Presentación sobre herramientas financieras (FBT) para el estudio de Cancer de Mama en México Seminario Taller Sobre Costo Efectividad De Cancer de Mama en México México DF, 2-4 Febrero 2011 Jeremy Lauer, OMS Ginebra
Objectives of this session The role of financial cost analysis in the planning process Overview of the Financial Budgeting Tool for Breast Cancer interventions Issues for consideration
Cost- Effectiveness Analysis The role of financial cost analysis in the planning and budgeting process I- Strategic plan II- Operational plan and budget proposal III- Budget negotiation IV- Budget consolidation and approval V- Financial tracking and audit Timeline Strategic areas Policies Targets Assess Resource Needs and affordability Activity plan Input requirements Input costs Preliminary budget Costs and budget for activity plan Internal revision Negotiation with Ministry of Finance and other financial sources Advocacy with funders Budget approval by Ministry of Finance Distribution of the budget by line items Monitoring of financial disbursements by budgetary line items Financial costing
The role of financial cost analysis in the planning and budgeting process: the need for continuous updates and revisions I- Strategic plan Timeline Strategic areas Policies Targets II- Operational plan and budget proposal Activity plan Input requirements Input costs Preliminary budget III- Budget negotiation Internal revision Negotiation with Ministry of Finance and other financial sources
Why do we have a separate tool and analysis for financial costs? The cost-effectiveness analysis (CEA): looks at total costs incurred from the societal perspective, over a standardised time-frame, regardless of whether those resources are already in place and financed, or not. Allows for comparison between a wide range of interventions. The financial cost-analysis (FBT) looks at the financial cash flows by year. This means that resources already in place and funded are not costed (e.g., equipment and human resources already in place). Capital costs are not annualised. Focuses on a selected set of activities and interventions. The FBT allows for context-specific planning in the medium-term and alignment with other national strategic planning documents.
Needs-based costing A historical incremental budgeting approach looks at what was spent last year and increases the budget by e.g., 5-10 % Does not allow for shifting between priorities. A needs-based cost assessment looks at population needs and is determined by the set policies and planned coverage targets Provides a powerful tool for making adjustments to the budget allocation. 250 200 150 100 50 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 Historical (example) Coverage-based (example)
Herramienta financiera (Financial Budgeting Tool - FBT) to accompany cost-effectiveness analysis The purpose is to facilitate an assessment of the financial resources (cash flows) that would be required to implement the scenarios for Breast cancer interventions. Costs are estimated at national level, from the health provider perspective. Costs are estimated for the entire planned Breast Cancer programme regardless of who would hold the budget for the various items.
Costs included - definitions Specific costs to Breast Cancer programme Costes de pacientes (procedimientos de tratamiento, medicamentos, instalaciones, diagnosticos, etc.) Costes de programes (los medios de comunicación de administración, aplicación de la ley en los diferentes niveles; equipment needed in health centres and hospitals; monitoring and evaluation surveys; mass media awareness raising and outreach in the community). incluye los costes de formación Shared system resources Inpatient and outpatient services, health worker salaries, community-based health workers, infrastructure and building maintenance.
Objectives and process of application of the tool in México Build on lessons learnt from the CEA analysis in terms of most costeffective interventions and estimate the financial cost of these. Estimate the costs of scaling up BrCa services and activities over 5-15 year time frame Incorporate as much shared input data as possible from the CEA analysis. Defining an action plan for the next 5-10 years to outline a proposed scale-up scenario Compare costs of a current scenario, with the costs of a "scale-up scenario".
What we present here is just an example Limited information inputted on local data regarding Coverage, Definition of the Interventions and their costs, and programme activities. Costs Millions LCU 120.000 100.000 80.000 60.000 40.000 20.000 0 Estadio III Estadio I PCE + IV + Tzmab Estadio IV PC extendida + IV PC Basico + IV Estadio II I - IV + conciencia Presente 60% I - IV combinación Presente 100% I - IV + media I - III + media + PCB I - IV + MS(40-69) I - IV + MS(50-69) I - III + MS(40-70) + PCE I - IV + CBE (40-69) I - III + CBE + PCB I - III + MS (40-70) + PCB + Tzmab I - III + MS(40-70) + PCB 0 5000 10000 15000 20000 25000 30000 35000 Efectos en DALYs perdido A more thorough assessment would be led by a country team of experts and based on: - the findings from the costeffectiveness analysis, and - other criteria (equity, political feasibility, health systems considerations, etc) i.e. the discussions in this workshop
Comparing two scenarios: 1. current delivery, and 2. proposed scale-up The proposed scale-up scenario can refer to increased population coverage of current services Increased quality of care provided of current services Adjustments to the screening process (frequency, inputs) Adjustments to the treatment and care provided (frequency, inputs) Intensified programmatic investments (mass media, training, etc) Change in strategy for more effective delivery Shifting patient load from Hospital level to Health Centre level to save costs. in our example we have focused on coverage increases. More country-specific information would be needed to undertake a more context-specific assessment.
A look at the tool and assumptions used for the example cost analysis for México
Interventions in current vs. scale-up scenario Interventions Select which interventions packages are included in the programs Interventions in Current Breast Cancer Program Interventions in Proposed Breast Cancer Program Awareness Basic Awareness Reach Out Program Biennial Screening None Diagnosis & Treatment Stage I to IV treatment combined Palliative Care Stage IV Palliative Care Extended 1 1 2 Awareness Basic Awareness Reach Out Program Bi Annual Screening Clinical Breast Examination (40 69 years) Diagnosis & Treatment Stage I to IV treatment combined Palliative Care Stage IV Palliative Care Extended Trastuzumab Stage IV Trastuzumab Trastuzumab Stage IV 1 Trastuzumab
Coverage trajectory 2009-2019 Awareness current Basic Awareness Reach Out Program 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Basic Awareness Reach Out Program 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% target Basic Awareness Reach Out Program 60% 64% 68% 72% 76% 80% 84% 88% 92% 96% 100% Biennial Screening Clinical Breast Examination (40 69 years) current None 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% target Clinical Breast Examination (40 69 years) 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80% Diagnosis & Treatment Stage I to IV treatment combined current Stage I to IV treatment combined 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80% 0.02 16% Palliative Care Stage IV Palliative Care Extended current Current coverage 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80% 0.02 16% Trastuzumab Trastuzumab current Current coverage 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80%
Detailed inputs and activities are defined by year (#1: equipment) Number of new equipment to purchase in each year: 2009 Minimum additional equipment needed 2010 2011 2012 Bone density: CT scanning system 7 4.00 1 1 1 Radiotherapy: linear accelerator 7 4.00 1 1 1 Radiotherapy: radiographic quality assurance 7 4.00 1 1 1 Mammograph: Radio quality 14 7.00 1.75 1.75 1.75 Mammograph: Radio machine 7 4.00 1 1 1 Mammograph: digital machine quality 7 4.00 1 1 1 X-ray machine 7 4.00 other <please specify>: 0 other <please specify>: 0 other <please specify>: 0
Detailed inputs and activities are defined by year (#2: training) Second course: Specialist training for surgeons or radiologists 2009 2010 2011 2012 2013 Participant Costs Number of Classes per year 0 1 1 1 1 Size of Class: 1 1 1 1 1 Per Diem Rate (Students): 1.00 1.00 1.00 1.00 1.00 Average Travel Costs: - - - - - Cost of Training Packet (per student): 2.00 2.00 2.00 2.00 2.00 Trainer costs: Total Student Costs: - 30.00 30.00 30.00 30.00 Number of Trainers per class: 1 1 0 0 0 Per Diem Rate (Trainers): 10.00 10.00 10.00 10.00 10.00 Hotel/travel costs (total for the course per trainer): - - - - - Other Costs: Total Trainer Costs: - 200.00 - - - Cost for lecture room rental Other Costs (per class): Total Other Costs: - - - - - Total Costs for Training: - 230.00 30.00 30.00 30.00
Results #1: assessment of resource needs for clinical services, based on our example Cost per woman >40 years, per year 2009 2010 2011 2012 Number of women aged 40+ 728,661 754,390 780,400 806,640 Cost per woman >40 years (current scenario) 1,557 1,826 2,091 2,351 Cost per woman >40 years (proposed scenario) 2,671 3,055 3,505 4,014 2013 2014 2015 2016 2017 2018 832,974 859,219 885,279 911,075 936,669 962,220 2,605 2,808 3,003 3,190 3,370 3,544 4,575 5,109 5,665 6,241 6,835 7,444
Results #2: assessment of resource needs for clinical services, based on our example 14,000 12,000 10,000 8,000 6,000 4,000 2,000-18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 - Costs for medical services in current scenario, million colones Current scenario 2010 2012 2014 2016 2018 Scale-up scenario 2010 2012 2014 2016 2018,, Trastuzumab Palliative Care Relapse diagnosis and treatment Trastuzumab Follow -up (all stages) Treatment stage IV Treatment stage III Palliative Care Treatment stage II Treatment stage I Diagnosis stage IV Relapse diagnosis and treatment Follow-up (all stages) Diagnosis stage III Diagnosis stage II Diagnosis stage I Screening Treatment stage IV Treatment stage III Treatment stage II Treatment stage I Diagnosis stage IV Diagnosis stage III Diagnosis stage II Diagnosis stage I Screening
8000 7000 6000 5000 Current scenario - Costes (milliones colones) Program costs Medical Devices Disposable Drugs Running costs for overhead Results #3 4000 3000 2000 1000 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Home based visit community Nurse / volunteer Additional Human Resources Health Centre Outpatient Visit Hospital Outpatient Visit Hospital Inpatient services Breakdown of costs by input sheds light on the budget categories, and who will bear the costs Proposed scale-up scenario - Costes (milliones colones) 8000 7000 6000 5000 4000 3000 2000 1000 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Program costs Medical Devices Disposable Drugs Running costs for overhead Home based visit community Nurse / volunteer Additional Human Resources Health Centre Outpatient Visit Hospital Outpatient Visit Hospital Inpatient services
Issues for consideration
Application of the FBT Will demonstrate future resource needs associated with a plan Could be used to illustrate cost savings: Treating women in late stages, vs. Comprehensive preventive screening programmes and treating women in earlier stages Incorporates demographic changes over time change in population size of various age cohorts can model an increase or decrease in incidence over time, based on the local context and expected change in risk factors. Waiting times not explicitly addressed but could be taken into account by estimating costs for the activities required to reduce waiting times
Issues for consideration The financial cost analysis should be based on an analysis of the current health systems constraints, and how to overcome them (access to care, quality of care), and link to the broader health sector plans. If estimated costs are deemed as not affordable, potential strategies include: Plan for a less ambitious strategy (lower coverage) Explore innovative ways to save costs (greater integration of services, shift service delivery to lower level facilities, use generic drugs, etc) Explore different options for financing the plan Link the implementation plan for Breast Cancer programme to the broader national health strategic plan
Tres dimensiones de financiamento Reduce la participación de los gastos ye las cuotas Ampliar la cobertura
Issues for consideration (contd.) Equity e.g., variation in access and quality of care by geography The role of public / private providers Coverage targets/ scale-up phasing aligned with national health investment plans National vs. Decentralised level planning Inflation and price changes over time not yet accounted for
Proposed next steps Strategic: Define the overall strategic plan and implementation plan Link these to broader national plans for the health sector Programmatic: Refine inputs and assumptions for the programmatic investments, including treatment protocols, and price data. Define the format of results that are useful in the Mexican context (cost categories, budget categories) Assess financing policy Assess financing options Develop financing strategy (how to ensure moving towards universal financial access with long-term predictability of funding)
Muchas gracias por su atención