How much is needed for continuing and scaling up the improved education of family doctors?
A new two-year Post University Specialty Training (PUST) programme in family medicine was introduced to improve the quality of postgraduate speciality medical education in Tajikistan. Postgraduate education of family doctors (FDs) needs to be urgently scaled up, as 38% of FD positions in Tajikistan remained unfilled in 2018. Moreover, the international financial support for the PUST programme is ending. This investment case assesses the minimum funding needed for the continuation and scale-up of PUST and establishes the rationale for the investment in the light of a recent evaluation.
The costs of the programme were calculated for 2018 and a scale-up forecast made for the period 2019–2023. The impact of the scale-up on the shortage of FDs was assessed. An evaluation using a Multiple Choice Questionnaire and Objective Structured Clinical Examination (OSCE) assessed and compared theoretical knowledge, clinical skills and competencies of PUST trained and conventionally trained FDs.
The annual costs of the programme were US$ 228,000 in 2018. The total investment needed for scaling up PUST from 31 new FDs in 2018 to 100 FD graduates each year by 2023 was US$ 802,000.However, when the retirement of FDs and population growth are considered, the scale-up will result only in maintaining the current level of FDs working and not solve the country’s FD shortage. The PUST FDs demonstrated significantly better clinical skills than the conventionally trained interns, scoring 60 and 45% of OSCE points, respectively. Theoretical knowledge showed a similar trend; PUST FDs answered 44% and interns 38% of the questions correctly.
The two-year PUST programme has clearly demonstrated it produces better skilled family doctors than the conventional one-year internship, albeit some enduring quality concerns do still prevail. The discontinuation of international support for PUST would be a major setback and risks potentially losing the benefits of the programme for family medicine and also other specialities. To guarantee the supply of adequately trained FDs and address the FD shortage, the PUST should be continued and scaled up. Therefore, it is essential that international support is extended and a gradual transition to sustainable national financing gets underway.
The implementation of business planning (BP) started as a donor-supported pilot to strengthen the performance of primary health care (PHC) facilities in 2005. Since then, the BP department of the Republican Clinical Center of Family Medicine (RCCFM) has been supported by the Enhancing PHC Services Project (Project Sino). National adaptation of BP practices is currently ongoing, but still to be completed. At the end of 2019, 33 of Tajikistan’s 58 rayons (districts) were implementing the BP1. The implementation in the current rayons still relies heavily on technical support from oblast trainers, and external financial support from Project Sino, the Aga Khan Health Services, and the WHO Country Office. In addition, Project Sino and its funding from the Swiss Agency for Development and Cooperation (SDC) will end in March 2021. This poses challenges to the continuation and national adaptation of this effective planning practice. It is, therefore, important to secure financing for the continuation of BP before this occurs.
This investment case i) highlights the benefits of the BP process, ii) analyses costs in a well-performing Konibodom rayon, and iii) assesses the funding needed for the continuation of BP in the rayons supported by Project Sino. The purpose of the case is to attract financial support from interested international donors and to advocate for the Ministry of Health and Social Protection for the Population (MoHSPP) to increase national funding for BP.
Demo version of a cost-benefit tool for contraceptive programmes
Hello, my name is Jari Kempers. I’m a health economist. With this short video, I’m going to present you a demo version of a cost-benefit tool that we have built for contraceptive programmes.
What is it?
It is an online tool that models health outcomes, and it compares the investment needed with the potential cost savings. And so, therefore, it is a cost-benefit analysis.
But more importantly, it is an advocacy and presentation tool. And it is used together with an investment case. So say, a three four-page document that you hand out to your counterparts in the meetings with the concrete recommendations and short to the point information. In essence, it is advocacy, supported by health economics.
In essence, it is advocacy supported by health economics. You want to convince the decision-makers that contraceptives are a good cost-saving investment.
First of all, experienced health economists are in short supply. And then finally you find one, and you get your study done. My observation is that health economic reports and studies are often, say underutilized, or only used once when the health economist is there and presents the work. And then it is not used anymore. So it’s not a very effective way of using these types of studies. And also, my observation is that the medical personnel are often not comfortable reusing or presenting these studies.
That’s why we started thinking about how we could help? How health economics work could be used more effectively and longer? That’s why we both built this online tool. And we paid special attention, and we limited the number of inputs that the user needs to use. And also, we made a kind of build-up on how the results are presented. So in a minute, I’ll show you the tool itself.
For whom it is?
The target audience, they are healthcare policymakers, the Ministry of Health, in some countries health insurance or the Ministry of Finance people. And is used by international organizations or SRH experts, and in general, persons who are not health economists.
Health economics service
What we offer is a health economics service. We do data collection that is needed to be done in order for the model to work in your situation. We collect the data on the contraceptives, contraceptive prevalence rate (mCRP), the method mix, the policy goals and so forth. There are also health outcome data what needs to be collected and costing of the family planning services.
The cost of providing the contraceptives and also inputs needed for modelling the averted healthcare costs. We localize the model to work in your country, but what is more important is that it needs to work hand in hand with the current advocacy messages, what we are currently working on, so they are working together.
We write an investment case, a three-page policy brief, investment case for the healthcare decision-makers with the concrete recommendations and straightforward results that they can easily get quickly from the document. And then we will leave you with the online tool, we do the base case. But later, you can do your own scenarios and you can save them on the tool, say, your method mix changes or your policy goal goes up or down. And you can model then yourself the economic impacts of the changes. I’ll show you a quick introduction to the online tool. I’ll show the user set up, the inputs what you need to choose, and then I’ll show you the results and the summary. In this video, we will skip the advanced inputs to save time. Okay, let’s get started.
So here, I’m going to walk you through the model as you would be using it in your meetings. We have on purpose limited the number of the inputs that the user needs to select. You start by selecting the time horizon. Typically, the year when you have the latest contraceptive prevalence rate data, in this exercise we assume that is 2020. Then, if your country has a five-year policy call, then you choose a target for five years. If you have, say, three years left of the plan, then you can choose a shorter time horizon. Here we have five years, from 2020 to 2025.
We can put multiple countries in the tool. In this case, I’ll show Mozambique. We have here multiple countries already in. You can choose then the geographic area. Typically countries deal with the entire country, but in some countries where there is a fragmented governmental structure and the procurement of contraceptives is pushed towards the local authorities, you may want to choose a province or even a city. Just that your numbers reflect the reality of what these decision-makers are dealing with. In this case, we will look at the entire country.
Next, you can choose different populations, say all women or in-union. You can also add adolescents, different age groups, or vulnerable groups. Here one should not do overkill. One should only choose the ones that you’re currently advocating for. In this case, we will look at women in-union, 15 to 49 years old.
Contraceptive prevalence rate
The whole forecast is driven by a modern contraceptive prevalence rate (mCRP). In the setup, we will put the current method mix. Different long-acting and short-acting methods, and the current portions.
Then you have the policy goal. In this case, we are advocating for a 5% increase in the uptake. Then you put the targeted contraceptive method mix for this year. It is all done here in the setup. Then the tool shows you the current method mix, and also the population. Say, here we have all the women and this is in-union. What we are actually looking at. Then, once you have selected all these. I jump right away to the results.
This is what you would use in your meetings. So, the point here is that we want to build up the results in a way that the policymakers, who are not experts in contraceptives or family planning, can still understand this.
Here, we are advocating for a 5% increase mCRP from 35% to 40% in five years time. What would it mean in terms of family planning users? So, in-union, this would mean from 1.6 million to 2.1 million in five years time.
What does it mean then in terms of health outcomes, if you have more family planning users? There are obviously less unintended pregnancies, and because there are fewer pregnancies, you have fewer live-births and abortions. Here we get the numbers for each year, and we have numeric tables for all of them. Then, because we have fewer pregnancies, you have fewer deliveries, abortions, you have a reduction in maternal mortality. In this case, there would be 3,300 deaths averted in the beginning, and that would increase to 4,400 averted deaths per year at the end of the forecast.
Then, there are two sides of the story. You have the investment needed, and you have the cost savings caused by the contraceptive use. First, we saw that the cost of family planning services. First of all, this shows that in five years, one would need a $50 million investment. This shows where the money would be spent.
Mainly on injectables and pills, and some on condoms. This is not just the devices or pills. Here the costing, what is done as a preparation for the model. It includes then consultations, say, you have an intake consultation, you have insertion or operation, then you have a control visit, yearly control visits or removals, all these things. It also depends on who is doing these consultations. Is it a midwife, GP or specialist? They all carry different time costs. This is based on the costing study.
Averted healthcare costs
Then the other side of the story is the averted healthcare costs. Because there are less pregnancies, less antenatal care and delivery care needed. There are less complications, there are less unsafe abortion-related care needed.
We saw in the previous tab that $50 million investment was needed. And the potential savings during this period would accumulate up to $172 million. Then we bring these together. This is the investment what you are lobbying for. The potential healthcare cost savings would be $172 million.
Then these would be the net savings for the Ministry of Health. This demonstrates that contraceptives would be a very good investment for the money of the Ministry of Health. Then we bring these also together for cost-benefit analysis. We add the yearly investment needed and the potential cost savings for every year.
Obviously, this is quite a lot of information for a decision-maker. Then we want you to be able to wrap up the meeting. In the way that they remember things, and here we have this kind of cards. For the five years, you would need to invest $50 million. At the end of the forecast, 2025, you have 2.1 million users. During the whole five year period, you would avert 3.6 million unintended pregnancies. Maternal deaths would be reduced by 23,000. And potential healthcare costs savings would be $172 million. And this would mean that the return on investment would be 1 to 3. Meaning that $1 spent on the contraceptives would save you potentially $3.
Interesting for your programme?
I hope you liked the modelling tool. If this is something for your country or for your programme, please send me an email and we can schedule another call to discuss the details.
Sexual and reproductive health (SRH) programmes for young people have a high priority in many low- and middle-income countries (LMICs). However, little is known about the economic aspects of these programmes. More information is needed to support policymaking and to accelerate the implementation of these programmes. This multi-country PhD thesis provides new evidence on costs and cost-effectiveness of young people’s SRH programmes in resource-limited settings. The six research papers are intended for national healthcare policymakers and public health programme managers in LMICs, and personnel of international organizations supporting their work. The World Health Organization (WHO) recommends the simultaneous implementation of health promotion and healthcare services. This thesis focuses on economic evaluations of these two pillars in the context of young people’s SRH. It is organized in two thematic sections; first school-based sexuality education (SBSE) programmes, and second youth-friendly sexual and reproductive health (YFSRH) services.
PhD book of Dr Jari Kempers
This is a PhD thesis of Jari Kempers: Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study.
Contact the author Jari Kempers, health economist PhD jari.kempers (a) Qalys.eu
Please cite this book as Kempers Jari. Economic Analysis of Youth Sexual and Reproductive Health Programmes – a Multi-Country Study. 2015. ISBN: 978-94-6259-771-6. http://www.Qalys.eu/PhD-Jari-Kempers
All rights are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, without permission of the author.
School-based sexuality education programs
The first thematic section presents economic analyses of school-based sexuality education programmes. There are numerous SBSE implementation guidelines for policy makers and programme managers. However, they are often left in the dark on budget implications and efficient design of SBSE programmes. The thesis addresses this by providing cost analyses and -comparisons of six real-world SBSE programmes in India, Indonesia, Kenya, Nigeria, Estonia and the Netherlands, by identifying efficient SBSE programme types and conducting an exploratory cost-effectiveness analysis on one the programmes.
This thesis suggests that SBSE programmes are potentially cost-saving and cost-effective in their public health objective to reduce unintended pregnancies, STIs and HIV infections. However, these outcomes are dependent on programme characteristics and context. The thesis demonstrates that SBSE programmes can be produced at a low cost per student when implemented as large scale intra-curricular programmes. It recommends countries to invest in scalable comprehensive intra-curricular SBSE programme models, that have demonstrated their effectiveness in a similar context. Moreover, the thesis shows that a context where sexuality is a sensitive issue increases costs and reduces the potential impact of SBSE programmes. The opposition has consequences for how and the pace at which SBSE programmes can be introduced and scaled-up, and for the content of sexuality education, i.e. comprehensive versus abstinence-only. Advocacy plays a key role in the success of the implementation of SBSE programmes. Advocacy appears to be a significant cost component, throughout all implementation phases, in many SBSE programmes. Despite this, advocacy is often not budgeted. Therefore, the thesis advises policymakers and programme managers to consider advocacy as a necessary and continuous investment. Lastly, a combination of SBSE and YFSRH services appears to be particularly effective.
Youth-friendly sexual and reproductive health services
The second thematic section presents economic analyses of youth-friendly sexual and reproductive health services. Young people have different healthcare needs and preferences than adults or children. It is important that healthcare systems offer youth-friendly SRH services that are accessible, acceptable and appropriate for young people. However, there is no single YFSRH service package that suits every country. Each country has to define its own package according to epidemiological, social and economic circumstances. This thesis supports these efforts by providing new evidence on the costs of two YFSRH services programmes in Estonia and Moldova, and on the cost-effectiveness of the latter programme. These programmes were selected because former Soviet Union and Eastern European countries are one of the frontiers in developments in young people’s SRH.
The thesis demonstrates that YFSRH services can be produced at a relatively low cost per patient. However, there is no clear answer to whether or not the YFSRH services are cost-saving and cost-effective. This is highly dependable on epidemiological context, especially HIV, and quality of the services. Nevertheless, the thesis recommends countries to invest in YFSRH services, which are an essential part of efforts to improve young people’s SRH, and to implement them together with SBSE programmes. Four chapters of this thesis include young people’s SRH programmes in Estonia. The country has become an internationally recognized success story on scaling up and sustaining national young people’s SRH programmes, with simultaneously improved SRH outcomes. A policy analysis summarizes the factors that contributed to successful scale-up of Estonian youth clinic network (YCN). First, Estonia had a favourable social and political climate for offering YFSRH services. Second, there was a clearly demonstrated need for the services. Third, there is a national professional organization, Estonian Sexual Health Association (ESHA), coordinating and representing youth clinics (YCs). Fourth, personnel of ESHA and YC’s played an important active role in advocating YFSRH services to policymakers. Fifth, the YCs receive sustainable funding through the national health insurance system. Sixth, the recognition of the improvements would not have been possible without the development of national reporting and monitoring systems, and many studies and international publications.
Measurement and attribution of impacts of young people’s SRH programs
This thesis demonstrates challenges with and provides recommendations for, measurement and attribution of impacts of the young people’s SRH programmes. It identifies the following main challenges with assessing the impacts of SBSE programmes: First, the long duration of SBSE programmes makes the use of pre- and post-measurements difficult and lengthy. Second, comparable control groups do not exist. Especially with integrated SBSE programmes, which are usually implemented country- or state-wide. Third, reliable SRH outcome data is not available, or even if data is available the challenge with attribution remains. Fourth, there is a delay between sexuality education (SE) and start of sexual intercourse. At the beginning of the SE programme pupils are usually quite young and not sexually active. They become sexually active several years later, and only then the impact can be assessed. Impact of YFSRH services is a combined result of healthcare services and health promotion. The challenges with assessing of impacts of YCs’ health promotion activities are similar to SBSE programmes. Comparable control groups and reliable SRH impact data do not exist, and there may also be a delay between health promotion and sexual behaviour. Measuring and attributing impacts of YCs’ healthcare services is easier. YCs usually have records on provided SRH services, which can be used for quantifying primary impacts of the healthcare services.
Despite these challenges, the thesis argues that assessing the impact and cost-effectiveness of young people’s SRH programmes is possible. It makes the following recommendations: First, impact- and economic evaluations of young people’s SRH programmes should be combined and planned together in advance. Second, a case-control design is a recommended approach. This requires identification of a comparable control group, or dividing sites randomly into intervention and control groups. Third, base-line measurements should be collected in both groups before the intervention begins. Fourth, special attention should be paid to that data collection captures the information needed for cost-effectiveness analysis. Priority should be given to health outcomes, and if these are not available then behaviour change outcomes should be collected. Fifth, a follow-up period should be for several years. It is important that individuals can be tracked and followed up over time.
Comparability of economic evaluations of young people’s SRH programs
The literature review for this thesis shows that economic evaluations of young people’s SRH programmes are scarce. The results of identified studies are largely incomparable, because the programmes and their contexts, research objectives and used evaluation methods are different, and due to a lack of transparency in documentation as well. The literature review process revealed that there are numerous publications on the impact and effectiveness of young people’s SRH programmes. Yet, very few had any cost- or cost-effectiveness components. This is surprising, especially because financial constraints are one of the main bottlenecks of implementation of young people’s SRH programmes. Most of the impact-only studies measure behaviour intentions (knowledge, skills, attitude) or behaviour changes (abstinence, condom use, number of sex partners), which are much easier to obtain and less suitable for cost-effectiveness analyses than health outcomes (pregnancies, abortions, STIs and HIV infections). Most of the identified economic analyses are limited to only HIV infections (cost per averted HIV infection and/or cost per DALY). The choice is understandable because averted HIV infections create the highest cost savings.
The thesis makes the following suggestions for building an evidence base and improving comparability of economic evaluations of young people’s SRH programmes. First, efforts should be made to combine impact studies with economic evaluations. Second, more attention should be paid to the use of comparable methods and indicators in economic evaluations of SRH programmes. Third, the results of economic evaluations should be compared. Fourth, documentation of methods, data and sources of economic evaluations of SRH programmes should be improved. Transparent reporting will improve the comparability of economic evaluations in the future.
Finally, the thesis makes the following general recommendations for economic evaluations of young people’s SRH programmes. Economic analyses should always aim to support decision making. These should be designed to answer questions that decision-makers are dealing with, and analyses should focus only on issues that are relevant for policymaking. Especially with young people’s SRH programmes health economists need to balance urgency for action (programme implementation) with the long time required for the collection of better data (impact and cost). In the low- and middle-income country context, affordability is the primary and often the only economic criterion included in the decision making process. Therefore the sequence of questions that economic evaluations address should be: How much the programme cost? Does it create cost savings somewhere else? Is it cost-effective? Lastly, complex research results should be simplified and communicated to decision-makers in their language.
Presentation of Dr Jari Kempers on Economic Analysis of Generic Substitution of Antihypertensive Medicines in Moldova. How much would a mandatory generic drug substitution policy save? What are the impacts on the National Health Insurance Company’s (CNAM) drug reimbursement budget and patients’ co-payments?
Substitution of original medicines with their generic equivalents is a key cost-containment strategy used in most of the countries in Europe. In Moldova, the raising drug reimbursement costs pose challenges to the financing of the healthcare system. However, an effective generic substitution policy is not in place yet.
This policy brief assesses the potential cost-savings generated by mandatory generic substitution of antihypertensive (AHT) medicines in Moldova and predicts the impacts on the National Health Insurance Company (CNAM) reimbursement budget and patients’ co-payments. The objective of this policy brief is to open policy discussion with this practical example of AHT drugs.
What does comprehensive sexuality education cost? Cost Analysis of Sexuality and Life Skills Programme in Tirana, Albania. Presentation by Dr Jari Kempers, health economist PhD. This policy brief documents the cost of Sexuality and Life Skills programme in Tirana in 2017, and predicts the investment needed a fully scaled up national sexuality education programme.
Sexuality and Life Skills programme is implemented by the Institute for Education Development of the Ministry of Education and supported by UNFPA and IPPF. The implementation started in public schools in 2015 and the programme is currently being scaled up.
This policy brief assesses the cost of the current programme in Tirana and forecasts the investment needed from the government for a fully scaled up national programme in public secondary schools of Albania. Moreover, the cost estimations serve as an example for other countries considering the implementation and scale-up of similar sexuality education programmes.
This economic analysis is commissioned by the UNFPA Eastern Europe and Central Asia Regional Office and UNFPA Albania Country Office.
The Spring Symposium of the Swiss Tropical and Public Health Institute in 2019.
Presentation of Dr Jari Kempers at the at the Spring Symposium of Swiss Tropical and Public Health Institute in May 2019. An Investment Case for Two-Year Post University Speciality Training in Family Medicine in Tajikistan.
The two-year post-university speciality training (PUST) family doctors are better: How to transition from international support to sustainable national funding?
According to the Ministry of Health and Social Protection of the Population (MoHSPP), 38% of the 5,333 family doctor positions in Tajikistan were not filled in 2018. Postgraduate education of adequately trained family doctors needs to be scaled up.
The two-year Post University Specialty Training (PUST) in Family Medicine has demonstrated to train significantly better-skilled family doctors, than the conventional one-year work experience in family medicine.
However, the ending of support from the Swiss Agency for Development and Cooperation (SDC) poses challenges to the sustainability and scale-up of PUST.
This investment case assesses the funding needed for a controlled and sustainable transition to national funding in the next five years. It proposes a combination of increasing national funding and gradually decreasing donor support. Moreover, the case predicts the funding needed for scaling up the PUST during the same period. It also provides the rationale for the investment.
Primary Human Papilloma Virus (HPV) testing is the currently recommended cervical cancer (CxCa) screening strategy by the Portuguese Society of Gynecology (SPG) clinical consensus. However, primary HPV testing has not yet been adopted by the Portuguese organized screening programs. This modelling study compares clinical benefits and costs of replacing the current practice, namely cytology with ASCUS HPV triage, with 2 comparative strategies: 1) HPV (pooled) test with cytology triage, or 2) HPV test with 16/18 genotyping and cytology triage, in organized CxCa screenings in Portugal.
A budget impact model compares screening performance, clinical outcomes and budget impact of the 3 screening strategies. A hypothetical cohort of 2,078,039 Portuguese women aged 25–64 years old women is followed for two screening cycles. Screening intervals are 3 years for cytology and 5 years for the HPV strategies. Model inputs include epidemiological, test performance and medical cost data. Clinical impacts are assessed with the numbers of CIN2–3 and CxCa detected. Annual costs, budget impact and cost of detecting one CIN2+ were calculated from a public healthcare payer’s perspective.
HPV testing with HPV16/18 genotyping and cytology triage (comparator 2) shows the best clinical outcomes at the same cost as comparator 1 and is the most cost-effective CxCa screening strategy in the Portuguese context. Compared to screening with cytology, it would reduce annual CxCa incidence from 9.3 to 5.3 per 100,000, and CxCa mortality from 2.7 to 1.1 per 100,000. Further, it generates substantial cost savings by reducing the annual costs by €9.16 million (− 24%). The cost of detecting CIN2+ decreases from the current €15,845 to €12,795. On the other hand, HPV (pooled) test with cytology triage (comparator 1) reduces annual incidence of CxCa to 6.9 per 100,000 and CxCa mortality to 1.6 per 100,000, with a cost of €13,227 per CIN2+ detected with annual savings of €9.36 million (− 24%). The savings are mainly caused by increasing the length of routine screening intervals from three to five years.
The results support current clinical recommendations to replace cytology with HPV with 16/18 genotyping with cytology triage as screening algorithm.
In Tajikistan, the management capacity of primary healthcare (PHC) systems needs to be improved, especially at the oblast and district levels. Since 2015, the PHC management course (PHCMC) has been implemented by the Post Graduate Medical Institute (PGMI), with the support of the Enhancing PHC Services Project (Project Sino) and since 2018 the Aga Khan Health Services Project. The experience gained to-date from 13 pilot rayons is encouraging. Project Sino, however, and its funding from the Swiss Agency for Development and Cooperation (SDC) will end in March 2021, which poses challenges to the continuation and the needed national scale-up of this essential training. It is important to secure finances for the continuation of the course before this occurs.
This investment case; i) highlights the benefits of the course, ii) analyses costs, and iii) assesses the funding needed for the continuation and scaling up at the national level. The purpose is to attract financial support from interested international donors and to advocate for the Ministry of Health and Social Protection for the Population (MoHSPP) to increase national funding for the course.
Presentation of Dr Jari Kempers on an Economic Assessment of Introducing Community Medical Assistants in Primary Healthcare in Moldova. Human resource needs and costs of community medical assistant services. This national-level economic analysis of the introduction of a new community medical assistant (CMA) service seeks to answer the questions: How many CMAs are needed? How quickly could the service be scaled up? By how much would primary healthcare capitation payments need to be increased to cover the costs of this new service?
Stay up to date. Get health economics news and tips for your work.
You can unsubscribe at any time
Schedule a call
Would you like to discuss how we could help you? Contact us, and we'll schedule a call with you.