Costing of the SDG Targets for Nutrition Christiane Rudert Mueni Mutunga Jun Fan UNICEF -EAPRO
Global Nutrition Targets (WHA/SDGs)
Global Nutrition Targets Financing How much each of these global nutrition targets costs? What can we buy with this investment? Nutrition Health/lives saved Economy How can it be financed? How can these analytics generate national political commitment? And how can we maximize the returns on investment?
Using Costing and Data Analytics To Mobilize Resources Types of analyses Types of engagement with governments Source of funding Estimating the costs for strategic planning and budget formulation Cost effectiveness analysis Development of key policy documents Prioritization of nutrition investments Public domestic revenue Overseas Development Assistance (ODA) Efficiency savings Benefit-cost analysis Advocacy for increased resource investment cases Borrowing Innovative financing (GFF, GIF, etc.)
Interventions Key Interventions to cost for Nutrition Balanced energy protein supplementation Multiple micronutrient supplementation Treatment of SAM IFA supplementation Multiple micronutrient supplementation IPTp Family planning WASH interventions Public provision of complementary foods Cash transfers Food fortification Calcium supplementation Prophylactic zinc supplementation Vitamin A supplementation Infant and young child feeding education Public provision of complementary foods Lipid-based nutrition supplements LLINs Lipid-based nutrition supplements Micronutrient powders Delayed cord clamping Magnesium sulphate Oral rehydration solution (ORS) ORS + Zinc Stunting Wasting Anaemia Nutrition Sensitive
Using Cost and Data Analytics for Nutrition Madagascar Estimating the costs for strategic planning and budget formulation Cost effectiveness analyses Benefit-cost analyses $200 $150 $100 $50 $0 Annual Public Sector Cost of Scaling-up Nutrition-specific Interventions (USD million) 153 101 125 79 61 15 0 15 4 15 10 19 31 46 64 85 110 138 15 19 25 34 46 15 15 15 15 15 15 15 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Current cost Additional costs Total 25% 38% 31% 6% Intervention Cost per DALY IYCN 12 Vitamin A supplementation 29 Therapeutic Zinc suppl./ors 216 Micronutrient powders 44 Deworming 264 Iron-folic acid supplementation 43 Iron fortification of staple foods Salt iodization Public provision of complementary food 3,256 CMAM for SAM 169 ANNUAL PUBLIC INVESTMENT Cost-effectiveness map: Regions with the lowest cost per case of stunting averted BENEFITS Consumables Transport Program cost Other inputs Human resources Globally $70 billion needed over 2016-2025, while the current planned expenditure is only $33 billion. (.87,1] (.745,.87] (.65,.745] [0,.65] Source: World Bank
Conceptual 10-Year Budget Set-up: What does it cost Philippines?
Example - Estimated Cost of Micronutrient Powder Distribution added on to DSWD 4Ps Family Development Session INTERVENTION TARGET COVERAGE AT SCALE UNIT # UNITS UNIT COST TOTAL UNIT COSTS MNP (Zn, Fe, +) Child 6-24m 884,063 MMP Sachet 120 $0.04 $4.34 $3,836,161 Breastfeeding Promotion Pregnant Women 25,222 Meeting Cost 1 $5.00 $5.00 $126,108 IYCF Promotion Child < 24m 25,222 Meeting Cost 4 $5.00 $20.00 $504,432 $4,466,701
Financial Perspectives on Interventions BASELINE LOSS $4.5 B/y COVERAGE % EFFECTIVENESS % $1.56 B/y ~$113 M/y BENEFIT $/year COST $/year Benefit-Cost Ratio #
Summary View and Benefit-Cost Ratio Y1 Y2 Y3 Y4 Y5 Y6 Y7 Y8 Y9 Y10 TOTAL BENEFITS ($ BILLION) COSTS ($ MILLION) TOTAL BENEFIT- COST RATIO 0.62 1.25 1.56 1.56 1.56 1.56 1.56 1.56 1.56 12.80 60 96 113 113 113 113 114 114 112 113 1,062 10.4 13.0 13.8 13.8 13.8 13.9 13.7 13.7 13.9 12.1
12 10 YEAR TOTAL BENEFIT $12.8 B OVERALL BENEFIT- COST RATIO 12.1 10 8 EVERY $1 INVESTED in these interventions can SAVE AROUND $12 in forgone earnings or health expenditures due to undernutrition. 6 4 2 COST $1.062 B Investing in the available effective and affordable nutrition interventions to address the huge economic burden of undernutrition can be Highly Cost-Effective 0 Benefit Cost
Costing of nutrition interventions Key questions What is the minimum funding required, if allocated optimally, to meet the nutrition targets? How can a fixed budget be allocated across interventions to minimise malnutrition and associated conditions? Which interventions should receive priority additional funding, if it were available? In a sub-national analysis: which geographical regions should receive priority additional funding, if it were available? How might trends in undernutrition change under different funding scenarios? How close is a country likely to get to their nutrition targets: with the current allocation of funding? with the current volume of funding, but reallocated optimally?
Key costing concepts: system versus society costs System costs consider the costs to supply a service Society costs consider the cost to access a service (such as transport for beneficiaries). The social cost adds together the system and the society cost Society costs such as transport are often high, explain why even when health care is provided free of charge at point of service, uptake remains low.
Key costing concepts: top-down and bottom up costing The top-down approach mainly relies on a review of available documentation, such as expenditure reports generated from the government s financial management information system or expert interviews, to make assumptions regarding the underlying cost structures The bottom-up approach, or ingredients approach, calculates the cost of service provision through direct observation of all inputs required in the delivery of that service
Key costing concepts: type of costs A first distinction is often made between direct and indirect costs: Direct costs are associated to one cost-centre. For example, the running costs of a regional food distribution system Indirect costs support various cost-centres and need therefore to be apportioned across these cost centres if a final unit cost per cost centre is to be obtained. For example, the costs associated to the central Ministry of Health.
Estimating the costs of nutrition interventions Ideally, data (total budget, total people reached) would be available at different levels of funding: In nutrition, this information is rarely available Eexpenditure data are often used instead i.e. ( top down approach) Calculate a single unit cost using available expenditure program data total intervention cost divided by the number of people covered at a specific coverage level Total cost/number of people covered E.g. $100/10 = $10 unit cost Make a distinction made between direct and indirect costs: Direct costs are associated to one cost-centre. For example, the running costs of a regional food distribution system Indirect costs support various cost-centres and need therefore to be apportioned across these cost centres if a final unit cost per cost centre is to be obtained. For example, the costs associated to the central Ministry of Health. Consider and include the marginal cost of an intervention is defined as cost of covering one more person for scaling up interventions
Estimating the costs of nutrition interventions System costs incurred to deliver intervention: Commodity costs Logistics and transport costs Staff costs Equipment costs Infrastructure costs Program management costs Cost incurred by beneficiaries to access a service (society costs) - not normally included in costing of program interventions but important to consider Transportation cost, User fees
Estimating the costs of nutrition interventions The marginal cost of expanding the coverage of interventions may not be linear. Usually dependent on the coverage level from which we start: Economies of scale can reduce the cost as interventions expand The need for additional infrastructure can increase the cost as interventions expand Saturation coverage as it becomes more difficult to reach the final few, and demand generation activities may be required Generally expect increasing marginal costs as interventions expand coverage to increasingly hard to reach populations [saturation]
Existing tools for nutrition impact and economic analyses Multiple interventions: Single intervention: Optimization Investment WBCi One Health Coverage FANTA CMAM MINIMOD Health impact PROFILES Budget impact Economic impact
Summary of tools UNICEF uses for economic analysis in health & nutrition Tool name What it does What UNICEF HSS step it corresponds to Transparency Strengths Weaknesses EQUIST Equity analysis!-6 (Costing not for budgeting but for scenario comparison Data sources identified User modification possible Costing data opaque Easy to use platform Graphic representation Some equity markers not available 54 countries to date costing data unclear HEAT Equity Analysis 1 Data sources available Measures the depth of inequities using a range of quantitative measures Cross country comparisons Cross year comparisons LiST DHIS2 Impact of intervention coverage changes Real time coverage data of subnational intervention coverage data Workforce Commodities 2,3,6 All data sets and sources identified Data entry at facility level determines quality Regularly updated (both data sets for countries and evidence based of effectiveness of interventions Aggregated subnational results GIS mapping Facilitates good reporting Quality of intervention coverage not taken into consideration in impact measures Some interventions not included One Health Costing a national health plan Impact measures Matching workforce with tasks 5,6 complete customisation Complexity increases trust of model Complexity required 3-6 months to do a complete national plan
Thank you!