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

Transcription

1 WHO/IVB/06.15 ORIGINAL: ENGLISH VImmunization Costing & Financing: A Tool and User Guide for comprehensive Multi-Year Planning (cmyp) Immunization, Vaccines and Biologicals

2 WHO/IVB/06.15 ORIGINAL: ENGLISH VImmunization Costing & Financing: A Tool and User Guide for comprehensive Multi-Year Planning (cmyp) Immunization, Vaccines and Biologicals

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/06.15 Printed: December 2006 This publication is available on the Internet at: Copies 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 2006 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 Tables and figures... v Abbreviations and acronyms... vii Acknowledgement... ix Introduction... xi 1. Strategic planning for immunization with costing... 1 A new approach to planning for immunization... 1 Why cost a cmyp?... 2 What are the costing linkages in the cmyp guidelines?... 2 What are the cmyp linkages with broader health sector costing exercises?... 4 What is the difference between costing a cmyp and the FSP? Overview of the cmyp costing and financing tool... 6 Can the tool be used in a decentralized setting?... 8 Can the Tool be damaged?... 8 What is the Tool not designed to do?... 9 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 1. Data Entry worksheet Review of each data table contained in the 1. Data Entry worksheet Costing results and tables Overview of the financing and financing projections worksheets Steps to complete the 4. 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 iii

5 7. Scenario-building Types of Scenario Using the Tool for scenario-building Annual monitoring using the costing and financing tool Other uses of the costing and financing tool information Annex I: Summary table of data needs and sources Annex II: Glossary of important cmyp costing terms iv

6 Tables and figures Table 1: System components to cost in a cmyp Table 2: Summary table of methods used in the Tool Table 3: Sections and data tables of the 1. Data Entry worksheet of the Tool Table 4: Costing table design Table 5: Examples of costing and financing scenarios to develop Table 6: Comparative analysis of different scenario results Figure 1: Costing linkages in cmyp guidelines... 3 Figure 2: Reconciling various objectives when planning for immunization... 4 Figure 3: Screen shots of cmyp costing and financing tool... 7 Figure 4: Design of the Tool... 8 Figure 5: Broad elements to cost in a cmyp Figure 6: Typical cost profile of an immunization programme Figure 7: Illustration of the detailed costing table Figure 8: Illustration of the FSP style costing table Figure 9: Example of baseline costing and financing graphs Figure 10: Example of the future resource requirements, financing and gap graphs Figure 11: Example of the gap analysis section of the Tool v

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8 Abbreviations and acronyms AE AD APR BCG CBAW CEA cmyp cmyp Tool DFID DT DTP EPI FIC FSP GAVI GDP GHE GIVS HepB Hib HIPC ICC IEC IMF IMR JE JICA JRF adverse events auto-disable syringe annual progress report Bacille Calmette-Guérin (vaccine) childbearing age women cost-effectiveness analysis comprehensive Multi-Year Plan for Immunization cmyp Costing and Financing Tool Department for International Development (UK) diphtheria-tetanus (vaccine) diphtheria-tetanus-pertussis (vaccine) Expanded Programme on Immunization fully immunized children financial sustainability plan Global Alliance for Vaccines and Immunization gross domestic product government health expenditure Global Immunization Vision and Strategy Hepatitis B (vaccine) Haemophilus influenza type B (vaccine) highly indebted poor country inter-agency coordinating committee information, education and communication International Monetary Fund infant mortality rate Japanese encephalitis Japan International Cooperation Agency WHO-UNICEF Joint Reporting Form vii

9 LCU MDG MDRI MMR MNT MoF MoH MTEF MYP NGO NHA NIP OPV PRSP PW SI SIA SWAp TB THE TT U1P ULY UNICEF USAID local currency units Millennium Development Goals multilateral debt relief initiative mumps, measles, rubella (vaccine) maternal and neonatal tetanus Ministry of Finance Ministry of Health medium term expenditure framework Multi-Year Plan for Immunization nongovernmental organization national health accounts National Immunization Programme oral poliovirus vaccine poverty reduction strategy papers pregnant women surviving infants supplemental immunization activities (campaigns) sector wide approach tuberculosis total health expenditure tetanus toxoid under one population useful life years United Nations Children s Fund United States Agency for International Development viii

10 Acknowledgements The immunization Costing and Financing Tool and User Guide were developed by the World Health Organization (WHO) Immunization Vaccines & Biologicals Department (IVB), and is the result of team work between partners to the Global Alliance for Vaccines and Immunization (GAVI) which is committed to the financial sustainability of immunization programmes in the poorest countries. These include the Bill & Melinda Gates Foundation, the Centre for Global Development, the Children s Vaccine Programme at PATH, the United Nations Children s Fund (UNICEF), the United States Agency for International Development (USAID), the World Bank, and the World Health Organization. WHO is grateful to members of the GAVI Financing Task Force who have supported this effort. ix

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12 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 GIVS 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 GIVS, and as a way of implementing GIVS at national level, countries are encouraged to develop their own comprehensive Multi-Year Plans (cmyp) for immunization. In 2005, in conjunction with their GAVI partners, WHO and UNICEF developed the Guidelines for Developing a Comprehensive Multi-Year Plan (cmyp) for immunization 1 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 national level, which in turn had lead to duplication of effort, high transaction costs for national partners and those with variable degrees of national ownership, and a lack of alignment with national systems. Through the GIVS initiative and framework, the cmyp process is expected to streamline immunization planning process at national level into a single comprehensive and costed plan. It is within this context that these new guidelines build on existing multi-year planning experience, while adding the critical elements of costing and financing by drawing heavily upon the methods developed for the immunization financial sustainability plans (FSPs). In the same way it is hoped that the costing and financing exercise will build on FSP costing tools and methodologies. In developing these guidelines it was broadly recognized that strategic planning for immunization would require credible information on how much was being spent, what it was being spent on, from which source, and how much future funding would be needed to reach programme objectives. Analysing the costing and financing of a comprehensive Multi-Year Plan (cmyp) is therefore a key step in the planning process of a national immunization programme (NIP). 1 See or WHO Department of Immunization Vaccines and Biologicals (IVB) Documents Centre, reference (WHO/IVB/05.20). xi

13 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 resource requirements and financing, and for analysing the corresponding financing gaps in reaching immunization programme objectives. The 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 Costing and Financing Tool, guidance on sources of information, and results analysis, as well as interpretation of findings. The User Guide is structured as follows: introduction on 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 of reference summary table of data needs, sources, and terminology. While the Tool and User Guide are principally targeted towards national immunization programme managers in the context of developing a comprehensive multi-year plan, they 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 for using the cmyp Costing and Financing Tool and understanding its User Guide. The intention is that these materials will be continually improved and updated. We therefore recommend that the User regularly visit the website to obtain the latest versions: at xii

14 1. Strategic planning for immunization with costing A new 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 Immunization Vision and Strategy (GIVS) for the period GIVS 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 GIVS, 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 linkages with the broader health sector or macroeconomic context. This experience has taught us that planning needs to reflect country priorities, to be aligned with country planning cycles, and to simplify and harmonize procedures. 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 GIVS initiative and framework, efforts have begun to streamline the immunization planning process at country level into a single comprehensive and costed plan. In summary, the WHO-UNICEF Guidelines for Developing a Comprehensive Multi-Year Plan for Immunization 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 the improved financial management sustainability of the programme; links annual work plans to the multi-year plan; links to the broader health sector planning and budgeting processes. WHO/IVB/

15 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. Indeed, the costing of a cmyp is thought to: 1) Strengthen national budgeting and planning for immunization and help 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? 2) Help in decision-making about programme improvements. An example would be 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. 3) Generate information that will help advocacy and mobilize the resources needed for vaccines 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. What are the costing linkages in the cmyp guidelines? The WHO-UNICEF Guidelines for Developing a Comprehensive Multi-Year Plan for Immunization 2 provides a series of steps to developing 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. 1 See or WHO Department of Immunization Vaccines and Biologicals (IVB) Documents Centre, reference (WHO/IVB/05.20). 2 cmyp Costing & Financing Tool User Guide

16 Figure 1: Costing linkages in cmyp guidelines Programmatic Objectives Costing Objectives Step 1 - Conducting a situational analysis Step 6 - Analyzing the costs, financing, and financial gaps in the cmyp Step 2 - Developing and prioritizing national objectives and milestones 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 3 - Planning strategies for each system component Step 11 - Establishing the timelines, responsible units and financial resources In broad terms, Step 6 has six components to it. The first is to undertake a diagnosis of the macroeconomic and health sector environment in which the immunization programme operates. This diagnosis recommends exploring three areas: (1) trends in government financing of health services; (2) the planning and budgeting processes for the health sector; (3) 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. The second and third components of Step 6 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. The fourth component of Step 6 is to analyse the results and interpret the findings, particularly with regard to the financing gaps for immunization. Lastly, identifying strategies and indicators that will help you move towards financial sustainability are the final components of Step 6. WHO/IVB/

17 What are the cmyp linkages with broader health sector costing exercises? Neither strategic planning for immunization, nor its costing, has ever been an easy process. 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 lens and context (see the diagram below). Figure 2: Reconciling various objectives when planning for immunization Poverty Reduction (MDG, PRSP, MTEF ) MoF Priorities World Bank MoH Policy Health Sector Planning, integration, SWAp New vaccine introduction, increasing coverage GAVI EPI objectives Polio, measles, campaigns, outbreaks, surveillance For example, the Ministry of Finance (MoF) might view immunization in the context of the Millennium Development Goals (MDG), or how it can contribute to poverty reduction. Thus any strategic planning for immunization should fit into these broader objectives as laid out in the MDG s, 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 health sector objectives and planning processes. The national immunization programme may have its own specific planning and budgeting objectives, and these can be different from those of the international agencies and initiatives supporting the programme. 4 cmyp Costing & Financing Tool User Guide

18 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 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 timeframe, more assumptions need to be made for future projections, and estimates become unreliable. Minimum five-year projections therefore seem useful, especially when linked to annual operational plans and allocations. What is the difference between costing a cmyp and the FSP? The new guidelines build on existing multi-year planning experience, while adding the critical elements of costing and financing, by drawing heavily upon the methods developed for the immunization FSP. In the same way, the costing and financing exercise builds on FSP costing tools and methodologies. Thus, for countries eligible for support from GAVI and the GAVI Fund, it is likely that an FSP has been developed using the Guidelines for Preparing a National Immunization Programme Financial Sustainability Plan, and related tools developed by the GAVI Financing Task Force. If this is the case, the costing exercise of the cmyp will be greatly facilitated. The cmyp Costing and Financing Tool and User Guide is a variation of the FSP Costing, Financing and Gap Analysis Tool (available on immunization_financing/tools), and it applies the same principles, concepts and methodologies. It is also possible that most of the costing data used in the FSP costing tool is applicable to the cmyp costing tool and can be updated to reflect the appropriate changes. For assistance with transferring the data from the FSP to cmyp costing tool, contact your regional counterpart, or send an to immunizationfinancing@who.int. WHO/IVB/

19 2. Overview of the cmyp costing and financing tool The cmyp Costing and Financing Tool (referred to as the Tool throughout the remainder of this User Guide) is a Microsoft Excel-based template that contains eight worksheets: 0) Print & Read Me 1) Data Entry 2) Calculations 3) Costing 4) Financing 5) Gap & Indicators 6) Graphs 7) Sustainability Of the eight worksheets, only two require data input The 1. Data Entry worksheet is where you need to enter all the data for the costing and resource requirements projections. The worksheet contains a series of data entry tables for the calculation 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 the User Guide are dedicated to explaining how to complete the worksheet and how to find the required data. The data on past and future financing is entered in the 3. Financing worksheets. Some suggestions on procedures to collect financing information is provided in Parts 5.4 and 5.5 of the User Guide and in Annex I. 6 cmyp Costing & Financing Tool User Guide

20 Figure 3: Screen shots of cmyp costing and financing tool 1. Data entry worksheet 3. Costing worksheet 5. Gap and indicators worksheet 6. Graphs The remaining worksheets are automatically generated based on the information entered in the 1. Data Entry and 4. Financing worksheets. The 2. Calculations worksheet consolidates the formulas that convert the information and data provided in the 1. Data Entry worksheet into the costing and estimates for resource requirements. The broad underlying methodology used in the 2. Calculations worksheet is described in Part 4 of the User Guide. The 3. Costing worksheet is linked to the 2. 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 5. Gap & Indicators worksheet is linked to the 4. 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. The 6. Graph worksheet is linked to numerous other worksheets in the 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 this User Guide. WHO/IVB/

21 The 7. Sustainability worksheet is linked to numerous other worksheets in the Tool and contains a number of automatically generated macroeconomic and financial sustainability indicators that can be used for the analyses. More information is available in Part 6.4 of the User Guide. Note that all the worksheets in the Tool are printer friendly. Figure 4: Design of the Tool 1. Data Entry Worksheet Data on Inputs & Activities Costing & Activities Data Collection Calculation Worksheet Gap, Indicators, Graphs and Sustainability Worksheets* Data on Financing Financing Tables 4. Financing Worksheet * Automatically generated worksheets Can the tool be used in a decentralized setting? It is important to note that the 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 parts of the Tool may need to be used at different levels of the system (sub-nationally). This may be of particular relevance in large country settings and where data collection needs to be undertaken at lower levels in the system. Can the Tool be damaged? Owing to its intricate linkages and formulas, the Tool is very sensitive to any formatting changes (adding/deleting cells, rows or columns) or 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, protective measures have been put in place and the worksheets are also password-protected. More detailed information about Tool protection and passwords is provided in Part 5.1 of this User Guide. 8 cmyp Costing & Financing Tool User Guide

22 What is the Tool not designed to do? The main purpose of the Tool is to provide assistance for the costing and financing elements of a cmyp, and to make projections of future resource requirements and financing to achieve the programme objectives. However, the 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 Tool, in its current design, is ill equipped to strengthen such a priority- setting exercise. Likewise, the Tool is not designed to determine allocative efficiency, when 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 Tool does not automatically factor in any scale effect. Ideally, costs would vary as the scale of immunization interventions changed. For instance, in economies of scale, costs would decrease as the scale (such as coverage) increased, as fixed inputs (such as buildings) were used more efficiently. There could however also be dis-economies 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 interventions results in cost savings. While techniques and methodologies are rapidly becoming available for a global level costing exercise where scale-up effects can be included, these have not yet been assimilated in this Tool. In the meantime, any scale effect needs to be done manually. 3) Finally, the 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 intervention programmes and packages of services. Work is ongoing to improve the Tool and to overcome these limitations. Where to send feedback and seek technical support? We welcome questions and comments on the Tool and User Guide. We have tried to identify any inconsistencies in the system, but 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 & Biologicals Expanded Programme on Immunization 20 Avenue Appia CH Geneva 27 Switzerland immunizationfinancing@who.int. WHO/IVB/

23 For questions, comments and technical assistance related to the development of a cmyp, contact your Regional Office. For general information on submitting the cmyp as part of a GAVI funding application, visit the GAVI website at More general information on immunization financing is available at immunization_financing. 10 cmyp Costing & Financing Tool User Guide

24 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 fixed 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. It will need to be composed of the right people, with the right skills, and it will need the right amount of time to complete the exercise. A focused and manageable group is needed of no more than three people. It will also 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 Developing a Comprehensive Multi-Year Plan for Immunization 2 paying particular attention to Step 6 - Analyzing the costs, financing, and financial gaps in the cmyp. Discuss the steps so that the group fully understands the task in 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 Available on or from WHO Department of Immunization Vaccines and Biologicals (IVB) Documents Centre, reference (WHO/IVB/05.20). WHO/IVB/

25 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 Tool and where to obtain the necessary data. The latest versions of the Tool and User Guide are available for download at immunization_financing/tools. Because these materials will be constantly improved and updated, it is important to visit the website regularly 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 coverage objectives, immunization schedule and expansion, and the same timing of specific campaigns as those defined in the cmyp. Also, activities that are specified in the cmyp should be budgeted for in the Tool (e.g. expanding the cold chain, strengthening outreach services, etc.). 4) Review the 1. Data Input worksheet of the 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 data needs. 5) Once all the data on inputs and activities has been collected, these should be entered in the appropriate tables of the 1. Data Entry worksheet. Review this worksheet carefully for any errors in data entry, or any omissions or oversights of data needs for the tables. Remember that the Tool is passwordprotected so data should not be pasted into the 1. Data Entry worksheet from another Excel worksheet. This could damage formulas, provide wrong results, or render the Tool useless. 6) Review the results of the costing in the 3. 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 Tool, or omissions of required data inputs. These should be reviewed. It can also 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 1. Data Entry worksheet. 7) Double-check the work as often as you think necessary. Remember to save the work frequently this updates the file and helps to ensure that you do not lose significant amounts of data once it is entered in the Tool. 8) After completion of the data and entry in the 1. 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 5. Gaps & Indicators and 6. Graphs worksheets of the 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. 12 cmyp Costing & Financing Tool User Guide

26 9) 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 4. Financing worksheets. For future financing, it is important to classify the funding according to its level of risk - secure versus probable. Suggestions on how to collect financing data are developed in Parts 5.4 and 5.5 of the User Guide. 10) Once the financing data is entered in the Tool, the work should be double-checked for any mistakes or results that merit double-checking. To identify errors, it can be helpful to review the 5. Gap & Indicators and 6. Graphs worksheets. Once the team is happy with the results and these have been double-checked for errors, the Tool can be saved as the baseline scenario. 11) A second analysis of the results should be made by comparing the estimated resource requirements and available funding the difference being the funding gaps needed to meet desired programme objectives. Again, it can be helpful to review the 5. Gap & Indicators and 6. Graphs worksheets in the analysis. 12) 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. WHO/IVB/

27 4. Important concepts, methodologies and terms This section of the User Guide provides important background information about basic costing concepts, methodologies and terms. Before starting the cmyp costing and financing exercise, it is essential to become familiar with these. 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. Figure 5: Broad elements to cost in a cmyp cmyp Objectives Strategies Inputs (e.g. vaccines) Activities (e.g. training) The table below illustrates the types of inputs and activities that are usual in an immunization programme. These are linked to the five system-components defined in the WHO-UNICEF Guidelines for Developing a Comprehensive Multi-Year Plan for Immunization. 14 cmyp Costing & Financing Tool User Guide

28 Table 1: System components to cost in a cmyp System Components Inputs Activities 1. Service delivery Human resources/salaries, outreach Training, workshops, etc. per diems, fuel for transport, operational cost of campaigns, etc. 2. Advocacy and communication Information, education and Social mobilization, IEC, developing communication (IEC) materials, advocacy and communication plan such as posters, etc. 3. Surveillance Surveillance and laboratory equipment Surveillance activities (sentinel sites, outbreak investigation, etc.) 4. Vaccine supply, quality and Vaccines, auto-disable (AD) syringes, Monitoring, vaccine stock logistics safety boxes, other injection supplies, management activities cold-chain equipment, vehicles, spare parts, incinerators, etc. 5. Programme management Computers, office supplies, etc. Meetings, planning, research, data management, expanded programme on immunization (EPI) reviews, cold-chain assessment, etc. The 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 each immunization programme. This is described in more detail in Parts 5.1 to 5.5 of this User Guide. At minimum, it is important to estimate the costs, financing and future resource requirements of each cmyp for all immunization-specific inputs and activities. All inputs and activities that are shared with the immunization programme, such as personnel, transportation and buildings, are optional. What is the difference between an immunization-specific input and a shared input? Immunization-specific costs include the value of inputs and activities that are used 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 outreach and supplemental immunization activities); 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.). A complete listing and definition of the immunizationspecific inputs are 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 immunization 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. Likewise, 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 paid for by the NIP. This makes it difficult to separate out the portion of these inputs that can be attributed to immunization. These are classified as shared costs. The use of buildings such as health centres are other typical shared inputs. WHO/IVB/

29 Given the relative difficulty in collecting information on shared costs in a programme and the fact 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. The added investment in time will result in a more accurate costing exercise. By excluding the shared inputs, 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/resource requirements of the programme if other inputs (such as vehicles) are frequently shared with other programmes. The Tool has been set up to allow for the calculation of shared inputs, if so desired. The process whereby the shared portion of a shared cost is separated out, is known as cost allocation, and the main method used is to allocate shared inputs to a programme based on the percentage time spent on immunization. Finally, estimations of costs, financing and future resource requirements should be made 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 3 and 5 future years. This is considered the standard period for making future projections of costs and resource requirements in a comprehensive multi-year plan (cmyp), especially if this is linked to annual operational plans. Optional forecast (beyond 5 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 timeframe, more assumptions have to be made regarding the possible unreliability of future trends and estimates. 4.2 What is the difference between a cost and a resource requirement? So far, the terms 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 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 referring to cost or resource requirements, although some differences in the calculation for vaccines will be mentioned in Part cmyp Costing & Financing Tool User Guide

30 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 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 is depreciated (or amortized) 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. To simplify the calculation, the methodology used in the Tool recommends using standard ULY for equipment (five years for vehicles, cold chain and other such items, and 25 years for buildings). Even if the equipment is older than five years and is still being used by the programme, the 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 indicators 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 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 the 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. WHO/IVB/

31 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 needed 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 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. As vaccines, injection supplies, personnel, transport, vehicles, and cold-chain equipment account for the bulk of the cost/resource requirement 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 under-estimations of the total cost/resource requirement. Figure 6: Typical cost profile of an immunization programme 14% 5% 29% 19% Vaccines Injection Supplies Personnel Transport Other recurrent costs Vehicles Cold Chain 10% 7% 16% 18 cmyp Costing & Financing Tool User Guide

32 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 (RCx, Yi) (RCx, Yi) Ω) x percentage use for immunization (RCx, Yi) Capital (CCx, Yi) = future quantities needed x (US$ price x Ω) (CCx, Yi) (CCx, Yi) x 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 (RCx, Yi) (RCx, Yi) Ω) x percentage use for immunization (RCx, Yi) Capital (CCx, Yi) = [ (existing + future quantities needed ) x (CCx, Yi) (US$ price x Ω)] / ULY x percentage use for immunization (CCx, Yi) (CCx, Yi) Where: (CCx, Yi) Total cost projections = sum of all recurrent cost projections + sum of all capital cost projections RCx = for recurrent cost category x CCx = for capital cost category x Yi = for year i Ω = for inflation WHO/IVB/

33 Which inflation and exchange rate should be used? Inflation refers to the phenomenon of prices rising over time. In this way costs/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/resource requirement estimates are reported in US dollars (although the 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 US dollar between 1993 and 2003, and represents the best estimate of future price inflation. The US dollar exchange rate selected for use in the Tool needs to be based on the published figures utilized in each country. These should be reported in the Background Information section of the 1. Data Entry worksheet. The Tool assumes a constant exchange rate over the projection period. Sources of the US 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 Tool estimates costs and future resource requirements of certain categories of input based on some agreed rules-of-thumb applied automatically in the Tool. This applies to injection supplies, cold chain and vehicle maintenance as follows. For injection supplies an approach that accurately reflects the use of resources is based on immunization practices for each antigen, linking this to the number of doses of vaccines. For example, one dose of measles 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 Tool recommends using 5% but this amount can be changed to suit a particular country setting. For vehicle maintenance the rule-of-thumb is to estimate the likely need 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 Tool recommends using 15% but this amount can be changed for a particular country setting. For other categories of inputs and activities such as training, social mobilization, IEC, surveillance, etc., the ingredients, or rules-of-thumb approaches, are not used. Because 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 20 cmyp Costing & Financing Tool User Guide

34 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 Tool. Table 2: Summary table of methods used in the Tool Method Name Methodology Inputs Activities Ingredients approach Quantities x price x Vaccines, personnel, Vaccines, personnel, percentage use for transport, vehicles, transport, vehicles, immunization cold-chain equipment cold-chain equipment Rule-of-thumb Immunization practice, Injection supplies, Injection supplies, fix percentage of the value of cold-chain maintenance, cold-chain maintenance, cold-chain equipment, vehicles maintenance vehicles maintenance fix percentage of fuel costs Past spending or budgeting Lump-sum spending or Training, social mobilization, Training, social mobilization, approach based on past expenditure IEC, surveillance and others IEC, surveillance and and budgets 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 resource requirements. For vaccines The method used to estimate the past cost of vaccines is based on the amount of vaccines supplied during a given year and the corresponding amount of vaccines that were administered. The quantity supplied per type of vaccine (Q supplied ) is calculated according to the following formula: Q Z Used = (Q Z Received + Q Z Initial Stock ) - (Q Z Remaining in Stock ) where z = DPT, measles, OPV, etc. An example Vaccines Stock at Quantities End of year stock Quantities used beginning of supplied during the year the year Doses Doses Doses Doses Measles 5, ,000 10,000 95,000 DTP 2,000 85,000 12,000 75,000 BCG 10, ,000 20, ,000 OPV 15, , , ,000 The cost of vaccines is calculated by multiplying the quantities supplied (Q supplied ) by the unit price for a given vaccine (P). WHO/IVB/

35 For example, the cost of DTP vaccine supplied in 10-dose vials would be: Cost DTP (10) = Q DTP (10) Supplied x P DTP (10) 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 supplied Z - doses administered Z ) / doses supplied Z x 100 where z = DTP, measles, OPV, etc. On the other hand, the method used to forecast 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), they 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 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 2000 for US$ 20,000 which will last five years before needing to be replaced, will have an annual financial cost of US$ 4,000 (US$ 20,000/5 ULY). The rational for this adjustment is that, without depreciating the value of inputs that last for more than one 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 for each year of 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, these 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. 22 cmyp Costing & Financing Tool User Guide

36 5. Using the cmyp costing and financing tool This section of the User Guide provides step-by-step instruction on how to use the cmyp Costing and Financing Tool, guidance on sources of information and how to analyse results and interpret findings. At first glance, the Tool can appear overwhelming, as it contains many interrelated worksheets. Fortunately, it is only necessary to work in two of these 3. The 1. Data Entry worksheet is where all the data necessary for the costing and resource 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 1. Data Entry worksheet in greater detail. The 4. Financing worksheet is where information on past and future financing is entered. Some suggestions on procedures to collect financing information is provided in Parts 4.3 to 4.5 of this User Guide and in Annex I. Parts will review the 4. Financing worksheet in more detail. 5.1 Overview of the 1. Data Entry worksheet Data Tables The 1. Data Entry worksheet is divided into eight sections that regroup the key inputs and activities that were described earlier. Each section contains a series of data tables required for the costing exercise. The titles of the eight sections and 24 data tables are summarized below. 3 If Microsoft Excel 2003 (or later) is used, these worksheet tabs are colour-coded in light purple. WHO/IVB/

37 Table 3: Sections and data tables of the 1. Data Entry worksheet of the Tool 0. Reference information 1. Vaccines & injection supplies 1.1 Demographic and other vaccine forecast information 1.2 Immunization schedule, vaccine prices and other vaccine reference information 1.3 Average price of injection equipment and cost of other injection supplies 1.4 Coverage and wastage objectives 1.5 Past and future DTP3 coverage 1.6 Specific target population for campaigns 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 & 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 & 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. Building & buildings overheads 8.1 Average prices and overheads costs of buildings 8.2 Existing and future needs of buildings 24 cmyp Costing & Financing Tool User Guide

38 Cell colour-coding and worksheet protection The 1. Data Entry worksheet has specific colour-coding for cells. The numerical data entries are white and easily recognizable, but other cells are colour-coded. The Print & Read Me worksheet in the Tool provides a legend explaining the colour-coded cells. Surrounding the 22 data tables of the 1. Data Entry worksheet are a number of yellow text boxes. These provide guidance on the tables and how to fill them out. In addition, there are click-on cell notes that look like this: (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. These should be read carefully. Tool protection The Tool is very sensitive to any formatting changes (adding/deleting cells, rows or columns) or editing (cut, copy or pasting of information from different sources). In order to protect it from any damages that could be caused by formatting or editing changes, certain protective measures have been put in place. For instance, the cells and worksheets in the Tool are locked and password-protected to avoid the deletion of rows or columns, since this would affect the integrity of the 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 the wrong cell, or a locked spreadsheet is deleted or modified, the following messages will appear. However, you can always insert new worksheets in the Tool in order to make separate calculations, create other graphs, or analyse the data. WHO/IVB/

39 How to unprotect the Tool? If it becomes necessary to unprotect the Tool and its worksheets, use the following password: MYPCT If you are unable to enter information into the Tool, it is possible that your computer has a firewall or an activated virus protection system that prevents you from using the Tool on your computer. If this is the case, and to by-pass the anti-virus software protection, you will need to unprotect the Tool using the password provided above, save it under a new file name, and then re-protect the Tool. Cutting & pasting data The Tool is very sensitive to the cut, copy and paste function of Excel. Copying and pasting data from other Excel workbooks into the Tool could break critical links, calculations and formulas, and create errors that could damage the Tool. The copy and paste function therefore carries a high risk of damaging the 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 Tool, use the paste special values option instead of the standard paste. This option is available from the Edit menu of Excel, and the following pop-up will be displayed. 26 cmyp Costing & Financing Tool User Guide

40 Currency and inflation Because prices and costs can be expressed in different currencies and can rise over time, the Tool has been 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 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 Tool will then make the exchange rate conversion to show the results in US dollars. The 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 % Totals or average quantities The information for Sections 2, 3, 4 and 8 of the 1. Data Entry worksheet is required by each country at administrative level (e.g. central, provincial, district and health centre levels). Depending upon data availability, you can either choose to work in averages, or total quantities of personnel, vehicles, or cold-chain units of equipment by administrative level. The Tool offers the work option either using total quantities of an input (e.g. the total number of motorcycles), 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 administration level? N Further suggestions on working with total or average quantities will be explained in greater detail in Part 5.2 below. WHO/IVB/

41 5.2 Review of each data table contained in the 1. Data Entry worksheet The 1. 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 for data sources. Section 0 - Reference information The reference information section is where essential country-specific details need to be entered. This is a crucial section of the 1. Data Entry worksheet. Formulas in the 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 as comprehensively as possible. The table below lists the data needs for the general information section of the Tool. Information needs Country Scenario 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 Remarks Enter the full country name. To experiment with various scenarios, label the starting point scenario (e.g. Baseline, HepB introduction, etc.). More about scenario building is developed in Parts Enter the first year of the cost/resource requirement projection. For example, if you are developing a cmyp for the period , the first year of projection will be 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 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 2005 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 (as a percentage of government health expenditure (GHE)). Enter the name and contacts of the main officer responsible for the Tool. 28 cmyp Costing & Financing Tool User Guide

42 It is important to mention that the 7. Sustainability worksheet of the Tool requires that data on the macroeconomic indicators be entered in this section of the 1. Data Entry worksheet. It is also 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 (NHA) World Bank data Section 1 - vaccines & injection supplies Vaccines and injection supplies are potentially the most important inputs to calculate for the cmyp costing exercise. Firstly, 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). Given the importance of vaccines and injection supplies, this section of the 1. Data Entry worksheet contains six required data tables. 1. Vaccines & injection supplies 1.1 Demographic and other vaccine forecast information 1.2 Immunization schedule, vaccine prices and other vaccine reference information 1.3 Average price of injection equipment and cost of other injection supplies 1.4 Coverage and wastage objectives 1.5 Past and future DTP3 coverage 1.6 Specific target population for campaigns The information in these tables is needed to calculate the past costs and future resource requirements of vaccines and injection supplies for both routine immunization services and campaigns supplemental immunization activities (SIAs). WHO/IVB/

43 The six data tables require the following information: 1.1 Demographic and other vaccine forecast information In table 1.1 enter the demographic data essential for making future projections of the target population. 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 (IMRs) as a share of births; information on pregnant women (PW) as a factor of births. The default value would be set at one, so in other words, for every pregnant women there would be at least one birth; information on childbearing age women (CBAW). 30 cmyp Costing & Financing Tool User Guide

44 Year of last population census (or year of best estimate) Total population (census year) (or best estimate) Population growth (%) Births (% total population) Infant Mortality Rate (per 1,000 live births) Pregnant women (as a factor of births) Childbearing age women (CBAW) (% of total population) WHO/IVB/

45 Note that there are two possible options for arriving at a figure for the target population either using the under one population (U1P) or surviving infants (U1P minus the under one mortality). 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 1.1 will allow the Tool to make forecasts for the target population that will be used to calculate future needs for most vaccines. Finally, a special case arises for projecting the needs of Tetanus Toxoid vaccine (TT) where the target population can either be pregnant women (PW) 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 PW, or preferably CBAW. The Tool allows for calculation of TT vaccine requirements for either target populations, depending on the country situation. Although there is some potential for double-counting, the TT coverage of PW is traditionally low, and is not considered to represent a significant cost factor. 1.2 Immunization schedules, vaccine prices and other vaccine reference information In table 1.2 you need to verify and enter information on the vaccine schedule. There is a standard list of vaccines already available and spaces for entering other vaccines not in the standard list. If you use a vaccine which is not listed such as diphtheria tetanus (DT), mumps, measles, rubella (MMR), or happen to procure the same vaccine in different vial sizes (e.g. routine oral poliovirus vaccine (OPV) in both 10- and 20-dose vials), these can be entered separately in the relevant cells coloured yellow. Note that table 1.2 is separated into two parts, separating routine immunization activities from those for SIAs (campaigns). For routine immunization, vaccines are separated into those that can be considered as basic vaccines from those that are new and underused by the national immunization programme. For campaigns, there is a standard list and also space to enter other types of campaigns that will require vaccines. 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 finally its unit price per dose (including freight and other charges). Finally, for the past costing of vaccines, table 1.2 requests information be input on the quantity of vaccines used and the number of doses administered. 32 cmyp Costing & Financing Tool User Guide

46 Types of vaccine Doses per Vial size Buffer stock Mixing Vitamin A Doses Doses Average Price per Price per schedule syringes supplied supplied Admin Wastage dose dose Routine Immunization No. No. Y / N Y / N Y / N No. doses No. doses (%) US$ US$ Traditional vaccines BCG DTP Tetanus (TT) Measles OPV Measles 2nd Dose Other vaccine (specify) Other vaccine (specify) Other vaccine (specify) Underused and new vaccines Yellow fever DTP-Hep B-Hib DTP-Hep B DTP-Hib Hep B Hib MMR JE Other vaccine (specify) Other vaccine (specify) Campaigns No. No. Y / N Y / N Y / N No. doses No. doses (%) US$ US$ Polio Measles Yellow fever MNT campaigns (CBAW) Other campaigns Other campaigns Other campaigns Other campaigns WHO/IVB/

47 In order to derive the quantities supplied for each type of vaccine (Q supplied), the following formula should be applied: Q supplied = (Q received + 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 1.1. 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 supplied - doses administered) / doses supplied x 100 Please review Part 4.5 of this User Guide for more information on the method for past costing of vaccines. Finally, it is important for the costing exercise to have unit prices for vaccines. Standard UNICEF reference prices have been built into table 1.2. 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 Vaccine prices and campaign naming Because the future price evolution of vaccines is uncertain, the methodology used in the Tool recommends making projections 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 Tool, however, also offers the possibility to enter alternative vaccine prices for future years. For information on vaccine prices, please consult the UNICEF Supplies Division website at supply. 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 adjusted accordingly. For instance, suppose that in a particular year there are various rounds of polio campaign targeting different population groups. In this instance it could be easier to treat them as separate campaigns altogether and name them differently in table 1.2 (e.g polio campaign round 1, or 2004 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 in table 1.2. Finally, any contingency for outbreaks of vaccine preventable diseases should be listed as a campaign, and labelled accordingly. 34 cmyp Costing & Financing Tool User Guide

48 1.3 Average prices of injection equipment and cost of other injection supplies In table 1.3 enter the average unit price of injections equipment for 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 and these 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. WHO/IVB/

49 Injection equipment Unit price Freight (%) Taxes Total unit (import, VAT( cost Routine immunization and campaigns US$ (%) (%) US$ AD syringe AD syringe for BCG Reconstitution syringe (BCG/Hib) Reconstitution syringe (Measles/Yellow fever) Safety boxes (5 litres) Vitamin A (per gel caps) Wastage on injection equipment No. syringes per safety box Other supplies 2005 Routine immunization US$ (Enter total expanditures) Cotton Vaccination cards Other (specify) Other (specify) Other (specify) 36 cmyp Costing & Financing Tool User Guide

50 Below table 1.3 there is the choice 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 (cotton for example). 1.4 Coverage and wastage objectives In table 1.4 enter projected coverage and wastage targets for each vaccine in the schedule that was specified in table 1.2. Note that coverage targets for routine immunization and for supplemental immunization activities should be entered separately. WHO/IVB/

51 Coverage objectives Wastage objectives Type of vaccine Routine immunization % % % % % % % % % Traditional vaccines BCG DTP(1) TT - Pregnant women TT - Child bearing age women Measles OPV (1) Measles 2nd dose Other vaccine (specify) Other vaccine (specify) Other vaccine (specify) Underused and new vaccines Yellow fever DTP-Hep B-Hib (1) DTP-Hep B (1) DTB-Hib (1) Hep B (1) Hib (1) MMR JE Other vaccine (specify) Other vaccine (specify) Campaigns % % % % % % % % % Polio Measles Yellow fever MNT campaigns (CBAW) Other campaigns Other campaigns Other campaigns Other campaigns 38 cmyp Costing & Financing Tool User Guide

52 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, while others will be covered by 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 and which is gradually phasing out DTP vaccine in favour of DTP-HepB vaccine. Example: 1.4 Coverage and wastage objectives Coverage objectives Type of vaccine Routine immunization % % % % % Traditional vaccines BCG DTP(1) Measles OPV (1) Underused and new vaccines Yellow fever DTP-Hep B-Hib (1) DTP-Hep B (1) 1.5 Past and future DTP3 coverage Future DTP3 coverage objectives % % % % % DTP3 coverage WHO/IVB/

53 1.5 Past and future DTP3 coverage In table 1.5 enter past and future DTP3 coverage rates. This information is not used for vaccine forecasting, but is needed to calculate various indicators in the 5. Gap Indicators worksheet of the Tool. 1.6 Specific target populations for the campaigns Since the target populations for campaigns can be different from the target populations for routine immunization, and these can vary depending on the type and timing of campaigns being conducted, this information needs to be entered separately in table 1.6. 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 input, in particular to the assessment of salaries and staff time actually spent on immunization activities. Small errors in estimation can translate into a large overestimation or underestimation of the costing exercise. Estimating personnel costs is complicated by the fact that some personnel time is: specific to the delivery of immunization services. This relates to staff time directly associated with the immunization service, spending 100% of their time working for the NIP (for example, all central-level staff working for the immunization department of the MoH); shared with other health services. This relates to staff time that is only partly assigned to immunization activities (for example a nurse at the health facility level spending 10% of her time providing vaccinations and the rest of her time working on other preventive/curative services). Personnel will be the main input where a large proportion of the costs are likely to be shared with other programmes. It is therefore important to get an accurate measure of the proportion of their time that staff actually work on immunization, as 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 buildings costs 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 buildings costs, and this 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, and so reporting shared personnel costs is invaluable. Specific techniques for this are provided below, and the Tool facilitates these calculations. Given the importance of personnel, this section of the 1. Data Entry worksheet contains three required data tables. 40 cmyp Costing & Financing Tool User Guide

54 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 personnel resource requirements. The three data tables require the following information: 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). Note that the personnel in categories already listed in the table are there as examples only, and should be replaced by the ones relevant to your country context. Then 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. WHO/IVB/

55 Routine immunization Outreach activities Supervision Type of staff Gross Other % Time Average No. Average No. monthly monthly working on days per per diems days per per diems wage benefits immunization month 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 Labortary personnel Logistician Monitoring/Surveillance/Evaluation officer Nurse Secretary Drivers Security guard Other (specify) Provincial US$ US$ (%) No. days US$/day No. days US$/day Health officer Medical officer Technicians Cold chain technician Logisticians Monitorin/Surveillance/Evaluation officer Secretaries Drivers Other (specify 42 cmyp Costing & Financing Tool User Guide

56 Then, for each category of staff, indicate whether they work full-time (100%) or part-time (less than 100%) for the national immunization programme. 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 daily 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 daily per diem rates. WHO/IVB/

57 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, 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/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 time spent on immunization should be used. For outreach the average number of workdays per month is the most reliable indicator of time spent on this activity. For calculating immunization personnel using an average number of staff at each administrative level. (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. If you decide to work with averages, 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 request information on: total number and category 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 a month spent on outreach and outreach per diems; number of days a month spent on supervision and the per diem rates. 44 cmyp Costing & Financing Tool User Guide

58 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 for 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 buildings inputs for immunization, staff time devoted to the programme can be used as a way of allocating the value of shared vehicles and buildings inputs. This will give a good approximation and will also save time. 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). Also, only enter the number of staff in the year they are expected to begin working. Note that for future projections of staff needs, it is only necessary to enter the quantities for the year in which the staff will start working. The Tool will automatically include these for the remainder of the period (because it is a recurrent cost) and will calculate the total cumulative number of staff for the projection period. If any staff are expected to be laid off, these 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 are reported in the background information section of the 1. 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). WHO/IVB/

59 Section 3 - vehicles & 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 a 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, vehicle costs and transportation are covered together in the 1. 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). 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 Tool will use methods to approximate them by applying a percentage increment on the known value of fuel. The Tool recommends applying 15% but you have the option to change this percentage factor to any other value you consider more appropriate. At the start of this section of the 1. Data Entry worksheet, you can enter and verify essential parameters for the calculations (such as fuel prices, rules-of-thumb for maintenance, ULY, etc.). 46 cmyp Costing & Financing Tool User Guide

60 Entering information in local currency? N (Enter N for $ Prices) Enter the annual % 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$) Enter the annual % increase in price of petrol 2 % (Recommended value is 2%. Note that this is a US$ inflation rate) Vehicle maintenance as a % 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) WHO/IVB/

61 Given the importance of vehicles and transportation, Section 3 of the 1. Data Entry worksheet contains three required data tables. 3. Vehicles & 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 The information in these tables is necessary to calculate the past costs and future resource requirements of vehicles and transportation. The three data tables are as follows: 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 all, or part, of the 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 you can replace the existing categories with the relevant ones for your country setting. There is also room to include more categories of vehicles, and this should 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, and in the other tables (table 3.2). 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, and the average fuel consumption per 100 km for each of the vehicles listed. 48 cmyp Costing & Financing Tool User Guide

62 Per vehicle type Type of vehicles Average price Distance Fuel % Time used new (2005) (Average km s consumption for per year) (litres per 100km) imuunization National US$ Km s l/100km s (%) 4 WD vehicles Trucks Cars Boats (motor) Bicycle Motorcycles Vehicles for sureveillance Regional US$ Km s l/100km s (%) 4 WD vehicles Trucks Cars Boats (motor) Bicycle Motorcycles Vehicles for sureveillance WHO/IVB/

63 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 may be difficult to estimate, but expert opinion or responses from a small sample survey of facilities may provide the necessary data. Alternatively, you could use the information included in table 2.2 by applying the average percentage time spent on immunization by staff at different levels. Alternatively, if Drivers are 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. 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 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 the cmyp and existing cold-chain reviews. 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 projections of future budget needs. It is important to ensure that transportation needs are not repeated in table 3.3. In other words, only include transportation needs that are not already captured in the transportation costs of tables 3.1 and cmyp Costing & Financing Tool User Guide

64 Expenditure Future budget needs Other transport costs US$ US$ US$ US$ US$ US$ Vaccine delivery Transport per diems for outreach Other (specify) Other (specify) Other (specify) WHO/IVB/

65 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 fleet of vehicles used by the immunization programme by vehicle category: numbers of cars; four-wheel drive vehicles; 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-Cruiser 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 so have the most knowledge of this information. 4) Get information on how many vehicles would be needed in the future. If calculating vehicles by using the average number of vehicles by administrative level. (Unless this information is readily available at the central or national level, it might be easier to work with average number of vehicles by administrative level. If you decide to work with averages, 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 request 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. 52 cmyp Costing & Financing Tool User Guide

66 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 importance 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 1. 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 Tool it is assumed that the cold-chain equipment is immunization specific. In other words, their 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. At the start of this section of the 1. 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 1. Data Entry worksheet contains three required data tables. 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 The information in these tables is needed to calculate the past costs and future resource requirements for cold-chain equipment, their maintenance (spare parts), and overhead costs (fuel, electricity, etc.). The three data tables are as follows. 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 you wish. Secondly, you need to enter average unit prices (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 by applying a set percentage of the capital cost of the equipment. The Tool recommends using 5% but you have the option to change this percentage factor to any other value you consider more appropriate for your country setting. WHO/IVB/

67 Per unit of equipment Type of cold chain Average price Average monthly Average yearly New (2005) overhead costs 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) 54 cmyp Costing & Financing Tool User Guide

68 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 level. 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 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 these 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 the cmyp and existing cold-chain reviews. 4.3 Other cold-chain needs not covered elsewhere If this is relevant to your NIP, enter in table 4.3 any of the lump sum costs of other cold chain needs not specified elsewhere. For example, you may need to include a budget for ice for outreach activities, or extra 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 cold-chain needs that are not already captured in the transportation costs of tables 4.1 and 4.2. WHO/IVB/

69 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) 56 cmyp Costing & Financing Tool User Guide

70 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 the data are provided. If calculating cold-chain equipment using total list of equipment in the country, take the following steps. 1) Assemble an itemized list of all cold-chain equipment in the country 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 (e.g. 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 the average ULY of the equipment. 4) Collect information on the future upgrading of the cold chain. If calculating cold-chain equipment using the average number of cold-chain units by administrative level. (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 you decide to work with averages, 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 numbers of children being immunized). 3) Interview these representative health facilities by administrative level, either by fax, telephone, or direct visit, and request 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 annual maintenance cost per type of cold-chain equipment, and the average ULY; information on future upgrading of the cold chain. WHO/IVB/

71 Section 5 - Operational costs of campaigns Increasingly, campaigns and supplemental immunization activities (SIAs) are becoming an integral part of country national immunization programmes, and an important strategy for eradicating and controlling diseases, and for raising coverage. While the needs for vaccines and injection supplies for campaigns are taken into account in Section 1 of the 1. 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 campaign. 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 for routine immunization. Section 5 of the 1. Data Entry worksheet contains two required data tables. 5. Operational cost of campaigns 5.1 Operational cost of campaigns 5.2 Average operational cost per child (used for future campaign operational costs) 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 below. Note that it is necessary to specify and name a type of campaign in table Operational costs 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 (that is, 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. 58 cmyp Costing & Financing Tool User Guide

72 Operational cost/child Type of campaigns US$ US$ US$ Polio Vaccines Per diems other operational costs Measles Vaccines Injection supplies Per diems Other operational costs Yellow fever Vaccines Injection supplies Per diems Other operational costs 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. 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 future resource requirements for 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 hover between US$ 0.5 and US$ 0.7 per child. If you do not have any existing data, we recommend you use these amounts. WHO/IVB/

73 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 under-funded. 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 uch as social mobilization, advocacy and communication activities, training, programme management, and monitoring and disease surveillance. Section 6 of the 1. Data Entry worksheet contains two required data tables. 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 The information in these tables is needed to calculate the past costs and future resource requirements for programme activities, other recurrent costs and surveillance. The two data tables are below. 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 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. 60 cmyp Costing & Financing Tool User Guide

74 Expenditure Future budget needs Programme Activities and Other Recurrent Costs US$ US$ US$ US$ US$ US$ Social Mobilization, Advocacy, and Communication Activities Budget for social mobilization Mass media Printed materials (banners, posters, IEC materials ) Other (specify) Training and Workshops Training activities Other (specify) Programme Management Meetings Evaluations: Programme reviews and assessments Office supplies Rental of buildings Other (specify) Other activities Financial sustainability activities Other (specify) WHO/IVB/

75 6.2 Total spending and future budget needs for surveillance and monitoring Table 6.2 covers expenditure and future budget needs for surveillance and monitoring for detection and notification, case and outbreak investigation, data management, and 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. 62 cmyp Costing & Financing Tool User Guide

76 Expenditure Future budget needs Surveillance and monitoring US$ US$ US$ US$ US$ US$ Detection and Notification Standards Identification and preparation of sites Clinician advocacy Notification and communication Active surveillance Case and outbreak verification and investigation Standard operating procedures Dispatch of specimens to the lab Data Management Standards of flow, frequency and format of data exchange Supplies for data management Feedback bulletin Laboratory Specimen kits and carriers Communications Data management Supportive Activities Evaluation and planning Resource management WHO/IVB/

77 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 1. Data Entry worksheet is included for reporting other immunization-specific capital inputs relevant to each immunization programme. Section 7 of the 1. 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 2 data tables are below. 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 you will be reporting on (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). 64 cmyp Costing & Financing Tool User Guide

78 Per unit of equipment Other equipment Average price Average monthly Average yearly New (2004) running costs maintenance cost US$ US$ US$ Waste management Incinerators Other (specify) Surveillance/Lab Equipment Specimen kits and carriers Lab equipment Other (specify) Office Equipment Desktop computers Photocopy machine Printer Other (specify) Other Other (specify) Other (specify) WHO/IVB/

79 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 projections of needs by type of equipment. When making the future projections, be sure to include the replacement of those currently used for the programme. Your estimates should be based on the need to reach programme objectives and targets as outlined in the cmyp. Remember that because equipment, once purchased, lasts for more than a year, their value needs to be depreciated to an annual equivalent using the ULY numbers of the vehicles. The method retained in the 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. 66 cmyp Costing & Financing Tool User Guide

80 Existing Old No. New in Total Additional equipment needed in the future Other equipment < No. No. No. No. No. No. No. No. Waste management Incinerators Other (specify) Surveillance/Lab Equipment Specimen kits and carriers Lab equipment Other (specify) Office Equipment Desktop computers Photocopy machine Printer Other (specify) Other Other (specify) Other (specify) WHO/IVB/

81 Section 8 - Buildings and buildings 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 buildings 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, and the information calculated in table 2.2 can be used to do this. The buildings and buildings overheads section of the 1. Data Entry worksheet contains two data tables. These tables are optional but we strongly recommended you use them if the data is available. The tables are needed to calculate past cost and future resources requirements for the portion of building space and buildings overheads (electricity, etc.) used by the NIP. 8. Building & buildings overheads 8.1 Average prices and overheads costs of buildings 8.2 Existing and future needs 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 are below. 8.1 Average prices and overhead costs 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 which 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 building (e.g. electricity, etc.), and the percentage space used for immunization. 68 cmyp Costing & Financing Tool User Guide

82 Per building type Building type Average price Average monthly % Space New (2004) overhead costs 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) WHO/IVB/

83 8.2 Existing and future needs of buildings In table 8.2 enter the total number of existing buildings 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 future projections, the estimates should be based on the needs to reach programme objectives and targets, and as outlined in the cmyp. 70 cmyp Costing & Financing Tool User Guide

84 Existing Old No. New in Total Additional buildings needed in the future Building type < 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 No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. No. Other (specify) WHO/IVB/

85 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 1. Data Entry worksheet of the Tool, you can review the results of the costing exercise in the 3. Costing worksheet. This worksheet contains three tables of results which are automatically generated. The first is a summary table that aggregates the cost and future resource requirement according to the five components of a cmyp. The second table provides the complete detail of the costing by disaggregated budget lines according to the five components and sub-components of a cmyp. Table 4: 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 72 cmyp Costing & Financing Tool User Guide

86 Figure 7: Illustration of the detailed costing table The detailed costing results, and the quantities, are provided for each year in this table. For instance, the vaccine cost for a particular year will be provided along with the number of doses needed. The third and final table is the standard costing table that breaks down the cost by category (recurrent and capital), and by strategy (total NIP, routine and campaign). WHO/IVB/

87 Figure 8: Illustration of the FSP style costing table Expenditure Future budget needs Cost category Total Routine Recurrent Cost US$ US$ US$ US$ US$ US$ US$ Vaccines (routine vaccines only) Traditional Vaccines New and underused vaccines Injection supplies Personnel Salaries of full-time NIP health workers (immunization specific) Per diems for outreach vaccinators/mobile teams Per diems for supervision and monitoring Transportation Fixed site and vaccine delivery Outreach activities Maintenance and overheads Cold chain maintenance and overheads Maintenance of other capital equipment Buildings overheads (electricity, water ) Short-term training IEC/social mobilization Disease Surveillance Programme Management Other routine recurrent costs Subtotal Recurrent Costs Routine Capital Cost Vehicles Cold chain equipment Other capital equipment Subtotal Capital Costs cmyp Costing & Financing Tool User Guide

88 Figure 8: Illustration of the FSP style costing table (cont d...) Expenditure Future budget needs Cost category Total Campaigns US$ US$ US$ US$ US$ US$ US$ Polio Vaccines Other operational costs Measles Vaccines and supplies Other operational costs Yellow Fever Vaccines and supplies Other operational costs MNT campaigns Vaccines and supplies Other operational costs Other campaigns (Year 1 - Round 1) Vaccines and supplies Other operational costs Other campaigns (Year 1 - Round 2) Vaccines and supplies Other operational costs Outbreaks Vaccines and supplies Other operational costs Other campaigns Vaccines and supplies Other operational costs Subtotal Campaign Costs WHO/IVB/

89 Figure 8: Illustration of the FSP style costing table (cont d...) Expenditure Future budget needs Cost category Total Other Costs US$ US$ US$ US$ US$ US$ US$ Shared Personnel Costs Shared Transportation Costs Construction of New Buildings Subtotal Optional GRAND TOTAL Routine (Fixed Delivery) Routine (Outreach Activities) Campaigns cmyp Costing & Financing Tool User Guide

90 Before moving on to financing, review the results of the costing in the 3. Costing worksheet. Closer examination of the tables may yield strange results. This could either be due to errors in the data, or data entry into the tool, or omissions of required data inputs. These should be reviewed. It can happen that costing results do not appear in the costing table, and if this is the case, it means that an important piece of information has not been entered in the 1. 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 financing needs to be mobilized in the future in order to meet cmyp objectives and targets. The 4. 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, understanding of who comprise the main donors to the programme, and also the level of government contribution in relation to the complete funding for immunization. Information on past financing for the NIP will need to be entered in the first table of the 4. Financing worksheet. Future Financing Financing projection allows for the quantification and classification of potential future funding. Combined with information on future resource requirements, the 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 4. Financing worksheet. Accuracy and reliability of future projections We recognize that it is difficult to predict future financing accurately. The accuracy of 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 secured funding and probable funding. The exercise of classifying future financing into these two categories is known as the risk assessment. WHO/IVB/

91 Secure funding refers to projected future financing available in the short term, that is considered 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 (such as highly indebted poor country (HIPC) 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 trends and amounts used as a guide to the future. 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 4. Financing worksheet, discuss the risks associated with each source of financing with the ICC members, and come to a consensus on those funds which should be classified as secure, and conversely, which funds should be considered as probable. 5.5 Steps to complete the 4. Financing worksheet There are four steps necessary to complete the 4.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 reference information section of the 1. Data Entry worksheet, where you can enter up to 16 different sources of funding (e.g. WHO, UNICEF, GAVI, or World Bank), of which two are default names (government and sub-national government). Each funding name entered will correspond to a funding column in the 4.Financing worksheet. 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 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. 78 cmyp Costing & Financing Tool User Guide

92 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 available 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. Thirdly, to ensure the most reliable projections for future financing, this can 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 may consider presenting the 3. Costing worksheets for their examination. 3) Print copies of the 4. 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. 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 4. Financing worksheet Once you have gathered all the financing data, it needs to be entered in the 4. 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 the financing tables in Step 3) into those funds that can be considered as secure and those which 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 the financing for you. This can be done in Step 2. WHO/IVB/

93 For past financing there is no risk assessment to be made. By definition, all past funding was secured. However, the risk assessment for future financing is done by using the Type Risk 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 a 1 in the Type Risk column, the financing will automatically appear in the column of total secure funding. If 2 is entered in the Type Risk 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 Type Risk will only accept entries for 1 and 2. If you enter any other value, the following pop-up message will appear. 80 cmyp Costing & Financing Tool User Guide