and the term resource requirement relates to how capital equipment is treated. Capital costs reflect inputs that are not consumed or replaced in one year or less (e.g. a vehicle or cold-chain equipment). In most cases, the treatment of recurrent inputs is the same whether we refer to cost or resource requirement, although some difference in the calculation of vaccines will be mentioned in part 4.5. What is the difference between a capital and a recurrent cost? A capital cost corresponds to an input that has a useful life of more than one year. In other words, these are inputs that are not consumed or replaced every year. The capital cost categories used in the cmyp Tool include the following: vehicles; cold-chain equipment, and other immunization-specific equipment (e.g. waste disposal). The suggested method for the treatment of capital cost is a simple, straight-line depreciation, i.e. the value of the new equipment is divided by its number of useful life years (ULY). A recurrent cost corresponds to an input that will be consumed or replaced in one year or less. The recurrent cost categories used in the cmyp include the following: vaccines; injection supplies; personnel; transport; maintenance and overheads; training; social mobilization/iec; surveillance and monitoring. Refer to Annex II at the end of this User Guide for a complete definition of these cost categories. When the term cost or cost projection is used, it implies that the value of capital equipment depreciates (or amortizes) over its lifetime known as useful life years (ULY). In other words, the value of the capital equipment is spread out over the number of years it will be used and brought to an annual equivalent. Once the capital equipment is older than its number of ULY, the equipment is considered to be fully depreciated (or amortized). This means that it no longer has a financial value. HO/IVB/

31 To simplify the calculation, the methodology used in the cmyp Tool recommends using standard ULY for equipment: 5 years for vehicles and cold-boxes; 10 years for refrigerators, and 25 years for buildings). Even if the equipment is more than five years old and is still being used by the programme, the cmyp Tool considers this item to be completely depreciated with zero financial value. It is possible to choose alternative values of ULY. The first advantage of depreciating (or amortizing) capital equipment when making cost estimates and cost projections, is that their value can be added to the recurrent costs for an accurate estimation of the total annual cost. Recurrent inputs are those that will be consumed or replaced in one year or less (e.g. vaccines, salaries, etc.). A second advantage is that important cost indicators can be computed with values that are comparable over time (e.g. annual variations in the cost per capita; cost per fully immunized child, or the cost as a percentage of gross domestic product [GDP]). However, as the object of the exercise is to calculate the financial resources that will need to be mobilized each year to reach the cmyp objectives, and also identify who will fund these needs over time, the costing approach described above has certain limitations. For example, suppose that next year there is a need to purchase 10 new refrigerators for the cold chain. Even if these refrigerators will last several years, it will still be necessary to mobilize all the funds in the next year to buy these 10 refrigerators. Taking the costing approach, you will underestimate the true financial resources that are needed in that particular year. This is the rationale for the resource requirements approach. When the term resource requirements is used (sometimes referred to as resource needs ), it implies that the full purchase cost of new units of capital equipment will be accounted for. Since this assumes that the existing equipment has already been paid for, the resource requirements approach is most relevant when looking at exact amounts of financing that need to be mobilized each year. This approach allows for comparisons between resource requirements and required financing, and also how the two need to be matched in order to reduce any financial gaps. 4.3 What are the basic costing methodologies used? Broadly speaking, the cmyp Tool employs three methods for costing and making projections of future resource requirements. The first method is known as the ingredients approach, where the value of an input is based on quantities, unit prices and percentage use for immunization these are the ingredients. Since vaccines, injection supplies, personnel, transport, vehicles, and cold-chain equipment account for the bulk of the cost and resource requirements of an immunization programme (at least 80% of the total), considerable emphasis is given to assessing these inputs accurately. If not, small inaccuracies in the estimations could translate into large over- or underestimations of the total cost and resource requirements. 20 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

32 W Figure 6: Typical cost profile of an immunization programme New vaccines, $0, 0% Injection supplies, $118,223, 3% Personnel, $1,458,877, 35% Underused vaccines, $1,573,161, 38% Transportation, $58,847, 2% Traditional vaccines, $406,079, 10% Other routine recurrent costs, $470,778, 11% Vehicles, $0. 0% Campaigns, $57,201, 1% Other capital equipment, $7,983, 0% Cold chain equiment, $0, 0% The basic methodology for calculating these inputs is based on the formulas listed below. 1) Past costing Recurrent (RCx, Yi) = existing quantities x US$ price x percentage (RCx, Yi) (RCx, Yi) use for immunization (RCx, Yi) Capital (CCx, Yi) = [existing quantities x US$ price ] / ULY (CCx, Yi) (CCx, Yi) (CCx, Yi) x percentage use for immunization (CCx, Yi) Total cost = sum of all recurrent costs + sum of all capital costs 2) Future resource requirements Recurrent (RCx, Yi) = future quantities needed x US$ (price x Ω) (RCx, Yi) (RCx, Yi) x percentage use for immunization (RCx, Yi) Capital (CCx, Yi) = future quantities needed x (US$ price x Ω) x (CCx, Yi) (CCx, Yi) percentage use for immunization (CCx, Yi) Total resource requirements = sum of all recurrent resource requirements + sum of all capital resource requirements 3) Cost projections to compare between past cost and future resource requirements Recurrent (RCx, Yi) = future quantities needed x (US$ price x Ω) (RCx, Yi) (RCx, Yi) x percentage use for immunization (RCx, Yi) Capital (CCx, Yi) = [(existing + future quantities needed ) x (US$ price (CCx, Yi) x Ω)] / ULY x percentage use for immunization (CCx, Yi) (CCx, Yi) (CCx, Yi) Total cost projections = sum of all recurrent cost projections + sum of all capital cost projections HO/IVB/

33 Where: RCx = for recurrent cost category x CCx = for capital cost category x Yi = for year i Ω = for inflation What inflation and exchange rate should you use? Inflation refers to the phenomenon of rising prices over time. In this way, costs and resource requirements can rise over time simply because of a rise in prices, rather than a rise in the quantity or quality of inputs purchased. For example, increasing fuel prices will increase the cost of transportation). Because the final costs and resource requirement estimates are reported in United States dollars (although the cmyp Tool allows prices to be entered in local currency), a standard inflation rate of 2% is recommended. This rate is based on the average consumer price inflation in the United States dollar between 2009 and 2014, and represents an estimate of future price inflation. The United States dollar exchange rate selected for use in the cmyp Tool needs to be based on the published figures utilized in each country. These should be reported in the Background Information section of the Data Entry worksheet. The cmyp Tool assumes a constant exchange rate over the projection period. Sources of the United States dollar exchange rate include the ministry of finance or central bank, as well as the World Bank and International Monetary Fund (IMF) offices. The second method used by the cmyp Tool estimates costs and future resource requirements of certain categories of input based on some agreed rules of thumb, applied automatically in the cmyp Tool. This applies to injections supplies, cold chain and vehicle maintenance as follows: For injection supplies, an approach that accurately reflects the use of resources takes into account immunization practices for each antigen, and links to the number of doses of vaccines. For example, one dose of measles vaccine would require one auto-disable (AD) syringe, one mixing syringe for reconstituting a 10-dose vial, and a portion of a safety box for disposal of the used syringes. Using the unit costs of each of these injection supplies, an approximate cost of supplies per measles dose administered can be calculated based on the vaccine forecast for measles. Future resource requirements for injection supplies are based on the same rule of thumb, as well as future projected doses of each vaccine in the vaccination schedule. For cold chain maintenance the rules of thumb to estimate the likely maintenance needs work by applying a set percentage of the capital cost of this equipment. The cmyp Tool recommends using 5%, but this amount can be changed for a particular country setting. For vehicle maintenance the rule of thumb is to estimate the likely needs based on a set percentage of fuel costs. Fuel for vehicles is likely to be the single most important input for transportation, and one for which records are reasonably good. Basing the set percentage on fuel rather than on the capital cost of the equipment (similar to cold chain), takes into consideration the utilization of the vehicles, where higher fuel consumption implies higher utilization and therefore higher maintenance needs. The cmyp Tool recommends using 15%, but this amount can be changed for a particular country setting. 22 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

34 W For other categories of inputs and activities such as training, social mobilization, IEC, surveillance, etc., the ingredients, or rules of thumbs approaches, are not used. Since they do not represent the major cost drivers for immunization programmes, less emphasis is placed on estimating them accurately, and approximations can be made using past spending (the budgeting approach). This is a method that is likely to yield estimates that are as accurate as applying the more complicated ingredients approach, and it has the advantage of requiring less data. This is therefore the third method used by the cmyp Tool. The three methods are summarized in Table 2. Table 2: Summary table of methods used in the cmyp Tool Method Name Methodology Inputs Ingredients approach Rule-of-thumb Past spending or budgeting approach Quantities x price x percentage use for immunization Immunization practice, fixed percentage of the value of coldchain equipment, fixed percentage of fuel costs Lump-sum spending or based on past expenditure and budgets Vaccines, personnel, transport, vehicles, cold-chain equipment Injection supplies, cold chain maintenance, vehicles maintenance Training, social mobilization, IEC, surveillance and others 4.4 What are some methodological differences and limitations? For some inputs, there will be slight deviations from the basic methodology described above. These are worth noting as they concern differences in approach between past costing and the estimation of future resources requirements. For vaccines The method applied to estimate the past cost of vaccines is based on the amount of vaccines used (administered + wasted) during a given year. The quantity used per type of vaccine (Q used ) is calculated according to the following formula: Q Z Used = (Q Z Supplied + Q Z Initial Stock ) (Q Z Remaining in Stock ) Where: z = DTP, measles, OPV, etc. Qz Supplied = Quantity of vaccines provided (either bought by the country or donated to the country) to the country in a given year Vaccines Table 3: Example of calculation of quantities of vaccine used Stock at beginning of the year Quantities supplied during the year End of year stock Quantities used Price per dose Doses Doses Doses Doses $/dose Measles DTP B C G OPV HO/IVB/

35 The cost of vaccines is calculated by multiplying the quantities used (Q used ) by the unit price for a given vaccine (P). For example, the costs of DTP vaccine supplied in 10-dose vials is: Cost DPT (10) = Q DTP(10) used x P DPT(10) = x $0.15 = $1500 An advantage of using this method is that vaccine wastage is implicitly assumed and can be derived from the same data using the following formula: Wastage rate Z = (doses used Z doses administered Z ) / doses used Z x 100 where z = DTP, Measles, OPV, etc. On the other hand, the method used to forecast the future vaccine requirements is based on coverage targets, wastage rate targets, unit prices and the size of the target population. Q Z Needed = (births x target coverage Z ) x doses in schedule x wastage Cost Z = Q Z Needed x P Z where the vaccine price (P Z ) is kept constant for the whole forecast period. For capital equipment Because capital items like vehicles and cold-chain equipment are purchased in one year, but will be used in the programme for several years until they need to be replaced (the ULY concept), these items are treated differently. In part 3.5 above, the different methods for treating capital costs are explained when describing the difference between the terms cost and resource requirements. To summarize, the cmyp costing exercise looks at one past year. Therefore, the cmyp Tool is estimating a past cost and the value of capital equipment is converted to an annual equivalent by using a straight line depreciation. This is equivalent to the annual financial cost of the capital goods and is calculated by dividing the value of the goods by the total ULY number in order to get an annual equivalent. For example, a new vehicle purchased in the year 2012 for US$ , which will last 5 years before needing to be replaced, will have an annual financial cost of US$ 6000 (US$ /5 ULY). The rationale for this adjustment is that, without depreciating the value of inputs that last for more than a year, it would be easy to get a distorted view of the long-term average annual cost of the programme. This would be the case if the total cost of the NIP was examined in a particular year when large investments in new vehicles and equipment had been made. Alternatively, when making future projections, it is important to know what resources are needed each year for the programme, irrespective of whether they are for inputs that will last for a year or more. This is because regardless of whether the input or activity is a recurrent or a capital cost, it will need to be purchased at a given point in time, and these resource requirements will need to be matched with corresponding financing. This understanding is vital to the financial sustainability of the programme: knowing what financial resources will need to be mobilized each year to reach the cmyp objectives, and who will be funding these needs over time. 24 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

36 W 5. Using the cmyp Costing and Financing Tool Part 5 of the User Guide provides step-by-step instruction on how to use the cmyp Costing and Financing Tool (the cmyp Tool), and guidance on sources of information, how to analyse results and interpret findings. At first glance, the cmyp Tool can appear overwhelming as it contains many interrelated worksheets. Fortunately, you will only need to work in three of these worksheets 6 : The Data Entry worksheet is where all the data necessary for the costing and resources requirements projections has to be entered. It contains a series of data tables for the calculations of vaccines, injection supplies, personnel, vehicles and transport, cold chain and maintenance, supplemental immunization activities, other recurrent and capital costs, and other costs not specified elsewhere. Parts will explain the Data Entry worksheet in greater detail. The Financing worksheet is where information on past and future financing is entered. Some suggestions on procedures to collect financing information are provided in parts of this User Guide, as well as in Annex I. Parts will explain the Financing worksheet in more detail. The Co-financing worksheet is where information on co-financing is entered. Some suggestions on procedures to collect financing information is provided in part 5.6 of this User Guide. 5.1 Overview of the Data Entry worksheet Data Tables The Data Entry worksheet is divided into eight sections, with an additional two sections for background information that regroup the key inputs and activities described previously. Each section contains a series of data tables required for the costing exercise. The titles of the ten sections and 25 data tables are summarized in Table 4. 6 In Microsoft Excel 2003 (or later) is used, these worksheet tabs are colour-coded in light purple. HO/IVB/

37 Table 4: Sections and data tables of the Data Entry worksheet of the cmyp Tool Reference information 0. Demographic information 0.0 Demographic and other vaccine forecast information 0.1 Past and future DTP3 coverage 0.2 Specific target populations for the campaigns 1. Vaccines and injection supplies 1.0 Cost of vaccines and injection supplies from the WHO Vaccine Forecasting Tool 1.1 Baseline expenditure on vaccines and injection supplies calculated without the WHO Forecasting Tool 1.2 Average price of injection equipment and cost of other injection supplies 1.3 Immunization schedule, target population, vaccine prices and other vaccine reference information 1.4 Coverage and wastage targets 2. Personnel costs 2.1 Staff categories, salaries/per diems and time spent on immunization 2.2 Average time spent on immunization and outreach (reference table) 2.3 Existing numbers of staff and future human resource needs (only in addition to those currently working for the programme) 3. Vehicles and transport costs 3.1 Average prices and utilization of vehicles 3.2 Existing vehicle numbers and future needs (including the future replacement of existing vehicles) 3.3 Other transport needs not covered elsewhere 4. Cold-chain equipment, maintenance and overheads 4.1 Average prices, running and maintenance costs of cold-chain equipment 4.2 Existing and future needs of cold-chain equipment (including the replacement of those currently used for the programme) 4.3 Other cold-chain needs not covered elsewhere 5. Operational cost of campaigns 5.1 Operational cost of campaigns 5.2 Average operational cost per child (used for future campaign operational costs) 6. Programme activities, other recurrent costs and surveillance 6.1 Total spending and future budget needs for programme activities and other recurrent costs 6.2 Total spending and future budget needs for surveillance and monitoring 7. Other equipment needs and capital costs 7.1 Average prices of other equipment needs 7.2 Projected number of additional equipment needs (including the replacement of those currently used for the programme) 8. Buildings and building overheads 8.1 Average prices and overhead cost of buildings 8.2 Existing and future need of buildings 26 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

38 W Cell colour coding and worksheet protection The Data Entry worksheet cells are colour coded and shaded to indicate their purpose. The colour, shading or border indicates whether these are: (1) for inputting data; (2) linked to another cell in the workbook; (3) calculated; (4) not filled; or (5) for labels. The full list of colour and style codes can be found in the Style worksheet (see Figure 7). Figure 7: The Style worksheet Surrounding the 25 data tables of the Data Entry worksheet there are yellow text boxes, providing guidance on the tables and how to fill them out. In addition, there are clickon cell notes that look like this: Figure 8: Example of guidance text boxes (Click on Cell) Channelled Funds Budget Support Pooled Funds World Bank Loans (Click on Cell) Data Source Tip (Click on Cell) Important Note When you click on or select these cells, a pop-up note will appear. This should be read carefully. HO/IVB/

39 Tool protection The cmyp Tool is very sensitive to any formatting changes (adding or deleting cells, rows or columns) and editing (cut, copy or pasting of information from different sources). In order to protect from any damages that can be caused by formatting or editing changes, certain protective measures have been put in place. For instance, the cells and worksheets in the cmyp Tool are locked and password protected to avoid the deletion of rows or columns, since this would affect the integrity of the cmyp Tool and could damage it. Likewise, some cells have been protected to prevent information being entered in the wrong cells. If information is entered in a wrong cell, or a locked spreadsheet is deleted or modified, the following message will appear: However, you can always insert new worksheets in the cmyp Tool in order to make separate calculations, create other graphs or analyse the data. How to unprotect the cmyp Tool If it becomes necessary to unprotect the cmyp Tool and its worksheets, use the following password: MYPCT If you are unable to enter information into the cmyp Tool, it is likely that your computer has a firewall or an activated virus protection system that prevents you from using the cmyp Tool on your computer. If this is the case, and in order to bypass the antivirus software protection, you will need to unprotect the cmyp Tool using the password provided above, save it under a new file name, and then re-protect the cmyp Tool. How to use +/ buttons Throughout the cmyp Tool, there are sections that are collapsed with +/ buttons to keep the worksheet more manageable. In order to access these sections, it is necessary to expand the collapsed section. To expand the section, the user can either: (1) select the + button located on the left hand side of the worksheet or; (2) double-click the collapsed section. Once you are done with the section, you can either select the button on the left hand side, or double-click the header of the expanded section. For example, the top screenshot in Figure 9 shows the Data Entry worksheet with the sections collapsed. If the sections are expanded, the user can see all of the detail (see lower section of Figure 9). 28 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

40 W Figure 9: Examples of collapsed and expanded sections Cutting and pasting data The cmyp Tool is very sensitive to the cut, copy and paste function of Excel. Copying and pasting data from other Excel workbooks into the cmyp Tool could break critical links, calculations and formulas, and create errors that could damage the cmyp Tool. The copy and paste function therefore carries a high risk of damaging the cmyp Tool, which would result in work having to be redone. If there is no option of entering data other than by pasting information into the cmyp Tool, please use the paste special values option (see Figure 10) instead of the standard paste option. This option is available from the Edit menu of Excel, but it will first display the following pop-up warning: HO/IVB/

41 Figure 10: Choose values from the Paste Special editing option Currency and inflation Because prices and costs can be expressed in different currencies and can rise over time, the cmyp Tool was designed to accommodate different currencies and inflation rates. At the beginning of most data tables, a Yes/No pull-down option allows you to select the currency of the price data to be entered in the table. For example, it may be easier to enter information on wages and salaries in local currency, whereas the price of an imported vehicle has probably been quoted in United States (US) dollars. Note that you cannot mix both that is, enter prices or values in both local currency and US dollars in the same table. Depending on whether data and prices are reported in local currency or US dollars, you will need to select the appropriate currency option, and the cmyp Tool will make the exchange rate conversions to show the results in US dollars. The cmyp Tool also offers the possibility to enter the relevant price inflation rates. The default and recommended value is 2%. Note that this is a default US dollar inflation rate and not a local currency inflation rate. The currency and inflation option boxes look like this: Entering information in local currency? N Forecasting inflation rates 2% 30 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

42 W Totals or average quantities Information for Sections 2, 3, 4 and 8 of the Data Entry worksheet is required for each country at administrative level (e.g. central, provincial, district and health centre levels). Depending on the data availability, you can either choose to work in averages, or total quantities of personnel, vehicles and cold chain units of equipment by administrative level. The cmyp Tool offers the work option of either using total quantities of an input (e.g. the total number of motorcycles per province) or an average quantity by administrative level (e.g. 10 motorcycles per province), which is then multiplied by the corresponding number of administrative levels to produce a total amount. An option box has been included to accommodate for this and it looks like this: Entering average quantities per administrative level N Further suggestions on working with total or average quantities will be explained in greater detail in part Review of each data table contained in the Data Entry worksheet The Data Entry worksheet is divided into eight sections, each containing a series of data tables that require information for the cmyp costing exercise. Each of these sections is described below including the 22 data tables, the methodologies used, and some general guidance on data sources. First section reference information The reference information section is where essential country-specific details need to be entered. This is a crucial section of the Data Entry worksheet. Formulas in the cmyp Tool are contingent upon the information provided here. If the information is only partially complete, the calculations may not yield the correct answers, and essential labelling of tables will not be done. Therefore, it is very important that this section of the worksheet is completed as accurately and comprehensively as possible. HO/IVB/

43 Data required for the general information section of the cmyp Costing and Financing Tool Information needs Remarks Country Scenario Baseline year First year of projection Name of country administrative structures Number of country administrative structures Names of country administrative structures Names of funding sources for immunization Macroeconomic indicators Officer responsible for the cmyp Costing and Financing Tool Enter the full country name. To experiment with various scenarios, label the starting point scenario (e.g. baseline, PCV introduction, etc.). More about scenario building is developed in parts of this User Guide. Enter the baseline year used for the cmyp. Enter the first year of the cost/resource requirement projection (e.g. if you are developing a cmyp for the period , the first year of projection will be 2016). Enter information on the names of the country health administration structure, starting with the highest level (e.g. central or national) and ending with the lowest level (e.g. health centre or health community). Enter information on the number of health administration structures in the country (e.g. number of provinces, districts or health centres). These should correspond to the number of administrative levels mentioned above (e.g. 1 central level; 18 provinces, etc.). Because the cmyp Tool has the option to enter prices and costs in local currency, it is important to provide exchange rate information so that the final calculations of costing, financing, resource requirements and gaps will be reported in US dollars. Enter the exchange rate for the years you are developing your cmyp. For instance, if in 2015 you are developing a cmyp for the period , then it is likely that the latest exchange rate information you have will be for the year Enter the names of the different funding sources for the NIP (e.g. government, UNICEF, World Bank, etc.). There is an option to enter 16 different funding sources. Two funding sources are set as default values (national and subnational government). Enter information on GDP in million local currency units (LCU), total health expenditure (THE) as a percentage of GDP, and government health expenditure (GHE) as a percentage of THE. Enter the name and contacts of the main officer responsible for the cmyp Tool. It is important to mention that the Sustainability worksheet of the cmyp Tool requires that data on the macroeconomic indicators be entered in this section of the Data Entry worksheet. It is better to use national data. However, in the absence of available information on GDP and health expenditures, international sources of data may be used. The following websites provide a good source of information: National Health Accounts International Monetary Fund A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

44 W Section 0: Demographic information Table 0.0: Demographic and other vaccine forecast information In Table 0.0 enter the demographic data essential for making future projections of the target population. In order to make the calculations, you will need to provide information on: the year of the last population census in the country; total population in the last census year; estimate of population growth rate; birth rate as a share of total population; infant mortality rates (IMR) as a share of births; information on pregnant women as a factor of births (the default value would be set at one, i.e. for every pregnant woman there would be a least one birth); information on childbearing age women (CBAW). Table 0.1: Past and future DTP3 coverage In Table 0.1, enter the DTP3 baseline and future coverage targets. This information is not used for vaccine forecasting, but is needed to calculate various indicators in the Gaps & Indicators worksheet of the cmyp Tool. Table 0.2: Specific target populations for the campaigns In Table 0.2, you can review the results for the projected immunizations. Do not enter any data into Table 0.2 at this stage as this table is auto-generated. Since the target populations for campaigns can be different from the target populations for routine immunization, which in turn can vary depending on the type and timing of campaigns being conducted, this information needs to be entered separately in Table 0.0. Note that there are two possible options for arriving at a figure for the target population either by using under one population (U1P) or surviving infants (U1P minus the under one mortality). HO/IVB/

45 The current convention is to make projections of vaccine requirements based on births. To do this you will need information on birth rates (as a percentage of the total population) only. If you decide to make projections based on surviving infants, you will need to enter the U1P as a percentage of the total population, and enter information on the IMR as a percentage of births. Entering the above information in Table 0.0 will allow the cmyp Tool to make forecasts for the target population that will be used to calculate the future needs for most vaccines. Finally, a special case arises for projecting the needs of tetanus toxoid vaccine (TT), for which the target population can either be pregnant women or childbearing age women (CBAW) aged between 15 and 46. In order to make the vaccine forecasts for TT vaccine, you will need to enter data on pregnant women, or preferably CBAW. The cmyp Tool allows calculation for TT vaccine requirements for either target populations, depending on the country situation. Although there is some potential for double counting, the TT coverage of pregnant women is traditionally low and is not considered to be a significant cost factor. Section 1: Vaccines and injection supplies Vaccine and injection supplies are potentially the most important inputs to calculate for the cmyp costing exercise. First, they will reveal the importance of vaccines as an input to the programme, as well as the implications for adopting a new or underused vaccine into the schedule. Secondly, this is one area for scenario building (e.g. changing coverage targets) and also understanding the impact of improving efficiency (e.g. reducing wastage or changing vaccine presentation). Reflecting the importance of vaccines and injection supplies, this section of the Data Entry worksheet contains five required data tables: 1. Vaccines and injection supplies 1.0 Cost of vaccines and injection supplies from the WHO Vaccine Forecasting Trial 1.1 Baseline expenditure on vaccines and injection supplies calculated without the WHO Forecasting Tool 1.2 Average price of injection equipment and cost of other injection supplies 1.3 Immunization schedule, target population, vaccine prices and other vaccine reference information 1.4 Coverage and wastage targets The information in these tables is needed to calculate the past costs and future resources requirements of vaccines and injection supplies for both routine immunization services and campaigns (supplemental immunization activities; SIAs). Table 1.0: Cost of vaccines and injection supplies from the WHO Vaccine Forecasting Tool If you have results from the WHO Vaccine Forecasting Tool, then transfer these results into Table 1.0. You do not have to enter data for the rest of Section 1, except Tables 1.3 and 1.4 needed to calculate GAVI co-financing amounts. If you do not have results, then skip to Table A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

46 W Table 1.1: Baseline expenditure on vaccines and injection supplies calculated without the WHO Forecasting Tool In Table 1.1, fill in the amount spent on traditional, underused and new vaccines for the baseline year. Also, fill in the amount spent on injection supplies for the baseline. For estimating the baseline vaccine expenditure, the quantity of vaccines used (number of doses administered + number of doses wasted) and their unit price are required. In order to derive the quantities used for each type of vaccine (Q used), the following formula should be applied: Q used = (Q administered + Q wasted) = (Q supplied + Q initial stock) (Q remaining in stock) The number of doses administered can be calculated based on coverage and the number of surviving infants, or U1P, depending on what you have chosen in Table 0.0 demographic information. Note that vaccine wastage rates are calculated based on this information and can be used as a point of reference for future wastage targets. The formula used for wastage is as follows: Wastage rate = (doses used doses administered) / doses used x 100 Table 1.2: Average prices of injection equipment and cost of other injection supplies In Table 1.2, enter the average unit price of injections equipment for auto-disable (AD) syringes, reconstitution syringes, and safety boxes. Note that UNICEF reference prices have already been included in the table. These prices are incremented by a standard 15% freight charge. In some countries, other taxes may be levied on injection equipment, which should be added (e.g. value added tax or customs duty). These unit prices can be changed if there are country-specific prices you prefer to use. Below Table 1.2, there is the option to enter an average wastage rate on injection supplies and syringe capacities of safety boxes. The default value on the wastage of injection equipment is set at 10% and 100-syringe capacity for a 5-litre safety box. Finally, there is an additional table that allows you to enter any other information regarding average lump sum spending on other injection supplies (e.g. cotton). Table 1.3: Immunization schedule, vaccine prices and other vaccine reference information In Table 1.3 you need to verify and enter information on your vaccine schedule. Note that Table 1.3 is divided into two parts, separating routine immunization activities from those for SIAs (campaigns). For each vaccine listed, you will need to enter the number of doses in the schedule, the vial size, whether a buffer stock needs to be accounted for (only applicable for new vaccine introduction), whether the vaccine needs to be reconstituted with mixing syringes, and its unit price per dose (including freight and other charges). HO/IVB/

47 UNICEF reference prices are listed in the Vaccine Prices worksheets. These can be changed if there are country specific prices you prefer to use for the relevant years of the cmyp costing and financing exercise. Make sure that the prices used are per dose and include all freight and other charges. Vaccine prices and campaign naming Vaccine prices Because the future price evolution of vaccines is uncertain, the methodology used in the cmyp Tool recommends making forecasts based on constant prices. In other words, to forecast the future needs of vaccines based on the last available year of vaccine price available, and to use the same prices for the entire projection period (up to five years). The cmyp Tool, however, also offers the possibility to enter alternative vaccine prices for future years. For information on vaccine prices, please consult the UNICEF Supply Division website: Campaign naming In each country, the types of campaigns that will be undertaken will vary greatly, and therefore the naming of the campaigns will need to be entered accordingly. For instance, suppose that in a particular year, there are various rounds of polio campaigns that are targeting different population groups. In this instance, it could be easier to treat them as separate campaigns altogether and name them differently in Table 0.0 (e.g polio campaign round 1; 2013 polio campaign round 2). Similarly, some routine immunization activities may have special outreach sessions targeting the hard-to-reach. These can be labelled as a type of campaign also in Table 0.0. Finally, any contingency for outbreaks of vaccine-preventable diseases should be listed as a campaign and labelled accordingly. 36 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

48 W HO/IVB/

49 Table 1.4: Coverage and wastage targets In Table 1.4 enter projected coverage and wastage targets for each vaccine in your schedule that was specified in Table 1.2. Note that coverage targets for routine immunization and for supplemental immunization activities should be entered separately Coverage and Wastage Targets Coverage Baseline Coverage Targets Type of Vaccine Routine Immunization % % % % % % It is important to note the WHO UNICEF recommendations for the forecasting of vaccines that have more than a one-dose schedule, and that these should be based on the first dose coverage target of these vaccines. For instance, any forecasting of DTP vaccine should be based on DTP1 and not DTP3 coverage objectives. Note that DTP1 coverage = DTP3 coverage + DTP3 drop-out rate. The latter information should be available from the WHO UNICEF Joint Reporting Form (JRF). Coverage targets when phasing in a new vaccine In cases where you would like to phase in the introduction of a new vaccine in your country, you will need to make the adjustment in Table 1.4 using the coverage targets entered. For instance, if you wish to introduce DTP-HepB vaccine gradually, this means that some population groups will be covered by DTP, will others will be covered with the new vaccine. Eventually the whole country will have the new combination vaccine, but in the interim you will need to adjust your coverage targets to ensure that the overall target is not exceeded. Otherwise you will over- (or under-) project vaccine needs. Table 1.4 below shows an example of a country with an overall DTP coverage objective of 80% for , which is gradually phasing out DTP vaccine in favour of DTP-HepB vaccine. Example: Coverage and Wastage Targets Coverage Baseline Coverage Targets Type of Vaccine Routine Immunization % % % % % DTP 8 0 % 6 0 % 2 0 % DTP-HepB 2 0 % 6 0 % 8 0 % 8 0 % Section 2: Personnel costs As personnel is frequently the single largest input to a NIP, considerable emphasis should be given to the accuracy in assessing its contribution, in particular to the assessment of salaries and staff time actually spent on immunization activities. Small errors in estimations can translate into a large overestimation or underestimation of the costing exercise. 38 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

50 W Estimating personnel costs is complicated by the fact that some personnel time is either: 1) specific to the immunization programme. This relates to staff time directly associated with the immunization service, spending 100% of their time working on immunization activities (for example, all central-level staff working for the immunization department of the MoH) or 2) shared with other health services. This relates to staff time that is only partly assigned to immunization activities (for example, nurses at the health facility level spending 10% of their time providing vaccinations and the rest of their time working on other preventive and curative services). Personnel will be the main input where a large portion of the costs are likely to be shared with other programmes. It is therefore important to get an accurate measure of the proportion of the time that staff actually work on immunization, because apart from the basic importance of personnel as a main cost driver to immunization programmes, this proportion is often used to estimate other shared costs. For example, if it is difficult to measure the proportion of vehicles or building cost that are allocated to immunization, you can simply use staff time devoted to the programme as a way of allocating the value of shared vehicles and building costs, which will give a good approximation. Collecting data on the percentage time spent on immunization is time-consuming, but this information will more accurately reflect the amount of government input to the programme, which is why reporting shared personnel costs is invaluable. Specific techniques for this are provided below, and the cmyp Tool facilitates these calculations. Given the importance of personnel, this section of the Data Entry worksheet contains three required data tables: 2. Personnel costs 2.1 Staff categories, salaries/per diems and time spent on immunization 2.2 Average time spent on immunization and outreach (reference table) 2.3 Existing numbers of staff and future human resource needs (only in addition to those currently working for the programme) The information in these tables is needed to calculate the past costs and future resource requirements. The three data tables require the following information: Table 2.1: Staff categories, salaries/per diems and time spent on immunization In Table 2.1, first enter information on the types or categories of staff working on the immunization programme, and whether they are full-time or part-time staff (e.g. EPI manager at national level, or outreach vaccinator at district level). You will need to enter the staff categories for each administrative level in the country (as reported in the reference information section). In a next step, enter information on average gross monthly salaries per category of staff listed in Table 2.1, and any other benefits, such as special non-transport allowances or subsidies. HO/IVB/

51 Table 2.1 Staff categories, salaries/per diems and time spent on immunization Routine immunization Outreach activities Supervision Type of staff Gross monthly wage Other monthly benefits % Time working on immunization Average No. days per month per diems Average No. days per month Central US$ US$ (% ) No. days US$/day No. days US$/day Nip manager EPI officer Administration Medical doctor Medical officer Medical assistant Health officer Laboratory personnel Logistician Monitoring/surveillance/evaluation officer Nurse Secretary Drivers Security guard Other (specify) per diems Provincial US$ US$ (% ) No. days US$/day No. days US$/day Health officer Medical officer Technicians Cold chain technician Logisticians Monitoring/surveillance/evaluation officer Secretaries Drivers Other (specify) 40 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

52 W Then, for each category of staff, indicate whether they work full-time (100%) or part-time (less than 100%) for the national immunization programme, both routine immunization and campaigns 7. The percentage time spent on immunization can be difficult to estimate. In general, expert opinion or responses from a small sample survey will provide sufficient information to estimate an average percentage time spent on immunization per category of staff. Because outreach activities in many countries are an essential component of routine immunization services, Table 2.1 requires information on the number of days spent working in an outreach capacity each month for the relevant category of staff, and the corresponding per diem rates. Although there are provisions in the table for staff per diem rates at most administrative levels of the system, it is expected that data will be concentrated at the lower levels since these staff are most likely to be involved in outreach immunization activities. Finally, in the last columns of Table 2.1, enter the same information for supervisory activities, i.e. the average number of days per month conducting supervisory visits for the relevant staff categories and the corresponding per diem rates. 7 Attention should be paid to avoid double counting of the cost of personnel for campaigns between Section 2 (Personnel cost) and Section 5 (Operational cost of campaigns). HO/IVB/

53 Data collection tips Because of the importance of getting good information for the calculation of personnel, some recommended steps for collecting the data are provided below: If calculating immunization personnel using total number of staff working for the programme, follow the steps below: 1) Identify all staff working for immunization (full-time or part-time) at each administrative level (e.g. national, provincial, district levels and service delivery levels), including all staff involved in outreach activities and supervision. Only include national staff and do not include the costs of international staff and consultants working on immunization for donor agencies. 2) Group all staff according to their category or grade level at the MoH (e.g. EPI manager, medical doctor, medical assistant, nurse, vaccinator, etc.). 3) Identify and attribute the gross monthly salary for each category of staff based on the salary scales available from the MoH. Note that when travel allowances are paid to staff, these should be included in the transportation cost category and not listed under personnel. 4) Identify all other allowances and benefits and estimate the average monthly value of these for each category of staff listed. 5) Identify the average time spent on immunization for each category of staff. For routine activities the average percentage of time spent on immunization should be used. For outreach the average number of workdays per month is the most reliable indicator of time spend on this activity. Unless this information is readily available at the central or national level, it might be easier to work with average numbers of staff by administrative level. For calculating immunization personnel using an average number of staff at each administrative level, see below for the steps recommended for data collection: 1) Collect information on the total number of fixed health facilities in the country by category and by different administrative levels (e.g. provincial hospitals, district health centres, dispensaries, or other fixed sites). These health facilities must provide immunization services. 2) For each type of health facility, select one that is representative (i.e. a representative provincial hospital or a representative district health centre). The term representative implies representative in size (total number of health workers) and utilization (in terms of children being immunized). 3) Interview these representative health facilities by administrative level, either by fax, telephone or direct visit and ask for information on: total number and categories of staff involved in immunization; average percentage of staff time spent each month on routine immunization services; average monthly staff salary, plus other allowances and benefits; number of days per month spent on outreach and outreach per diems number of days per month spent on supervision and the per diem rates. Table 2.2: Average time spent on immunization and outreach (reference table) Table 2.2 is a reference table and does not require any information to be entered. The table is automatically generated based on the information provided in Tables It will calculate the overall average percentage time spent on immunization by all staff at each administrative level. It will also calculate the average percentage time spent on outreach for all staff involved in outreach activities. Note that Table 2.2 will not be activated unless Table 2.1 includes information on the percentage time spent on immunization, and Table 2.3 contains information about quantities. The purpose of this table is to facilitate the calculation of other shared costs. For example, if it is not possible to measure the proportion of shared vehicle or building inputs for immunization at a given administrative level, staff time devoted to the programme can be used as a way of determining the value of shared vehicles and building inputs. This will give a good approximation and will also save time. 42 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

54 W Table 2.3: Existing numbers of staff and future human resource needs (only in addition to those currently working for the programme) In Table 2.3, enter the number of staff currently working for immunization, by staff type and for the different administrative levels, and also your projections of future staff needs. Estimates of future staff should be based on the needs to reach programme objectives as defined in the cmyp. Do not enter the future evolution of total staff, but only the additional numbers of staff needs above and beyond those already engaged in immunization (e.g. in order to improve coverage at the district level your programme may need an additional 100 vaccinators). Note that for future projection of staff needs, it is only necessary to enter the numbers for the year in which the staff will start working. The cmyp Tool will automatically include these staff for the remainder of the period (because it is a recurrent cost), and calculate the total cumulative number of staff for the projection period. If any personnel are expected to be made redundant, they should be deducted by entering each individual as a negative number in the year the person ceases to work. Table 2.3 has an option to work with total numbers of staff, or average numbers by administrative level. To work with average numbers of staff by administrative level, select Y on the options box for Table 2.3, and only include the average number of staff per administrative level obtained in your survey. Otherwise, select N. For the calculations to work you need to ensure that the total number of administrative levels in the country is reported in the background information section of the Data Entry worksheet. In some instances, collecting information on the number of staff can be made easier by surveying the personnel in a sample of health facilities in each administrative level, and extrapolating for the rest of the country by multiplying by the total number of corresponding administrative levels. For example, if each district has one health facility with an average of one vaccinator and one medical officer working for immunization, then it is possible to estimate the total staff by multiplying this average number of staff per district by the total number of districts in the country (see the data collection tips box above). Section 3: Vehicles and transport costs Vehicles and transportation in many countries are the weakest link in any immunization programme. For this reason, it is important to know how much is needed to operate and maintain the fleet of vehicles to deliver vaccines, supplies and immunization services. Because some of the data needs for estimating transportation (such as maintenance), are related to the capital cost of vehicles, the costs of vehicles, vehicle costs and transportation are covered together in the Data Entry worksheet. The methodology used for estimating vehicle costs is based upon the numbers of vehicles used by the NIP (quantities), their unit cost (prices), and their utilization by the programme (percentage spent on immunization). HO/IVB/

55 The methodology used for calculating transportation focuses on fuel, as fuel is likely to be the single most important item for transportation and an input for which records are reasonably good (i.e. average mileage of vehicles, average fuel consumption per unit of mileage, and the price of fuel). Since data on vehicle maintenance is among the most difficult to measure, the cmyp Tool will use methods to approximate them by applying a percentage increment on the known value of fuel. The cmyp Tool recommends applying 15% but you have the option to change this percentage to any other value you consider more appropriate. At the start of the Data Entry worksheet, you can enter and verify essential parameters for the calculations (such as fuel prices, rules of thumb for maintenance, ULY, etc.). Entering information in local currency? N (Enter N for $ Prices) Enter the annual percentage increase in price of petrol 2% (Recommended value is 2%. Note that this is a US$ inflation rate. Do not enter a LCU inflation rate) Fuel price per litre (2004) (in US$) Enter the annual percentage increase in price of petrol 2% (Recommended value is 2%. Note that this is a US$ inflation rate) Vehicle maintenance as a percentage of fuel costs 15% (Recommended value is 15%) Average useful life year of vehicles (ULY) 5 (Recommended value is 5 years not more than 10 years) Given the importance of vehicles and transportation, Section 3 of the Data Entry worksheet contains three required data tables. The information in these tables is needed to calculate the past costs and future resource requirements for vehicles and transportation. The three data tables are as follows: 3. Vehicles and transport costs 3.1 Average prices and utilization of vehicles 3.2 Existing vehicle numbers and future needs (including the future replacement of existing vehicles) 3.3 Other transport needs not covered elsewhere Table 3.1: Average prices and utilization of vehicles In Table 3.1 first enter information on the types or categories of vehicles used by the immunization programme, and whether these vehicles are in use full-time or part-time. Enter vehicle categories for each administrative level in the country. Note that the vehicle categories listed in Table 3.1 are examples only, and that you can replace the existing categories with the relevant ones for your country setting. There is also room to include more categories of vehicles, which can be done in the yellow cells in the first administrative level of Table 3.1. Once the categories of vehicles are entered, they will automatically be updated for lower administrative levels, as well as in the other tables (Table 3.2). 44 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

56 W Then enter the estimated average unit price (including all taxes) for each type of vehicle, and information on the average number of kilometres travelled each year, as well as the average fuel consumption per 100 km for each of the vehicles listed A verage Prices and U tilization of Veh icles Per Veh icle Type Type of Veh icles A N ( A K F ( Y ( L $ K L / vg. Price ew Distance vg ms uel consumption % time used for 2013) per ear) itres per 100k m) immunization ms 100K ms % $ K ms L / 100K ms % $ K ms L / 100K ms % Finally, enter data on the utilization of vehicles for immunization. If the vehicles are exclusively purchased for the NIP, enter 100%. For other vehicles, the percentage time spent on immunization can be difficult to estimate, but expert opinion or responses from a small sample survey of facilities may provide the necessary data to estimate these. Alternatively, you could use the information included in Table 2.2 by applying the average percentage time spend on immunization by staff at different levels. Alternatively, if drivers is listed as a staff category in Table 2.1, you can use the information to obtain the percentage time that they are spending on immunization. Table 3.2: Existing vehicle numbers and future needs (including future replacement of existing vehicles) In Table 3.2, enter the total number of existing vehicles and future additional needs, by vehicle type and by administrative level. For existing vehicles, you will need to separate those units that were purchased during the baseline year from those that were purchased before. For future projections, make sure to include the replacement of those currently used for the immunization programme. The cmyp Tool will automatically compute the year when vehicles need to be removed from service based on the ULY specified. However, it will not automatically account for their replacement. New vehicles therefore need to be reported separately, and in line with your preferred methods of purchase and timing. Estimates should be based on the needs to reach programme objectives and targets and those outlined in your cmyp and existing cold chain reviews. HO/IVB/

57 Table 3.3: Other transport needs not covered elsewhere In case there are other transport needs that are not captured in Tables 3.1 and 3.2, these should be entered in Table 3.3. For example, there may be separate fuel budgets for vaccine delivery or for payment of transport per diems to outreach vaccinators, etc. To account for these, enter lump sum costs in Table 3.3 as well as any projection of future budget needs. It is important to ensure that transportation needs are not repeated in Table 3.3. In other words, only include other transportation needs that are not already captured in the transportation costs of Tables 3.1 and A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

58 W Data collection tips Because of the importance of getting good information for the calculation of vehicles and transport, some recommended steps for collecting the data are provided below: If calculating vehicles using total number of vehicles used by the programme, take the following steps: 1) Collect information on the total number of vehicles used by the immunization programme by vehicle category: cars, four-wheel drives, motorcycles, bicycles, boats, etc. 2) Select from each type of vehicle one that is representative. For instance, the fleet of four-wheel drive vehicles may be composed of several models (e.g. Toyota Land Cruisers or Mitsubishi). Choose the model that is most representative in terms of numbers, age, mileage, and usage. 3) Interview drivers at the central level NIP department of the MoH. For each vehicle type, ask them to provide (to the best of their knowledge) an average fuel consumption for these vehicles, the average distance travelled per year, the percentage time the vehicle is used for immunization-related activities, and the average ULY of the vehicles. Preferably choose drivers that have been working for the NIP for several years and therefore have the best knowledge of this information. 4) Get information on how many vehicles would be needed in the future. Unless this information is readily available at the central or national level, it might be easier to work with average numbers of vehicles by administrative level. If calculating vehicles using the average number of vehicles by administrative level, the recommended steps to collect the needed data are as follows: 1) Collect information on the total number of fixed health facilities in the country by category and by different administrative levels (e.g. provincial hospitals, district health centres, dispensaries, or other fixed sites). These health facilities must provide immunization services. 2) For each type of health facility, select one that is representative (i.e. a representative provincial hospital or a representative district health centre). The term representative implies representative in size (total number of health workers) and utilization (in terms of children being immunized). 3) Interview these representative health facilities by administrative level, either by fax, telephone or direct visit and ask for information on: total number of vehicles used in immunization and by category; average percentage time these vehicles are used by the NIP; average price of each type of vehicle; average ULY of vehicles; average annual distance travelled (in kilometres) and the average fuel consumption (in litres per 100 km) for each vehicle type; the number of vehicles that would be needed in the future. Section 4: Cold-chain equipment, maintenance and overheads The cold-chain equipment needed for any national immunization programme is as important as the vaccines themselves. Therefore, particular attention should be paid to the estimation of needs for cold chain, particularly in the context of new vaccine introduction. Because some of the data needs for estimating cold chain maintenance and overheads are related to the capital cost of cold-chain equipment, these costs are covered together in the Data Entry worksheet. The methodology used for estimating the cost of cold-chain equipment is based on units of equipment (quantities), and their unit cost (prices). In the cmyp Tool it is assumed that the cold-chain equipment is immunization specific. In other words, its utilization is 100% for the immunization programme. Therefore, there is no need (as with personnel or vehicles) to specify the percentage of time spent on immunization. HO/IVB/

59 At the start of this section of the Data Entry worksheet, you can enter and verify essential parameters for the calculations (such as rules of thumb for maintenance, ULY, etc.). Given the importance of the cold chain, Section 4 of the Data Entry worksheet contains three required data tables. The information in these tables is needed to calculate the past costs and future resource requirements for cold-chain equipment, its maintenance (spare parts) and overhead costs (fuel, electricity, etc.). The three data tables are as follows: 4. Cold-chain equipment, maintenance & overheads 4.1 Average prices, running and maintenance costs of cold-chain equipment 4.2 Existing and future needs of cold-chain equipment (including the replacement of those currently used for the programme) 4.3 Other cold-chain needs not covered elsewhere Table 4.1: Average prices, running and maintenance costs of cold-chain equipment In Table 4.1, first enter information on the types (or categories) of cold-chain equipment used by the NIP (e.g. freezers, refrigerators, cold boxes, or vaccine carriers) as well as the main categories of spare parts (e.g. burners, wicks, etc.) and other cold chain supplies (e.g. ice packs, etc.). In Table 4.1, there are listings for types of cold-chain equipment. These should be replaced by categories that are relevant to your NIP. If the equipment used is not already listed in the table, you can replace the existing categories with the relevant ones. There is also room to include more categories, if considered necessary. Secondly, you need to enter average unit price (including all taxes) for each type of cold-chain equipment listed, such as the average price of a new refrigerator or cold box. As mentioned in part 3.4 of this User Guide, a rule of thumb used to estimate the likely maintenance costs of each type of cold-chain equipment is applying a set percentage of the capital cost of this equipment. The cmyp Tool recommends using 5%, but you have the option to change this percentage to any other value you consider more appropriate for your country setting. 48 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

60 W Table 4.1 Average prices, running and maintenance costs of cold-chain equipment Per unit of equipment Type of cold chain Average price new (2005) Average monthly overhead costs Average yearly maintenance cost Equipment US$ US$ US$ Cold room Cold boxes Vaccine carriers Refrigerator (electric) Refrigerator (gas) Main spare parts and other US$ US$ US$ Ice packs Thermocouples Electric heaters Burners Generators Other (specify) HO/IVB/

61 Table 4.2: Existing and future needs of cold-chain equipment (including the replacement of those currently used for the programme) In Table 4.2, enter the total number of existing units of cold-chain equipment that are used by the NIP along with your future projection of needs, by type of cold-chain equipment and by administrative levels. For existing cold-chain equipment, you will need to separate those units that were purchased during the baseline year from those that were purchased before. When making future projections, be sure to include the replacement of those currently used for the programme. The cmyp Tool will automatically compute the year when the cold-chain equipment needs to be removed from service, based on the ULY specified. However, it will not automatically account for their replacement. You need to report this separately and in line with your preferred methods and timing. Estimates should be based on the needs to reach programme objectives and targets and those outlined in your cmyp and existing cold chain reviews. Table 4.3: Other cold chain needs not covered elsewhere If relevant to you NIP, enter in Table 4.3 any of the lump sum cost of other cold chain needs not specified elsewhere. For example, you may need to include a budget for ice for outreach activities, or fuel for the cold chain. It is important to ensure that cold chain needs are not repeated in Table 4.3. In other words, only include other cold chain needs that are not already captured in the transportation costs of Tables 4.1 and A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

62 W Table 4.3 Other cold-chain needs not covered elsewhere Expenditure Future budget needs Other cold chain needs US$ US$ US$ US$ US$ US$ Ice for outreach activities Fuel for cold chain Other (specify) Other (specify) Other (specify) HO/IVB/

63 Data collection tips Because of the importance of getting good information for the calculation of cold-chain equipment and its related maintenance and overheads, some recommended steps for collecting this data are provided below. If calculating cold-chain equipment using the total list of equipment in the country, take the following steps: 1) Assemble an itemized list of all cold-chain equipment in the country and by type of equipment (e.g. freezers, refrigerators, cold boxes, vaccine carriers etc.) and spare parts. This information should be available from the cold chain logistics person at the central cold room. 2) Using expenditure statements, invoices and receipts on the purchase of cold-chain equipment (or a recent cold chain review), attribute the correct purchase price to each type of cold-chain equipment. If the purchase price for a specific model is not known, use the average price for that category of equipment. For instance there may be various models of fridges and freezers (RCW, Electrolux, Sibir, etc.). If the unit price of each model is not known, use the average price for the whole category. 3) By means of interviews with the cold chain logistics and repairs staff, determine the average monthly running cost, the average yearly maintenance cost of type of cold-chain equipment listed and average ULY of the equipment. 4) Collect information on the future upgrading of the cold chain. Unless this information is readily available at the central or national level, it might be easier to work with average numbers of cold chain units by administrative level. If calculating cold-chain equipment using the average number of cold chain units by administrative level, the recommended steps to collect the needed data are as follows: 1) Collect information on the total number of fixed health facilities in the country by category and by different administrative levels (e.g. provincial hospitals, district health centres, dispensaries, and other fixed sites). These health facilities must provide immunization services. 2) For each type of health facility, select one that is representative (i.e. a representative provincial hospital or a representative district health centre). The term representative implies representative in size (total number of health workers) and utilization (in terms of number of children being immunized). 3) Interview these representative health facilities by administrative level, either by fax, telephone or direct visit and ask for information on: total number of cold chain units used, and by categories of cold chain; average price of each type of cold chain unit; average monthly running cost, the average yearly maintenance cost per type of cold-chain equipment, and the average ULY; information on future upgrading of the cold chain. Section 5: Operational cost of campaigns Increasingly, campaigns and supplemental immunization activities (SIAs) are becoming an integral part of countries national immunization programmes, and an important strategy for eradicating and controlling diseases, as well as for raising coverage. While the needs for vaccines and injection supplies for campaigns are taken into account in Section 1 of the Data Entry worksheet, you still need to budget for the operational costs. The methodology used to calculate the operational costs of campaigns is based upon estimates of an average campaign operational cost per child, and by applying this unit cost to the future target number of children in the campaigns. This simplifies the costing exercise and allows you to take into account the fact that a campaign may be targeting an entirely different age group than the one applicable for routine immunization. 52 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

64 W Section 5 of the Data Entry worksheet contains two required data tables. The information in these tables is needed to calculate the past costs and future resource requirements for the operational needs of the campaigns. The two data tables are as follows: 5. Operational cost of campaigns 5.1 Operational cost of campaigns 5.2 Average operational cost per child (used for future campaign operational costs) (Note that it is necessary to specify and name a type of campaign in Table 5.2). Table 5.1: Operational cost of campaigns In Table 5.1, you need to provide information on past operational costs by type of campaign (e.g. polio, measles, etc.). The main operational costs are broken down into per diems awarded to health workers during the campaign (i.e. the personnel costs of the campaign), and other operational costs. Typically, these would include training, transport, and social mobilization inputs that were provided specifically for each campaign listed. The amounts entered in Table 5.1 should exclude any spending on vaccines and injection supplies. Note, however, that these are shown in the table as reference cells. O F Y $ $ $ $ $ $ perational Cost of Campaigns Baseline uture ears Type of Campaigns P e r d i e m s O t h e r o ptio e rn aa l c o s t s P e r d i e m s O t h e r o ptio e rn aa l c o s t s P e r d i e m s O t h e r o ptio e rn aa l c o s t s P e r d i e m s O t h e r o ptio e rn aa l c o s t s P e r d i e m s O t h e r o ptio e rn aa l c o s t s Once the lump sum amounts are entered into Table 5.1, the average operational cost per child will be automatically calculated. This amount is the ratio between the lump sum operational amount and the number of children vaccinated as reported in Table 1.2. These average operational costs per child can be used in the projections of future needs for supplemental activities. It is important to note that this method assumes that any capital equipment purchased for supplemental activities will subsequently be used in the routine programme. These should therefore be included and adequately labelled as part of the Section 3 and 4 data tables. HO/IVB/

65 Table 5.2: Average operational cost per child (used for future campaign operational costs) In Table 5.2, you need to report average campaign operational costs per child. These will be used to make the projections of resource requirements for the future campaigns that are planned for in Table 1.6. It is important to ensure that Tables 1.2, 1.4 and 1.6 are completed correctly. Remember that it is possible to use the average operational costs per child that are calculated in Table 6.1 as a reference number. However, if these are not calculated (e.g. there were no past yellow fever campaigns but you plan to conduct some in the future), they will need to be estimated, or approximated, using the average operational cost per child from other similar types of campaigns. For example, the average operational cost per child for a measles campaign is likely to be very similar to that of a yellow fever campaign. Most in-depth costing studies for campaigns find that the average operational costs per campaign between US$ 0.5 and US$ 0.7. If you do not have any data, you we recommend you use these amounts. Section 6: Programme activities, other recurrent costs and surveillance Programme activities, other recurrent costs and surveillance are critical components of an immunization programme, but are often underfunded. For the most part, these inputs will not be the major cost drivers of the programme and for this reason less emphasis is placed on estimating these costs accurately. However, it is critical to budget for them accordingly. Typically, programme activities and other recurrent cost categories will cover areas such as social mobilization, advocacy and communication activities, training, programme management and monitoring and disease surveillance. Section 6 of the Data Entry worksheet contains two required data tables. The information in these tables is needed to calculate the past costs and future resources requirements for programme activities, other recurrent costs and surveillance. The two data tables are listed below: 6. Programme activities, other recurrent costs and surveillance 6.1 Total spending and future budget needs for programme activities and other recurrent costs 6.2 Total spending and future budget needs for surveillance and monitoring 54 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

66 W Table 6.1: Total spending and future budget needs for programme activities and other recurrent costs In Table 6.1, you need to enter past expenditure and future budget needs for activities and other recurrent cost categories listed. Future budgets can be approximated by the total lump sum expenditure on these categories, and the future resource requirements can be projected by inflating these amounts forward. In many countries, these elements of the programme are often financed by external donors, usually through annual lump sums for these inputs. Tracking the financing provided will be a good proxy of their cost, and this information should be used. Table 6.2: Total spending and future budget needs for surveillance and monitoring Table 6.2 covers past expenditure and future budget needs for surveillance and monitoring for detection and notification, case and outbreak investigation, data management, laboratory and supportive activities. Future budgets can be approximated by the total lump sum expenditure on surveillance and monitoring, and the future resource requirements will be projected by inflating these amounts forward. In many countries, these elements of the programme are often financed by external donors, usually through annual lump sums for these inputs. Tracking the financing provided will be a good proxy of their cost, and this information should be used. HO/IVB/

67 Section 7: Other equipment needs and capital costs In the event that you need to include equipment other than vehicles and cold chain, Section 7 of the Data Entry worksheet is included for reporting other immunizationspecific capital inputs relevant to your immunization programme. Section 7 of the Data Entry worksheet contains two required data tables. 7. Other equipment needs and capital costs 7.1 Average prices of other equipment needs 7.2 Projected number of additional equipment needs (including the replacement of those currently used for the programme) The information in these tables is needed to calculate the past costs and future resource requirements for other equipment needs and capital costs. The two data tables can be found below. Table 7.1: Average prices of other equipment needs In Table 7.1, you first need to enter information on the types (or categories) of capital equipment on which you will be reporting (e.g. computers, generators or incinerators). If the NIP uses capital equipment that is not already listed in the table, you can replace the existing categories with the relevant ones. There is also room to include more categories. Enter information on the average prices (including all taxes) and overheads of other equipment needs and capital costs listed. Typically these will include equipment for waste management (such as incinerators), surveillance and laboratory equipment, and office equipment (such as computers). 56 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

68 W Table 7.2: Projected number of additional equipment needs (including the replacement of those currently used for the programme) In Table 7.2, enter the total number of existing units of other equipment that are used by the NIP, as well as future projection of needs by type of equipment. When making the future projections, be sure to include the replacement of equipment currently used for the programme. Your estimates should be based on the need to reach programme objectives and targets as outlined in your cmyp. Remember that because equipment, once purchased, lasts for more than one year, its value needs to be depreciated to an annual equivalent using the ULY numbers of the vehicles. The method retained in the cmyp Tool is to use five ULYs for equipment. The ULY number can be changed if you wish to use a more appropriate number for your country context. HO/IVB/

69 58 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

70 W Section 8: Buildings and building overheads A final input to be considered for the cmyp costing exercise is the building space used to provide fixed-site immunization service deliveries (e.g. outreach post), for the storage of vaccines and supplies (e.g. cold room building), or other building space used by the NIP (e.g. surveillance laboratory or incinerator building). In view of the relatively small value of building space in the total annual cost or future resource requirements of the immunization programme, approximations can be made and are likely to yield an estimate that is as accurate as applying a more complicated method. Types of building to include would be hospitals, provincial hospitals, district health centres, dispensaries, and other typical fixed health posts available in the country and used to deliver immunization services. The simplest way to estimate the value of buildings is to use estimates of new construction costs for suitable buildings. Calculating the capital cost of buildings also involves an allocation of space devoted to immunization activities. A division can be roughly estimated using staff time allocation. The information calculated in Table 2.2 can be used to make this estimation. The building and building overhead section of the Data Entry worksheet contains two data tables. These tables are optional, but we strongly recommend you use them if the data is available. The tables are needed to calculate past cost and future resource requirements for the portion of building space and building overheads (i.e. electricity, etc.) used by the NIP. 8. Buildings and building overheads 8.1 Average prices and overhead cost of buildings 8.2 Existing and future need of buildings The information in these tables is needed to calculate the past costs and future resource requirements for other equipment needs and capital costs. The two data tables can be found below. Table 8.1: Average prices and overhead cost of buildings In Table 8.1, you first need to enter information on the types of buildings that provide immunization services, by administrative level. Various building categories are listed in the table. You may change or add categories according to your country situation and administrative structure. If there are building categories relevant to you that are not already listed in the table, you can replace the existing ones. For each building type, enter the average cost of the construction of the buildings, the average monthly running costs of these buildings (i.e. electricity, etc.), and the percentage of space used for immunization. HO/IVB/

71 Table 8.1 Average prices and overhead cost of buildings Per building type Building type Average price new (2013) Average monthly overhead costs % space used for EPI National US$ US$ (%) EPI offices Central cold room Health clinic Health facilities Dispensaries Surveillance laboratory Other (specify) Regional US$ US$ (%) EPI offices Cold room Health clinic Health facilities Dispensaries Surveillance laboratory Other (specify) 60 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

72 W Table 8.2: Existing and future need of buildings In Table 8.2, enter the total number of existing buildings that are used by the NIP, along with your future projection of needs, by type of building and by administrative level. For the existing buildings, separate those units that were built during the baseline year from those that were built before. When making the future projections, the estimates should be based on the needs to reach programme objectives and targets, and as outlined in the cmyp. HO/IVB/

73 Table 8.2 Existing and future need of buildings Existing Old No. New in Total Additional buildings needed in the future Building type < No. No. No. No. No. No. No. No. EPI offices Central cold room Health clinic Health facilities Dispensaries Surveillance laboratory Other (specify) EPI Offices Cold room Health clinic Health facilities Dispensaries Surveillance laboratory Other (specify) Outreach facilities Building for incinerators Health clinic Health facilities Dispensaries Other (specify) Outreach facilities Building for incinerators Health clinic Health facilities Dispensaries Other (specify) No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. 62 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

74 W 5.3 Costing results and tables Once all the data for the cmyp costing exercise has been collected and entered in the appropriate tables of the Data Entry worksheet of the cmyp Tool, you can review the results of the costing exercise in the Costing worksheet. This worksheet contains tables of results, which are automatically generated. Below is a summary table that aggregates the cost and future resource requirements according to seven components of cmyp (see Table 5). The top portion of Table 6 shows the standard costing table in the cmyp Tool that breaks down the cost by category (recurrent and capital), and by strategy (total NIP, routine and campaigns). The lower portion of Table 6 provides the complete detail of the costing by disaggregated budget lines according to the seven components and subcomponents of cmyp. This table provides the detailed costing results and quantities. For instance, the vaccine cost for a particular year will be provided along with the number of doses needed. Table 5: Costing table design Components Sub components Vaccine supply and logistics 1. Adequate supply of vaccines and injection equipment Traditional routine vaccines Underused and new vaccines Campaigns 2. Procurement of adequate cold-chain equipment and spare parts 3. Procurement of vehicles 4. Procurement of other equipment Service delivery 5. Adequate human resources 6. Adequate transportation needs and other recurrent overheads for service delivery 7. Capacity-building 8. Operational costs of campaigns Advocacy and communication Monitoring and disease surveillance Programme management Supplemental immunization activities Shared health systems costs HO/IVB/

75 Table 6: Illustration of the costing table Before moving on to financing, review the results of the costing in the Costing worksheet. Closer examination of the tables may yield strange results. This could be due to errors in the data, or data entry into the cmyp Tool, or omissions of required data inputs. These should be reviewed. It can happen that costing results do not appear in the costing table. If this is the case, it means that an important piece of information has not been entered in the Data Entry worksheet. 5.4 Overview of the financing and financing projections worksheets Once the costing exercise is completed, the next step is to collect information on financing. This will help you analyse and understand who has been funding your immunization in the past, and how much finance needs to be mobilized in the future in order to meet cmyp objectives and targets. The Financing worksheet has been developed for entering information needed on past and future financing, and is a crucial step in the analysis of the funding gaps. Past financing: Information on past financing allows for analysis of the NIP financing structure, and who are the main donors to the programme, as well as the level of government contributions in relation to the complete funding for immunization. Information on past financing for your NIP will need to be entered in the first table of the Financing worksheet. 64 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

76 W Future financing: Financing projection allows for the quantification and classification of potential future funding. Combined with the information on future resource requirements, the cmyp Tool will help you evaluate the funding gaps, i.e. the difference between resource requirements and available funding. This is a critical element of financial sustainability planning. Information on future financing also needs to be entered in the other five tables of the Financing worksheet. Accuracy and reliability of future projections We recognize that it is difficult to predict future financing accurately. Accuracy in your projections will tend to decline as years are added to the predictions. Likewise, it is difficult to make accurate predictions about future financing trends, particularly as governments and external partners are often unable to make long-term commitments for funding. It will be necessary to make the most reliable projections possible through: (1) diagnosis of the macroeconomic and health sector environment in which the immunization programme operates; (2) discussions with focal points at the MoH finance department, the MoF, and ICC partners. Since the financing projections made can only be best estimates, it is important to remember that a funding gap of some size is always to be expected when projecting many years into the future. It is useful to think of the final results as indicative of the future requirements and financing challenges faced by the NIP. Given the uncertainty surrounding the future, especially when it relates to financing, two types of funding need to be considered: secure funding and probable funding. The exercise of classifying future financing into these two categories is known as risk assessment. Secure funding refers to the projected future financing available in the short term that is considered as assured. This implies that the funding has been committed, and is guaranteed to be made available (for instance, there is a commitment in writing). For the most part, secure funds are pledged over two to three years or less, except in the case of: GAVI Fund awards; budget support; monies that are pooled (e.g. in a sector-wide approach (SWAp); or debt relief funding for immunization (e.g. for highly indebted poor country [HIPCs], or multilateral debt relief initiatives [MDRI]). Probable funding refers to all other funding that is not assured, but is likely to be made available in the short and medium term. The term probable indicates that the projected future funding is likely to be based on historical trends or other information, including discussions with ministries and donors. For instance, if certain international donors, such as UNICEF, have been supporting the NIP for many years but can only commit funds one year at a time, any funding beyond this year might be classified as probable, with past tends and amounts used as a guide to future developments. Another example of probable funding could be future funds awarded from debt relief programmes or new donors that could support the programme. When completing the Financing worksheet, discuss the risks associated with each source of financing with the ICC members, and come to a consensus on which funds should be classified as secure, and conversely, which funds should be considered probable. HO/IVB/

77 5.5 Steps to complete the Financing worksheet There are four steps necessary to complete the Financing worksheet. Step 1: Enter names of funding sources The first step is to specify the names of the different sources of funding for your NIP. These need to be entered in the top section of the Financing worksheet, where you can enter up to 14 different sources of funding (e.g. WHO, UNICEF, GAVI, or World Bank), of which 3 are default names (government, subnational government and government co-financing of GAVI vaccines). Each funding name entered will correspond to a funding column. What is meant by a financing source? A source of financing refers to the agents providing the funds for immunization. Given the difficulties in tracking the exact source of financing, countries are asked to report only the source of financing closest to the end use. Therefore, transfers of bilateral donor agency resources to multilateral agencies (such as WHO or UNICEF), or to a health fund or the national treasuries (through pooled funds or budget support), are not attributed to the donor countries. This is of particular (and growing) significance in countries receiving bilateral aid through sector-wide approach (SWAp) programmes and national budget support. In the cmyp Tool, only the last source of funding before use by the programme is reported. For example, if the United States Agency for International Development (USAID) channels their funds for immunization through UNICEF, the funding is considered as UNICEF funds. In other words, UNICEF is the end source. Step 2: Collect information on past and future financing The second step involves collecting information on past and future financing. First review key planning documents (e.g. national health sector plan, past MYP for immunization, financial sustainability plan, expenditure reports submitted to donors, etc.) for any information on past or future financing for the NIP. Secondly, review any information on historical trends in government financing for immunization and growth rates in immunization budgets and health spending, as well as any past trends in international donor support for immunization. To ensure the most reliable projections for future financing, this could be done through: (a) diagnosis of the macroeconomic and health sector environment in which the immunization programme operates; (b) discussions with focal points at the MoH finance department, the MoF and ICC partners. Proceed as follows to obtain the other financing information needed: 1) Meet with each source of funding (existing and potential) as identified in step 1 above. 2) Provide them with the results of the costing/future resource requirements analysis of your NIP. You might consider printing the Costing worksheets for their examination. 3) Print copies of the Financing worksheet for use in your discussions with each funding source. Alternatively you might leave prints of these tables and ask them to fill them out for you. 66 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

78 W 4) Use the ICC mechanism to facilitate this process. 5) When making future financing projections, you are encouraged to explore other funding possibilities. Step 3: Enter the information collected into the Financing worksheet Once you have gathered all the financing data, it will have to be entered into the Financing worksheet. Past financing should be reported in the first financing table. Future financing data should be entered in the last five tables. Step 4: Risk assessment Because future financing is uncertain, it is necessary to classify the funding (identified in step 2 and reported in to the financing tables in step 3) into those funds that can be considered as secure and those that should be considered as probable. The process of classifying future financing into these two categories is known as the risk assessment. You may use information on the financing structure of your NIP, and past trends in financing from each source to help with this assessment. Alternatively, ask donors to classify their own risk assessment of their financing for you. This can be done in step 2. For the past financing, there is no risk assessment to be made. By definition, all past funding was secured. The risk assessment for future financing is done by using the Risk type column next to each source of financing column. Simply enter 1 for secure funding and 2 for probable funding, using the definitions outlined above. The table below provides you with an example: Notice that if you enter 1 in the Risk type column, the financing will automatically appear in the column of total secure funding. If you enter 2 in the Risk type column, the financing will automatically appear in the column of total probable funding. The column UNFUNDED is the difference between Total resource requirements and total secure and probable funding. This refers to the amounts that are not covered by any funding. In order to avoid any miscalculations based on the risk assessment, the column Risk type will only accept entries for 1 and 2 from the top-down menu. If you enter any other value the following pop-up message will appear. In addition, a risk type check is included. HO/IVB/

79 Table 7: Financing worksheet Cost Category Total Resource Req uirements A vailab le F inancing Total Prob ab le F U N F U N inancing DE D RIS K TY PE CHE CK Routine Recurrent Costs U S $ U S $ U S $ U S $ ( $ Vaccines routine vaccines only) Traditional - U nderused $ - N ew $ - Inj ection supplies $ - Personnel S alaries of full-time N IP h ealth w ork ers ( immunization speci c $ - Per-diems for outreach vaccinators/ mob ile teams $ - Per-diems for supervision and monitoring $ - Transportation F ( $ ix ed site strategy incl. vaccine distrib ution) - O utreach and mob ile strategy $ - M aintenance and overh ead Cold ch ain maintenance and overh eads $ - M aintenance of oth er capital eq uipment $ - Building overh eads ( electricity, w ater ) $ - S h ort-term training $ - IE C/ social mob ilization $ - Disease surveillance $ - Programme management $ - O th er routine recurrent costs $ - $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! $ - O K! 68 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

80 W 5.6 Steps to complete the Co-financing worksheet The Co-financing worksheet is where GAVI-eligible countries may enter data to calculate the amount of government co-financing required according to the country grouping level. There are five steps to completing the Co-financing worksheet. Step 1: Selecting your country grouping level To select your country grouping level, select the drop box arrow located next to the cell marked GAVI Country Grouping (Select) under the section Calculation of the GAVI Vaccine Co-Financing Amounts for the cmyp. The three options are low-income group, intermediate group, and graduating group. Step 2: Vaccination schedule Under the country group level, there is a table containing GAVI-supported vaccines. Next to the vaccine of interest, select yes in the column GAVI Supported and fill in the start year for co-financing (see Table 8). Table 8: Vaccine schedule in the Co-financing worksheet Step 3: Select the minimum co-financing level In the box labelled GAVI minimum co-financing levels, select yes for the GAVI minimum co-financing levels and no to set custom co-financing levels. By selecting no, you can select a higher than minimum GAVI requirement. Step 4: Check the co-financing levels If you selected no in step 3, enter your own co-financing levels. Otherwise, check if the co-financing levels in the first table are correct (see Figure 11). HO/IVB/

81 Figure 11: Illustration of co-financing levels Example of low-income country Step 5: Review results The results can be found under the last section of the worksheet. Review these results and then enter them into the Financing worksheet. 70 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

82 W 6. Analysis of results Once all the required information is entered in the cmyp Tool, a number of basic analyses should be undertaken to understand what the data has uncovered about the situation with regard to costing, financing and funding gaps. Analysing the results is also a way of determining whether information entered in the Data Entry and Financing worksheets is comprehensive and accurate, and reflects the objectives and strategies of the cmyp. Any analysis of the results of the cmyp Tool is likely to draw upon the information presented in the Gaps & Indicators, Graphs, and Sustainability worksheets. The Gaps & Indicators worksheet contains several tables presenting year-to-year variations in resource requirements, secure and probable financing, and financing gaps. In addition, this worksheet contains specific tables and graphs that analyse the composition of the funding gaps. The Graphs worksheet contains key charts on the baseline costing and financing results, and other graphs on the future resource requirements, financing and gaps. These will help you understand the level of resource requirements needed, and what financing will be available in the future. The Sustainability worksheet contains a table and chart that contextualize the immunization programme within the broader macroeconomic and health systems. This sheet is important when considering the overall financial sustainability of the programme. In the event that you wish to calculate other indicators, or prepare other charts that are not presented in the Gaps & Indicators and Graphs worksheets, you can easily insert new worksheets into the cmyp Tool to carry out separate analyses. Remember that when developing your cmyp document, it is important to prepare a written analysis of the data and findings, including the use of indicators and graphs. Some suggestions are provided below. Important notes on analysis Prior to analysing the results from the cmyp Tool, remember that the choice of the information used can change the results and conclusions obtained. For instance, the costing results will be different depending on whether you choose to include only immunization-specific costs or also shared costs. Likewise, because of the risk assessment done on future financing, any analysis of future trends in financing and gaps will depend on whether you choose to present only secured funding, probable funding, or both. Make sure that your analysis specifies what information is being included. HO/IVB/

83 6.1 Analysis of past costing and financing (baseline) A baseline analysis of past costing and financing for the programme will give you a sense of how much your programme currently costs, what are the major cost drivers, and who is paying for what. To help you analyse the baseline costing and financing of your programme, consider commenting on the following: The baseline cost profile. This shows the breakdown of immunization by cost category and as a relative share of the total. This will help identify what have been the major NIP cost drivers, and any changes through the years. The first pie chart presented in Figure 12 shows an example of a cost profile for an immunization programme. In many instances, it is likely that vaccines and personnel will account for at least 50% of the overall costs of a programme. The baseline financing profile. This shows the structure and breakdown of immunization financing by source and in relative share of the total. This will help identify the major sources of funding for the programme. When looking at the financing profile it is useful to compare the share of government versus external funding for immunization. This will give you an impression of how self-sufficient, financially sustainable or donor-dependent your immunization programme will be (see the second pie chart in Figure 12). Baseline indicators. These indicators are calculated in the Gaps & Indicators worksheet and refer to items such as the cost per capita and the cost per DTP3 child. Refer to Annex II at the end of this User Guide for a complete definition of these indicators and how to interpret them. 72 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

84 W Figure 12. Examples of baseline costing and financing charts Baseline Cost Profile (Routine only) Injection supplies, $118,223, 3% New vaccines, $0, 0% Personnel, $1,458,877, 35% Underused vaccines, $1,573,161, 38% Transportation, $58,847, 2% Traditional vaccines, $406,079, 10% Other routine recurrent costs, $473,072, 11% Vehicles, $0. 0% Campaigns, $57,201, 1% Other capital equipment, $7,983, 0% Cold chain equiment, $0, 0% Baseline Financing Profile (Routine only) Other capital equipment, $0, 0% Cold chain equiment, $376,734, 7% Campaigns, $335,160, 6% Traditional vaccines, $862,939, 16% Vehicles, $220,32, 4% Other routine recurrent costs, $522,054, 10% Transportation, $101,174, 2% Injection supplies, $118,223, 3% Personnel, $1,488,055, 28% Underused vaccines, $1,138,337, 21% New vaccines, $0, 0% In a written analysis of the baseline costing and financing of the programme, consider commenting on some summary figures, such as: total NIP programme costs; vaccine costs as a share of total costs; share of financing by government versus other external sources of funds. For an example, see Table 9 and the comments below it. HO/IVB/

85 Table 9: Example of the first indicators table from the Gaps & Indicators worksheet Sample analysis (EXAMPLE ONLY) Baseline Indicators (2004) 2013 (US$) Total immunization expenditures Campaigns Routine immunization only per capita 0.4 per DTP child 16.3 % Vaccines and supplies 38.0% % National funding 6.9% % Total health expenditures 7.5% % Government health expenditures 13.7% % GDP 0.2% Total shared costs specific costs % Shared health systems cost 16% TOTAL In the baseline year (2013), total spending on immunization amounted to US$ 14.3 million half of which was to cover the costs of supplementary immunization campaigns. In other words, one in every two United States dollars for immunization was spent on routine services. In per capita terms, the cost of immunization was about US$ 0.4. Likewise, the immunization cost per DPT3 immunized child (approximation of the cost per fully immunized child), was US$ 16. Analysing the breakdown by cost category, we find that half the costs are to cover vaccines, injection supplies and staff costs. Looking at financing, we note that less than 10% of the immunization programme is funded using government resources. UNICEF and the GAVI Fund are the two largest donors to the programme and account for half the financing. This indicates that the programme is highly donor-dependant for a priority health intervention like immunization. However this is not entirely surprising, as funding for the health sector has remained low at around US$ 5 6 per capita. Fully supporting the national immunization programme in the future would require allocating about 10% of the overall government health budget. It will be important to strengthen efforts to ensure continued increase in government and partner funding for immunization, and to ensure that future funds are secured. 6.2 Analysis of future resource requirements, financing and gaps In the same way as with past costing and financing, a number of basic analyses can be undertaken to understand future resource drivers of each immunization programme, the main sources of secured funding, how resources are mobilized and spent over the projected period, and how quickly the gap begins to grow. During a five-year projected period, resource requirements can be expected to increase with population growth, the introduction of new or underutilized vaccines, periodic supplementary immunization activities, and purchases of cold-chain equipment. It is useful to review how these change over time. 74 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

86 W To help analysis of future costing and financing of the programme, consider commenting on the following: The future cost profile. Analysing the future resource requirements by cost category and trends over the projected period will help identify the major cost drivers of your NIP and any changes over the years. The area graph presented below is an example of a future cost profile for an immunization programme (see Figure 13). This graph is available in the Graphs worksheet of the cmyp Tool. In many instance, it is likely that vaccines and personnel will account for at least 50% of the overall costs of a programme. The future financing profile. Analysing future financing by source and trends over time will highlight who are the likely major contributors to future immunization. Remember that with the risk assessment, there will be two estimates of future funding: a worst case scenario using only secure funds; and a best case scenario using secure and probable funds. The area graph presented below is an example of a future financing profile for an immunization programme (see Figure 13). This graph is available in the Graphs worksheet of the cmyp Tool. This analysis will be very helpful in identifying the future funding gaps and where efforts need to be concentrated in order to mobilize resources. The level and composition of the gaps. The Gaps & Indicators worksheet of the cmyp Tool will be the most useful in the analysis of any gaps, and the indicators table will provide a broad sense of their magnitude. A specific section of the worksheet is dedicated to the composition of the gaps. This will help you identify the major cost categories of the programme that remain unfunded, the size of the funding gaps and any changes over the years (see Table 10). HO/IVB/

87 Figure 13: Examples of the future resource requirements, financing and gap graphs Projection of future resource requirements $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $ Traditional vaccines Underused vaccines New vaccines Injection supplies Personnel Cold chain equipment Transportation Other capital equipment Other routine recurrent costs Campaigns Vehicles Future secure financing and gaps $10,000,000 $9,000,000 $8,000,000 $7,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $ Government GAVI (NVS) WHO JICA Sub-national Gov. GAVI (HSS) UNICEF Funding gap Gov. co-financing of GAVI vaccine GAVI (ISS) UNF Im 76 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

88 W Table 10: Example of the gap analysis section of the cmyp Tool Composition of the funding gap Total US$ US$ US$ US$ US$ US$ Vaccines and injection equipment Personnel Transport Activities and other recurrent costs Logistics (vehicles, cold-chain and other equipment) Campaigns Total funding gap* * Immunization-specific funding gap. Shared costs are not included. Figure 14: Composition of the funding gap* Vaccines and injection equipment Personnel Transport Activities and other recurrent costs Logistics (vehicles, cold chain and other equipment) Campaigns % 20% 40% 60% 80% 100% Note that with the risk assessment on funding, there will be two estimates of the financing gap. The cmyp Tool allows you to analyse the composition of the gap according to secure funding only, or both secure and probable funding (see Figure 14). HO/IVB/

89 What are the different types of funding gaps? Gap with secure funding: This refers to the difference between projected resource requirements and secure financing over the corresponding period. [gap with secure funding = resource requirements secure funding] Gap with probable funding: This refers to the difference between projected resource requirements and both secure and probable financing over the corresponding period. [gap with probable funding = resource requirements (secure + probable funding) ] Many indicators are calculated in the Gaps & Indicators worksheet, for example, future cost per capita, the cost per DTP3 child, and funding gaps as a share of total resource requirements. Refer to Annex II at the end of this User Guide for a complete definition of these indicators and how to interpret them. In a written analysis of the future costing and financing of the programme, you may consider commenting on some summary figures, such as: total projected resource requirements over the cmyp period; total projected funding gap; funding gap as a percentage of resource requirements; total projected funding gap as a share of a projected total spending on the health sector; vaccine expenses as share of total gap. For an example, see Table 11 and the comments below it. 78 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

90 W Resource requirements, financing and gaps Table 11: Example of the Gaps & Indicators table Sample analysis (EXAMPLE ONLY) Total US$ US$ US$ US$ US$ US$ Total resource requirements Total resource requirements (routine only) per capita per DTP targeted child % Vaccines and supplies % % % % % % Total financing (secured) Government Donor 1 Donor 2 Donor 3 Donor 4 GAVI Funding gap % of total needs 24% 55% 92% 95% 95% 74% Total financing (not secured probable) Government Donor 1 Donor 2 Donor 3 Donor 4 GAVI Funding gap % of total needs 9% 28% 5% 29% 49% 27% In order to reach the cmyp objectives, expenditure on immunization would need to increase. Over the period, a resource envelope of about US$ 54 million would be needed. These resources include all needs for inputs (vaccines, personnel, cold chain, vehicles, transport, etc.), and activities (training, social mobilization, surveillance, outreach, etc.). The resource envelope translates to US$ 16 per DTP3-targeted child. This unit cost is about the same as the 2012 baseline cost, as the increase in cost is offset by higher coverage. As more children are immunized, the overall unit cost per child will drop as the costs, and particularly the fixed costs, are spread across a larger number of children. The year 2017 marks a year where large investments in equipment renewal will be needed. Looking at future financing, it is estimated that US$ 16 million can be considered as secured funding between 2014 and Out of the total resource envelope required, a funding gap of US$ 38 million emerges. In other words, 71% of resources needed to meet programme objectives do not have secured funding. If monies are included that will probably be made available but are not secured, the funding gap for the entire period drops to US$ 13 million, in other words 25% of overall resources are unfunded. In the future most of the funding gaps will be for vaccines, activities and logistics. 6.3: Analysis of immunization strategies In addition to the analyses that focus on the composition of costs by cost category (in order to understand the cost drivers of the programme), it will be useful to look at the composition of the costs according to immunization strategies. In other words, trying to understand how the costs are broken down into different delivery strategies to raise coverage fixed site delivery, outreach and campaigns and what will be the dominant strategy. HO/IVB/

91 Such an analysis will also confirm whether the strategy as defined in the cmyp objectives has been adequately represented. For instance, you can check whether the timing of campaigns is aligned with those outlined in your cmyp objectives. Similarly, if one of the cmyp objectives is to strengthen outreach activities, you would expect that a significant portion of the costs would go towards this strategy. Finally, it can also highlight any imbalance is the choice of strategies. For instance, it is widely considered that focusing too strongly on campaigns at the expense of routine delivery systems is not sustainable in the long term. It is important to ensure that campaigns complement routine activities rather than the reverse. The cost by strategy graph in the Graphs worksheet will give an example of how future resource requirements needed to meet the cmyp objectives can be divided into different delivery strategies (see Figure 15). Figure 15: Example of the cost by strategy graph of the Graphs worksheet Costs by Strategy (EXAMPLE ONLY) Costs by strategy (US$ Millions) $16.0 $14.0 $12.0 $10.0 $8.0 $6.0 $4.0 $2.0 $ Campaigns Routine (fixed delivery) Routine (outreach activities) Supplementary activities are necessary in order to reach cmyp objectives. For instance, a polio subnational immunization day is planned for 2014, measles campaigns are scheduled for 2015 and 2018, and a tetanus campaign for While in the 2012 baseline year, almost 50% of expenditure went on campaigns, such activities and costs will be lower in the period. The average spending on campaigns over the next five years will average 20% of overall spending on immunization. 80 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

92 W 6.4: Sustainability analysis The results of the cost, financing, and gap analysis can be further analysed in order to give a comprehensive picture of prospects for financial sustainability. For example, the cmyp objectives and strategies should be considered affordable if the projected funding gap with government and partner financing is small enough to be realistically filled, taking into account constraints in financing of the health sector. The Sustainability worksheet contains a table and chart linking future resource requirements to the broader macroeconomic and health systems context, such as GDP or health expenditure. The table in this worksheet calculates a number of indicators, which will be extremely useful when evaluating the overall financial sustainability of your programme. For instance, if resource requirements for the immunization programme account for a very large share of the overall health budget, it will be necessary to consider whether some elements of the programme are affordable or realistic. For an example, see Table 12 and the comments below it. HO/IVB/

93 Table 12: Example of the table and graph of the Sustainability worksheet Immunization in relation to macroeconomic indicators Sustainability analysis (EXAMPLE ONLY) US$ US$ US$ US$ US$ Reference Per capita GDP ($) Total health expenditures per capita ($) Population GDP ($) Total health expenditures ($) Government health expenditures ($) Resource requirements for immunization Routine and campaigns ($) Routine only ($) per DTP3 child ($) % Total health expenditures Resource requirements for immunization Routine and campaigns 9.20% 10.60% 7.10% 11.50% 10.30% Routine only 8.20% 7.50% 7.10% 9.60% 7.30% Funding gap With secure funds only 1.90% 5.40% 6.10% 10.60% 9.40% With secure and probable funds 0.60% 2.70% 0.20% 3.10% 4.90% % Government health expenditures Resource requirements for Immunization Routine and campaigns 16.70% 19.20% 12.80% 20.90% 18.70% Routine only 14.90% 13.70% 12.80% 17.40% 13.30% Funding gap With secure funds only 3.40% 9.90% 11.20% 19.30% 17.10% With secure and probable funds 1.10% 5.00% 0.40% 5.70% 8.90% % GDP Resource requirements for immunization Routine and campaigns 0.19% 0.22% 0.15% 0.24% 0.21% Routine only 0.17% 0.16% 0.15% 0.20% 0.15% Per capita Resource requirements for immunization Routine and campaigns Routine only The annual resource requirement needed to reach the cmyp objectives over the period will represent between 9% and 11% of the overall health budget. Considering only government health budgets, the needs for the programme will represent between 13% and 21%. The important yearly fluctuations result from timing of campaigns and renewal of important equipment (such as cold chain). Reaching the objectives of the cmyp will place significant pressure on the health budgets, particularly in a context where spending on health is low less than US$ 10 per capita. 82 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

94 W 6.5 Dashboard The Dashboard worksheet includes a summary of the costing and financing situation of the country (see Figure 16). This includes a summary of baseline year expenditures and the projected financing situation. This summary pulls from the results in the Costing worksheet and data entered into the Financing worksheet. The results in this worksheet can be used to quickly identify the effect of modifications to the data. Figure 16: Dashboard of the cmyp Tool HO/IVB/

95 7. Scenario building Strategic planning for immunization will require considering alternative programmatic improvements, or strategies, for reducing funding gaps, by exploring different options for mobilizing funding by using existing financial resources for immunization more efficiently. Since estimating future resource requirements for immunization is not a science, the results will be very dependent upon the availability of data and the assumptions made. Resource estimations should be an iterative process, whereby the results improve in time as better data becomes available. Thus, scenario building is a relevant exercise for careful priority setting, and the standard way of dealing with such uncertainty (and dependence on assumptions), whether these are related to costs or financing. Although baseline projections of future resource requirements, financing and gaps should be your best estimates (realistic and reliable), it may be useful to explore the impact on total resource requirements, financing and funding gaps for other programme scenarios. In its simplest form, scenario building implies varying key assumptions (such as costs or coverage), and assessing how sensitive the resource requirement estimations are to those changes. Similarly, scenarios can reflect more ambitious programme objectives and targets, or alternatively less ambitious ones following historic financing allocation trends. Resource estimations can also be made for the different levels of future financing and budget constraints. 7.1 Types of Scenarios Scenarios can be devised in many ways as illustrated in Table A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

96 W Table 13: Illustration of scenario building Types of scenario Costing Financing Costing and financing Administrative level Long-term horizon Examples For measuring the impact on the cost of reducing vaccine wastage, changing coverage targets, introducing a new vaccine, changing vaccine presentation, strengthening outreach, renewing the cold chain, etc. For measuring the impact on available financing and the funding gaps of increasing government contributions, alternative ways of using GAVI Fund grants, generation of new resources through alternative health financing mechanisms, or earmarking of HIPC funds for immunization, etc. For measuring the combined effect on costs, financing and funding gaps of introducing a new vaccine and increasing government funding. Many countries, provinces or regions vary in terms of geographical terrain, population density, and socioeconomic levels. These differences at the subnational level can affect the ability of immunization programmes to function and the amount of resources required for each area. Additionally, in countries with decentralized planning processes, decision-making about resources available for operational costs is often conducted at the subnational level. For these reasons, it is often useful to estimate resource requirements at the subnational level rather than at the national level. In most cases, the planning horizon will be five years or less. In the rare cases where the planning horizon is greater, or you simply wish to explore a long-term horizon in the context of a financial sustainability analysis of the immunization programme, it is possible to create a scenario that will look beyond five years. 7.2 Using the cmyp Tool for scenario building To develop alternative scenarios, the easiest way to proceed is to create separate versions of the cmyp Tool by saving it under different file names. Make sure to label the scenario in the background information section of the Data Entry worksheet of the cmyp Tool and label the Excel file to make it easy to refer to the different versions. Scenario building encourages you to identify and consider the main drivers of the funding gap; to identify cost saving measures, and to explore ways to improve the efficiency of resources, as well as options to mobilize additional resources for the programme. Because of the ease of developing costing and financing scenarios using the cmyp Tool, we recommend that you develop a comparative table of results that might look like Table 14. HO/IVB/

97 Table 14: Comparative analysis of different scenario results Scenario name Description Total resource requirements (US$) Total financing (US$) Total gaps (US$) Baseline Scenario 1 Scenario 2 Scenario 3 Scenario 4 Based on current objectives and targets as defined in your cmyp example: introduction of a new vaccine in five years example: alternative coverage and wastage targets example: increase government financing example: alternative coverage and wastage targets and increase government financing $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ In a written analysis of the scenarios, select one or two of the most feasible and affordable ones. The findings from these scenarios should be analysed in the same way as the baseline scenario (refer to part 6 of this User Manual). In any case, it is essential to clearly communicate the results of the different scenarios. The final choice of scenarios with respect to resource requirements estimates and/or future financing should be based on discussions with the various stakeholders and partners. This will increase the acceptability of the results and buy-in from stakeholders, and lead to formulation of the most realistic scenarios building exercise. 86 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014

98 W 8. Annual monitoring using the cmyp Costing and Financing Tool The cmyp costing and financing exercise should not been seen as a one-off exercise, but one that needs to be updated in conjunction with the annual planning exercise, or as programme objectives and goals change. This is an iterative process in which the results improve as time goes by and better data becomes available. The cmyp Tool is designed to make annual updates relatively straightforward, and we strongly encourage you to do this. The largest investment in time is the initial effort to input the cmyp Tool with all the essential data, and subsequent updates or modifications, as better data becomes available, or as programme objectives and goals change, will not be time consuming. This will also provide many advantages in terms of strengthening the annual planning and budgeting exercise for immunization. It will also offer opportunities to review key assumptions, parameters and programme objectives to give up-to-date cmyp costing estimates, and strengthen financial management of the programme and its reporting requirements. 8.1 Annual planning and financial resources The WHO UNICEF guidelines for comprehensive multi-year planning for immunization 8 recommends that for every year of the cmyp period, an annual workplan be prepared for the forthcoming year, and that this should include relevant costing and financing elements. Strong annual and multi-year planning, in conjunction with a budgeting process, is absolutely essential to plan for, monitor and manage the immunization programme, and to ensure that enough money is available to support planned inputs and activities aimed at reaching objectives and targets. The cmyp Tool includes the Annual Plan worksheet to help the user develop their annual workplan (see Table 15). 8 WHO and UNICEF, 2014 (see footnote 1, page 1) HO/IVB/

99 Table 15: Annual Plan worksheet Taking into account its estimations of resource requirements and financing needs over the cmyp period, the cmyp Tool is a good starting point for amassing the annual costing and financing data needed for the annual workplan, and for getting a sense of available funding and funding shortfalls. Much information will be available from the Costing worksheet where for each year, the tables provide both the detailed costing results and annual quantities for inputs (e.g. vaccines, cold-chain equipment, etc.). In the same way, budgeted amounts for activities can provide a useful starting point for identifying the overall resource envelope planned for each year. 8.2 Review of key assumptions on the costing It will be useful to return to the cmyp Tool annually to review key assumptions. For instance, if a new population census was undertaken recently which provided new demographic data, these can easily be entered in the cmyp Tool, and all the calculations will automatically be redone based on this new information (e.g. vaccine forecasts). It is also possible that during the implementation phase of the cmyp, certain activities or programmatic objectives might change, such as the rescheduling of a vaccination campaign, or the postponement by one year of the introduction of a new vaccine. Such changes in key assumptions for the cmyp costing are easy to make in the cmyp Tool and should be done in the Data Entry worksheet. Systematically reviewing the assumptions and making any corresponding changes will ensure that your cmyp costing estimates are always up-to-date. 8.3 Financial management and trends on immunization financing If regularly updated and used, the cmyp Tool has the potential to be a powerful financial management tool for an immunization programme. For instance, every year it is worth reviewing financing projections in light of the risk assessment carried out, to verify whether funding that was classified as secure did materialize, or alternatively, how much of the probable funding materialized during the year as payment for inputs and activities to reach planned objectives. This will give an indication of how effective the resource mobilization strategies for immunization have been, how volatile the programme is to changes in levels of funding being made available, and how programme targets and goals, such as coverage, are affected by funding shortfalls. 88 A Tool and U ser G uide for cmyp Costing and Financing: U pdate May 2014