Aggregate cost implications of selected Cost-Drivers in the Tanzanian Health Sector

Health is an important aspect of life of which one of its determinants is healthcare which is consumed in order to restore back deteriorated health to optimal pre-illness levels. The consumption of healthcare however has cost implications and accounts for a large share of resources directed towards the health sector. In health sector financing, it is vital to identify major cost components and create awareness about the costs of decisions. It is thus vital to identify factors that can cause changes in the cost of identified activities. A number of costly programs have been initiated and some others are on the horizon. In order to create awareness about the financial consequences of these decisions and to draw attention to the financing needs of the health sector, it is considered necessary to analyze the major health sector programs and initiatives with regard to the changes in costs brought about by new strategies, guidelines and interventions (including the adoption of new technologies), and aggregate these costs. The main objective of this study was to identify cost-driving decisions in the health sector. The study methodology comprised of three independent but complementary methodologies and activities: (a) Desk review of literature and documents; (b) Interviews with officials from MOHSW, programs and agencies involved in setting and promoting standards at international level; (c) collection of primary data/information and subsequent analysis of the same. The study reviewed 11 plans, including summary plans like the Health Sector Strategic Plan III and the Primary Health Services Development Program 2007 -2017 and national disease control programme plans/strategies. However, not all of cost-driving decisions in these plans could be integrated into the analysis because the plans are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. In addition the costs of some decisions in some plans/strategies HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. It should also be noted that the consultants did not assess all plans/strategies and their associated costs as to their plausibility. This was neither task of the consultants, nor would the time allocated to the study have allowed such an in-depth review. The study reviewed a total of 11 multi-year plans/strategies and found four plans to be affected by costs of decisions. Such decisions are: the adaption of WHO recommendations on Anti-retroviral Treatment eligibility criteria; re-treatment of conventional nets; indoor residual spraying; sustaining availability of long lasting insecticide treated nets (LLINs); provision of delivery kits to pregnant women in public health facilities, and the potential future introduction of a malaria vaccine, human papilloma virus and pneumococcal vaccines, which affect the Health Sector HIV and AIDS Strategic Plan II (HSHSP II) 2008 – 2012, the Malaria Mid-Term Strategic Plan 2008 – 2013 (NMCP), the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 (the Road Map), and the Expanded Program on Immunization 2010 - 2015 Comprehensive Multi Year Plan (EPI), respectively. The study found that these decisions have a significant cost implication to a tune of US$ 706,688,405 over a five year period 2011- 2015. The initially estimated costs of programs that are currently being updated (HSHSP II, EPI, NMCP and the Road Map) is US$ 2,297,009,378 exclusive of the identified cost drivers. The estimated cost of decisions is about 8 % of the total costs for health sector in Tanzania (HSSP III estimate) and about 3.3% of the 2009 GDP and added nominal per capita health spending/cost of US$ 17.3 (2009 population estimate) for five year period (annual per capita cost of US$ 3.46). This expenditure will definitely boost per capita health spending (US$ 13.45 in 2008/9). However, concerted revenue effort is needed if we are to hit HSSP III target of US$ 26.6 in 2014/15. The National Strategy for Non-communicable Diseases 2009 – 2015 did not include estimates, while most parts of the National Road Map Strategic Plan to Accelerate Reduction of Maternal, Newborn and Child Deaths in Tanzania 2008 – 2015 are undergoing reprogramming, as the previous cost estimates are regarded not to be realistic relative to achieving plan objectives. The rest of the programs are not significantly affected by cost of decisions. However, the estimated cost is likely to be higher owing to the fact that costs of some decisions in MMAM components such as HRH, infrastructure, health care financing strategy, mhealth, etc. are not established or are in the process of being costed or reviewed. Prevention and treatment of illness are the major strategies used to maintain or improve the health status of a population. Allocation of health resources are usually skewed towards treatment probably because addressing existing illnesses seem a present and clear danger than addressing potential illnesses which is what prevention is all about. Prevention and health promotion however lead to greater benefits than treatment in the long run in the sense that it reduces future demand for treatment than treatment alone does and has stronger merit good characteristics than treatment of illness. Health planning should thus intensify focus on prevention through promoting lifestyle and behaviour changes as well as intensifying prevention and health promotion at community level. Most health sector multi-year plans are characterized by heavy resource dependence on development partners. Such levels of dependence tend to compromise control over some decisions especially those supported by financiers. That is, recipients may be tempted to accept a full funded activity even if there is an ongoing similar activity which ends up creating parallel rather than complementary activities with cost implications. Thus, the financiers and recipients should undertake thorough analysis of potential decisions based on their cost implications (direct and indirect) as well as the time parameters, while avoiding decisions that spin off similar activities rather than complementing the existing ones. This can be facilitated by coordinated analysis from the MOHSW by keeping and monitoring comprehensive cost driver table enriched by inputs from all health sector programs and plans. Continuous reviews of the plans enhance the capacity of programs to adequately identify cost drivers and therefore enhance the planning process. However, reviews are not always undertaken on time and as regular as possible due to lack of resources or transfer of resources set aside for review process to implement other pressing components of the plan. MOHSW should make costing part of the plan a compulsory exercise for approval by the management and should not endorse plans which have not been adequately costed. MOHSW should also consider making reviews of multi-year plans a prerequisite for release of fund for subsequent implementation. Moreover, the reviews should integrate all stakeholders and involve technical people who are knowledgeable in costing and planning. The fact that most of the multi-year plans had indicative budgets, while others are not costed at all, warrants the conclusion that the basic knowledge in costing such as collaboration, parameter assumptions, time, manpower, and resources is lacking. Emphasis should thus be placed on developing and improving costing capacity in the programs as well as the MOHSW in terms of acquiring costing tools and exposure. The MOHSW should ensure that the priority activities of the strategies/plans are funded. This could be done through lobbying the government and other stakeholders for more resources. Protocols such as Abuja Declaration 2001, in which African governments committed themselves to scale up health budget to 15% of the annual budget, could be useful in this end. Also the government and local authorities through laws/bylaws could establish and commit specific sources of resources for the health sector. This should be pursued by keeping a close eye on the ratio of available resources to required resources which can indicate opportunities which development partners can be of help as well as providing an indication of the realism of planning. A review of the plans found the ratio of available resources to required resources to be 76 and 84 percent, respectively, for the Health Sector Strategic Plan III and the Expanded Program on Immunization 2010 – 2015 Comprehensive Multi Year Plan. The Malaria Medium Term Strategic Plan 2008-2013 on the other hand had the lowest ratio of available resources to required resources of 35 percent.