Costing analyses for interventions to be implemented by the

Costing analyses for interventions to be implemented
by the Mesoamerican Health Initiative
Instituto Nacional de Salud Pública
Prepared by:
Aracena Genao, Belkis
Danese De Los Santos, Laura
González Domínguez, Dayana
Martínez Pérez, Araceli
Sosa Rubi, Sandra
Valencia-Mendoza, Atanacio
Cuernavaca, Mexico, December 2009
CONTENTS
BACKGROUND AND INTRODUCTION ...................................................................... 33
PRINCIPLES OF COSTING ........................................................................................... 55
Direct incremental unit costs ................................................................................................55
Incremental unit costs .............................................................................................................66
Costing Methods Overview .....................................................................................................66
Data Collection ...................................................................................................................................... 77
Data Management and Cost Estimations ................................................................................... 77
VECTOR-BORNE DISEASES ........................................................................................ 77
Methods .........................................................................................................................................77
Description of the interventions ................................................................................................... 88
Methods for unit costs estimation........................................................................................... 11
Estimation of the resource needs for Malaria .................................................................... 13
Estimation of the resource needs for Dengue .................................................................... 14
Data sources ..................................................................................................................................... 15
Results ..................................................................................................................................... 15
Malaria ................................................................................................................................................ 15
Dengue ................................................................................................................................................ 17
Discussion: ............................................................................................................................. 19
IMMUNIZATIONS.....................................................................................................
Methods ...................................................................................................................................
Interventions....................................................................................................................................
Vaccines costs ..................................................................................................................................
Scaling-up ..........................................................................................................................................
Results .....................................................................................................................................
Discussion ..............................................................................................................................
NUTRITION ...............................................................................................................
19
19
19
21
23
24
24
27
Methods ................................................................................................................................... 27
Interventions and ........................................................................................................................... 27
target populations.......................................................................................................................... 27
Delivery Platforms ......................................................................................................................... 28
Results ..................................................................................................................................... 30
1. Promotion of breastfeeding and appropriate complementary feeding practices
................................................................................................................................................................ 31
2. Improved water, sanitation, and hygiene behaviors .................................................. 32
3. Prenatal micronutrient supplements ................................................................................ 33
4. Universal food fortification programs ............................................................................. 33
5. Vitamin A supplementation .................................................................................................. 34
6. Therapeutic zinc supplements ............................................................................................. 34
7. Multiple micronutrient powders ........................................................................................ 34
8. Clinical management of severe acute malnutrition (SAM) ...................................... 35
9. Fortified complementary food - Prevention/treatment of moderate malnutrition.
................................................................................................................................................................ 35
Discussion .............................................................................................................................. 36
MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH ..............................
36
Methods ...................................................................................................................................
36
1
Interventions.................................................................................................................................... 36
Costs analysis ................................................................................................................................... 37
Results ..................................................................................................................................... 37
Panama .................................................................................................................................................... 37
Mexico ...................................................................................................................................................... 38
Guatemala............................................................................................................................................... 39
Nicaragua................................................................................................................................................ 39
Discusion ......................................................................................................................................40
CONSULTED BIBLIOGRAPHY .................................................................................... 41
ANEXXES......................................................................................................................... 43
2
BACKGROUND AND INTRODUCTION
Funded by the Bill & Melinda Gates Foundation (BMGF), the Mesoamerican
Health Initiative (MHI) is a joint regional effort, which seeks to reduce health
disparities among Mesoamerican populations. To this end, MHI has
established four thematic axes according to the most relevant health
conditions in Mesoamerica, namely relating to: nutrition, maternal and child
health, vaccination and vector-borne diseases, particularly malaria and
dengue fever.
The Mesoamerican region is formed by the seven countries of Central
America (Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua,
and Panama) and the ten states of the Southeastern region of Mexico
(Campeche, Chiapas, Guerrero, Morelos, Oaxaca, Puebla, Quintana Roo,
Tabasco, Veracruz, and Yucatan). In 2008, the total population across the
Mesoamerican region was estimated to be approximately 71,785,000
inhabitants, where 41,778,000 were of Central America and 30,007,000 were
of Southeastern Mexico. The region is generally poor, but there are marked
differences in economic development and per capita income. For example,
per capita income, as defined by the World Bank, ranges from ―very low‖ in
Nicaragua (US$1.025, ranked 142nd out of 182 countries) to ―mediumlow‖ in
Panama (US$6.784, ranked 71st in the same World Bank list) (World Bank,
2009). The region is considered to be in the process of urbanization, albeit
with significant differences among countries. While Panama is 73.2% urban,
Honduras and Guatemala have the lowest proportions of urban population at
47.9% and 48.5%, respectively. The proportion of the population who is
indigenous also varies greatly among countries: 40% of Guatemala’s
population is comprised of indigenous groups, while in Costa Rica and El
Salvador, only 1.7% and 0.2% of the populations, respectively, are
indigenous.
On the other hand, there are several aspects in which the countries present
very similar characteristics — mainly related to inequalities in the access to
and quality of services available for the poor, rural populations, and
indigenous people. Health systems are chronically underfinanced and the
resources available tend to concentrate in more metropolitan areas, where the
majority of qualified health personnel also are concentrated. Additionally, due
to rapid rates of urbanization, many population groups are living in
marginalized urban areas in conditions equal to or worse than those found in
rural areas.
To address the specific components under each of the MHI axes (nutrition,
maternal and child health, vaccination and vector-borne diseases), technical
thematic groups have been formed from the following participants:
representatives from the Ministries of Health (MoH) in Belize, Guatemala,
Honduras, El Salvador, Nicaragua, Costa Rica, Panama, and Mexico;
regional and international experts in the four MHI intervention areas; and
representatives from several collaborating agencies.
To select health interventions specific to each of the four components of focus
for the MHI, extensive literature reviews were conducted in parallel to identify
evidence-based practices that have effectively been shown to be effective and
3
cost-effective. This required documenting outcomes, impacts, and the costeffectiveness of a variety of health interventions, the most promising health
interventions were then selected from what had been gathered. These
interventions were discussed extensively within the working group and with
the country representatives.
In October 2009, each of the four technical thematic groups released a master
plan according to its respective component of health and in which a series of
interventions had been proposed for scale-up as part of the MHI. The
objectives stated in the master plans are the following:




The main objective of the nutrition component is to reduce the
prevalence of maternal and child undernutrition in Mesoamerica by
supporting the evidence-based and effective implementation of
programs and regional actions. The primary target populations are
children less than 2 years of age and pregnant or breastfeeding women
who live in poor and disadvantaged households or belong to
disadvantaged populations, such as indigenous populations.
The objectives of the maternal, neonatal and reproductive health
component are to reduce maternal mortality by 75%, reduce neonatal
mortality by 50%, and achieve universal access to reproductive health
services, including family planning by the year 2015, in line with the
United Nations 2009 Millennium Development Goals (MDGs) report.
The main objective of the vaccination component is to systematically
identify the barriers to vaccination in the most vulnerable populations in
Mesoamerica and to use innovative approaches to address the barriers
in order to achieve ≥ 90% effective vaccination coverage among target
populations, as well as to decrease the burden of vaccine-preventable
diseases and childhood mortality in the most vulnerable populations.
The objectives of the vector-borne diseases component are to
eliminate local malaria transmission in the Mesoamerican Region
(southern Mexican states and all countries in Central America) and to
effectively reduce dengue transmission and mortality in Mesoamerica.
Although the master plan suggests a basic package of health interventions,
policy makers in each country must define the specific strategic plan to
allocate resources in order to cover health needs and reduce health
disparities in specific areas within their countries.
One of the critical steps before scaling-up the interventions will be to generate
information on how much additional funding is necessary to reach desired
levels of coverage and to generate information on the particular levels of
coverage that are achievable given particular amounts of resources.
A large number of studies have attempted to estimate global resource needs
for the scaling-up of health interventions aimed at meeting MDGs 1, 4, 5, and
6, which overlap with the MHI objectives. However, these single global
estimates of intervention costs are not precisely relevant to individual
countries or regions of the MHI, since global estimates for the MDGs tend to
have a greater emphasis on costs estimated for Africa and Asia, where
personnel and supply costs differ from those for the Mesoamerican region.
4
The objective of this analysis is to estimate direct incremental unit costs of the
interventions proposed for the MHI in the areas of nutrition and maternal,
neonatal and reproductive health. In the case of the vector-borne diseases
and vaccines components, we estimate incremental unit costs (taking into
account direct and indirect costs) at the time that we present preliminary
projections of the resource needs to meet the objectives.
It is important to mention that for the specific interventions proposed by the
technical thematic groups, some information required to estimate resource
needs is lacking in the master plans and initial diagnostics. For instance,
except for the vaccination component, initial coverage levels for the
interventions planned for scale-up are missing, which has introduced
difficulties in estimating the extent to which interventions need to be scaled-up
to meet the objectives. Secondly, a diagnostic tool for infrastructure
availability and capacity utilization rates is missing, which is very important to
know where and to what degree interventions can be scaled-up. Finally, there
is not a diagnostic to measure current human capacity availability, which is
also important to determine where and to what degree interventions can be
scaled-up.
During the writing of this document, it has not been possible to accurately
estimate resource needs to meet the MHI objectives in the maternal, neonatal
and reproductive health area as well as in the nutrition one. Rather, at this
time, we present estimations of the incremental unit costs for the
interventions, which is an important ingredient to estimate the amount of
additional funding required to meet the MHI objectives once the
aforementioned information is generated.
Incremental unit costs as well as direct incremental unit costs will be a very
useful ingredient for the Mesoamerican countries and potential donor for
health financial planning and for making grants when seeking additional
funding for scale-up.
This document is organized as follow. First, an overview of the costing
principles and methods that is common to the four health areas is given. Then
we present in separate sections each of the methods, results and discussion
of each health component.
PRINCIPLES OF COSTING
Direct incremental unit costs were estimated for the nutrition and maternal,
neonatal and reproductive health, while incremental unit costs were estimated
for the case of vector-borne diseases and vaccines.
In this section we overview the costing principles and methods that were
common to the four health areas.
Direct incremental unit costs
The analysis of direct incremental unit costs is concerned with marginal
changes in costs, and it assumes that overhead items, such as infrastructure,
administrative, among other overhead costs, will remain approximately the
same while scaling-up a given set of interventions. This kind of analysis is
appropriate for mobilizing resources from donors who are interested in
5
financing just the recurrent costs (no capital costs) for scaling-up
interventions, just as in this case with the BMGF. Also, it is the appropriate
analysis for when the planned level of scaling-up does not require an extra
level of infrastructure, organizational resources, and other overheads because
the organization/facility is not working at its full capacity. In contrast, using
direct incremental unit costs is not an appropriate approach when scaling-up
interventions requires a significant investment in infrastructure, administrative
staff, and other overheads. In such a case, an assessment of the required
investment in overheads would be necessary.
Incremental unit costs
The analysis of incremental unit costs is concerned with marginal changes in
costs, and it allow variations in overhead items, such as infrastructure,
administrative, among other overhead costs, while scaling-up a given set of
interventions. As apposite to the direct incremental unit costs, this kind of
analysis is appropriate for mobilizing resources from donors who are
interested in financing the total cost ofscaling-up interventions. This is the
appropriate analysis when planning to scale-up interventions that requires a
significant investment in infrastructure, administrative staff, and other
overheads.
It is also necessary to clarify that both type of analyses do not include the
costs necessary to ensure that the intervention activities are able to function
well, nor does it include health information system and monitoring and
evaluation costs. Some governance aspects, such as improving strategic
vision, accountability, transparency (including regulation), participation, and
consensus orientation, which could be required for a successful
implementation of the MHI, are not costed in the MHI.
Costing Methods Overview
For the case of the nutrition; vector-borne diseases and maternal, neonatal
and reproductive health areas, the interventions’ incremental unit costs were
obtained using an ingredients approach. In the ingredients approach, the cost
of any input to a production process is the product of the quantity used and
the value (or price) of each unit. The ingredients approach is useful for many
reasons. The most important are that it allows analysts and policy-makers to
validate the assumptions used, to judge whether estimates presented can be
applied to their settings, and, if necessary, to change some of the parameters
to replicate the analysis for their settings. All costs are expressed in terms of
2009 constant, rather than current US dollars. They therefore do not try to
project rates of inflation, but they reflect real costs.
For the case of the vaccination area, a mixed approach was used. In such
approach the costs analysis was split into two parts, vaccine costs and nonvaccine costs. The vaccine costs were estimated using an ingredients
approach, while the non-vaccine costs of scaling-up vaccination was
extrapolated to the Mesoamerican countries from published literature (more
details are given in the vaccines section).
6
Data Collection
For the nutrition; vector-borne diseases and maternal, neonatal and
reproductive health components of the MHI, the interventions in the master
plans were translated into quantities of ―ingredients‖ or quantities of inputs
(personnel time, medicines, medical supplies, etc.) directly needed to carry
out them. Such translations were obtained through structured interviews with
experts in each of the four components. To prepare the structured interviews,
literature and clinical guidelines were reviewed to get a sense of the
resources necessary for each intervention. For the maternal, neonatal and
reproductive health interventions, the quantities of ingredients were obtained
by interviewing nurses, physicians and obstetrician/gynecologists involved in
obstetric and neonatal care. For the nutrition, immunization, and vector-borne
areas, interviews were carried out with program managers in the respective
components to translate interventions into ingredients.
Once the information on quantities of ingredients was obtained, we developed
instruments for price and cost data collection (the instruments are
supplemented in separate files). In order to collect cost data from the
countries in the Mesoamerican region, these cost data collections instruments
were sent to the component-specific representatives from all of the MoHs.
Collected cost data is provided in a separate supplemented Excel file.
Data Management and Cost Estimations
Collected data were compiled and compared to form the basis of a set of
costing sheets in Excel for the different interventions. The cost of each
intervention was obtained by the sum of the products of the quantity used and
the value (or price) of each unit of inputs.
Equipment and vehicle costs were considered as capital costs in the case of
the vector-borne diseases and vaccines components. Following standard
practice, capital costs were annualized over the useful life of the factor input,
i.e. the 'equivalent annual costs' were calculated. For country-specific
analysis, the local rate of return on long-term government bonds would ideally
be used as the social discount rate for costs. For our purposes, a 3% discount
rate was used, as recommended by most economic evaluation guidelines
(Drummond et al., 1997).
All costs figures were converted to 2009 dollars using the exchange rates for
November 12, 2009 according to the different currencies within the
Mesoamerican region.
VECTOR-BORNE DISEASES
Methods
The resource and cost estimation processes detailed in this report were
conducted between September and December 2009. The main purpose of
this exercise was to calculate the needed resources to confront dengue and
malaria issues in the Mesoamerica region. All eight Mesoamerican countries
(i.e. Honduras, Nicaragua, Guatemala, Costa Rica, El Salvador, Panama,
Belize, and the southeastern part of Mexico) within the initiative were
7
considered in this report, and calculations were performed to reach effective
levels of control for dengue and malaria in the region.
Description of the interventions
Malaria
Selecting the interventions for malaria control are essentially focused on
avoiding the vector-to-human mode of transmission, as well as fighting the
effects associated with the disease. In that context, actions that would direct
the effective control of malaria, and even its eradication in the near future,
were identified. These actions were organized in four packages that differed in
terms of the combination of included interventions and the time and duration
proposed for each intervention’s application.
The design of the four intervention packages was based on the length of
malaria persistence among targeted communities, and this report on
resources is based on this structure; therefore, it is important to mention the
difference among the strata. The first stratum contains the communities that
have had seven or more years of persistence in the transmission of malaria.
The second stratum contains the communities that have had four to six years
of persistence. The third stratum corresponds to the communities that have
had a malaria persistence of two or three years. The last stratum consists of
those communities that have had one year of malaria persistence.
The four packages contain similar interventions with minor differences among
each other. The first group of actions Focalized Intensive Treatment (TFzI)
consists of offering a unique dose of malaria treatment per month for a period
of three months. At the same time of delivery as the first dose, 100% of the
houses in the community and it’s periphery will be sprayed based on the radio
of flight of the vector and the resting places of the mosquito. Another action
included in this package is the cleaning of natural breeding places, and the
application of larvicide in those places where the entomological study has
made recommendations. The delivery of insecticide-treated bednets (ITNs)
was another action included. Additionally, the working group came to a
consensus about the need of strengthening the epidemiological alertness, and
following this construction of this objective, they proposed the establishment
of a network consisting of volunteer notifiers (1 for every 100 inhabitants). In
this package, the delivery of medicines to confirmed cases of malaria and
cohabitants of the cases has been included, along with the active surveillance
of those cases by personnel of the malaria control program in applicable
countries.
The second package Focalized Treatment (TFz) includes the spraying of
100% of the houses within the community, treatment with the massive unique
dose treatment, distribution of ITNs, strengthening the epidemiological
alertness, treatment of confirmed cases and cohabitants, and additional
measures of physical control.
The Focal Treatment (TFc), the third package of actions, includes the focus
on spraying houses only where cases have been reported and have also
received treatment, in addition to strengthening the epidemiological
surveillance and evaluation of the usage of ITNs, according to the
characteristics of the community.
8
The fourth group of actions (VEE) was specifically directed to the
epidemiological and entomological surveillance alertness and the focused
treatment of detected cases. The expectation of this group was that at the
moment of implementing this package, the levels of malaria transmission
would be completely controlled and the presence of cases would be very low.
The implementation structure for these groups is depicted below in Table 1.1.
Table 1.1. Interventions for malaria: implementation structure for the
four targeted groups.
Stratum
1
TFzI
TFz
TFc + VEE
TFc + VEE
I
II
III
IV
2
TFz
TFz
TFc + VEE
TFc + VEE
3
TFz
TFz
VEE
VEE
Years
4
TFc
TFc
VEE
VEE
5
TFc
TFc
VEE
VEE
6
TFc
VEE
VEE
VEE
Dengue
Regarding dengue, the strategies were conceived in three categories:
(1) The actions of control, including: domestic hygiene promotion
(physical control measures), community participation interventions
(environmental control), elimination of disposable breeding sites
(clean-up campaigns), control of breeding sites (application of
chemical or biological agents), insecticides spraying (focalized in
areas where cases have been confirmed), emergency control
(aerial spraying of insecticides in outbreak situations);
(2) The adequate management of severe cases by strengthening
clinical capabilities of health personnel to adequately identify and
treat severe dengue cases, which is the most appropriate
intervention to prevent premature mortality (lethality) by dengue
infection.
(3) Definition of surveillance and control interventions by stratifying the
levels of risk and population size. Control interventions are
implemented according to the population size (< 100,000, 100,000
to 350,000, and >350,000) into:

Basic: passive surveillance, community participation (CP) and health
promotion (HP) with local resources

Selective: active surveillance, CP, HP, elimination and control of
productive breeding sites, focalized treatment of areas with
transmission

Integrated and intensive: active surveillance, early case detection, CP,
HP, elimination and control of productive breeding sites before and
after transmission cycles, focalized treatment of areas with
transmission, use of ovitraps, entomological surveys to measure the
impact of control
9
According to level of risk, localities are defined as:

Low-risk: occasional dengue transmission

Moderate-risk. Irregular dengue transmission

High-risk: frequent dengue transmission, concentration of more than
50% of cases, detection of severe dengue
The package of interventions is organized to universally cover all areas at-risk
with at a minimum of actions: community participation schemes,
environmental control and elimination of breeding sites, and clinical
management of cases. As the risk increases, the type and intensity of the
interventions proposed in lower risk areas does as well. For example,
elimination of breeding sites in high-risk areas will be performed before,
during, and after the transmission period, while in moderate- and low-risk
areas, it will be performed only before the transmission period. The idea
behind the strategy to intensify the elimination of breeding sites after the
transmission period was to decrease the risk of vertical transmission to
emerging adult female mosquitoes that could reignite transmission early in the
next season. In the same sequence, the use of insecticide spraying with ultralow volume (ULV) was restricted to high-risk areas and areas with intensive
transmission, regardless of their risk situation.
The organization for detecting dengue cases by levels of risk was based on
the passive surveillance of suspected cases already in place in the low-risk
areas and was supported by the health reports of health units and under the
notification rules within each country. The detection of cases in moderate-risk
areas will be supported by the establishment of febrile clinics in an attempt to
detect early cases of dengue, especially in areas classified as high-risk by
entomological surveys. In high-risk areas, case detection activities will be
intensified once a case is confirmed within 100 to 300 meters around the
suspected index case.
Community participation and health promotion
Community involvement and health promotion strategies will be an essential
component of the vector control activities, especially in the low- and
moderate- risk areas where other interventions will not be so intensive. It is
expected that community participation will be modulated by the entomological
environment and intensified according to the transmission period. Emphasis
should be established before the transmission period starts in order to
decrease the availability of breeding sites before the rainy season. Health
promotion will guide the community as to what activities must be performed in
order to tackle the main breeding sites and to identify the warning signs that
correspond to increased risks of severity for dengue infection.
Environmental control of breeding sites
Multisectorial involvement will be required to tackle the main determinants of
dengue breeding environment. Besides the health sector, municipal and
government agencies responsible for urban planning must be incorporated
into discussions in order to recover urban public spaces and reduce the
breeding potential in urban centers by improving basic urban infrastructure
and the provision of regular potable water.
10
Elimination and control of breeding sites
Efforts toward the control of larval densities are focused on the threshold of
less than 1% of households with breeding mosquitoes in order to reduce
transmission risks. These levels of control are not attainable in all countries,
nor in every urban center or city in the region. Therefore, the strategy
proposes to concentrate the control efforts toward targeting the most
productive breeding sites and eliminating risks of disposable breeding. These
activities should be performed before the transmission cycle and the rainy
season in the low- and moderate-risk areas and intensified in the high-risk
areas before, during, and after the transmission cycle in order to reduce the
vector densities all year long and prevent the vertical transmission into the
next season.
Focalized treatment
Evidence demonstrates the clustering of dengue transmission in the early
stages of the epidemic and around the first index cases; therefore, the
strategy considers the performance of intensive control actions around index
cases and the houses surrounding such cases in order to decrease dispersal
of transmission on a local and regional basis. Actions must be performed at
the earliest detectable moment possible for a suspected or confirmed case,
and the actions that must be performed include spraying of households,
elimination and control of breeding sites, intensive search for febrile cases
until confirmation in an area within 100 to 300 meters of a care depending on
the ability of detection (the shorter distance, the earlier the detection). The
minimum distance has been determined to be at least 9 blocks surrounding
the index case.
Spatial spraying and use of ovitraps
Aerial spraying with ULV machines and vehicles is proposed in outbreak
situations and once the interventions for control have proved inefficient. Use
must be restricted to high-risk areas and in situations that outreach local
resources. Ovitraps must be incorporated in high-risk areas to evaluate the
impact of all interventions performed especially when insecticide spraying is
used.
Clinical management of cases includes upgrading skills of health personnel to
identify and treat dengue cases. Issues included in the costing exercise are
laboratory tests for serology and treatment costs in primary health centers as
well as the costs for hospitalization of severe cases.
Methods for unit costs estimation
Cost data were collected and analized using an ingredients-based costing
methodology based on Mexican Vectors Program guidelines (Centro de
control de Enfermedades Transmitidas por Vectores-CENAVECE). The
interventions were translated into input types and quantities by an expert
consultant and the personnel working on the programs of dengue and malaria
in Mexico.
To account for the likely variability between countries in aspects, such as,
inputs combination used to implement the interventions and prices/costs of
such inputs, two questionnaires were designed, one for dengue and one for
11
malaria to explore local quantity and price of every input used to implement
the interventions (see supplemented files 1.1 and 1.2). Both questionnaires
underwent a pilot test under the responsibilities of the national program for
malaria and dengue, respectively, with both programs in correspondence with
the person in charge of the vectors program in Morelos, Mexico. Finally, these
questionnaires were sent by e-mail to those responsible for the vector control
programs in each country. In addition to the detailed questionnaires and to
assess the costs for activity inputs, it was requested that each country fill out
a form to register the purchase prices for each of the resources used in the
activities.
The calculations estimated for all the interventions were assumed to have a
pyramidal structure formed by brigades, in which the basic unit is the
promoter or technician of the program who functionally assumes the rolls of
seeking the assets for the infected cases, as well as finding the trainer of
volunteers who will notify the community in which he/she works, motivating
the community to undertake measures to avoid contact with the vector and to
obtain appropriate attention for an individual presenting any symptoms that
suggests the presence of dengue or malaria. The pyramidal structure also
includes the brigades’ functions that are related to applying insecticide both
inside and outside the domicile and supporting the community activities to
physically control the vector.
Brigades for intervention cost estimates integrate four technicians led by one
brigade commander. The brigades are grouped by sector and a head of the
sector leads each sector. Over the sector is the district head, which is
responsible for the supervision of all four sectors. These considerations were
taken while estimating the unit costs and served to prorate those resources,
and although, they are not a direct part of the cost of the interventions, they
are essential to the accomplishment of activities.
Regarding personnel compensation, all workers were considered to have
effectively worked seven hours a day for 220 days per year. For the
estimation of the intervention costs, activities were identified that may contain
two or more tasks. For example, the physical treatment for breeding zones
includes two big activities. First, communal meetings take place in which
training and motivation is provided to the inhabitants of the community so that
they understand the importance of their participation in the interventions. The
second activity corresponds to the cleaning, which includes
hydroentomological recognition of the affected zone, pre- and post-cleaning
surveys and the cleaning itself of the breeding place.
The estimation of costs of the interventions considered three groups of inputs:
personnel costs, such as the salaries of the applier and the brigade leader
among other personel; capital costs, which include the costs related to
furniture and equipment, such as vehicle, machines for the application of the
insecticide; and supplies, which includes insecticide, gasoline, and medicines.
The costs attributable to the payment of per diem were included under the
category for other items. The prices/costs of the items used in the analysis
correspond to the average of those reported by the countries. Information on
input costs was requested to all the countries in the Mesoamerican region,
however we just got data from Costa Rica, Guatemala and Mexico.
12
Therefore, the average includes data from Costa Rica and Guatemala, in
addition to the following reports from Mexico: the CENAVECE, the state of
Morelos, and the cities of Tapachula and Tuxtla Gutiérrez in the state of
Chiapas, Mexico.
Capital costs were discounted at a rate of 3%. The analysis was performed
from the perspective of the financer, and the estimations are annual.
The populations at which the interventions were directed, which are the
populations at risk, are presented in Tables 1.2 and 1.3.
Table 1.2. Mesoamerica dengue epidemiology situation
Country
Risk
population
Households
Belize
177,591
Costa Rica
3,793,146
El Salvador
4,417,610
Guatemala
3,374,626
Honduras
5,072,228
Mexico
24,075,769
Nicaragua
5,234,876
Panama
2,655,920
Source: PAHO 1999-2008.
Average annual
suspected cases
39,465
842,922
981,691
749,917
1,127,162
5,350,171
1,163,306
590,204
54
11,754
7,448
5,293
17,888
23,354
4,685
2,063
Severe
dengue
cases
0
55
128
18
973
2,228
266
3
Confirmed cases
7
264
6,827
931
462
16,987
1,140
654
Table 1.3. Mesoamerica malaria epidemiology situation
Country
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Risk population
Households
227,477
1,595,907
2,226
825,351
809,125
1,898,142
505,119
479,914
71,259
450,165
673
250,443
244,489
388,289
145,762
152,890
Average annual
cases
746
1,693
38
17,900
997
1,880
1,745
1,745
Source: data provided by the national programs
Estimation of the resource needs for Malaria
The element that most influence the estimation was the specific stratum in
which the communities have been organized. The households located in
communities from the first stratum will be treated with intra-domiciliary
spraying during the first four years of the execution of the project, and in the
last two years, only 10% of the households will be sprayed. Additionally, for
resource estimation, the first year, which will be the most intensive for this
stratum, was the only year that accounted for the recruitment and training of
one voluntary notifier per 100 inhabitants. Because the estimation of active
surveillance resources included treatment for all malaria cases and the their
cohabitants, each household with a malaria case was estimated to have five
persons (at least 4.5 cohabitants per case). Also in the first year, resources
were counted so that 100% of the inhabitants were treated with a unique dose
every three months. For years 2, 3 and 4, the amount of resources were
associated with offering this treatment to 50% of the inhabitants, and 15%, in
the last two years. The resources for treating breeding places were estimated
under the assumption of each community having three breeding places. For
13
the resource estimation, during the six-year duration of the project, resources
were accounted for the plans to physically treat all breeding sites, including
chemical treatment of 50% of them during the first year of project
implementation.
The last element considered in the estimation of resources for the malaria
activities was the distribution of two ITNs for 80% of the houses within the
communities.
The resource estimations for the residing population in localities categorized
in Stratum II assumed that 100% of households would be treated with intradomiciliary spray during the first three years, 10% in the fourth and fifth years,
and given that the previously described package focuses on epidemiological
surveillance, for the sixth year, the spraying of houses was not considered.
The criterion for estimating resources for recruiting and training notifiers was
similar to that of the previous stratum, where total resources were calculated
for the first year of execution and for each 100 inhabitants having one notifier.
The criterion for the active search of cases, as well as treating cases with
unique dose, was similar to that of Stratum I, differing only in that in this
stratum, it was assumed that this strategy was highly effective and that no
more than 6% of the population presented an event associated with malaria.
Additionally, the resource estimations for the physical treatment of the
deposits was the same as that in Stratum I; however, since this stratum did
not consider chemical handling, this intervention was not considered in the
estimation. Regarding the distribution of ITNs, the method for resource
estimation was similar to that explained for Stratum I.
In Stratum III, all the houses of the localities were sprayed during the first two
years. Similar to Strata I and II, the recruitment and training of a volunteer
notifying per hundred inhabitants were included in the estimation. As for the
active search for cases, in addition to the administration of single-dose
treatments during the first 2 years, 100% of the awaited cases and their
cohabitants were accounted for in the resource estimation. To obtain the
expected cases, the average of registered cases in the past three years was
used, and similar to the previous strata, 4.5 cohabitants per case was
assumed. In years 3 to 5 of implementation, an annual reduction of 70% is
expected, and 80%, between the fifth and sixth years. The treatment of
deposits is similar to the previous stratum, and, additionally, no ITNs will be
distributed among the inhabitants of these localities.
Estimation of the resource needs for Dengue
Estimation of resource needs for dengue control was established by taking
the population in each locality and deriving the number of households with
the assumption that each household has 4.5 cohabitants. Since the total
number of dengue cases per locality and year for a 5-year period was not
available, an average of the annual cases per year for each country was
taken to estimate the resources needed for surveillance, control, and clinical
management. According to epidemiological records and statistics published,
we distributed the proportion of cases to the various risk levels in the following
way: 70% in high-risk areas, 20% in moderate-risk, and 10% in low-risk areas.
All estimates were performed according to this proportion.
14
Community participation and health promotion interventions were estimated
by combining a set of strategies performed in a community, and the overall
estimate of this package of activities was then attributed to every 50,000
people receiving the package twice a year.
The control activities were estimated by dengue cases within a target area of
200 households as the basic parameter of the interventions. Control activities
were estimated according to the distribution of cases by levels of risk. Aerial
spraying was only estimated for moderate- and high-risk areas in the case of
an epidemic. Intra-domiciliary spraying was estimated for moderate- and highrisk areas depending on the proportion of cases.
Serological estimates for the minimum number of tests performed by country
per year were derived from the number of suspected cases or the proportion
of cases confirmed. Isolation tests were estimated by taking only 10% of the
confirmed cases. The number of blood count tests was estimated based on
the number of tests for all dengue hemorrhagic fever cases at three tests for
every DHF case.
Data sources
The input prices used in this analysis were obtained from the reports of three
countries: Costa Rica, Guatemala, and Mexico. The information regarding the
useful life of the capital goods was obtained either directly from the countries
or from the WHO-CHOICE database (WHO-CHOICE, 2009).
As we are projecting resource needs over a period of 6 years in the future, it
is important to express the resource needs for each year in prices of that year.
Therefore, the rates of inflation were obtained from official agencies, such as
central banks and offices of statistics representative of the country under
view.
Epidemiological and geographical information (e.g. whether a locality was
marshy, presence of dengue, geographical and population sizes, number of
households, cases) were provided by the countries representatives and by
PAHO.
Results
Malaria
Table 1.4 shows the unit costs for the malaria control interventions. The
chemical treatment of the deposits was the most expensive activity, followed
by the physical handling of deposits. Although this activity is community-led, it
requires the support of program personnel and the participation of the
promoter of the program in the verification surveys (pre- and post-cleaning of
deposits), which was the element that most influenced the cost of this activity.
The third most expensive activity was that of intra-domiciliary spraying.
Treatment by unique dose was the cheapest activity, costing only US$1.40.
15
Table 1.4. Unit cost of Malaria control interventions
Intervention
Control interventions
Chemical control breeding
places*
Intradomiciliar spraying
Insecticide treated nets
Community participation
interventions
Recruitment and training of the
voluntary notifiers
Physical control breeding places
Treatment interventions
Suppressive treatment
A unique dose treatment
Expression of unit costs
Cost in US$
Cost per breeding chemically
treated
Cost per household treated
Cost per net distributed
30.5
Cost per notifier
14.6
Cost per breeding physically
treated
24.9
Cost per suspected case
treated
Cost per confirmed case treated
0.8
23.1
9.5
1.4
*Its does not included the hydroentomologicol recognition, which has a cost of US$11.90.
Table 1.5 shows the estimated amount of resource needs for controlling
malaria in the region of Mesoamerica by intervention type across the six years
that the project is foreseen to last. The analysis by country indicates that the
greatest percentage of the total resource needs corresponds to Mexico,
possessing 32% of the total resources, followed by Honduras and Guatemala
with 23% and 21% of the total amount, respectively. Corresponding with just
0.1% of the total resources, El Salvador possessed the smallest percentage,
though this is dependent on the malaria eradication situation in the country.
The distribution of resources by activity, also shown in Table 1.5, depicts how
the major proportion of resources, more than the 89% of the total, will be
destined to household spraying, an activity that has been identified as highpriority to prevent human-vector contact.
Table 1.5. Resource needes to control malaria in Mesoamerica by country and
by intervention (US$ thousands)
Intradomi
ciliar
spraying
13,816.6
Recruitme
nt and
training of
the
voluntary
notifiers
73.0
Active
surveillan
ce
11.8
A unique
dose
malaria
treatment
522.4
Physical
control
breedingplaces
346.6
Chemical
control
breedingplaces
4.5
Impregnat
ed nets
923.1
Total
15,697.9
Costa Rica
El
Salvador
16,357.3
261.7
24.2
355.9
52.5
0.1
475.9
17,527.5
4.4%
221.9
0.3
0.5
8.5
6.2
0.3
11.9
249.7
0.1%
Guatemala
72,609.1
125.0
223.4
3,079.7
2,118.6
29.0
4,063.6
82,248.3
20.7%
Honduras
81,301.9
127.9
137.4
3,476.8
2,418.2
95.0
4,195.2
91,752.2
23.1%
115,430.5
339.9
37.6
5,087.4
3,249.2
23.6
4,420.1
128,588.3
32.4%
15,615.2
36,712.5
81.2
72.1
25.2
22.1
541.8
1,346.0
674.2
2,162.8
12.1
27.0
764.2
2,462.0
17,713.9
42,804.6
4.5%
10.8%
352,065.0
88.8%
1,081.1
0.3%
482.2
0.1%
14,418.5
3.6%
11,028.2
2.8%
191.6
0.0%
17,315.9
4.4%
396,582.5
Country
Belize
Mexico
Nicaragua
Panama
Total
%
Table 1.6 shows the estimates of resource needs by year across countries.
Given the structure of the project, which possesses an intensive phase in the
16
%
4.0%
first year, the largest percentage of the resources (25.3%) should be applied
in the first year, 68% in years 2, 3, and 4. The smallest percentage (3.4%)
corresponded to year 6 of activities, when actions are focused on
epidemiological and entomological awareness.
Table 1.6. Resource needs to malaria control in Mesoamerica for country
and type of intervention (US$ thousands)
Country
Belize
Costa Rica
El Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Total
%
1
5,041.3
6,221.1
64.4
22,035.0
22,681.3
26,090.3
4,939.1
13,221.6
100,294.2
25.3%
2
4,310.7
6,221.6
55.0
18,750.3
20,060.3
26,541.0
4,586.4
11,496.9
92,022.3
23.2%
Year
3
4,225.8
2,763.1
56.6
18,944.1
21,166.8
29,891.1
4,003.9
11,639.6
92,690.9
23.4%
4
1,400.1
1,721.7
59.2
17,670.2
21,686.2
34,428.0
3,097.7
4,047.8
84,111.0
21.2%
5
531.7
376.9
7.1
2,500.3
3,034.8
5,406.1
618.9
1,671.3
14,147.1
3.6%
6
188.2
223.1
7.4
2,348.4
3,122.8
6,231.8
467.9
727.4
13,317.0
3.4%
Total
15,697.9
17,527.5
249.7
82,248.3
91,752.2
128,588.3
17,713.9
42,804.6
396,582.5
The distribution for strata (shown in Table 1.7) shows that 79.5% of the
resources will be used for Stratum I, 17% for II, and the remaining 3.5% for
Stratum III.
Table 1.7. Resource needs to control malaria in Mesoamerica by country
transmission levels (US$ thousans)
Country
Belize
Costa Rica
El
Salvador
Guatemala
Honduras
Mexico
Nicaragua
Panama
Total
%
Stratum I
US$x1000
%
4,388
1.4%
5,959
1.9%
250
74,715
87,427
118,845
11,439
12,191
315,213
79%
0.1%
23.7%
27.7%
37.7%
3.6%
3.9%
100%
Stratum II
US$x1000
%
10,794
16.0%
4,235
6.3%
7,245
4,057
6,353
4,446
30,292
67,422
17.0%
0.0%
10.7%
6.0%
9.4%
6.6%
44.9%
100%
Stratum III
US$x1000
%
516
3.7%
7,333
52.6%
Total
US$x1000
15,698
17,528
0.0%
2.1%
1.9%
24.3%
13.1%
2.3%
100%
250
82,249
91,753
128,589
17,714
42,805
396,583
289
268
3,391
1,830
321
13,947
3.5%
Dengue
Table 1.8 shows the results on unit costs for the interventions considered for
the effective control of dengue throughout the region of Mesoamerica. The
promotion activities, which include diverse and directed actions for obtaining
active participation of the community in the control of dengue, were the most
expensive, totaling up to US$2,307 in a community of 50,000 inhabitants.
The hospitalization costs of patients with hemorrhagic dengue were the
second most expensive intervention with US$116.30.
Table 1.8. Unit costs for dengue interventions in the Mesoamerica region
Intervention
Expression of unit costs
Cost in US$
17
Vectors control interventions
Intradomiciliar spraying
Space spraying
Household larval control
Diagnosis inteventions
Virus isolated
Serology
Hematology biometry
Community participation
interventions
Promotion
Treatment interventions
Ambulatory health care
Inpatient health care
Cost per household controlled
Cost per hectare treated
Cost per household controlled
1.92
5.95
1.65
Cost per laboratory test
Cost per laboratory test
Cost per laboratory test
7.65
25.59
5.1
Cost per package by 50,000
people twice a year
2,307.15
Cost per case treated
Cost per severe case treated
35.08
116.32
According to the results, the accomplishment of the dengue control activities
requires an investment of US$63.3 million per year, of which approximately
63% of costs correspond to Mexico (See Table 1.9). Excluding Mexico, the
total amount of resources required drops to US$23.7 million per year, with
Nicaragua requiring approximately 21% of the total require investment.
Table 1.9. Annual resources needed to confront dengue in Mesoamerica
by country and by intervention (US$ thousands)
Intradomicil
iar spraying
Costa
Rica
El
Salvador
Guatema
la
Hondura
s
Mexico
Nicaragu
a
Panama
Belice
Total
%
Space
sprayin
g
Househo
ld larval
control
Virus
isolate
d
Serolo
gy
Hematolo
gy
biometry
Promoti
on
Ambulato
ry health
care
Hospitala
ry health
care
Total
%
811.4
0.0
2,264.9
0.0
61.5
0.2
71.2
82.5
1.3
3,293.0
5.2%
1,513.9
41.2
2,283.8
2.9
201.0
1.1
71.8
143.7
8.2
4,267.5
6.7%
81.2
0.0
3,939.1
0.1
17.5
0.0
123.9
20.4
0.2
4,182.4
6.6%
459.5
135.3
3,006.5
0.2
38.6
10.0
94.5
42.0
75.8
19,167.6
280.0
15,696.7
12.7
1,765.0
33.4
493.5
1,835.4
254.0
3,862.5
39,538.
3
6.1%
62.5
%
1,203.9
530.1
1.5
130.5
70.2
0.0
3,245.2
2,311.6
115.8
0.6
0.3
0.0
102.9
46.6
0.1
2.8
0.0
0.0
102.0
72.7
3.6
113.4
48.5
0.1
21.4
0.2
0.0
7.8%
4.9%
0.2%
23,769.1
37.6%
657.2
1.0%
32,863.5
51.9%
16.9
0.0%
2,233.2
3.5%
47.5
0.1%
1,033.3
1.6%
2,286.1
3.6%
361.1
0.6%
4,922.6
3,080.3
121.1
63,267.
8
Table 1.10 that the at-risk localities with populations between 100,000 and
350,000 inhabitants will need US$32.6 million per year, an amount equivalent
to 52% of the total necessary resources per year to anticipate and fight the
consequences of the fastidiousness in the entire region. Nevertheless, after
excluding Mexico, the total resource needs drops to US$23.7 millions. In both
scenarios, the stratum for high-risk populations needed the largest percentage
of resources (70% including Mexico and 57.5% without Mexico) (Table 1.11).
Table 1.10. Annual resources needed for dengue control in Mesoamerica
by level of risk and by population (US$ thounsands)
Localities size/Risk
<100,000
inhabitants
100,000 to 350,000
inhabitants
>350,000
inhabitants
Total
Low risk
Moderate risk
501
High risk
Total
2,073
2,574
5,949
4,250
22,399
32,597
6,057
12,506
2,213
6,463
19,827
44,298
28,096
63,268
Table 1.11. Annual resources needed to dengue in Mesoamerica by level
of risk and by population, excluding Mexico (US$ thounsands)
18
Localities size/Risk
<100,000
inhabitants
100,000 to 350,000
inhabitants
>350,000
inhabitants
Total
Low risk
Moderate risk
0
High risk
Total
121
121
2,895
3,332
3,691
9,918
3,867
6,761
0
3,332
9,824
13,636
13,691
23,729
Discussion:
The results shown in the present study, aimed at informing the initiatives with
the goals of achieving an effective control of dengue and malaria, has
estimated that an annual investment of US$129.4 million will be required, of
which 51.1% will be needed for the control of malaria.
The country that pulled a considerable proportion of these costs was shown to
be Mexico, and by excluding Mexico from the analysis, the investment total
was reduced to US$68.4 million per year. By including malaria control
activities and excluding dengue control activities for Mexico, the required
annual total was shown to be US$89.8 million. The average cost per
inhabitant comes out to be US$10.40 for malaria and US$1.30 for dengue.
When excluding Mexico, the average cost per inhabitant is reduced to
US$7.50 dollars for malaria and US$0.95 dollars for dengue.
It was intended that unit costs be estimated for each country to calculate
estimations with a high level of precision and specificity, while taking into
consideration the national production factors and the national prices for the
production factors. Though general parameters exist, contents in the guides of
the international organizations (e.g. WHO, PAHO) and operation forms in
reality differ among countries, which is to be expected. Nevertheless, the few
resource and cost responses from the countries detailed in this report
prevented the attainment of this objective, which is why these resource
estimations by country may not reflect the necessities of each country in an
individual way. However, since the strategy is focused on the Mesoamerican
region and does not distinguish results by country, the exercise complies with
the fundamental purpose of informing stakeholders the total resource
requirements in the region to effectively control the effects of dengue and
malaria.
IMMUNIZATIONS
Objective: To estimate resource needs to reach 95% vaccination coverage
rates for the following biological vaccines in the Mesoamerica region: BCG1,
DPT3, HepB3, Hib3, Sabin2 or IPV2, MMR1, PCV7-2 and Rotavirus2.
Methods
Interventions
The Immunizations Working Group proposed a set of interventions in three
different lines of action: (1) pilot projects to fill gaps in knowledge; (2)
strengthening immunization policy; and (3) implementation of evidence-based
practices. These lines of action are based on the idea that pilot projects can
be used along with policy advancements to scale-up interventions through the
19
use of data-driven decision making. Taken from the master plan, Table A1 in
the Annex shows the proposed effective practices or interventions, the
process for implementation, geographical context, target population(s), scale,
countries where practices were implemented, and sources for information.
At the time of writing this report, there was not enough information to cost the
pilot projects for filling key gaps in knowledge, since the policymakers in
Mesoamerica together with technical experts had yet to determine the type
and scope of pilot projects appropriate for their countries. The same can be
said with respect to interventions aimed at strengthening immunization policy.
Based on this, this report only estimates the incremental costs for reaching
95% vaccination coverage rates for the following biological vaccines in the
Mesoamerica region: BCG1 (Bacille Calmette-Guérin), DPT3 (diphtheria,
pertussis, and tetanus), HepB3 (Hepatitis B), 3 Hib (Haemophilus influenzae
type B), OPV2 (oral polio vaccine, also known as the Sabin vaccine) or IPV
(inactivated polio vaccine), MMR1 (measles, mumps, and rubella), PCV7-2
(heptavalent Pneumococcal conjugate vaccine) and Rotavirus2.
The estimated costs included vaccine costs and scale-up costs for cold chain
supplies, training and supervision, vehicles and transport, social mobilization,
surveillance, monitoring and evaluation (M&E), waste management,
personnel, and overhead costs.
Vaccines costs included the costs for all the vaccines used in the national
immunization program and were based on each country’s vaccination
schedule for BCG1, DPT3, HepB3, Hib3, Sabin2 or IPV, and MMR1,vaccines
as well as vaccines that will be newly adopted into the schedule, PCV7-2 and
Rotavirus2. The vaccine costs included the vaccine price as purchased
through the PAHO Revolving Fund (PAHO, 2009). Cold chain equipment
costs included the annual capital cost of existing and newly purchased cold
chain equipment specifically used for the purpose of the National
Immunization Program. These costs typically consisted of the costs for
freezers, refrigerators, cold boxes, and vaccine carriers. Training costs
included short-term, in-service training expenditures for immunization
activities that were reported to occur on a regular basis for any type of health
staff involved (e.g. introductory training for new vaccines, injection safety,
logistics, vaccine management). Vehicles costs included the annual value of
existing vehicles that were being used specifically by the National
Immunization Program. These typically consist of cars, four-wheel drive
trucks, motorcycles, bicycles, and/or boats. Transport costs included the
costs related to the operations and maintenance of vehicles for the delivery of
vaccines, supplies, and immunization services (e.g. fuel). Social
mobilization/IEC (information, education and communication) costs included
all spending on social mobilization activities and materials for IEC regarding
the benefits of immunization. Disease surveillance and monitoring: costs
captured all spending for disease surveillance, as well as supervision and
monitoring activities. Personnel costs included the salary and benefits of fulltime and program-specific personnel involved with the organization and
delivery of immunization activities. Personnel costs also included per-diems
and other incentives for service delivery and outreach activities. Maintenance
and overhead costs included the maintenance costs of cold chain equipment
and building overhead costs (e.g. electricity).
20
Vaccines costs
Vaccines were estimated as ―bundled‖ costs for the purchased prices through
the PAHO Revolving Fund. These costs covered safe injection supplies, such
as, syringes and safety boxes. Adjusted for wastage based on vial sizes,
shipping and freight were also included as a percentage of the price per dose
as done by Wolfson et al. (2008), as shown in Table 2.1. Costs for disposable
items (e.g. syringes, safety boxes) were based on 2005 international prices
assuming 10% wastage for the auto-disposable syringes, reconstitution
syringes, and safety boxes.
Table 2.1. Vaccine costs
Price per dose, US$ of
2009
0.1054
0.158
3.45
3.6
Average vaccine wastage
rate (%)**
% of vaccine price
charged for freight
Average vaccine wastage
rate**
BCG
DTP
50
0.7
DTP-Hib
30
1.5
DTP-Hepatitis B-Hib
15
5.8
DTP-IPV-Hib
10
5.5
OPV
0.17
IPV
30
1.1
Measles / MMR
0.92
Hep B
0.2679
40
7.3
Hib
3.45
27.7
0
Rotavirus
5.5
15
9.5
Measles &Rubella
0.51
5
6
PCV7
21.75
40
7.3
Varicella
9.365
5
2.5
Hep A
7.3963
*/Prices for Vaccines Purchased Through the PAHO Revolving Fund, 2009. Source: IMMUNIZATION
NEWSLETTER, Volume XXXI, Number 1, February 2009
**/ taken from Bulletin of the World Health Organization 2008;86:27–39
For each vaccination strategy, the required number of doses was based on
the appropriate target population (in this case, newborns), combined with the
gap between current and desired coverage levels for each Mesoamerican
country, where desired coverage rates were set at 95%. Table 2.2 shows the
current immunization coverage rates by country. Since rotavirus and
pneumococcus vaccines were recently introduced in Honduras, Mexico and
Nicaragua and pneumococcus in Panama, we assumed that the current
coverage rates were 50% for both rotavirus and pneumococcus vaccines
based on recent estimations from Mexico. Table 2.3 shows the projected
number of newborns that would remain unvaccinated if the vaccination
coverage rates are maintained at these levels. Table 2.4 shows the additional
number of newborns that should be reached to achieve 95% coverage rates
for all the biological vaccines of interest.
Table 2.2. Vaccination coverage rates in the Mesoamerican countries,
2005
21
Belize
Costa
Rica
El
Salvador
Guatemala
Honduras
México
Nicaragua
Panamá
Coverage
BCG
96
88
84
96
91
99
99
99
Polio3
96
91
89
92
91
98
87
86
DPT1
97
89
89
99
88
99
92
95
DPT3
96
91
89
92
91
98
86
85
Hib3
96
89
89
39
91
98
86
85
Hep B3
96
90
89
39
91
98
86
85
MMR
95
89
99
93
92
96
96
99
MMR2
87
…
87
NA
NA
97
NA
89
BCG:
bacille Calmette-Guérin (anti-tuberculosis vaccine)
Polio3: third dose of polio vaccine (oral polio vaccine or inactivated polio vaccine)
DPT1:
first dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
DPT3:
third dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
Hib3:
"third dose of Haemophilus influenzae type b (Hib) vaccine (as monovalent Hib or combination vaccine)"
Hep B3: third dose of hepatitis B vaccine (as monovalent hepatitis B or combination vaccine)
MMR:
first dose of measles, mumps, rubella vaccine
MMR2: second dose of measles, mumps, rubella vaccine (when offered in the routine program)
Source: PAHO, Immunization in the Americas, 2006 summary. Available at
http://www.paho.org/English/AD/FCH/IM/IMBrochure_2006.pdf
Table 2.3. Projected number of newborns uncovered by vaccination (in
thousands)
Belize
Costa
Rica
El
Salvador
Guatemala Honduras México* Nicaragua Panamá
Total
Total
1
newborns
7.0
79.5
165.6
438.1
206.9
601.8
153.9
70.1
1722.9
BCG
0.3
9.5
26.5
17.5
18.6
6.0
1.5
0.7
80.7
Polio3
0.3
7.2
18.2
35.0
18.6
12.0
20.0
9.8
121.2
DPT1
0.2
8.7
18.2
4.4
24.8
6.0
12.3
3.5
78.2
DPT3
0.3
7.2
18.2
35.0
18.6
12.0
21.5
10.5
123.4
Hib3
0.3
8.7
18.2
267.2
18.6
12.0
21.5
10.5
357.2
Hep B3
0.3
8.0
18.2
267.2
18.6
12.0
21.5
10.5
356.4
MMR
0.4
8.7
1.7
30.7
16.6
24.1
6.2
0.7
88.9
BCG:
bacille Calmette-Guérin (anti-tuberculosis vaccine)
Polio3: third dose of polio vaccine (oral polio vaccine or inactivated polio vaccine)
DPT1:
first dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
DPT3:
third dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
Hib3:
third dose of Haemophilus influenzae type b (Hib) vaccine (as monovalent Hib or combination vaccine)
Hep B3: third dose of hepatitis B vaccine (as monovalent hepatitis B or combination vaccine)
MMR:
first dose of measles, mumps, rubella vaccine
MMR2: second dose of measles, mumps, rubella vaccine (when offered in the routine program)
*/ includes just the newborns from the 10 states within the mesoamerican health initiative
1/Source: PAHO, Immunization in the Americas, 2006 summary. Available at
http://www.paho.org/English/AD/FCH/IM/IMBrochure_2006.pdf
Table 2.4. Number of newborns who need to be covered to reach 95%
coverage rates by vaccine
Costa
El
Belize
Rica
Salvador Guatemala Honduras México* Nicaragua Panamá
Total
BCG
0.0
5.6
18.2
0.0
8.3
0.0
0.0
0.0
32.1
Polio3
0.0
3.2
9.9
13.1
8.3
0.0
12.3
6.3
53.2
DPT1
0.0
4.8
9.9
0.0
14.5
0.0
4.6
0.0
33.8
DPT3
0.0
3.2
9.9
13.1
8.3
0.0
13.9
7.0
55.4
Hib3
0.0
4.8
9.9
245.3
8.3
0.0
13.9
7.0
289.2
Hep B3
0.0
4.0
9.9
245.3
8.3
0.0
13.9
7.0
288.4
MMR
0.0
4.8
0.0
8.8
6.2
0.0
0.0
0.0
19.7
BCG:
bacille Calmette-Guérin (anti-tuberculosis vaccine)
Polio3: third dose of polio vaccine (oral polio vaccine or inactivated polio vaccine)
DPT1:
first dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
DPT3:
third dose of diphtheria-pertussis-tetanus vaccine (as DPT or combination vaccine)
Hib3:
third dose of Haemophilus influenzae type b (Hib) vaccine (as monovalent Hib or combination vaccine)
Hep B3: third dose of hepatitis B vaccine (as monovalent hepatitis B or combination vaccine)
MMR:
first dose of measles, mumps, rubella vaccine
*/ includes just the newborns from the 10 states within the mesoamerican health initiative
Table 2.5 shows the current vaccination schedules for each of the
Mesoamerican countries. As depicted in the table, different countries in the
22
region use different combination vaccines. To achieve 95% coverage rates
for each biological, this suggests that different countries will be required to
buy different vaccines, respective of their schedules. For example, all
countries except Costa Rica, use the combined vaccine DTP-Hepatitis B-Hib,
while Costa Rica uses separate DTP, Hepatitis B and Hib vaccines.
Table 2.5. National immunization schedules for all Mesoamerican
countries
BCG
DTP
DTP-Hib
DTPHepatitis
B-Hib
DTP-IPVHib
OPV
IPV
Measles /
MMR
Hep B
Mexico
2009
NB
Guatemala
2007
NB
Belize
2008
NB
El
Salvador
2007
NB
Honduras
2008
NB
Nicaragua
2007
NB
4y
1.5y,5y
4 years
1.5y,4y
1.5y,4y
1.5y
2m,4m,6m
2m,4m,6
m
2m,4m,6
m
2m,4m,6
m
2m,4m,6m,
1.5y,4y
2m,4m,6
m, 4y
2m,4m,6
m,1.5y,4y
2m,4m,6
m,1.5y,4y
2m,4m,6
m
1y
1y, 2y
1y,4y
1y
NB,1m,7
m
1y
2m,4m,6
m
2m,4m,6
m,1.5y
1y,6y
NB,2m,4
m
Hib
Rotavirus
Measles
&Rubella
2m,4m
2m,4m
Costa
Rica
2008
NB
2m,4m,6
m,1.25y,4
y
Panamá
2007
NB
2m,4m,6
m
4y
1.5y
DTPHepatitis
B-Hib
2m,4m,6
m,4y
NB,2m,4
m,6m,1.5
y,4y
1.25y,esc
uela
NB,2m,6
m
2m,4m,6
m,1.25y
2m,4m,6
m
1y,4y
NB
2m,4m
1y-4y
2m,4m,6
m
2m,4m,6
PCV7
2m,4m,1y
m
Varicella
Hep A
BCG:
bacille Calmette-Guérin (anti-tuberculosis vaccine)
DPT:
diphtheria-pertussis-tetanus vaccine
Hib:
haemophilus influenzae type B vaccine
Hep B
hepatitis B vaccine
OPV:
oral polio vaccine
IPV:
inactivated polio vaccine
MMR:
measles, mumps & rubella vaccine
PCV7
heptavalent Pneumococcal Conjugate Vaccine
Hep A
hepatitis A vaccine
m: months of age; y: years of age
*/Prices for Vaccines Purchased Through the PAHO Revolving Fund, 2009. Source: IMMUNIZATION
NEWSLETTER, Volume XXXI, Number 1, February 2009
**/ taken from Bulletin of the World Health Organization 2008;86:27–39
1y
1.5y
Scaling-up
Non-vaccine costs of scaling-up capacity to increase vaccination coverage
rates for existing vaccines and new vaccines was obtained from Wolfson et al.
(2008). Departing from their system for estimating scale-up costs (nonvaccine costs) in low- and middle-income countries, we estimated nonvaccine scale-up cost per child born (US$8.50), and used it for our
estimations in the Mesoamerican countries.
In estimating costs of scaling-up, Wolfson et al. used country-specific
variables to define likely production function rules for each component (2008).
The main assumptions and variables Wolfson et al. (2008) used for each
component (both capital and recurrent costs) were derived from various
23
sources, including: a country classification used by McKinsey & Company
management consulting firm in a report to the GAVI Alliance on barriers to
improved performance in immunization systems (McKinsey, 2004), the
Commission on Macroeconomics in Health infrastructure index (Ranson et al.
2003), a transportation index based on available modes for transportation and
communication (Limao et al. 2001), as well as district-level vaccine coverage
and country-reported, immunization-specific indicators (WHO 2005). The
McKinsey & Company’s classification categorizes countries into three types:
TU or ―turn around‖ countries, which are low performers where major system
strengthening is required; SI or ―strategic intervention‖ countries, which are
middle performers in need of targeted interventions; and SA or ―stand alone‖
countries, which are higher performers with good infrastructure. The
classification is based on an assessment of political and financial
commitment, physical infrastructure and equipment availability, monitoring
and information systems, human resource availability, and social mobilization
strategies (McKinsey, 2004).
Additionally, non-vaccine costs for scale-up were broken down into the
following cost categories using the estimated distribution reported by Wolfson
et al. (2008) for the WHO Region of the Americas: cold chain (20%), training
and supervision (31%), vehicles and transport (11%), social mobilization
(13%), surveillance and M&E (10%), waste management (1%), personnel
(9%), and overheads (5%).
Results
Table 2.6 shows the estimates for the resources needed to vaccinate a cohort
of newborns each year and by country, according to the type of vaccine and
scaling-up cost concept. According to the results, an estimate of US$109.5
million would be required to reach 95% vaccination coverage rates for all
biologicals, including new vaccines (rotavirus and pneumococcus). Of the
US$109.5 million, 0.5% would be required to fill the coverage gap for currently
in-use vaccines, while 86.1% of the costs would go towards introducing the
new vaccines, and the remaining 13.4% corresponds to system scale-up
(non-vaccine costs). The resource needs by county are as follows: US$0.59
million for Belize, US$6.82 million for Costa Rica, US$14.17 for El Salvador,
US$37.2 for Guatemala, US$9.8 for Honduras, US$28 for Mexico, US$7.3 for
Nicaragua, and US$5.6 for Panama.
Discussion
Estimates presented here rest on the current available data on coverage
rates, which are thought by the experts that need further validation. As pilot
projects are implemented and coverage rates are validated, it will allow us to
project more reliable estimates.
Projections presented here were done without an appropriate assessment of
the infrastructure availability and current capacity utilization levels as well as
an appropriate assessment of the current human capacity availability. Both
diagnostics are essential to accurately estimate non-vaccine costs of scalingup.
24
It is also important to mention that hereby we are no costing the pilot projects
to fill gaps in knowledge, nor the needed interventions for strengthening
immunization policy that would be required for achieving the objectives of the
MHI in its immunization component.
25
Resource Needs to reach 95% coverage rates of vaccination in a birth cohort in the Mesoamerican region
Costa Rica
El Salvador
BCG
Polio3
DTPHepatitis BHib 1
DTPHepatitis BHib 3
MMR
in use
vaccines
0
0
Belize
NA
NA
0.9
2.1
(1.1)
(2.7)
2.9
8.9
(2.1)
(6.5)
0.0
11.7
(0)
(15)
1.3
7.4
(0.8)
(4.3)
0
0
NA
NA
0.0
8.2
(0)
(8.5)
0.0
7.0
(0)
(19.4)
5
45
(0.9)
(7.6)
0
NA
47.2
(59.6)
82.6
(60.9)
0.0
(0)
120.4
(70)
0
NA
38.4
(39.8)
0.0
(0)
289
(48.3)
0
0
NA
NA
22.5
6.5
(28.4)
(8.2)
41.3
0.0
(30.4)
(0)
54.6
11.9
(69.8)
(15.2)
34.4
8.4
(20)
(4.9)
0
0
NA
NA
49.9
0.0
(51.7)
(0)
29.1
0.0
(80.6)
(0)
232
27
(38.8)
(4.5)
0
NA
79
1.2
136
1.0
78
0.2
172
1.8
0
NA
96
1.3
36
0.6
598
0.5
Rotavirus
Neumococo
New
vaccines
Total
vaccines
77.0
456.8
(14.4)
(85.6)
874.5
5,187.4
(14.4)
(85.6)
1,821.6
10,805.4
(14.4)
(85.6)
4,819.1
28,586.0
(14.4)
(85.6)
1,138.0
6,750.1
(14.4)
(85.6)
3,309.9
19,634.0
(14.4)
(85.6)
846.5
5,021.0
(14.4)
(85.6)
385.6
4,574.0
(7.8)
(92.2)
13,272
81,015
(14.1)
(85.9)
534
90.0
6,062
88.9
12,627
89.1
33,405
89.8
7,888
80.3
22,944
81.8
5,867
80.7
4,960
88.7
94,287
86.1
534
90.0
6,141
90.1
12,763
90.1
33,483
90.0
8,060
82.1
22,944
81.8
5,964
82.0
4,996
89.3
94,885
86.6
Cold chain
Training &
supervision
Vehicles and
transport
Social
mobilization
Surveillance,
M&E
Waste
management
Personnel
Overheads
Costs of
scaling-up
11.9
(20)
135.2
(20)
281.5
(20)
744.8
(20)
351.7
(20)
1,023.1
(20)
261.6
(20)
119.2
(20)
2,929
(20)
18.4
(31)
209.5
(31)
436.4
(31)
1,154.4
(31)
545.2
(31)
1,585.8
(31)
405.5
(31)
184.7
(31)
4,540
(31)
6.5
(11)
74.3
(11)
154.8
(11)
409.6
(11)
193.5
(11)
562.7
(11)
143.9
(11)
65.5
(11)
1,611
(11)
7.7
(13)
87.8
(13)
183.0
(13)
484.1
(13)
228.6
(13)
665.0
(13)
170.1
(13)
77.5
(13)
1,904
(13)
6.0
(10)
67.6
(10)
140.8
(10)
372.4
(10)
175.9
(10)
511.5
(10)
130.8
(10)
59.6
(10)
1,464
(10)
0.6
5.4
3.0
(1)
(9)
(5)
6.8
60.8
33.8
(1)
(9)
(5)
14.1
126.7
70.4
(1)
(9)
(5)
37.2
335.1
186.2
(1)
(9)
(5)
17.6
158.3
87.9
(1)
(9)
(5)
51.2
460.4
255.8
(1)
(9)
(5)
13.1
117.7
65.4
(1)
(9)
(5)
6.0
53.6
29.8
(1)
(9)
(5)
146
1,318
732
(1)
(9)
(5)
59.5
10.0
675.8
9.9
1,407.6
9.9
3,723.9
10.0
1,758.7
17.9
5,115.4
18.2
1,308.2
18.0
595.9
10.7
14,645
13.4
Total
593.3
6,816.8
14,170.3
% of the
grand total
0.54
6.22
12.94
BCG
0
NA
0.9
(1.1)
2.9
(2.1)
1/Number in parentheses indicate percentages within their categories.
Guatemala
Honduras
México*
Nicaragua
Panamá
37,207.2
9,818.7
28,059.3
7,272.1
5,591.6
33.97
0.0
8.96
1.3
25.62
0
6.64
0.0
5.11
0.0
(0)
(0.8)
NA
(0)
Total
109,529.3
(0)
5
(0.9)
26
NUTRITION
Methods
To address the main nutrition problems in the Mesoamerica region, the
Nutrition Technical Group recommended ten selected practices that have
demonstrated efficacy or effectiveness in many countries for reducing stunting
and micronutrient deficiencies and for improving maternal, neonatal, and child
health outcomes related to nutrition. For the purpose of this costing exercise,
the proposed effective practices were enumerated and are shown in Table 3.1
with its respective target population.
Table 3.1. Nutrition interventions
Intervention
Nutrition Education
1. Promotion of
breastfeeding and
appropriate
complementary
feeding practices
U
n
i
v
e
r
s
a
l
a. Breastfeeding promotion
and support.
b. Complementary feeding
promotion (not provision
of food ).
Details
Target Group
Costed delivery
platform(s)
a. Primary health care
system.
b. Communication campaign.
c. CCTs or/and C-BPs.
Individual and group counseling
about adequate breastfeeding and
complementary feeding practices.
Pregnant mothers/ parents of
infants under 6 months of age
and children under 2 years of
age.
Improved hygiene. Counseling
about food safety, use of soap,
hand washing, etc.
Improved water and sanitation
Improve water quality (use of
bleach, filters).
Populations with high
prevalences of infectious
diseases and to areas where
water safety is not guaranteed
CCTs or/and Community
Nutrition Programs.
Iron-folate supplements.
Pregnant women.
Primary health care system.
Maintain and strengthen ongoing
universal food fortification
programs (example: flour, sugar or
salt fortification).
Entire population.
Market-based delivery
systems.
5. Vitamin A supplementation
Biannual supplementation of
megadoses of vitamin A.
Children 6-59 months of age, from
poor rural areas and urban slums
and indigenous and afrodescendant populations.
Vaccination campaigns.
6. Therapeutic zinc supplements
Use of 10 to 14 day treatment
course with zinc as part of the
standardized treatment for
diarrhea.
Children under the age of 5 in
areas with high prevalences of
infectious diseases and evidence
of zinc deficiency.
Primary health care system.
Micronutrient powders for home
fortification.
Children younger than 2 years in
low-income households.
CCTs or/and Community
Nutrition Programs.
Severe primary undernutrition
cases.
Primary health care system.
Populations with high prevalence
of children 6-24 months of age
with WAZ< - 2SD.
CCTs or/and Community
Nutrition Programs.
2. Improved water, sanitation and hygiene
behaviors
Micronutrients
3. Prenatal
micronutrient
supplements
4. Food fortification
programs
a. Iron supplements
b. Folic acid supplements
Micronutrient fortification
of staples/other foods
Micronutrients
7. Multiple micronutrient powders
L
o
c
a
l
i
z
e
d
Complementary and Therapeutic Feeding
8. Clinical management of severe acute
malnutrition (SAM)
9. Fortified complementary food
Use of standardized, evidencebased protocols to manage severe
acute malnutrition at a clinical
setting.
Identification of circumstances in
which food supplementation is
needed.
Provision of complementary food
in these circumstances.
Related interventions
10. Conditional Cash Transfers (CCT)
Interventions and target populations
The practices were grouped in three different packages targeted to different
populations, and one core group of cost-effective interventions was
recommended for national level implementation. In the core group, the
practices for universal coverage included: counseling for breastfeeding and
adequate complementary feeding practices, food supplementation with
27
vitamin A, therapeutic zinc supplementation, hygiene promotion, prenatal
supplements, and fortification of staple.
Two other intervention packages were proposed to reduce undernutrition in
areas with high prevalences of stunting, micronutrient deficiencies, food
insecurity, and poverty. In addition to the basic core of interventions, the first
package includes conditional cash transfer (CCTs) programs and the
provision of fortified complementary foods. The second package includes the
basic core interventions plus fortified complementary foods or micronutrient
powders, which is considered a less costly intervention for effectively reducing
stunting.
Finally, the recent emergence of cases of severe acute malnutrition in
Guatemala due to extreme climate conditions motivated the inclusion of
clinical management of severe acute malnutrition (SAM), which has
demonstrated efficacy, as part of the proposed interventions.
Delivery Platforms
The costs of the nutrition interventions depend on the systems through which
they are delivered (Horton, Sheekar et al. forthcoming). Each of the selected
interventions for nutrition possessed a variety of delivery platform possibilities
that targeted different population groups and required different personnel and
supplies.
There were five delivery platforms considered for implementing the nine
proposed interventions. Interventions are proposed to be delivered through
one or more of the following: the primary health care system, vaccination
campaigns, market-based systems, communication campaigns and/or CCTs
or Community-Based Nutrition Programs (C-BPs). For costing purposes, each
intervention was placed within a delivery platform that was considered most
appropriate and feasible (see Table 3.2).
28
Delivery Platform
Intervention ID
· Promotion of breastfeeding and
1 appropriate complementary feeding
practices.
3
1
Primary health care
system.
· Prenatal micronutrient supplements/
iron and folic acid.
6 ·
8
2
3
Vaccination
campaigns.
Market-based
delivery.
Conditional Cash
Transfer Programs /
4
Community-Based
Nutrition Programs.
5
Communication
campaigns.
Therapeutic zinc supplements.
Children under 2 years old.
Pregnant women.
Children under the age of 5 years in
areas with high prevalences of
infectious diseases and evidence of
zinc deficiency.
In poor rural areas and urban slum and
indigenous and afro-descendant
population.
In poor rural areas and urban slum and
indigenous and afro-descendant
population.
Areas with high prevalences of
infectious diseases and evidence of
zinc deficiency.
· Clinical management of Severe Acute
Severe primary undernutrition cases.
Malnutrition (SAM).
5 ·
Vitamin A supplementation.
· Fortification of staple food (Salt
4 iodization, sugar with vitamin A, wheat,
maize, rice, vegtable oil).
· Promotion of breastfeeding and
1 appropriate complementary feeding
practices.
· Improved water, sanitation and
2
hygiene behaviors.
7
Target population
Children 6-59 months of age.
National level.
All populations in the region.
National level.
Children under 2 years old.
High prevalences of infectious
Low income population where water
diseases and to areas where water
safety is not guaranteed.
safety is not guaranteed.
· Distribution of micronutrient powders
Children 6-24 months of age.
for children 6-24 months of age.
· Complementary food (delivery of
9 complementary food) for children 6-24
months of age.
· Promotion of breastfeeding and
1 appropriate complementary feeding
practices.
Low-income households in rural areas
and urban slums.
Children 6-24 months of age.
Low-income households in rural areas
and urban slums.
Children under 2 years old.
National level.
Instead of considering CCTs as a single intervention for the program, it was
considered as a delivery platform. CCT programs can support nutrition
improvement, but they were not costed in this document. This is because they
often have multiple components aiming to address multiple objectives, such
as, reducing household vulnerability and breaking the intergenerational
transmission of poverty, not contained within the scope of the Mesoamerican
initiative. However, it is important to address the situations where CCTs have
previously been instituted, where nutrition interventions targeted to lowincome populations could be delivered through already-existing CCT
mechanisms at a lower cost.
Several of the selected interventions have the potential to be delivered
simultaneously through several of the aforementioned platforms. For example,
the vitamin A intervention can be delivered simultaneously through the health
care system and through vaccination campaigns; however, for this analysis, it
was costed only through vaccination. In communication campaigns, which can
promote any education message, such as, hygiene or prenatal supplements,
it is reasonable to assume that the cost of a campaign does not vary
according to the message, but rather according to the media and exposure
time. Because of this, breastfeeding promotion was selectively costed in this
platform and was then extrapolated to other platforms. Across the program,
breastfeeding promotion and complementary feeding practices was the only
practice costed for three different delivery platforms simultaneously – primary
health care system, communication campaign and though CCTs or C-BPs.
Grouped by delivery platforms, eleven interventions were costed (see Table
3.2).
29
Results
For resource inputs costs, data from Mexico, Panama, Nicaragua, and
Guatemala were obtained through data collection instruments filled out by
each country. In addition, information on quantities came from WHO
guidelines, literature, and expert opinion: complementary information on
prices came from WHO-CHOICE1 and published literature. Incremental costs
for the interventions are presented in Table 3.3 and described below.
1
Within WHO-CHOICE classification regions AMR B includes Belize, Costa Rica, El Salvador,
Honduras, Mexico and Panama and AMR D includes Guatemala and Nicaragua.
30
Five years incremental costs
4. Food fortification programs
2009 US$ in millions
Guatemala
Food
Private
sector costs
Mexico
Public sector Total Private +
costs
Public sector costs
Sugar
Vegetable oil
Wheat flour
Maize flour expanded
fortification package
Maize flour reduced
fortification package
14.00
0.97
14.97
Private
sector costs
Total Private +
Public sector
Public sector
costs
costs
174.54
136.08
1.03
1.27
175.57
137.35
0.87
1.10
1.97
11.35
1.45
12.79
367.97
10.05
378.02
3925.60
97.23
4022.82
156.32
9.78
166.10
1667.66
96.95
1764.62
Reduced package: iron, folic acid and vitamin B-12
Expanded package: Includes reduced package + vitamins B-1, B-2, B-3, B-6, vitamin A, and zinc
Sugar and vegetable oil, only vitamin A was included
Source: Fiedler and Macdonal (forthcoming)
1. Promotion of breastfeeding and appropriate complementary feeding practices
Promoting exclusive breastfeeding within the first hour of birth and continued
exclusive breastfeeding for 6 months after childbirth has been shown to be
one of the most cost-effective nutrition health interventions. Continued
breastfeeding beyond six months should be accompanied by consumption of
nutritionally adequate, safe, and appropriate complementary foods that help
meet nutritional requirements when breast milk is no longer sufficient
(UNICEF 2008). These two interventions are heterogeneous in design; thus,
their costs depend largely on program planning and implementation.
1.1 Primary health care system
Within its primary health care system, the Nicaraguan Ministry of Health has
been working with the Mother Baby Friendly Health Units Initiative (MBFHI).
Taking into account the costs for seven health centers, the average cost of
certifying a hospital to be Baby Friendly was US$6,489 per health center, and
the average cost of monitoring was US$375 (Nicaragua contact).
With the ingredients approach, the estimated incremental cost (including time
per medical officer and nurse plus materials, such as laminates and flyers) for
breastfeeding promotion was estimated to be US$4.29 for Mexico and
US$4.79 for Panama. For other countries, information was not available for
inputs, and total results may be somewhat underestimated. Training is an
essential component of this intervention. It may include videos and teaching
31
packs for pediatric and medical staff. A training workshop cost around
US$450 per 15 health personnel (see Table 3.3).
1.2 CCTs or/and C-BPs
Delivered with Community-Based Programs (C-BPs), breastfeeding is more
focalized, but resulted in a higher cost. Fiedler (2003) (Fiedler 2003) did a
very detailed, activity-based costing analysis of the Honduras CommunityBased Integrated Child Health Program AIN-C. He estimated a recurrent cost
of US$8.16 per child per year.
1.3 Communication campaign
Finally, based on media costs from WHO-CHOICE and costs from Panama, a
4-month, television and radio communication campaign based on short spots
(20 seconds) within the districts was estimated to cost around US$120,670
dollars.
An example of the amount of resources needed for a health-related
communication campaign can be taken from the 10-week, national campaign
for HIV/AIDS in El Salvador ―Unámonos contra la discriminación", which
costed US$400,000 (Gesaworld 2006).
Thus, depending on the duration and specific communication channels (e.g.
national or district television, radio channels) the cost may vary widely.
Countries thus need to select a specific communication strategy that fits within
their goals and their available modes of communication.
2. Improved water, sanitation, and hygiene behaviors
Hygiene promotion, basic sanitation facilities, and water supply (water for
domestic purposes) are well recognized to reduce morbidity. The simple
measure of washing hands with soap has shown to be associated with a
reduction of 43 percent in diarrheal disease (Curtis and Cairncross 2003).
However, the cost of such an intervention significantly varies depending on its
magnitude (ingredients). Therefore, it is suggested that countries define what
will be included according not only to local needs but also to budget
constraints.
For the costing analysis, two basic packages were considered. The first
involves hand washing with soap, filters, or chlorine for water improvement
education. This practice might be included as an extra subject for CCTs
(already in Mexico through Oportunidades program workshops) or C-BPs),
which would have an estimated minimal incremental cost of US$0.34 per
child, including the incremental time of the personnel plus extra educational
materials per child.
The second package involved the construction of basic sanitation facilities
(excreta disposal, such as household pit latrine). This intervention, according
to the Global Water Supply and Sanitation Assessment 2000 Report, cost
US$60 per capita for Latin America. Taking a relatively short lifetime of five
years for a latrine and straight-line amortization resulted in an annual cost of
US$12 per capita per year (Cairncross and Valdmanis 2006)
32
3. Prenatal micronutrient supplements
During pregnancy, a woman’s daily intake requirements for certain nutrients,
such as folic acid (folate) and iron, increases. Prenatal micronutrient
supplementation is a standardized intervention, and across the countries
within this initiative, the dose period varies. For calculations routine
supplementation tablets containing 60 mg elemental iron once daily for 14
months and 0.4 mg/d folic acid daily for 12 months was recommended for
every pregnant woman.
The costs included iron and folic acid supplements in addition to the time of
the medical practitioner. The cost of this intervention is mainly the cost of the
supplements which varies slightly through countries. On average, it cost
$US7.00 per pregnant woman.
4. Universal food fortification programs
Cost for fortification — the addition of micronutrients to a processed food to
improve the food’s nutritional quality — depends largely on the micronutrient
used to fortify, the food vehicle chosen for fortification, and industry structure
of the food that is fortified.
The staples food candidates for being fortified in the Mesoamerican region
identified were: (1) sugar fortified with vitamin A; (2) vegetable oil fortified with
vitamin A; (3) salt iodization; (4) maize foritified with iron and folic acid; and (5)
wheat flour fortified with iron and folic acid.
For costing universal food fortification programs, it is needed to select the
specific food vehicle and analyze the consumption of the product as well as
the conditions of the industry that produce it. J. Fiedler and Macdonald are
working in a forthcoming paper which will cost the fortification of maize flour,
wheat flour, sugar, and vegetable oil for 48 countries including Guatemala and
Mexico. The estimates for Guatemala and Mexico from their study are
presented in Table 3.3. For Guatemala, sugar fortification was not costed in
this report since a current country program with adequate coverage exists.
Guatemala reported to have a cost of US$1.00 per metric ton/per year,
including both public and private costs (Guatemala contact).
For Mexico, Fiedler and Macdonald (forthcoming)(Fiedler and Macdonald
forthcoming) estimate the total incremental costs of a 5-year sugar fortification
program in Mexico to be US$ 175.6 million, including both private and public
sector costs. What was of interest for us were the private sector’s incremental
costs — those additional costs that the private sector is expected to incur due
to fortification. Those costs were estimated in US$1.03 million for the first 5
years.
Wheat flour fortified with iron and folic acid and iodized salt are currently
operating in Guatemala (Guatemala contact), and public sector costs of
fortifying wheat flour were estimated to be US$1.10 million for five years.
As depicted in Table 3.3, the cost of fortifying maize was found to be more
than ten times the cost of fortifying wheat flour, vegetable oil, or sugar. This is
mainly due to the characteristics of the maize flour industry which has
significant variations in technology, plant sizes, economies of scale, and,
hence, costs.
33
Moreover, Panama reported having salt (iodized) and wheat and maize flour
(fortified with iron and folic acid). The incremental costs of such programs
were not identified since they are absorbed by the private sector (Panama
contact).
5. Vitamin A supplementation
Vitamin A supplementation has demonstrated efficiency and costeffectiveness in reducing childhood mortality. According to the WHO, the
recommended doses of vitamin A supplementation for the prevention of
vitamin A deficiency for infants aged 9-11 months is a megadose (100,000
IU), and for children aged, 1–4 years 200,000 IU. The optimal interval
between doses is four to six months. A dose should not be given too soon
after a previous dose of vitamin A supplement (the minimum interval is one
month) (WHO 2003). Calculations were based on two megadoses per year.
This intervention can be delivered using the primary health care system,
supplemented by some form of outreach, such as vaccination campaigns.
Since the fixed costs for vaccination campaigns are not expected to vary, the
costs of providing vitamin A in campaigns and primary health are considered
comparable for the purposes of this document.
The cost per dose of vitamin A ranges from $0.01 (Mexico contact) to $0.46
(Nicaragua contact). The supplement costs plus the health staff time and
informational material was estimated for this intervention in US$1.72.
6. Therapeutic zinc supplements
Zinc supplementation has a considerable beneficial effect on the clinical
course of acute diarrhea as an adjunct therapy to oral rehydration solution
(ORS) (Robberstad, Strand et al. 2004). The standard recommended
treatment is one tablet of 20 mg/day of zinc for 14 days. The cost of the
supplement significantly varies across countries from US$1.12 (Guatemala) to
US$8.23 (Mexico) per treatment. Within this scheme, the intervention cost,
which includes the supplement plus the general practitioner’s time to
diagnose, varies in function to the cost of the zinc tablets. The average cost is
US$5.36 per treated child with diarrhea.
7. Multiple micronutrient powders
Costs for micronutrient powders — easily sprinkled onto foods prepared at
home to provide the daily requirements — varies from US$0.015 to US$0.038
per sachet. A home fortification regimen consists of 60 single-dose sachets
for each child (6-24 months of age), consumed over 60 to 120 days, not
exceeding one sachet per day.
The costs for distributing this product in already focalized CCTs programs or
C-BPs contain a slightly increasing cost for distributing the micronutrient
supplement. On average, the incremental costs of delivering micronutrient
powders per child was estimated to cost US$2.66, including twice the human
resources costs since it is delivered twice per year (Guatemala and Nicaragua
contact).
34
8. Clinical management of severe acute malnutrition (SAM)
Severely malnourished children — visibly severe wasting, with very low
weight for height (below 3 z-scores of the median) or with the presence of
nutritional edema — need special urgent care. The standard treatment
protocol for managing this condition is a medically intensive treatment in
hospital settings(WHO 1999).
A severely undernourished child normally needs to be treated, in addition to
nutrition restoration, to avoid many potential fatal complications, such as,
hypothermia, hypoglycemia, sepsis, as well as associated conditions, such
as, vitamin A deficiency, dermatosis, parasitic worms, and diarrhea, which
increase the likelihood of contracting infections. To cost this intervention, all
inputs for treatments addressing potential complications, infections, and
related conditions were identified based on WHO guidelines for managing
SAM.
The cost of this intervention mainly depends on the number of days the
patient remains in hospital, rather than the number of complications, since
medicines for treating all complications are fairly similar in prices and do not
represent a high percentage of the total cost. Thus, a ―best‖ and ―worst‖ case
scenarios were modeled. Since it has been recognized that managing SAM
lasts for 3 to 7 days, the worst-case scenario assumes that the patient is
hospitalized for seven days and the best case assumes hospital discharge
after three days. Clinical management of a severe acute malnourished child is
estimated to range from US$201 to US$349.
9. Fortified complementary food - Prevention/treatment of moderate
malnutrition.
After the period of exclusive breastfeeding (6 months), complementary food
should be varied to fulfill the requirements of energy and micronutrients, and
in the situation of food insecurity, the use of fortified complementary food may
be necessary to ensure adequate intake levels of particular nutrients(WHO
2002).
The cost of this intervention varies especially according to the fortified
complementary food that a country utilizes. Soy-based fortified food blends
are often less costly, ranging from US$12.11 (Honduras Papilla CSB) to
US$46.14 (Nicaragua cereal CSB) to feed a child during the period of 6 to 24
months of age. The most expensive types of complementary food are fortified
milks, which ranges from US$98.62 (fortified milk in Costa Rica) to
US$110.15 (Tenutre in Mexico) to meet the daily requirements during the 624 month age range. The other fortified complementary foods, with the
exception of Incaparina in Guatemala which only costs US$10 dollars, are
captured within this range.
Since this complementary food would be delivered through any of the already
CCTs or the C-BPs, the cost of the intervention consists of the fortified food
plus extra human resources required to hand out and explain the feeding
procedure to the mother/parents of the 6- to 24-month old child. The
estimated cost per country is presented in table 3.3, which logically varies
depending on the fortified food used.
35
Discussion
As expected, interventions with the highest direct costs were the clinical
management of severe acute malnutrition and fortified complementary foods,
while the less expensive interventions were the micronutrient interventions.
An important limitation of this study was the lack of price information for health
inputs from most of the Mesoamerican countries. Because of this, it was
necessary to impute average costs from the countries which information was
available.
The direct incremental costs presented here are useful for the countries
wishing to more accurately define the interventions planned for
implementation and with the information provided for making a diagnosis of
the population already covered, it would be possible to estimate the global
budget required per country to scale-up interventions.
MATERNAL, NEONATAL AND REPRODUCTIVE HEALTH
Methods
Interventions
The most important goals in this area were to reduce maternal mortality by
75%, reduce neonatal mortality by 50%, and achieve universal access to
reproductive health services including family planning by the year 2015, in line
with the United Nations 2009 Millennium Development Goals (MDG) report.
The main interventions proposed in the area of maternal and newborn health
were (also in Table A2 in the Anexx):

Maternal health: implementation of basic Emergency Obstetric Care
(EmOC), and interventions aimed at improving care of obstetric
emergencies related to infections, eclampsia, hemorrhage and
abortion; and community awareness, education and training to improve
these outcomes.

Neonatal health: essential newborn care, care for the low birth weight
newborn and emergency care for newborns with complications.

Reproductive health and family planning: implement quality family
planning services for adolescents; ensure access to counseling and
services for at least six contraceptive methods ensure access to
vasectomy, and post-partum and post-abortion contraceptive
counseling and services.
In this section we intend to offer basic information related to the direct costs of
the list of maternal and newborn interventions defined in the master plan. This
information will be a useful ingredient for countries to make projections of the
potential costs of investment in specific maternal and newborn health
interventions and the costs of reducing gaps in health. We will also
disaggregate the direct cost into its various components to identify the items
of greatest financial burden for each health intervention.
Information on input costs was requested to all the countries in the
Mesoamerican region, however we just got data from Guatemala, Mexico,
36
Nicaragua and Panama. Therefore, we intend to develop an exercise to
estimate direct incremental costs of each intervention included in the master
plan for those four countries in Mesoamerica.
Costs analysis
Direct costs were collected through the use of input tables consist of
medicines, personnel, personnel time invested in each intervention. These
tables were developed with information from experts in obstetric and neonatal
care in Mexico. This information served as a reference for shaping the
information requested to each team of the Mesoamerica country network (See
supplemented excel file 4.1).
Two aspects were considered to develop the input tables: i) verification of the
use of health resources in each intervention according to what was suggested
by the literature; ii) interviews to experts in obstetric and neonatal care. The
former was used to build the input matrix for each health intervention. The
second required to perform semi-structured interviews (Henández-Sampieri,
1999) to physicians and nurses working in maternal and newborn health
services areas from hospitals and clinics. Interviews were carried out in
September 2009 in the Women’s Hospital in Yautepec, Morelos and the
Mexican Institute of Social Security (IMSS) located in Cuernavaca, Morelos.
The costs of maternal and newborn interventions were estimated using the
Mother Baby Package (MBP) developed by the World Health Organization.
The model was developed in the Excel and it contains dynamic cost sheets to
estimate different types of costs.
The MBP allowed us to estimate costs that can be disaggregated in different
type of inputs such as medicines, working-hours, medical inputs, vaccines,
laboratory inputs and infrastructure. In this study we focused on estimating the
costs related with the use of medicines, working-hours and health inputs.
By using the MBP it is possible to obtain direct cost per each intervention:
normal delivery, haemorragia, eclampsia, sepsis, family planning including
oral contraceptives, injectable contraceptives, condoms, intrauterine device
(IUD), vasectomy, sub-dermal implant (Norplant). It is possible to obtain
information by type of costs: variable and capital costs. In this study capital
costs were not included. Finally it is possible to report costs by level of care;
hospital or health centre. Additionally we estimated manually the cost of
neonatal complications such as hypoxia and neonatal asphyxia; as well as
manual vacuum aspiration (MVA). All costs estimates were converted into
dollars of 2009.
Results
Panama
Direct costs per intervention from Panama are reported in Table 4.1. The
greatest cost was the cost for sepsis care at a cost of US$1,112, follow by
manual vacuum aspiration (MVA) at a cost of US$475.40 and eclampsia at a
cost of US$217.30. The lowest cost was for oral contraceptive at a cost of
US$0.2 dollars.
37
For the costs per type of health input, in most of the interventions the highest
costs are represented by consumable health supplies. The exceptions are two
contraceptive methods: IUD and the sub-dermal implant (see Table 4.1).
Direct costs for hypoxia and asphyxia were not estimated because we did not
have information regarding the input costs in this country.
Table 4.1. Direct unit costs per intervention for Panama in 2009 US
dollars.
Consumable
Supplies
Maternal
Normal Delivery
15.63 (40.3%)
Maternal complications
Eclampsia
61.44 (28.3%)
Hemorrhage
37.05 (64.8%)
Sepsis
942.27 (84.7%)
Manual vacuum
aspiration (MVA)
474.69 (98.8%)
Family Planning
FP- Oral
FP- Condom
5.56 (98.1%)
FP- Injection
0.08 (2.3%)
FP- IDU
5.06 (28.3%)
FP- Sterilization
8.08 (75.3%)
(1)
FP- Norplant
0.92 (0.7%)
Medicines
Health Personnel
Total Direct
Costs
7.59 (19.6%)
15.59 (40.2%)
38.80
10.6 (4.9%)
13.62 (23.8%)
126.17 (11.3%)
145.3 (66.9%)
6.51 (11.4%)
43.56 (3.9%)
217.30
57.20
1,112.00
0.01 (0.0%)
0.74 (0.74%)
475.40
0.02 (10.8%)
0.16 (89.2%)
0.11 (1.9%)
0.16 (4.6%)
0.22 (1.2%)
0.83 (7.8%)
0.62 (0.5%)
0.20
5.70
3.50
17.80
10.70
126.1
3.30 (93.2%)
12.60 (70.5%)
1.81 (16.9%)
124.54 (98.8%)
1. The price of the sub-dermal implant from Panama was taken from the price reported by Mexico.
Mexico
Direct cost estimations per type of intervention in Mexico are shown in Table
4.2. The health care service with the highest costs was sepsis at a cost of
US$858, followed by care for eclampsia at a cost of US$328 and
hemorrhages at a cost of US$69. Note that medicine in this country
represented the greatest financial burden within the direct costs of most of the
interventions.
Table 4.2. Direct unit costs per intervention for México in 2009 US
dollars.
Maternal
Normal Delivery
Eclampsia
Hemorrhage
Sepsis
Family Planning
FP- Oral
FP- Condom
FP- Injection
FP- IDU
FP- Sterilization
(1)
FP- Norplant
Consumable
Supplies
Medicines
Health Personnel
Total Direct
Costs
44.9 (75.7%)
7.6 (12.7%)
6.85 (11.5%)
59.33
69.5 (21.2%)
56.12 (80.5%)
278.5(32.4%)
147.6 (44.9%)
10.04 (14.4%)
456.4 (53.2%)
111.3 (33.9%)
3.55 (5.1%)
123.42 (14.4%)
328.40
69.70
858.38
0.14 (6.9%)
0.09 (4.3%)
0.14 (2.6%)
0.18 (1.7%)
0.35 (2.3%)
0.21 (0.1%)
1.96
2.66
5.10
11.00
15.35
144.48
1.82 (93.1%)
2.57 (96.6%)
0.08 (1.6%)
1.27 (11.6%)
12.99 (84.6%)
20.24 (14.0%)
4.94 (95.8%)
9.50(86.8%)
2.01 (13.1%)
124.03 (85.8%)
The costs of asphyxia and hypothermia were not estimated because
information regarding prices were not available for the main medical inputs.
38
In general, interventions for the care of maternal complications are
considerably more expensive than the care of normal delivery and family
planning methods.
Training costs of Obstetric Emergency Management
The training for obstetric emergency management in Mexico is provided
through a 16-hour course provided by the Advanced Life Support in Obstetrics
(ALSO). The course fee per person is US$378.79, including two-days worth of
training time and course materials. This course is aimed at general
physicians, obstetricians, gynecologists, pediatricians and general nurses,
and it includes topics such as, acute hypertensive disease in pregnancy,
obstructed labor, shoulder dystocia, intrapartum fetal monitoring, prevention
and management of postpartum hemorrhage, fetal resuscitation and
ultrasound type ―FAST‖ for obstetric emergencies.
Guatemala
Because some prices of consumable supplies in Guatemala were extremely
high and no reliable, the average cost for a few consumable supplies were
imputed from Mexico and Panama2. For extremely high prices, we preferred
to work with prices closer to international market values.
Table 4.3 shows direct costs per intervention for Guatemala. The most costly
intervention was the manual vacuum aspiration at a cost of US$672, followed
by sepsis care at a cost of US$582 and eclampsia care at a cost of US$206.
Table 4.3. Direct costs per intervention from Guatemala, 2009 in US
dollars
Consumable
Supplies
Maternal
Normal Delivery
46.35 (989.8%)
Maternal complications
Eclampsia
171.09 (82.7%)
Hemorrhage
66.61 (89.8%)
Sepsis
571.68 (98.2%)
Manual vacuum
aspiration (MVA)
672.14 (99.9%)
Family Planning
FP- Oral
0.00
FP- Condom
3.60 (99.3%)
FP- Injection
5.20 (83.9%)
FP- IDU
7.02 (94.5%)
FP- Sterilization
8.09 (76.5%)
(1)
FP- Norplant
3.19 (2.2%)
Medicines
Health Personnel
Total Direct
Costs
3.32 (6.4%)
1.93 (3.7%)
51.60
3.82 (1.8%)
6.46 (8.7%)
3.79 (0.7%)
31.98 (15.5%)
1.15 (1.5%)
6.74 (1.2%)
206.89
74.20
582.21
0.07 (0.01%)
0.04(0.01%)
672.25
1.44 (97.5%)
0.04 (2.5%)
0.02 (0.7%)
0.04 (0.6%)
0.05 (0.7%)
0.14 (1.3%)
0.10 (0.1%)
1.48
3.60
6.20
7.43
10.57
145.02
0.96 (15.5%)
0.36 (4.8%)
2.34 (22.1%)
141.73 (97.7%)
1. Some prices of the health inputs for the MVA procedure in Guatemala were taken from the prices reported by
Panama.
2. The price of the sub-dermal implant from Panama was taken from the price reported by Mexico.
Nicaragua
Intervention costs in Nicaragua were obtained from a cost sheet provided by
the Nicaraguan MoH in 2009. There was information from a single health
intervention, normal delivery care coinciding with the 12 health interventions
2
For imputing the prices for Guatemala, the unitary prices for consumable consumptions in
Mexico and Panama were averaged.
39
that comprise the basic package defined for Mesoamerican countries. In
Table 4.4, we report direct costs of normal delivery care and some medical
interventions similar to the interventions included in the basic package defined
by the Mesoamerican team of experts (preterm labor and newborn sepsis).
The direct cost of the normal delivery is US$16. For this intervention, the
highest cost is personnel time at a cost of US$7.17 (44.2%), followed by
consumable supplies at a cost of US$ 5.81(35.8%).
Costs of normal delivery care in Nicaragua were the lowest compared to the
ones estimated in the other three countries. We attribute this low cost to the
low level of salaries for health personnel in this country.
Table 4.4. Direct costs per intervention from Nicaraguain 2009 US
dollars.
Some complications
Preterm labor
Sepsis of Newborn
Consumable
Supplies
Medicines
Health Personnel
Total Direct
Costs
3.19 (4.2%)
13.73 (16.6%)
32.70 (43.4%)
11.51 (13.9%)
39.41 (52.3%)
82.76 (69.5%)
75.30
82.76
5.81 (35.8%)
3.23 (19.9%)
7.17 (44.2%)
16.21
Maternal
Normal delivery
Discusion
Interventions with the highest direct costs were those involving the care of
maternal complications (eclampsia, hemorrhage, and sepsis) as well as
manual vacuum aspiration. These high costs are mainly attributable to
medicine and consumable supply prices.
Among the family planning methods, the most expensive were sterilization,
sub-dermal implants, and injection.
The highest direct cost for normal delivery care was from Guatemala. This
high direct cost is attributed to the cost of consumable supplies. In contrast,
Nicaragua reported the lowest cost of normal delivery care, in part, related to
the country’s reported low cost of consumable supplies and health personnel.
These results are also important to identify prices of health supplies and drugs
each country is possesses. We have found that prices of some consumable
supplies and medicines can vary considerably between countries. It is
important to consider that lower prices can represent significant savings when
there are plans to expand health intervention coverage to a level that is
needed in the region.
The main limitation of this work is the lack of price information for health
inputs from most of the countries involved in the MHI. Similarly, for those
countries partial information has been obtained, we were required to impute
some data from where cost information was not available.
40
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42
ANEXXES
Table A1. Opportunity map (Inteventions)
Areas of Opportunity
Strategies to reach target populations
Monitoring and Evaluation
Indicators
Validity of
Immunization
Coverage Levels
Lot quality sampling assessment baseline and
subsequent assessments
Percentage of validity assessments
performed/assessments planned
Serologic analysis of a sample of patients to validate
coverage levels (tetanus or hepatitis B)
Percentage of concordance between
reported rates and those identified
during the assessment
Rapid monitoring assessment supervision and
evaluation
Coverage level by specific biologic
agent and with full vaccine schedule
.
Increase effective
coverage
Reaching 95%
coverage rate per
biological
Prevent missed opportunities and unmet needs by:
- Community-based educational campaigns to reach
the most socially excluded populations with culturally
appropriate messages regarding the benefit of
vaccination
- Supplementary outreach campaigns that take
services out into communities through mobile camps
usually accompanied by energetic information
campaigns regarding the benefits of vaccination
Integrated rapid-impact package of intervention with
other health-related interventions (maternal,
nutrition, vector-borne diseases) (see probable
indicators on table 7).
Number and % of municipalities
distributing culturally appropriate
materials
Number of persons reached with
educational materials, talks or
workshops
Percentage of community-based
workshops conducted versus those
planned
Percentage of people reached by
education activities / community
population
Change in the coverage rate from
baseline to intervals
Public-private partnerships to develop social
marketing strategies
Verified effective vaccine coverage
rate in target population
Capacity-building at all levels with a focus at the
community level and then at every level of the
national immunization program
An alternative proxy measure has
been suggested by the COFVAL,
correlating 1) the data on mortality
and morbidity with 2) the data on raw
coverage for each disease-vaccine
by federal, state/provincial and local
level.
Unify information systems at the country level (Use
mobile technology and internet-based systems to
assist in vaccination-registry or a unified regional
vaccination registry)
For permanent health-centers need more hours of
operation (weekends, holidays, and evenings)
Effective vaccine use, contrast:
a) the number of doses bought (at
national, district, municipal level)
b) coverage for a specific disease
Percentage of health centers with
extended service hours (among those
for which this was a problem in the
community).
Information Systems
Unify information systems at the country level (Use
mobile technology and internet-based systems to
assist in vaccination-registry or a unified regional
vaccination registry – nominal census data)
Capacity building at all levels
Number of children/% of children in
registry from target population
Number of municipalities/% of
municipalities using mobile
technology to collect data/register
children
Number of municipalities/% of
municipalities using internet based
systems to assist in vaccine registry
or regional vaccination registry
Number of health works/% of health
workers that have been trained to use
43
mobile technology and/or internetbased systems of vaccine registry
Monitoring and
Evaluation of
National
Immunization
Programs
Capacity building of personnel at the community
level for monitoring vaccine uptake/demand of
vaccine
Percentage of active vaccine at the
different locations (national, regional,
local, and community level
Supervision of cold-chain activities
Number/Rate of illness due to VPDs
in target population
Community needs assessment
Use a performance improvement and process
evaluation approach to diagnose and systematically
improve services, starting at the facility level by the
community
Providing community-health workers with information
on how to use data for monitoring and evaluation,
how to engage community leaders, and how to
better manage vaccine stocks
Number/Rate of deaths due to VPDs
in target population
Change in the burden of VPD in
target population
Change in the differences between
the burden of VPDs in target
populations and national averages
Number of lab tests for VPDs
completed for target population
Epidemiologic
Surveillance
Improved detection by laboratory-based surveillance
Creation or strengthening of a regional network of
surveillance (epidemiologic and laboratory-based)
Operational Activities
of the National
Immunization
Program
- Cold-Chain
Increased number of supervisors and increased
training of supervisors
Use a performance improvement and process
evaluation approach to diagnose and systematically
improve services, starting at the facility level by the
community
- Human Resources
Number of staff trained at all levels
Percentage of workshops at all levels
including community-based
conducted versus those planned
Percentage of supervisions
conducted at all levels including
community-based conducted versus
those planned
Knowledge
Management
**Web-based Library as part of the Mesoamerican
Public Health Institute as a site for exchanging
information on guidelines’, norms, technical
procedures, publications, effective practices.
Number of virtual websites
Number of publications in peerreviewed journals
Number of contributions to national or
regional guidelines
Number of effective practices shared
by countries through the use of virtual
information networks
Introduction of New
Vaccines
Introduction of vaccines that may have a higher
impact on decreasing the burden of disease in
children under 5:
-Rotavirus
-Conjugate pneumococcal heptavalent
Percentage of countries that
introduce rotavirus (monovalent or
pentavalent)
Use seed money and search for other sources of
sustainability to introduce these vaccines through
PAHO, local governments, and GAVI (Honduras and
Nicaragua)
Percentage of countries that
introduce conjugate pneumococcal
heptavalent vaccine
Taken from the Immunization Master Plan, September 30 2009.
** There is an existent web-based library platform established by the Virtual Mesoamerican Public Health Institute
where countries can build upon their interventions and activities
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Table A2. List of maternal and neonatal interventions and delivery platforms costed
Intervention
Maternal
Normal delivery care
Details
Target Group
Potential delivery
platform(s)
Prevention and
management of infections:
Clean delivery
Antibiotics
Vaccines
Skin Care-to-skin
Maternal- Complications
Interventions to
The Pan American Health
reduce maternal
Organization (PAHO)
death
promotes a more focused
for acute postpartum
now on effective
vaginal bleeding
interventions because of the
immediately
costs, including essential
obstetric care (EOC),
delivery assistance by
trained personnel and better
access to health care
services maternal quality.
Eclampsia
Staff, medicines available,
protocols available and
known to everyone. Staff
attending antenatal better
prepared to detect early
cases of pre-eclampsia
Reduction of maternal morbidity and
mortality by direct causes
Hemorrhage
An essential component in
the field of mortality from
hemorrhage is assured
availability of safe blood
Reduction of maternal morbidity and
mortality by direct causes
Sepsis
Management of maternal
sepsis (including treatment
with intravenous or
intramuscular antibiotics)
Reduction of maternal morbidity and
mortality by direct causes
Increased number of
hospitals with trained
personnel to prevent and
treat postpartum
infections. Availability of
highly effective antibiotics
Increased frequency of use
of effective modern
contraception after childbirth
and abortion
The segmentation analysis of family
planning services has shown little
attention to rural, indigenous and high
maternal and infant mortality. In fact, the
existence of an unmet demand indicates
the possibility of expanding the scale of
public family planning services
(Valladares R. y Luigi J. 2008).
Increased use of a method for high
efficiency and increased male
involvement in FP
Critical capabilities to
manage complications in
hospitals and health
centers
Increasing the rate of continued use of
the methods. Decreased fertility
Key management
capabilities in health
centers and hospitals
Family planning:
Implementation of
contraceptive services
post-partum and postabortion
The "Vasectomy" to
the list of methods
available to the
population actually
Implant and IUD Intrauterine device
Decreased fertility especially
married women. Decreased
grand multiparity should
have an effect on maternal
mortality
Improvement of Procedures
as offered and delivered
contraceptive methods.
Better understanding of the
cost of program
Need training hospitals for
the care of complex cases
and implement a referral
network with efficient
transfer can affect costs
Reduction of maternal morbidity and
mortality by direct causes
Improved obstetric care in
hospitals and centers.
More trained personnel.
Better referral systems to
solve complex problems
Reduction of maternal morbidity and
mortality by direct causes
An important component is
prenatal care that is
crucial for early detection
of risk cases. The hospital
staff should be well
equipped to handle
emergencies by preeclampsia/eclampsia.
Worth the same
considerations of high staff
turnover that affects
training costs
Staff trained to treat
bleeding complications
and identify the need for
transfusion and / or
transfer to better-equipped
center
Community campaign:
community health workers
incorporate messages on
vasectomy techniques
Source: Prepared with information from the Mesoamerican Health Initiative (MHI), 2009
45