Normative Costing of Essential Health Service Package in Laos PDR
Conducted by Dr. Shankar Prinja from the World Bank, this study focused on estimating the costs of delivering essential health services in Laos PDR. The research aimed to assess the unit costs of core service packages, compare normative and bottom-up cost estimates, and undertake Health Technology Assessment for interventions under the Essential Health Service Package. Findings from the study provided valuable insights for scaling up health services while considering fiscal capacity and rational prioritization within the EHSP framework.
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Normative Costing of Essential Health Service Package in Laos PDR Dr. Shankar Prinja World Bank
Outline Background Aims and Objectives Methodology Key Results Limitations Recommendations
Background Development and implementation of an Essential Health Service Package (2018- 2020) initiated Three important questions: cost of delivering the services/package its feasibility given the fiscal capacity whether there is any need or rationality in prioritization within the EHSP Understanding the costs of delivering health interventions and the major cost drivers is critical to expanding access to health services.
Aims and Objectives Primary - Estimate the unit cost of individual core service packages which are part of EHSP - Assess the total cost of EHSP implementation in Laos PDR under various scenarios of scale up. Secondary - Compare the normative and bottom-up cost estimates - Undertake Health Technology Assessment for interventions
Normative Financial Costing : Steps Involved Step 1: Identification of core service package by level of service delivery Step 2: Identify individual services within the core service package, by level of service delivery Step 3: Collect data on the type and quantity of recurrent operational resources per service within the service package, by level of service delivery Step 4: Collect data on prices of each of the resource identified as per point no. 3 Step 5: Collect data on the expenditure of program management, at overall program level
Normative Financial Costing : Steps Involved. Step 6: Scale up of the normative unit cost identified vide 1-5, for resources not accounted Step 7: Estimate the unit cost of individual core service packages under EHSP Step 8: Identify alternative scale up scenarios Step 9: Assess the cost of implementation of alternative scale up scenarios
Adaptation of ESP for Costing ESP Document was very comprehensive However, ESP categories for certain services were: Less specific in terms of individual services Less specific in terms of target population Technical consultation with program staff coordinated by the WHO and World Bank Adaptation of ESP for costing was done Stratification within certain ES categories Merging of certain categories Identification and Suitable allocation of Cross cutting services
Illustration 1: Merging of ESP categories Old ESP Categories New ESP for Costing ES 16 Routine minimum ANC care ANC Care Package ES 22 Provide deworming ES 23 Daily iron folic acid tablets ES 24 Td Vaccination ES 25 Counselling on STI and HIV
Illustration 2: Stratification of ES categories Old ESP Categories ES 60: IMNCI services New ESP for Costing Infantile very severe disease/local bacterial infection management Jaundice management Feeding problem/low weight for age management diarrhea management pneumonia management Fever management Measles management Dengue management Ear problem management sore throat management anemia management Old ESP Categories New ESP for Costing ES 46: Management of newborn with complications Sepsis management Jaudice management Severe asphyxia management Malformation management Seizure management Preterm birth complication management for newborn
Data collection Type of Data Unit of Measurement Data Sources Remarks Human Resource Each of these data points were elicited from the TGW members as per their clinical opinion or STG. Type of HR Time per service delivered Wage rate TWGs STGs Accounts department Drugs and Consumables Quantity used per service episode Price TWGs STGs Procurement department Diagnostics cost Number of diagnostic tests per service Price of diagnostic test TWG and STG Price based on payment rates under national scheme insurance Program management expenditure cost Overhead Cost Annual management Expenditure on program Program division Development partner % of total cost represented by overheads at each service delivery level Proportion of total cost represented by building and space, medical equipment and non-clinical HR in health facility Bottom up and health facility costing analysis Derived based on analysis of the bottom-up facility cost data Scaleup Factor (To be used only when the normative estimates are compared with bottom-up costing estimates) To be coordinated with teams undertaking bottom-up and HF costing non-medical & and health Gaps in capital infrastructure % increase in number of health centres, district hospitals, provincial and central hospitals required WHO report
Methods Deviation Program Management & Governance: Scale-up using NHA estimates Cost of Existing Capital: Not accounted Cost of Additional Capital Resource Required: Not accounted
Analytical Approach Step 4: Total annual cost estimation for each EHSP Step 3: Care Utilization Pattern Step 2: Demand estimation Step 1: Unit cost estimation
Unit Cost Estimation Unit cost Inputs Cost Quantity Price/Wage Human Resource Cost (X): Time spent per service*Wage per minute Human Resource: Type and time per service/procedure (in minutes) Wage per minute (using monthly salary) Drugs Cost (Y): Quantity of drug (s) used*Price per unit Drugs: Type and quantity of drugs used per episode treated Price per unit Consumables Cost (Z): Quantity of consumable (s) used*Price per unit Consumables: Type and quantity of consumables used per episode treated Price per unit Diagnostics Cost (W): Number of test (s) done*Price per test Diagnostic tests: Type and number of tests per episode treated Price per test Unit cost (U): X+Y+Z+W
General Framework of Annual Cost Estimation * Denotes Multiplication
Analysis at Glance What we included for all services? What was included additionally? What it does not include? - Cost of augmentation of capital resources required for implementing EHSP -Value of existing capital resources - Human resource - Drugs - Consumables - Diagnostics - Cost of program administration and governance
Total Cost* of EHSP (In billion Laos kip) 4000 3662 Billion Laos Kip 3500 3000 2500 2029 Billion Laos Kip 2000 1500 1276 Billion Laos Kip 1000 707 Billion Laos Kip 500 0 2019 2020 Without Scale up With Scale up *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Key Financial Indicators 2019 2025 Indicators Without Scale up With Scale up Without Scale up - With Scale up Health expenditure as % of GDP# 2.40% 2.40% - Total cost EHSP (In billion Laos kip) 707 1,276 2,029 3,662 Per capita EHSP cost (In thousand Laos kip) 99 178 258 511 Per capita EHSP cost (USD) 12.1 21.8 31.6 62.6 EHSP Cost as % of Current Government Health Expenditure 37.8% 67.9% 98.5% 195% Total cost of EHSP as percentage of GDP 0.48% 0.86% 1.37% 2.47% *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Costs* (In Billion Laos kip), by Type of Services 2019 2025 % Change Without Scale up* With Scale up# Without Scale up* With Scale up# Family Planning 2 4 6 11 180 Immunization 16 29 83 150 425 Tuberculosis 29 53 187 337 535 Non-communicable diseases 75 135 301 543 302 Malaria 24 44 82 148 239 HIV 77 138 150 271 96 Antenatal care services 52 93 170 306 228 Abortion, intranatal and postnatal services 45 82 98 177 116 DCDC 250 452 517 933 106 Newborn care services 15 27 31 56 104 Neonatal & Child health services 60 108 311 562 422 Reproductive & adolescent care services 61 111 93 168 51 Total 707 1,276 2,029 3,662 187 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Annual EHSP Cost by Service Domain 2019 2025 4% 2% 15% 11% 33% 35% 54% 46% Immunisation Communicable disease RMNCH + A Non-communicable disease Immunisation Communicable disease RMNCH + A Non-communicable disease
Annual ESP Cost by Nature of Service 2019 2025 19% 26% 28% 37% 44% 46% Curative Preventive Promotive Curative Preventive Promotive
Annual ESP Cost, by place of service delivery 2019 2025 % Change Without Scale up 167 With Scale up Without Scale up 333 With Scale up % Change Non Facility# 302 601 99 Facility 540 974 1696 3061 214 Total 707 1276 2029 3662 187 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses. # Includes mobile and outreach services
Annual ESP Cost by place of service delivery 2019 2025 16% 24% 76% 84% Non - Facility Facility Non - Facility Facility
Annual ESP Cost by Place of Service Delivery 2500 2000 139 240 Billions, Laos Kip 1500 339 336 1000 32 63 635 84 500 94 18 264 6 315 161 0 2019 2025 Outreach Community Health center DH A DH B Provincial & Regional Central *Estimates of cost are representative of value of recurrent resources that would be required.
Annual EHSP cost by Input Resources 2019 2025 7% 19% 12% 10% 12% 58% 69% 13% HR Diagnostics Drugs Consumables HR Diagnostics Drugs Consumables
Annual Cost* of RMNCH by Service Objective Annual Cost, Billion Laos kip (USD) 2019 2025 Change (%) Without Scale up With Scale up Without Scale up With Scale up SO1 2 (0.00) 4 (0.00) 6 (0.00) 11 (0.00) 180 SO2 52 (0.01) 93 (0.01) 170 (0.02) 306 (0.03) 228 SO3 45 (0.01) 82 (0.01) 98 (0.01) 177 (0.02) 116 SO4 15 (0.00) 27 (0.00) 31 (0.00) 56 (0.01) 104 SO5 60 (0.01) 108 (0.01) 311 (0.04) 562 (0.06) 422 SO7 61 (0.01) 111 (0.01) 93 (0.01) 168 (0.02) 51 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Distribution of RMNCH Cost by Service Objective 2019 2025 22% 26% 13% 24% 14% 44% 19% 26% 5% 7% Safe Delivery Emergency Obstretic Care, MDSR, Safe Abortion EENC Child Curative Care Nutrition Safe Delivery Emergency Obstretic Care, MDSR, Safe Abortion EENC Child Curative Care Nutrition
Annual Cost of Routine Immunization: Scenario Analysis 100 90 24 80 Billions, Laos Kip 12 70 60 11 18 50 47 40 34 30 54 20 23 10 16 0 At current levels of coverage with current delivery pattern (2019) Achieving 95% coverage with current delivery pattern with additional vaccines Achieving 95% coverage with targeted delivery pattern (80% fixed site and 20% outreach, additional vaccines) Fixed Mobile Outreach *Estimates of cost are representative of value of recurrent resources that would be required.
Annual Cost of Routine Immunisation, 2019-2025 300 259 253 244 244 242 226 250 BILLIONS, LAOS KIP 200 144 140 137 135 135 134 125 150 100 76 50 0 WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Input-wise distribution of cost of Immunization, 2019-2025 100 90 83 83 83 80 70 70 Billions, Laos Kip 56 55 60 47 50 38 64 64 64 38 40 34 Consumables Vaccines Human Resources 54 30 30 51 42 43 23 23 23 22 21 22 21 22 18 16 20 35 29 28 27 19 20 19 20 19 19 19 19 13 10 12 11 11 11 10 8 5 5 5 4 3 3 3 3 2 2 2 2 2 2 1 1 - Fixed Fixed Fixed Fixed Fixed Fixed Fixed Mobile Mobile Mobile Mobile Mobile Mobile Mobile Outreach Outreach Outreach Outreach Outreach Outreach Outreach 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required.
Annual Cost of Routine Immunization: Scenario Analysis 200 180 160 43 140 Billions, Laos Kip 21 120 19 32 100 85 24 80 Outreach Mobile Fixed 12 60 11 61 18 98 47 40 34 54 42 20 29 23 16 0 Without Scale up With Scale up Without Scale up With Scale up Without Scale up With Scale up Achieving 95% coverage with current delivery pattern Achieving 95% coverage with targeted delivery pattern (80% fixed site and 20% outreach) *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Total Cost of Routine Immunization, 2019-2025 300 General Administration Costs 250 BILLIONS, LAOS KIP Program management costs 116 200 113 109 109 108 101 150 Outreach 8.8 8.6 9.0 9.1 8.4 22.1 8.3 23.1 22.0 22.0 23.4 61 22.7 100 30 21 21 Mobile 38 47 8.1 56 17.6 50 83 83 83 Fixed 70 34 55 38 16 0 2019 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required.
Total Cost of Routine Immunization by Level, 2019 2025 160 140 120 Billions, Laos Kip 100 80 60 40 20 0 2019 2020 2021 2022 2023 2024 2025 Health center Mobile_HC District Hospital A Mobile_DH District Hospital B outreach strategy_HC Provisional & Regional outreach strategy_DH Central *Estimates of cost are representative of value of recurrent resources that would be required.
Annual Cost of HIV services, 2019- 2025 300 271 250 200 Billion, Laos Kip 150 Without Scale up With Scale up 138 150 100 77 50 0 2019 2020 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Annual Cost of HIV services, by level 160 Total Cost: 150 Billion Laos Kip 7 140 20 2 120 Billions, Laos Kip Total Cost: 77 Billion Laos Kip 100 55 3 80 10 1 60 29 27 40 15 20 38 20 0 2019 2025 Outreach Community Health center DH A DH B Provincial & Regional Central *Estimates of cost are representative of value of recurrent resources that would be required.
Annual HIV Cost by Input resources 2019 2025 13% 13% 28% 28% 12% 12% 47% 48% Human Resources Drugs Diagnostics Consumables Human Resources Drugs Diagnostics Consumables
Distribution of Cost by Type of HIV Services 2019 2025 1% 1% 13% 1% Peer education on STI including HIV Free condom provision HIV counselling and test STI Management 1% 0% 13% 0% 43% 42% CD4 counting 39% ART for HIV positive TB test for HIV postive 38% 4% 4%
Annual Cost of NCD Services, by Level, 2019-2025 543 600 BILLIONS, LAOS KIP 465 500 391 322 400 301 258 254 300 216 190 179 140 135 200 105 75 100 0 WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Annual Cost of NCD Services, by Level, 2019-2025 350 300 53 250 Billions, Laos Kip 46 Central Provisional & Regional District Hospital B District Hospital A Health center 200 96 38 82 32 150 69 25 59 56 50 100 18 44 42 35 39 32 12 34 27 28 22 50 20 23 18 14 13 53 46 9 39 33 27 21 17 0 2019 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required.
Proportional Distribution of NCD Service Cost, 2019 - 2025 Counselling Screening 25% 28% CVD treatment 61% 22% Diabetes treatment 11% 3% CRD treatment 11% Cancer treatment
Annual Cost of NCD Services, by Type of Service, 2019-2025 100% 90% Cancer Counselling (Cancer) COPD Diabetes Counselling Diabetes Screening (Diabetes) Stroke CVD Counselling (CVD) Screening (CVD) General 80% 70% 60% 50% 40% 30% 20% 10% 0% 2019 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required.
Annual Cost of Tuberculosis Service Delivery, 2019-25 400 337 BILLIONS 284 300 232 187 182 157 200 138 129 101 95 76 100 53 53 29 0 WITHOUT SCALE WITHOUT SCALE WITHOUT SCALE WITHOUT SCALE WITHOUT SCALE WITHOUT SCALE WITHOUT SCALE WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP UP UP UP UP UP UP UP 2019 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Annual Cost of Tuberculosis Service Delivery, by Level 200 180 47 160 140 39 Billions, Laos Kip 120 47 32 100 39 25 32 80 27 22 19 25 60 18 27 19 13 22 14 40 18 12 11 14 7 7 11 20 39 7 34 7 4 28 22 4 18 13 9 0 2019 2020 2021 2022 2023 2024 2025 Health center District Hospital A District Hospital B Provisional & Regional Central *Estimates of cost are representative of value of recurrent resources that would be required.
Annual Cost of Malaria Service Delivery, 2019-25 143 148 139 160 134 130 140 120 BILLIONS 100 82 79 77 74 72 80 60 45 44 40 25 24 20 0 WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITH SCAE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP WITHOUT SCALE UP 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required. # Scale up is done for Program management, Governance and Administration expenses.
Annual Cost of Malaria Service Delivery, by Level 90 80 12 11 11 10 70 10 12 12 12 Billions, Laos Kip 60 11 11 Central Provisional & Regional District Hospital B District Hospital A Health center 19 18 18 50 17 17 40 19 18 18 17 16 30 3 3 20 4 4 20 20 19 18 18 6 6 10 5 5 6 6 0 2019 2020 2021 2022 2023 2024 2025 *Estimates of cost are representative of value of recurrent resources that would be required.
Limitations Data Availability Resource Use Intervention implementation details (Example: Surgical and Dental) Resource use (Drugs for Cancer treatment, procedure for dental ailments) Price information of drugs/ consumables/ tests Hospital Information System Disease wise details of service utilization (consultations, admissions, procedures, tests) by level of facility was not available. Eliciting the data from the TWG was challenging. Indirect Costs such as administrative, program management Standard Treatment Guidelines
Recommendations & Way Forward Increase the public spending on health ESP Costing Analysis could be used for developing Sector-wise Plans Establish MIS system which enables updating of cost analysis in future. Prioritize ESP package by identifying scale-up of cost-effective interventions
