Helping Countries Improve Child Health: Costing and Financing Community-Based Care

 {Photo credit: Zina Jarrah/MSH, Tanzania.}A community health worker takes blood to check for malaria.Photo credit: Zina Jarrah/MSH, Tanzania.

Diarrhea, malaria, and pneumonia are leading causes of child mortality, accounting for nearly 44 percent of deaths among children under five worldwide.  The World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), the United States Agency for International Development (USAID), and the Global Health Initiative (GHI) promote integrated community case management (iCCM), the delivery of timely and low-cost interventions at the community level by community health workers (CHWs), as an effective strategy to deliver life-saving interventions for major childhood illnesses. 

Management Sciences for Health (MSH), through a sub-grant from University Research Council (URC), LLC’s TRAction Project, has developed a spreadsheet-based and user-friendly tool to assess the costs of integrated community case management (iCCM) programs. This iCCM Costing and Financing Tool allows users to calculate the costs and financing elements linked to all elements of the vertical iCCM program, including service delivery, training, supervision, and management from community to central levels.

MSH spoke with Zina Jarrah, a technical advisor in MSH’s Health Financing Unit, about the tool and how countries can utilize it for improving children’s health. Jarrah has developed several of MSH’s costing and financial tools, including the iCCM Costing and Financing Tool, and has provided training to partners, NGOs, and Ministries of Health. 

What is the iCCM costing and financing tool? How does the iCCM costing and financing tool help save children's lives and ensure children's access to health care?

Integrated Community Case Management (iCCM) is the provision of curative care by community-based health workers, typically for pneumonia, diarrhea and malaria, to children under five. iCCM programs target rural and hard-to-reach areas that would not otherwise have access to formal health facilities or care. iCCM programs have been heralded as a key initiative to bring proven, life-saving treatments to children for diseases that have relatively simple cures in many cases.

Several developing countries have adopted and promoted iCCM policies to improve access to care and subsequently reduce child mortality. However, although iCCM has shown great promise in increasing health coverage, especially for children living in remote locations, some low-income countries have not implemented iCCM programs, partly due to their concern or uncertainty about the costs and financing of iCCM programs. 

The iCCM Costing and Financing tool can be used in a variety of ways: to determine the costs of establishing a new iCCM program; to scale-up coverage of an existing iCCM program; or to show the costs of adding more services to the iCCM package. Knowing the costs of the program is an essential component in advocating for iCCM programs; by showing how much the total cost of the program will be, or the marginal cost of expanding the program, iCCM implementers can make a case for the funding needed for their programs.  

Are there other similar ICCM tools in use, or is this unique in the global health sphere?

As far as we know, this is a unique tool in that it is developed specifically to cost vertical iCCM programs, and is fully customizable to each country’s context and program. There are other costing tools that conduct costing on a more macro-level (such as the OneHealth tool) but our iCCM Costing and Financing Tool is made for iCCM implementers and managers at the country level to look at the specific needs for their programs. This is also evidenced by the fact that a number of international organizations (such as UNICEF, Global Fund) as well as implementing NGOs (such as Save the Children, IRC) have expressed an interest in the tool.

How did MSH develop the tool?

Through a subgrant from URC through the TRAction Project, funded by USAID, the team from MSH's health financing unit, including Project Director David Collins, Kate Wright, Angie Lee, and me, field-tested the iCCM tool in two countries: Malawi and Senegal, along with a subsequent test in Indonesia.

To date our country applications have been driven mostly by our own project requirements, but as the iCCM tool is starting to be requested by different partners and countries around the world, we should soon have some evidence of how the tool can have an impact on a program. For example, in Burundi, the iCCM costing is just about to get under way; one of the goals of the costing will be to advocate to the Burundian MOH that the current malaria-only program should be expanded to include pneumonia and diarrhea as well. We have also been requested by UNICEF to use the tool in Zambia and Madagascar, in order to advocate for the use of rapid diagnostic tests (RDTs) to confirm a malaria diagnosis, instead of presumptively treating all fever cases as malaria and thereby causing massive wastage of anti-malarial medications.

The Guardian (UK) hosted an online discussion September 12th on child health and improving care with community-based care, namely iCCM. One question from the moderator asked if ICCM is sustainable. Does this tool address this question of ICCM's sustainability?

The iCCM Costing and Financing tool definitely addresses sustainability; As the name suggests, there is a financing component to the tool which allows the user to input any known funding sources for the program. The sources of funding can be linked to a particular aspect of the iCCM program (for example, if a donor will fund all malaria medications), and the tool will then calculate the gap in funding, based on the total estimated costs of the program. The tool calculates the costs of the iCCM program for one baseline year and five projection years, so it is possible to do a sustainability analysis over the six total program years to see what is expected to be funded, and what still requires funding. As mentioned previously, the tool can be used to advocate for additional funding, and to show the expected outputs of the program based on that funding in terms of populations covered and services provided to children under 5.

What’s next for the tool?

The Bill & Melinda Gates Foundation awarded MSH a contract to implement the iCCM Costing and Financing Tool in seven countries: DRC, Cameroon, Ethiopia, Sierra Leone, South Sudan, Uganda, and Zambia. We’re currently in the process of conducting these costing studies and will be linking our results to evaluations of the iCCM programs; this will allow us to provide key data not only on the costs of iCCM programs, but also on their impact. It is our hope that, by showing the cost to achieve impact, such as the cost per life saved, we can provide even greater advocacy for iCCM programs. The results from this work will be showcased at the iCCM Symposium that will be hosted by UNICEF in Nairobi, in December 2013.  

In addition to Nairobi, we're presenting the tool at a panel during UN General Assembly Week on frontline health workers, convened by Johnson & Johnson (New York); in October at CORE Group's Fall Meeting (Washington, DC), and the Canadian Society for International Health's Global Health Meeting (Canada); and at the Third Global Forum on Human Resources for Health (Brazil).

As more and more donors, implementing agencies, and governments are turning to iCCM as a key mechanism to reduce child mortality, the iCCM costing and financing tool can play a critical role in planning, budgeting, financing and advocating for these programs.  

How would a country obtain or work with the tool, if interested?

Just get in touch with us, and we’ll work something out!