comprehensive Multi-Year Planning (cMYP) A Tool and User Guide for cMYP Costing and Financing

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WHO/IVB/14.06

DEPARTMENT OF IMMUNIZATION,

comprehensive Multi-Year

Planning (cMYP)

A Tool and User Guide for cMYP Costing and Financing

Update 2014

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WHO/IVB/14.06

comprehensive Multi-Year

Planning (cMYP)

A Tool and User Guide for cMYP Costing and Financing

Update 2014

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The Department of Immunization, Vaccines and Biologicals thanks the donors whose unspecified financial support

has made the production of this document possible.

This document was produced by the Expanded Programme on Immunization

of the Department of Immunization, Vaccines and Biologicals

Ordering code: WHO/IVB/14.06 Printed: April 2014

This publication revises the original publication (WHO/IVB/06.15)

published in December 2006

This publication is available on the Internet at:

www.who.int/vaccines-documents/

Copies of this document as well as additional materials on immunization, vaccines and biologicals may be requested from:

World Health Organization

Department of Immunization, Vaccines and Biologicals CH-1211 Geneva 27, Switzerland

• Fax: + 41 22 791 4227 • Email: [email protected] •

fax: +41 22 791 4857; email: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; email: [email protected]).

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

The named authors alone are responsible for the views expressed in this publication.

Printed by the WHO Document Production Services, Geneva, Switzerland

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Abbreviations and acronyms

AD auto-disable syringe APR annual progress report

BCG bacille Calmette-Guérin (tuberculosis vaccine) CBAW childbearing age women

CEA cost-effectiveness analysis

cMYP comprehensive Multi-Year Plan (for immunization) cMYP Tool cMYP Costing and Financing Tool

DFID Department for International Development (United Kingdom) DTP diphtheria-tetanus-pertussis (vaccine)

EPI Expanded Programme on Immunization FIC fully immunized children

GAVI the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunisation)

GDP gross domestic product

GHE government health expenditure

GIVS Global Immunization Vision and Strategy GVAP Global Vaccine Action Plan

HepB hepatitis B (vaccine)

Hib Haemophilus Influenzae type B (vaccine) HIPC highly indebted poor country

ICC inter-agency coordinating committee IEC information, education and communication IMF International Monetary Fund

IMR infant mortality rate

JICA Japan International Cooperation Agency JRF WHO–UNICEF Joint Reporting Form LCU local currency units

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MDG Millennium Development Goal MDRI multilateral debt relief initiative MoF ministry of finance

MoH ministry of health

MTEF medium-term expenditure framework MYP multi-year plan (for immunization) NHA national health accounts

NIP national immunization programme OPV oral polio vaccine

PRSP poverty reduction strategy papers

SIA supplemental immunization activities (campaigns) SWAp sector-wide approach

TB tuberculosis

THE total health expenditure TT tetanus toxoid (vaccine) U1P under one population ULY useful life years

UNICEF United Nations Children’s Fund US$ United States dollars

USAID United States Agency for International Development WHO World Health Organization

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This document has been revised by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF), with the support of other immunization partners, to reflect the updated version of the cMYP Costing and Financing Tool.

The revised document replaces the previous publication, Immunization costing &

financing: a tool and user guide for comprehensive Multi-Year Planning (cMYP) (2006, WHO/IVB/06.15).

The original contributors to the document are partners of the GAVI Alliance:

the Bill & Melinda Gates Foundation, the Centre for Global Development, the Children’s Vaccine Programme at PATH, UNICEF, the United States Agency for International Development (USAID), the World Bank and WHO.

The revisions were made by Claudio Politi, Michael Hinsch (WHO Headquarters) and Ann Levin, independent consultant. We would like to express our gratitude to Jean-Bernard Le Gargasson (Agence de Médecine Préventive), William Meaney and Viktor Galayda (independent consultants) who reviewed the document. Our special thanks go to the numerous national EPI Managers and colleagues from WHO and UNICEF regional and country offices and immunization partners who contributed to the review.

Acknowledgments

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* The 2005 publication was recently revised under a slightly different title:

World Health Organization (WHO), United Nations Children’s Fund (UNICEF).

WHO–UNICEF guidelines for comprehensive multi-year planning for immunization: update September 2013. Geneva: WHO; 2014 (WHO/IVB/14.01;

http://apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf?ua=1, accessed 27 May 2014).

Introduction

Responding to global immunization challenges, including the need to protect more people and introduce new vaccines, and in consultation with their other partners, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) developed the Global Immunization Vision and Strategy (GIVS) for the period 2006–2015, followed by the Global Vaccine Action Plan (GVAP) for the period 2011–2020. GVAP is a framework that offers policy-makers and stakeholders a unified vision of immunization and a set of strategies from which countries can select those most suited to their specific needs. In conjunction with GVAP, and as a way of implementing GVAP at national level, countries are encouraged to develop their own comprehensive multi-year plans (cMYP) for immunization.

In 2005, in conjunction with their GAVI Alliance partners, WHO and UNICEF developed the WHO–UNICEF guidelines for developing a comprehensive multi- year plan (cMYP)^* as a means of providing support for countries to improve their immunization planning. This new approach was guided by the need to simplify and harmonize the proliferation of varied immunization planning activities at the national level, which in turn had led to duplication of effort, high transaction costs, and a lack of alignment with national systems. The cMYP process is expected to streamline the immunization planning process at national level into a single comprehensive and costed plan. With the GVAP initiative and framework, the cMYP guidelines and tools have been revised, taking into account the countries’ experience on developing multi-year planning during the GIVS period.

In the development of these user guides, it was broadly recognized that strategic planning for immunization requires credible information about how much was currently being spent, what it was spent on, from what source the funding came, and how much future funding would be needed to reach programme objectives. Analysing the costing and financing of a cMYP is therefore a key step in the planning process of a national immunization programme (NIP).

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To help undertake the costing and financing elements of a cMYP, a Microsoft Excel-based tool was developed – the cMYP Costing and Financing Tool – to make it easy to estimate past costs and financing for immunization, to aid in making future projections of resources requirements and financing, and for analysing the corresponding financing gaps in reaching immunization programme objectives. The cMYP Costing and Financing Tool (the cMYP Tool) is accompanied by this comprehensive User Guide, which provides an overview of important concepts, methodologies and definitions.

It also provides step-by-step instruction on how to use the cMYP Tool, guidance on sources of information, and results analysis, as well as guidance on interpretation of findings.

The User Guide is structured as follows:

• introduction to strategic planning for immunization and costing

• overview of the costing and financing tool

• suggestions on procedures

• basic concepts, methodologies and terms

• how to use the costing and financing tool

• how to analyse the results and interpret findings

• how to develop alternative scenarios for costing and financing

• how to use the tool for annual monitoring

• other uses of the information from the costing and financing tool

• annexes: (1) reference summary table of data needs and sources; (2) glossary of terms.

While the cMYP Tool and User Guide are principally targeted at national immunization programme managers developing comprehensive multi-year plans, the documents can also be used by researchers, consultants, international donors and other health planners in developing countries. No prior experience or formal training in health economics is necessary in implementing the cMYP Tool and understanding its User Guide.

The intention is that these materials will be continually be improved and updated.

We therefore recommend that users regularly visit the website to obtain the latest versionsǂ.

ǂ Available at: www.who.int/immunization/programmes_systems/financing/tools/cmyp/en

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1.1 A revised approach to planning for immunization

Responding to global immunization challenges, including the need to protect more people and introduce new vaccines, WHO and UNICEF, in consultation with other partners, have developed the Global Vaccine Action Plan for the period 2011–2020.

GVAP is a framework that offers policy-makers and stakeholders a unified vision of immunization and a set of strategies from which countries can select those most suited to their specific needs.

In conjunction with GVAP, countries are encouraged to develop a cMYP for immunization. Yet to date, the planning experience at country level for immunization has revealed many shortcomings. Plans are based upon a review of past achievements and problems; they are not sufficiently forward-looking; there are separate plans for each initiative or target disease; plans may be developed to fit particular funding proposals rather than reflecting country priorities; plans are not well costed to identify clear funding needs and resources gaps, and many plans have very little connection with the broader health sector or macroeconomic context.

This experience has taught us that planning needs to reflect country priorities and align with country planning cycles. The planning process must be simplified and harmonized.

To address these issues, the WHO and UNICEF cMYP process for immunization began in 2005, with the formulation of new guidelines and tools. Through the GVAP initiative, the cMYP Guidelines and Tool have been revised to streamline the immunization planning process at country level into a single comprehensive and costed plan aligned with the new framework.

In summary, the WHO–UNICEF guidelines for comprehensive multi-year planning for immunization¹provides a new approach to planning that:

• ensures that the strategies in the plan are sufficiently comprehensive;

• integrates and consolidates activities with other health interventions and within the immunization programme to solve shared problems;

• plans by immunization system components rather than by disease or initiative;

• evaluates the costs and financing of the cMYP to ensure improved financial management sustainability of the programme;

• links annual workplans to the multi-year plan;

• links to the broader health sector planning and budgeting processes.

1 WHO and UNICEF, 2014 (see footnote 1, page 1)

1. Strategic planning for

immunization with costing

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1.2 Why cost a cMYP?

It is broadly recognized that strategic planning for immunization requires credible information about cost to achieve the programme objectives, estimate available funding, allocate funds within the programme, and avoid funding shortfalls. For this reason, analysing the costing and financing of a cMYP is a key step in the planning process.

The costing of a cMYP is thought to have a number of benefits.

It strengthens national budgeting and planning for immunization and helps to answer the fundamental questions of how much it will cost to reach programme objectives, who will pay for these needs, and how to prioritize activities based on available funding.

It helps in decision-making about programme improvements, for example, understanding the cost implication of introducing new vaccines. A baseline costing of the programme would enable the development of scenarios for improvements, and understanding the incremental costs of such improvements.

It generates information that will help advocacy and mobilize the resources needed for vaccination and immunization. A solid understanding of the funding gaps can facilitate discussion with ministries and donors on how to mobilize the resources required for the programme.

1.3 What are the costing linkages in the cMYP guidelines?

The WHO–UNICEF guidelines for comprehensive multi-year planning for immunization provide a series of steps to develop a comprehensive plan. Step 6 of these guidelines relates to analysing the costs, financing, and financial gaps in a cMYP.

Note that the basis of the costing should be the programmatic objectives and milestones defined during steps 1 to 3 (see Figure 1).

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Figure 1: Costing linkages in cMYP guidelines

Step 2 Objectives &

milestones

Step 3 Planning strategies

Step 4 Links to national,

regional and international goals Step 5

Activity timeline, monitoring & evaluation Step 6

Cost & financing &

resource mobilization Step 7 Putting cYMP

into action

Step 1 Situation analysis

1. Health sector analysis 2. Estimating costing and

financing of the cMYP 3. Scenario building using

the costing tool 4. Interpreting costs,

financing and gap results 5. Developing financial

sustainability strategies 6. Financial sustainability indicators and targets

Step 6 has six components to it. Step 6(1) is to undertake a diagnosis of the macroeconomic and health sector environment in which the immunization programme operates.

This diagnosis recommends exploring three areas: (a) trends in government financing of health services; (b) the planning and budgeting processes for the health sector;

(c) current or potential reforms which may have an impact on the immunization programme. Such a diagnosis will strengthen any projections of future financing for immunization, and assessment of the reliability of future funding.

Steps 6(2) and 6(3) are to estimate the baseline costing and financing of the immunization programme, making future projections of resource requirements based on the programmatic objectives defined under steps 1 to 3 of the cMYP, and to develop alternative scenarios for resource requirements and financing.

Step 6(4) is to analyse the results and interpret the findings, particularly with regard to the financing gaps for immunization. Lastly steps 6(5) and 6(6) are to identify strategies and indicators that will help you move towards financial sustainability.

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1.4 What are the cMYP linkages with broader health sector costing exercises?

Neither strategic planning for immunization, nor its costing, have ever been easy processes. The immunization programme is one of many components of a country’s health system. It is supported by a broad range of national and international partners and actors that can have differing objectives and needs, and might view planning for immunization within a different context (see Figure 2).

Figure 2: Reconciling various objectives when planning for immunization

Poverty Reduction (MDG, PRSP, MTEF ...)

New vaccine introduction, increasing coverage ...

Health Sector Planning, integration, SWAp ...

Polio, measles, campaigns, outbreaks, surveillance ...

EPI Objectives GAVI

World Bank MoH Policy MoF Priorities

The ministry of finance (MoF), for example, might view immunization in the context of the Millennium Development Goals (MDGs), or how it can contribute to poverty reduction. Thus, any strategic planning for immunization should fit with these broader objectives as laid out in the MDGs, and any budgeting for immunization would need to appear in the relevant national budgeting processes such as a medium-term expenditure framework (MTEF).

The ministry of health (MoH), on the other hand, would view immunization in the context of the broader objectives and planning process. The national immunization programme may have its own specific planning and budgeting objectives, and these can be different from those of international agencies and initiatives supporting the programme.

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Although the different planning processes and objectives are not necessarily in competition, reconciling all these in the context of a strategic plan for immunization is not an easy task, and it is therefore important that objectives and priorities are aligned.

Similarly, the costing information generated through the cMYP development should link to the relevant consolidated costing and budgeting plan for the health sector.

If applicable, it can be useful to link various ongoing exercises such as: poverty reduction strategy papers (PRSP); health sector and public expenditure reviews; budgeting, allocation, and expenditure (MTEF, NHA); and external support and resource mobilization processes (such as donor round tables, SWAp, etc.). This has the effect of increasing the visibility of immunization during health sector planning processes and can increase the chances of mobilizing the resources needed for the programme.

Because the relevant planning cycles and costing/budgeting exercises for the health sector differ between countries, and budgeting formats can also vary from one country to the next, it is not possible to develop a costing template that will fit into every existing situation. To reconcile this difficulty, the cMYP Costing and Financing Tool includes a costing table that provides the most disaggregated level of costing possible.

This facilitates how specific budget lines in the cMYP costing table can be linked and matched to budget lines in another. (More on the costing table is available in part 5.3).

Also, the period covered by resource estimation should be set for five years, as with a longer time frame, more assumptions need to be made for future projections, and estimates become unreliable. Maximum five-year projections therefore seem useful, especially when linked to annual operational plans and allocations.

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The cMYP Costing and Financing Tool (referred to as the cMYP Tool throughout the remainder of this User Guide) is a Microsoft Excel-based template.

2.1 Description of the worksheets in the cMYP Tool The cMYP Tool contains the following worksheets:

• Home page

• Style

• Checklist

• Dashboard

• Data Entry

• Costing

• Financing

• Gaps & Indicators

• Graphs

• Sustainability

• Co-financing

• Vaccine Prices

• Annual Workplan

• Index

The Home worksheet is where you can find shortcuts to important sections, and a schematic of the main activities required to complete the cMYP. Clicking the shortcut icons along the upper bar take the user to the Checklist, Co-financing worksheet, and Graphs worksheet. Every other worksheet will have similar shortcuts leading back to the home page and the checklist. Shortcuts on the home page, located next to

“START HERE”, take you to the three worksheets that require data input and the three review worksheets.

The Style worksheet contains descriptions of different styles, formats and colours used for text and numbers in the cMYP Tool.

2. Overview of the cMYP

Costing and Financing Tool

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The Checklist contains a checklist of all the necessary data inputs. As you enter data, you should keep track of what you have done by double clicking the appropriate boxes on the checklist. This will help you monitor progress during the data entry and remind you of what additional data entry is required.

The Dashboard contains a summary of the costing and financing situation and a summary of baseline annual expenditures. It also has a table with the financing information of the baseline year, which is useful for the financing indicators on the Joint Reporting Form. The summaries will automatically update as data are entered into the cMYP Tool.

Start by selecting “Enter/edit costing data” on the Home worksheet.

The Data Entry worksheet is where you need to enter all the data for the costing and resources requirements projections. The worksheet contains a series of data entry tables for the calculations of vaccines, injection supplies, personnel, vehicles and transport, cold chain and maintenance, supplemental immunization activities, other recurrent and capital costs, and other costs not specified elsewhere. Given the importance of this worksheet, parts 5.1 and 5.2 of this User Guide are dedicated to explaining how to complete the worksheet and find the required data.

Go back and select “Enter/edit financing data” on the Home worksheet.

Data on past and future financing are entered in the Financing worksheet.

Some suggestions on procedures to collect financing information are provided in parts 5.4 and 5.5 of the User Guide and in Annex I.

Go back and select “Enter/edit co-financing data” on the Home worksheet.

The data on GAVI co-financing are entered in the Co-financing worksheet.

Some suggestions on procedures to collect co-financing information are provided in part 5.6 of the User Guide.

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Figure 3: Screen shots of the cMYP Costing and Financing Tool (illustration only)

1. Data Entry Worksheet 2. Costing Worksheet

3. Gaps & Indicators worksheet 4. Graphs

The remaining worksheets are automatically generated based on the information entered in the Data Entry, Financing and Co-financing worksheets.

The Calculations worksheet consolidates the formulas that convert the information and data provided in the Data Entry worksheet into the costing and estimates for resource requirements. The broad underlying methodology used in the Calculations worksheet is described in part 4 of the User Guide. This worksheet is hidden and is available for developers.

The Costing worksheet is linked to the Calculations worksheet and presents the results by means of various costing tables. These costing tables are described in part 5.3 of the User Guide.

The Gaps & Indicators worksheet is linked to the Financing worksheet and generates a summary table of costs, future resource requirements, financing and gaps needed for complete financial diagnosis of the cMYP. This worksheet automatically calculates a range of indicators that should be used in the analyses. It contains several tables presenting year-to-year variation of secure and probable financing, and makes overall estimates for the financing gaps and how they will evolve over time. These indicators are explained in parts 6.1 and 6.2 and in the Annex to the User Guide.

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The Graphs worksheet is linked to numerous other worksheets in the cMYP Tool and contains a number of automatically generated charts and graphs needed for analyses.

This worksheet contains charts that plot the future resource requirement profiles and the future financing and gap profiles. These help clarify the level of resource requirements needed by the NIP, and also what financing will be available in the future. More information is available in parts 6.1 and 6.3 of the User Guide.

The Sustainability worksheet is linked to numerous other worksheets in the cMYP Tool and contains a number of automatically generated macroeconomic and financial sustainability indicators that can be used for your analyses. More information is available in part 6.4 of the User Guide.

The Vaccine Prices worksheet contains detailed information on numerous vaccines and vaccine supplies. On this sheet you will find the following information about each item: vaccine, vaccine code, formulation, mode of administration, recommended schedule, doses per vial, and price per vial. The following information is provided for vaccine supplies: injection supplies/equipment, references, units per box, cost per box, freight cost, and total cost.

The Annual Plan worksheet contains a template to be used for listing the main activities to be carried out during each year of the planning period. The template is structured in a way that allows regular updating of implementation rates according to the timeline expected.

The Index contains a list of the worksheets and a summary of the content of each worksheet. In addition, the worksheets that require user input are indicated.

Note that all the worksheets in the cMYP Tool are printer friendly.

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Figure 4: Design of the cMYP Tool

Enter/Edit1.

Costing data

Review gaps &

indicators report (autogenerated) Review sustainability

analysis (autogenerated)

Review costing report (autogenerated)

Enter/Edit3.

Costing data

Enter/Edit2.

Financing data

2.2 Can the cMYP Tool be used in a decentralized setting?

It is important to note that the cMYP Tool allows for a generalized approach but can be customized to fit a particular country situation or context. For instance, it is not restricted to any particular country administrative level. In a decentralized setting, different sections of the cMYP Tool may need to be used at different levels of the system (subnationally). This may be of particular relevance in large country settings and where data collection needs to be undertaken at lower levels in the system or where subnational (e.g. provincial) planning and budgeting is required to implement the immunization programme activities.

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2.3 Can the cMYP Tool be damaged?

Owing to its intricate linkages and formulas, the cMYP Tool is very sensitive to any formatting changes (adding or deleting cells, rows or columns) and editing (cut, copy and standard pasting of information from different sources). In order to protect it from any damage caused by formatting or editing changes, certain protective measures have been put in place and the worksheets are also password protected.

More detailed information about cMYP Tool protection and passwords is provided in part 5.1 of this User Guide.

2.4 What is the cMYP Tool not designed to do?

The main purpose of the cMYP Tool is to facilitate costing and finance estimation of a cMYP, and to make projections of future resource requirements and financing to achieve programme objectives. However, the cMYP Tool currently has three areas of limitation.

1) The first is that it was not designed for cost–effectiveness analysis (CEA), which can assist in evaluation and comparison for alternative uses of scarce resources. Although defining programme objectives and strategies during the development of a cMYP should be based on cost–effectiveness considerations (particularly in relation to new vaccine introduction), the cMYP Tool, in its current design, is ill-equipped to strengthen such a priority-setting exercise.

Likewise, the cMYP Tool is not designed to determine allocative efficiency.

A critical consideration in any planning and budgeting exercise must be the efficient use of funds.

2) The second limitation is that in its current format, the cMYP Tool does not automatically factor in any scale effect. Ideally, costs would vary as the scale of immunization interventions changes. For instance, with economies of scale, costs would decrease as the scale (such as coverage) increases, as fixed inputs (such as buildings) are used more efficiently. There could, however, also be diseconomies of scale, whereby costs increase proportionally if the last people to be reached and immunized live in areas that are difficult to access. There can even be economies of scope, when combining intervention results in cost savings.

While techniques and methodologies are rapidly becoming available for global level costing exercises, where scale up effects can be included, these have not yet been assimilated into the cMYP Tool. In the meantime, any scale effect needs to be done manually.

3) Finally, the cMYP Tool is immunization specific, and is therefore not adapted to include the costing of other health interventions. Moreover, it has limited linkage with other existing tools available for costing health interventions, programmes and packages of services.

Work to improve the cMYP Tool and to overcome these limitations is continuing

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2.5 Where to send feedback and seek technical support

We welcome questions and comments on the cMYP Tool and User Guide. While we have tried to identify any inconsistencies in the system, if you discover any errors, encounter any problems, or have any suggestions on how to improve these materials, we encourage you to bring these to our attention. Please direct your comments to:

The World Health Organization

Department of Immunization, Vaccines and Biologicals Expanded Programme on Immunization

20 Avenue Appia CH–1211, Geneva 27 Switzerland

[email protected]

For questions, comments and technical assistance related to the development of a cMYP, please contact your regional offices. For general information on submitting the cMYP as part of a GAVI funding application, visit the GAVI website at www.vaccinealliance.org.

More general information on immunization planning and financing is available at:

www.who.int/immunization/programmes_systems/financing/en/

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Before starting the cMYP costing and financing exercise, several principles should be noted. The first is the importance of creation of leadership and ownership of the cMYP development process within the immunization department of your MoH. It is equally important to inspire commitment and buy-in to the process, priorities and strategies for immunization from the stakeholders represented on the Inter-agency Coordinating Committee (ICC). Because any costing and financing resource requirement projection exercise will invariably be based on many assumptions, limited data and future uncertainties mean that these assumptions need to be agreed upon in close cooperation and agreement with all stakeholders so that the final estimations for the cMYP will be credible, acceptable, and useful.

Unfortunately, there is no blueprint for the process and therefore considerable time can be taken up tailoring the cMYP costing and financing exercise to each individual country. The exercise cannot be done in isolation and will need the collaboration of colleagues in the MoH and the MoF, as well as all development partners supporting immunization, for data collection, analysis, feedback and review.

The second principle is the importance of putting together a good team to work on the cMYP costing and financing exercise. The team will need to be composed of the right people, with the right skills, and they will need the right amount of time to complete the exercise. A focused and manageable group of no more than three people is required.

It will be important to decide on who will lead and who will coordinate the team.

Below are some suggestions on steps and procedures for the team.

1) The cMYP development team should read the WHO–UNICEF guidelines for comprehensive multi-year planning for immunization,² paying particular attention to step 6: Analysing the costs, financing, and financial gaps in the cMYP.

Discuss the steps so that the group fully understands the task at hand, how the costing steps of the cMYP development will inform the overall financial sustainability planning for the NIP, and also what needs to be done to achieve these objectives.

2) Read the User Guide to understand the methodologies, key concepts and terms needed, and to obtain step-by-step instructions on how to use the cMYP Tool and where to obtain the necessary data. The latest versions of the cMYP Tool and User Guide are available for download.³ Because these materials will be constantly improved and updated, it is important to visit the website regularly

3 Available at: www.who.int/immunization/programmes_systems/financing/tools/

cmyp/en/

3. Some principles and

suggestions on procedure

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to obtain the latest version.

3) Review the objectives, strategies, and macroeconomic/health sector context developed for your cMYP, and determine what will constitute your baseline scenario for the costing. For example, the baseline scenario needs to include the same actual coverage achieved, immunization schedule and expansion, and the same timing of specific campaigns as those defined in your cMYP.

Also, activities that are specified in the cMYP should be budgeted for in the cMYP Tool (e.g. expanding the cold chain, strengthening outreach services, etc.).

4) Review the Data Entry worksheet of the cMYP Tool to determine what data is needed and how best to collect it. Collecting and synthesizing data can be difficult since information sharing among external development agencies involved in health, and the different ministries and their internal departments, may be weak.

It may be more useful to print the entire worksheet to use as a data collection instrument. This way the different data tables can be distributed to those people that will be collecting the data or who will be providing the information.

Refer to Annex I of this User Guide for suggestions as to where to find data for the costing, or techniques for estimating some data needs.

5) A checklist is available on the Checklist worksheet to assist the user in keeping track of completed sections.

6) Once all the data on inputs and activities has been collected, these should be entered in the appropriate tables of the Data Entry worksheet of the tool.

Review this worksheet carefully for any errors in data entry, or any omissions or oversights of data needs for the tables. Remember that the cMYP Tool is password protected and data should not be pasted into the Data Entry worksheet from another Excel file. This could damage formulas, provide wrong results, or render the cMYP Tool useless.

7) Review the results of the costing in the Costing worksheet. Close inspection of the tables may yield strange results. This could be due to errors in the data or data entry into the cMYP Tool, or omissions of required data inputs. These should be reviewed. It can happen that costing results do not appear in the costing table.

If this is the case, it could be due to important information not having been entered into the Data Entry worksheet.

8) Double-check the work as often as you think necessary. Remember to save the work frequently. This updates your file and helps to ensure that you do not lose significant amounts of data once it is entered in the cMYP Tool.

9) After completion of data entry in the Data Entry worksheet, a first analysis should be made of the results obtained. Parts 6.1 to 6.4 of this User Guide offer suggestions on how to analyse the findings. Ensure review of the Gaps & Indicators and Graphs worksheets of the cMYP Tool. It is important to make a first analysis so that the team can present the results and validate them with a broader group, such as the ICC.

10) Once the costing of the cMYP is finalized, and estimates have been made for future resource requirements, the team will need to collect information on past and future financing. This information should be entered in the Financing worksheets.

For future financing, it is important to classify the funding according to its level of risk – secure versus probable. Suggestion on how to collect financing data is developed in parts 5.4 and 5.5 of the User Guide.

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11) After finalization of the financing of the cMYP, the team will need to collect information on co-financing requirements for GAVI vaccines. This information should be entered in the Co-financing worksheet. Instructions for using this worksheet can be found in part 5.6 of the User Guide.

12) Once the financing data is entered in the cMYP Tool, the work should be double- checked for any mistakes or results. To identify errors, it can be helpful to review the Gaps & Indicators and Graphs worksheets. Once the team is satisfied with the results and these have been double-checked for errors, the cMYP Tool can be saved as the baseline scenario.

13) A second analysis of the results should compare the estimated resource requirements and available funding, to identify the gap in funding needed to meet desired programme objectives. Again, it can be helpful to review the Gaps

& Indicators and Graphs worksheets in the analysis. A summary of the results is available on the Dashboard worksheet.

14) Using the baseline scenario, the team may be interested in exploring alternatives to evaluate what impact a change in cMYP objective may have on projected resource requirements, financing and gaps. Various scenarios can be developed, and guidance on this is provided in parts 7.1 and 7.2 of this User Guide.

15) The final step is filling in the Annual Plan worksheet where the main activities for each year of the planning period should be listed with timeline.

Their implementation should be monitored during the year.

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Part 4 of the User Guide provides important background information on basic costing concepts, methodologies and terms. Before starting the cMYP costing and financing exercise, it is essential to become familiar with these terms.

Figure 5: Broad elements to cost in a cMYP

ObjectivescMYP

Strategies

Activities (e.g. training) Inputs

(e.g. vaccines)

4.1 What to cost in a cMYP

The costing exercise needs to account for all the inputs and activities designed to carry out the strategies needed to reach the programme objectives, as defined in the cMYP.

Table 1 illustrates the types of inputs and activities that are usual in an immunization programme. They are linked to the health system components defined in the WHO–UNICEF guidelines for comprehensive multi-year planning for immunization.⁴

4. Important concepts,

methodologies and terms

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Table 1. Health system components to cost in a cMYP

Health system components Inputs Activities

Leadership & governance Programme management,

computers and office equipment Meetings, planning, research, data management, expanded programme on immunization (EPI) reviews, cold chain assessment, etc.

Health workforce Human resources/salaries, outreach

per diems Supervision, training, workshops,

etc.

Finance Financial resources Budgeting and monitoring

expenditures Medical product and technology Vaccines, auto-disable (AD)

syringes, safety boxes, other injection supplies, cold-chain equipment vaccines, cold chain and logistics

Vaccine procurement and storage; monitoring; vaccine stock management activities

Service delivery Transport, operational cost for

routine immunization and campaigns Operations for immunization delivery Information Information, education and

communication (IEC) materials, such as posters, etc.; surveillance and laboratory equipment

Social mobilization, IEC, development of advocacy and communication plan, surveillance

The cMYP Tool is designed around this framework and requires the necessary data entry to calculate the costs and resource requirements for inputs and activities relevant to your immunization programme. This is described in greater depth in parts 5.1 to 5.5 of this User Guide.

At a minimum, it is important to estimate the costs, financing and future resource requirements of your cMYP for all immunization-specific inputs and activities.

All inputs and activities that are shared with other programmes, such as personnel, transportation and buildings are optional.

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What is the difference between an immunization-specific input and a shared input?

Immunization-specific costs include the value of inputs and activities undertaken specifically for immunization.

In other words, their utilization is 100% for the NIP. Typically, immunization-specific recurrent inputs include: vaccines;

injections supplies; full time immunization personnel (including those who conduct outreach and supplemental immunization activities); the transport costs incurred by the NIP (e.g. fuel and maintenance cost of the vehicles owned by the NIP); training activities; social mobilization; surveillance activities, etc. On the other hand, immunization-specific capital inputs can include vehicles and cold-chain equipment to be used specifically for the NIP, together with other inputs used specifically by the programme (e.g. waste disposal, etc.). The complete listing and definition of the immunization- specific inputs can be found in Annex II at the end of this User Guide.

Shared costs include the value of inputs that are not specific to immunization and which are used by different programmes or activities in the health sector, i.e. their utilization for the NIP is less than 100%. For instance, a nurse working in a district health centre is likely to be providing immunization services as well as other curative and preventive services.

Only a portion of that nurse’s salary and time can be attributable to immunization. Lik ewise, a vehicle in a district health centre (such as a four-wheel drive) may be used by staff working for programmes other than immunization, such as malaria or tuberculosis (TB) programmes. Therefore, only a portion of the fuel and maintenance cost of these vehicles will be borne by the NIP. The remaining portion will be borne by the budget of the district health administration.

This makes it difficult to separate out the portion of these inputs that can be attributed to immunization. These inputs are classified as shared costs. Other typically shared inputs are health centres, cold chain storage buildings and the use of some cold-chain equipment.

Given the relative difficulty in collecting information on shared costs in a programme and that these costs are not tied to funding that is specifically set aside for immunization (the most relevant for the cMYP costing and financing exercise), the estimation of shared costs is optional.

However, we strongly recommend that these shared costs are taken into account, since in most countries shared inputs are likely to be quite significant. In some countries, there might not even be any specific funding for immunization at subnational level.

The added investment in time will result in a more accurate costing exercise.⁵ If shared inputs are excluded, the analysis will: (a) underestimate the true government contribution to immunization, since many of the shared inputs tend to be funded from national resources (especially for personnel costs); (b) underestimate the total cost and resource requirements of the programme if other inputs (such as vehicles) are frequently shared with other programmes.

The cMYP Tool has been set-up to allow for the calculation of shared inputs, if so desired. The process whereby the portion of a shared cost is separated out is known as cost allocation. Its main method is to allocate shared inputs to a programme based on the percentage time spent on immunization. The various cost allocation methods will be explained in the sections of this User Guide that introduce categories of shared costs, such as personnel, vehicles and buildings.

5 We recommend also to liaise with National Health Account teams in countries which adopted the methodology to report health expenditure. See also: www.who.int/nha/en/

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Finally, estimations of costs, financing and future resource requirements should be done for a particular set of years or time period.

• One past year. The rationale for looking at a past year is to have a baseline reference year from which comparisons can be made between how much the programme currently costs, and what will be the future resources required.

• Between three and five future ye ars. This is considered the standard period for making future projections of costs and resource requirements in a cMYP, especially if this is linked to the annual operational plans.

• Optional forecast (beyond five years). In some instances, it may be useful to forecast the costs and resource requirements for the programme beyond the 3–5 year planning cycle of the cMYP. This is explained in greater depth in parts 7.1 and 7.2 of the User Guide. Note that in the case of a longer time frame, more assumptions have to be made regarding the possible unpredictability of future trends and estimates.

4.2 What is the difference between a cost and a resource requirement?

So far, the term cost and resource requirement have been used interchangeably, but it is important to clarify the difference between them. Generally speaking, a costing exercise is associated with a retrospective analysis (past year), whereas, resource requirements are associated with a prospective analysis of future projections (3–5 future years).

In the cMYP Tool, the distinction between the term “cost” and the term “resource requirement” relates to how capital equipment is treated. Capital costs reflect inputs that are not consumed or replaced in one year or less (e.g. a vehicle or cold-chain equipment). In most cases, the treatment of recurrent inputs is the same whether we refer to cost or resource requirement, although some difference in the calculation of vaccines will be mentioned in part 4.5.

What is the difference between a capital and a recurrent cost?

A capital cost corresponds to an input that has a useful life of more than one year. In other words, these are inputs that are not consumed or replaced every year. The capital cost categories used in the cMYP Tool include the following:

vehicles; cold-chain equipment, and other immunization-specific equipment (e.g. waste disposal). The suggested method for the treatment of capital cost is a simple, straight-line depreciation, i.e. the value of the new equipment is divided by its number of useful life years (ULY).

A recurrent cost corresponds to an input that will be consumed or replaced in one year or less. The recurrent cost categories used in the cMYP include the following: vaccines; injection supplies; personnel; transport; maintenance and overheads; training; social mobilization/IEC; surveillance and monitoring. Refer to Annex II at the end of this User Guide for a complete definition of these cost categories.

When the term cost or cost projection is used, it implies that the value of capital equipment depreciates (or amortizes) over its lifetime – known as useful life years (ULY).

In other words, the value of the capital equipment is spread out over the number of years it will be used and brought to an annual equivalent. Once the capital equipment is older than its number of ULY, the equipment is considered to be fully depreciated (or amortized). This means that it no longer has a financial value.

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To simplify the calculation, the methodology used in the cMYP Tool recommends using standard ULY for equipment: 5 years for vehicles and cold-boxes; 10 years for refrigerators, and 25 years for buildings). Even if the equipment is more than five years old and is still being used by the programme, the cMYP Tool considers this item to be completely depreciated with zero financial value. It is possible to choose alternative values of ULY.

The first advantage of depreciating (or amortizing) capital equipment when making cost estimates and cost projections, is that their value can be added to the recurrent costs for an accurate estimation of the total annual cost. Recurrent inputs are those that will be consumed or replaced in one year or less (e.g. vaccines, salaries, etc.).

A second advantage is that important cost indicators can be computed with values that are comparable over time (e.g. annual variations in the cost per capita; cost per fully immunized child, or the cost as a percentage of gross domestic product [GDP]).

However, as the object of the exercise is to calculate the financial resources that will need to be mobilized each year to reach the cMYP objectives, and also identify who will fund these needs over time, the costing approach described above has certain limitations.

For example, suppose that next year there is a need to purchase 10 new refrigerators for the cold chain. Even if these refrigerators will last several years, it will still be necessary to mobilize all the funds in the next year to buy these 10 refrigerators. Taking the costing approach, you will underestimate the true financial resources that are needed in that particular year. This is the rationale for the resource requirements approach.

When the term “resource requirements” is used (sometimes referred to as

“resource needs”), it implies that the full purchase cost of new units of capital equipment will be accounted for. Since this assumes that the existing equipment has already been paid for, the resource requirements approach is most relevant when looking at exact amounts of financing that need to be mobilized each year. This approach allows for comparisons between resource requirements and required financing, and also how the two need to be matched in order to reduce any financial gaps.

4.3 What are the basic costing methodologies used?

Broadly speaking, the cMYP Tool employs three methods for costing and making projections of future resource requirements.

The first method is known as the ingredients approach, where the value of an input is based on quantities, unit prices and percentage use for immunization – these are the ingredients. Since vaccines, injection supplies, personnel, transport, vehicles, and cold-chain equipment account for the bulk of the cost and resource requirements of an immunization programme (at least 80% of the total), considerable emphasis is given to assessing these inputs accurately. If not, small inaccuracies in the estimations could translate into large over- or underestimations of the total cost and resource requirements.

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Figure 6: Typical cost profile of an immunization programme

Personnel, $1,458,877, 35%

Injection supplies, $118,223, 3%

New vaccines, $0, 0%

Underused vaccines,

$1,573,161, 38%

Traditional vaccines, $406,079, 10%

Campaigns, $57,201, 1%

Other capital equipment,

$7,983, 0%

Cold chain equiment, $0, 0%

Vehicles, $0. 0%

Transportation,

$58,847, 2%

Other routine recurrent costs,

$470,778, 11%

The basic methodology for calculating these inputs is based on the formulas listed below.

1) Past costing

• Recurrent _{(RCx, Yi)} = existingquantities _{(RCx, Yi)}x US$ price_{(RCx, Yi)} x percentage use for immunization_{(RCx, Yi)}

• Capital _{(CCx, Yi)} = [existingquantities _{(CCx, Yi)}x US$ price_{(CCx, Yi)}] / ULY _{(CCx, Yi)} x percentage use for immunization _{(CCx, Yi)}

• Total cost = sum of all recurrent costs + sum of all capital costs 2) Future resource requirements

• Recurrent _{(RCx, Yi)} = futurequantities needed _{(RCx, Yi)}x US$ (price_{(RCx, Yi)} x Ω) x percentage use for immunization_{(RCx, Yi)}

• Capital _{(CCx, Yi)} = futurequantities needed _{(CCx, Yi)}x (US$ price_{(CCx, Yi)} x Ω) x percentage use for immunization_{(CCx, Yi)}

• Total resource requirements = sum of all recurrent resource requirements + sum of all capital resource requirements

3) Cost projections – to compare between past cost and future resource requirements

• Recurrent _{(RCx, Yi)} = futurequantities needed _{(RCx, Yi)}x (US$ price_{(RCx, Yi)} x Ω) x percentage use for immunization_{(RCx, Yi)}

• Capital _{(CCx, Yi)} = [(existing + futurequantities needed _{(CCx, Yi)}) x (US$ price

(CCx, Yi) x Ω)] / ULY _{(CCx, Yi)} x percentage use for immunization (CCx, Yi)

• Total cost projections = sum of all recurrent cost projections + sum of all capital cost projections

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Where:

RCx = for recurrent cost category x CCx = for capital cost category x Yi = for year i

Ω = for inflation

What inflation and exchange rate should you use?

Inflation refers to the phenomenon of rising prices over time. In this way, costs and resource requirements can rise over time simply because of a rise in prices, rather than a rise in the quantity or quality of inputs purchased. For example, increasing fuel prices will increase the cost of transportation).

Because the final costs and resource requirement estimates are reported in United States dollars (although the cMYP Tool allows prices to be entered in local currency), a standard inflation rate of 2% is recommended. This rate is based on the average consumer price inflation in the United States dollar between 2009 and 2014, and represents an estimate of future price inflation.

The United States dollar exchange rate selected for use in the cMYP Tool needs to be based on the published figures utilized in each country. These should be reported in the Background Information section of the Data Entry worksheet.

The cMYP Tool assumes a constant exchange rate over the projection period. Sources of the United States dollar exchange rate include the ministry of finance or central bank, as well as the World Bank and International Monetary Fund (IMF) offices.

The second method used by the cMYP Tool estimates costs and future resource requirements of certain categories of input based on some agreed rules of thumb, applied automatically in the cMYP Tool. This applies to injections supplies, cold chain and vehicle maintenance as follows:

• For injection supplies, an approach that accurately reflects the use of resources takes into account immunization practices for each antigen, and links to the number of doses of vaccines. For example, one dose of measles vaccine would require one auto-disable (AD) syringe, one mixing syringe for reconstituting a 10-dose vial, and a portion of a safety box for disposal of the used syringes.

Using the unit costs of each of these injection supplies, an approximate cost of supplies per measles dose administered can be calculated based on the vaccine forecast for measles. Future resource requirements for injection supplies are based on the same rule of thumb, as well as future projected doses of each vaccine in the vaccination schedule.

• For cold chain maintenance the rules of thumb to estimate the likely maintenance needs work by applying a set percentage of the capital cost of this equipment.

The cMYP Tool recommends using 5%, but this amount can be changed for a particular country setting.

• For vehicle maintenance the rule of thumb is to estimate the likely needs based on a set percentage of fuel costs. Fuel for vehicles is likely to be the single most important input for transportation, and one for which records are reasonably good. Basing the set percentage on fuel rather than on the capital cost of the equipment (similar to cold chain), takes into consideration the utilization of the vehicles, where higher fuel consumption implies higher utilization and therefore higher maintenance needs. The cMYP Tool recommends using 15%, but this amount can be changed for a particular country setting.

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For other categories of inputs and activities such as training, social mobilization, IEC, surveillance, etc., the ingredients, or rules of thumbs approaches, are not used.

Since they do not represent the major cost drivers for immunization programmes, less emphasis is placed on estimating them accurately, and approximations can be made using past spending (the budgeting approach). This is a method that is likely to yield estimates that are as accurate as applying the more complicated ingredients approach, and it has the advantage of requiring less data. This is therefore the third method used by the cMYP Tool. The three methods are summarized in Table 2.

Table 2: Summary table of methods used in the cMYP Tool

Method Name Methodology Inputs

Ingredients approach Quantities x price x percentage use

for immunization Vaccines, personnel, transport, vehicles, cold-chain equipment

Rule-of-thumb Immunization practice, fixed

percentage of the value of cold- chain equipment, fixed percentage of fuel costs

Injection supplies,

cold chain maintenance, vehicles maintenance

Past spending or budgeting

approach Lump-sum spending or based on

past expenditure and budgets Training, social mobilization, IEC, surveillance and others

4.4 What are some methodological differences and limitations?

For some inputs, there will be slight deviations from the basic methodology described above. These are worth noting as they concern differences in approach between past costing and the estimation of future resources requirements.

For vaccines

The method applied to estimate the past cost of vaccines is based on the amount of vaccines used (administered + wasted) during a given year. The quantity used per type of vaccine (Q _used) is calculated according to the following formula:

Q_{Z Used} = (Q_{Z Supplied} + QZ Initial Stock) – (QZ Remaining in Stock)

Where:

z = DTP, measles, OPV, etc.

Qz Supplied = Quantity of vaccines provided (either bought by the country or donated to the country) to the country in a given year

Table 3: Example of calculation of quantities of vaccine used

Vaccines Stock at beginning of the

year

Quantities supplied during

the year

End of year

stock Quantities used Price per dose

Doses Doses Doses Doses $/dose

Measles 5 000 100 000 10 000 95 000 0.30

DTP 2 000 85 000 12 000 75 000 0.27

B C G 10 000 135 000 20 000 125 000 0.08

OPV 15 000 250 000 150 000 115 000 0.15

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The cost of vaccines is calculated by multiplying the quantities used (Q _used) by the unit price for a given vaccine (P).

For example, the costs of DTP vaccine supplied in 10-dose vials is:

Cost _{DPT (10)} = Q DTP(10) used x P _DPT(10)= 10 000 x $0.15 = $1500

An advantage of using this method is that vaccine wastage is implicitly assumed and can be derived from the same data using the following formula:

Wastage rate _Z = (doses used _Z – doses administered _Z) / doses used _Zx 100 where z = DTP, Measles, OPV, etc.

On the other hand, the method used to forecast the future vaccine requirements is based on coverage targets, wastage rate targets, unit prices and the size of the target population.

Q_{Z Needed} = (births x target coverage _Z) x doses in schedule x wastage Cost _Z = Q_{Z Needed} x P_Z

where the vaccine price (P_Z) is kept constant for the whole forecast period.

For capital equipment

Because capital items like vehicles and cold-chain equipment are purchased in one year, but will be used in the programme for several years until they need to be replaced (the ULY concept), these items are treated differently. In part 3.5 above, the different methods for treating capital costs are explained when describing the difference between the terms cost and resource requirements.

To summarize, the cMYP costing exercise looks at one past year. Therefore, the cMYP Tool is estimating a past cost and the value of capital equipment is converted to an annual equivalent by using a straight line depreciation. This is equivalent to the annual financial cost of the capital goods and is calculated by dividing the value of the goods by the total ULY number in order to get an annual equivalent. For example, a new vehicle purchased in the year 2012 for US$ 30 000, which will last 5 years before needing to be replaced, will have an annual financial cost of US$ 6000 (US$ 30 000/5 ULY).

The rationale for this adjustment is that, without depreciating the value of inputs that last for more than a year, it would be easy to get a distorted view of the long-term average annual cost of the programme. This would be the case if the total cost of the NIP was examined in a particular year when large investments in new vehicles and equipment had been made.

Alternatively, when making future projections, it is important to know what resources are needed each year for the programme, irrespective of whether they are for inputs that will last for a year or more. This is because regardless of whether the input or activity is a recurrent or a capital cost, it will need to be purchased at a given point in time, and these resource requirements will need to be matched with corresponding financing. This understanding is vital to the financial sustainability of the programme:

knowing what financial resources will need to be mobilized each year to reach the cMYP objectives, and who will be funding these needs over time.

comprehensive Multi-Year Planning (cMYP) A Tool and User Guide for cMYP Costing and Financing

comprehensive Multi-Year

Planning (cMYP)

A Tool and User Guide for cMYP Costing and Financing

Update 2014

comprehensive Multi-Year

Planning (cMYP)

A Tool and User Guide for cMYP Costing and Financing

Update 2014

Contents

Abbreviations and acronyms

Acknowledgments

Introduction

1. Strategic planning for

immunization with costing

2. Overview of the cMYP

Costing and Financing Tool

3. Some principles and

suggestions on procedure

4. Important concepts,

methodologies and terms