Presentación sobre herramientas financieras (FBT) para el estudio de

Cancer de Mama en México

Seminario Taller Sobre Costo Efectividad De Cancer de Mama en México

México DF, 2-4 Febrero 2011

Jeremy Lauer, OMS Ginebra

Objectives of this session

• The role of financial cost analysis in the planning process

• Overview of the Financial Budgeting Tool for Breast Cancer interventions

• Issues for consideration

The role of financial cost analysis in the planning and budgeting process

II- Operational plan and budgetproposal

III- Budget negotiation

IV- Budget consolidation and approval

V- Financialtracking andaudit

Activity planInput requirementsInput costsPreliminary budget

Internal revisionNegotiation with

Ministry of Finance and other financial sources

Advocacy with funders

Budget approval by Ministry of Finance

Distribution of the budget by line items

Monitoring of financial disbursements by budgetary line items

I- Strategicplan

TimelineStrategic

areasPoliciesTargets

Cost-Effectiveness

Analysis

Costs and budget for activity plan

Assess Resource Needs and

affordability

Financial costing

The role of financial cost analysis in the planning and budgeting process: the need for continuous updates

and revisions

II- Operational plan and budgetproposal

Activity planInput requirementsInput costsPreliminary budget

I- Strategicplan

TimelineStrategic

areasPoliciesTargets

III- Budget negotiation

Internal revisionNegotiation with

Ministry of Finance and other financial sources

Why do we have a separate tool and analysis for financial costs?

The cost-effectiveness analysis (CEA):– looks at total costs incurred from the societal perspective, over a

standardised time-frame, regardless of whether those resources are already in place and financed, or not.

– Allows for comparison between a wide range of interventions.

The financial cost-analysis (FBT) – looks at the financial cash flows by year. This means that resources

already in place and funded are not costed (e.g., equipment and human resources already in place). Capital costs are not annualised.

– Focuses on a selected set of activities and interventions.– The FBT allows for context-specific planning in the medium-term and

alignment with other national strategic planning documents.

Needs-based costing

• A historical incremental budgeting approach looks at what was spent last year and increases the budget by e.g., 5-10 %– Does not allow for shifting between priorities.

• A needs-based cost assessment looks at population needs and is determined by the set policies and planned coverage targets– Provides a powerful tool for making adjustments to the budget allocation.

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Historical (example) Coverage-based (example)

Herramienta financiera (Financial Budgeting Tool - FBT) to accompany cost-effectiveness analysis

• The purpose is to facilitate an assessment of the financial resources (cash flows) that would be required to implement the scenarios for Breast cancer interventions.

• Costs are estimated at national level, from the health provider perspective.

• Costs are estimated for the entire planned Breast Cancer programme – regardless of who would hold the budget for the various items.

Costs included - definitions

Specific costs to Breast Cancer programme• Costes de pacientes (procedimientos de tratamiento, medicamentos,

instalaciones, diagnosticos, etc.)

• Costes de programes (los medios de comunicación de administración, aplicación de la ley en los diferentes niveles; equipment needed in health centres and hospitals; monitoring and evaluation surveys; mass media awareness raising and outreach in the community).

• incluye los costes de formación

Shared system resources• Inpatient and outpatient services, health worker salaries, community-based health

workers, infrastructure and building maintenance.

Objectives and process of application of the tool in México

• Build on lessons learnt from the CEA analysis in terms of most cost-effective interventions and estimate the financial cost of these.

• Estimate the costs of scaling up BrCa services and activities over 5-15 year time frame

• Incorporate as much shared input data as possible from the CEA analysis.

• Defining an action plan for the next 5-10 years to outline a proposed “scale-up scenario”

• Compare costs of a “current” scenario, with the costs of a "scale-up scenario".

Presente 100%

Presente 60%

Estadio I

Estadio II

Estadio III

Estadio IV

I - IV combinación

I - IV + MS(50-69)

I - IV + MS(40-69)

I - IV + conciencia

I - IV + media

I - IV + CBE (40-69)

PC Basico + IV PC extendida + IV

I - III + media + PCB

I - III + CBE + PCB

I - III + MS(40-70) + PCB

I - III + MS(40-70) + PCE

PCE + IV + Tzmab

I - III + MS(40-70) +

PCB + Tzmab

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What we present here is just an example

A more thorough assessment would be led by a country team of experts and based on:

- the findings from the cost-effectiveness analysis, and

- other criteria (equity, political feasibility, health systems considerations, etc)

– i.e. the discussions in this workshop

Limited information inputted on local data regarding Coverage, Definition of the Interventions and their costs, and programme activities.

Comparing two scenarios: 1. current delivery, and 2. proposed scale-up

The proposed scale-up scenario can refer to• increased population coverage of current services• Increased quality of care provided of current services

– Adjustments to the screening process (frequency, inputs)– Adjustments to the treatment and care provided (frequency, inputs)– Intensified programmatic investments (mass media, training, etc)

• Change in strategy for more effective delivery– Shifting patient load from Hospital level to Health Centre level to

save costs.

→ in our example we have focused on coverage increases. More country-specific information would be needed to

undertake a more context-specific assessment.

A look at the tool and

assumptions used for the example cost analysis for México

Interventions in current vs. scale-upscenario

Select which interventions packages are included in the programs

Awareness1

Biennial Screening1

Diagnosis & Treatment

Palliative Care Stage IV2

Trastuzumab Stage IV Trastuzumab Stage IV1 Trastuzumab

Palliative Care Extended

Interventions

Basic Awareness Reach Out Program

None

Stage I to IV treatment combined

Palliative Care Extended

Trastuzumab

Palliative Care Stage IV

Basic Awareness Reach Out Program

Stage I to IV treatment combined

Interventions in Current  Breast Cancer Program Interventions in Proposed  Breast Cancer Program

Awareness

Bi‐Annual Screening

Diagnosis & Treatment

Clinical Breast Examination (40‐69 years)

Coverage trajectory 2009-20192009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Awareness Basic Awareness Reach Out Program

current Basic Awareness Reach Out Program 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

target Basic Awareness Reach Out Program 60% 64% 68% 72% 76% 80% 84% 88% 92% 96% 100%

Biennial Screening Clinical Breast Examination (40‐69 years)current None 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

target Clinical Breast Examination (40‐69 years) 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80%

Diagnosis & Treatment Stage I to IV treatment combinedcurrent Stage I to IV treatment combined 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80%0.02 16%

Palliative Care Stage IV Palliative Care Extendedcurrent Current coverage 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80%

0.02 16%Trastuzumab Trastuzumabcurrent Current coverage 60% 60% 60% 60% 60% 60% 60% 60% 60% 60% 60%

target Target coverage 60% 62% 64% 66% 68% 70% 72% 74% 76% 78% 80%

Detailed inputs and activities are defined by year (#1: equipment)

Number of new equipment to purchase in each year:

2009Minimum additional equipment needed

2010 2011 2012

Bone density: CT scanning system 7 4.00                        1 1 1Radiotherapy: linear accelerator 7 4.00                        1 1 1

Radiotherapy: radiographic quality assurance 7 4.00                        1 1 1Mammograph: Radio quality 14 7.00                        1.75 1.75 1.75

Mammograph: Radio machine 7 4.00                        1 1 1Mammograph: digital machine quality 7 4.00                        1 1 1

X-ray machine 7 4.00                       other <please specify>: 0 ‐                        other <please specify>: 0 ‐                        other <please specify>: 0 ‐                        

Detailed inputs and activities are defined by year (#2: training)

Second course: Specialist training for surgeons or radiologists 2009 2010 2011 2012 2013

Number of Classes per year 0 1 1 1 1

Participant CostsSize of Class: 1 1 1 1 1

Per Diem Rate (Students): 1.00 1.00 1.00 1.00 1.00

Average Travel Costs: - - - - -

Cost of Training Packet (per student): 2.00 2.00 2.00 2.00 2.00

Total Student Costs: - 30.00 30.00 30.00 30.00

Trainer costs:

Number of Trainers per class: 1 1 0 0 0

Per Diem Rate (Trainers): 10.00 10.00 10.00 10.00 10.00

Hotel/travel costs (total for the course per trainer): - - - - -

Total Trainer Costs: - 200.00 - - -

Other Costs:

Cost for lecture room rental

Other Costs (per class):

Total Other Costs: - - - - -

Total Costs for Training: - 230.00 30.00 30.00 30.00

Results #1: assessment of resource needs for clinical services, based on our example

2009 2010 2011 2012

Number of women aged 40+ 728,661 754,390 780,400 806,640 Cost per woman >40 years (current scenario) 1,557 1,826 2,091 2,351

Cost per woman >40 years (proposed scenario) 2,671 3,055 3,505 4,014

2013 2014 2015 2016 2017 2018

832,974 859,219 885,279 911,075 936,669 962,220 2,605 2,808 3,003 3,190 3,370 3,544 4,575 5,109 5,665 6,241 6,835 7,444

Cost per woman >40 years, per year

Results #2: assessment of resource needs for clinical services, based on our example

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Trastuzumab

Palliative Care

Relapse diagnosis andtreatmentFollow-up (all stages)

Treatment stage IV

Treatment stage III

Treatment stage II

Treatment stage I

Diagnosis stage IV

Diagnosis stage III

Diagnosis stage II

Diagnosis stage I

Screening

Costs for medical services in current scenario, million colones

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Palliative Care

Relapse diagnosis and treatment

Follow -up (all stages)

Treatment stage IV

Treatment stage III

Treatment stage II

Treatment stage I

Diagnosis stage IV

Diagnosis stage III

Diagnosis stage II

Diagnosis stage I

Screening

Scale-up scenario

Current scenario

Results #3

Current scenario - Costes (milliones colones)

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Program costs

Medical Devices Disposable

Drugs

Running costs for overhead

Home based visit community Nurse /volunteer

Additional Human Resources

Health Centre Outpatient Visit

Hospital Outpatient Visit

Hospital Inpatient services

Proposed scale-up scenario - Costes (milliones colones)

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Program costs

Medical Devices Disposable

Drugs

Running costs for overhead

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Additional Human Resources

Health Centre Outpatient Visit

Hospital Outpatient Visit

Hospital Inpatient services

Breakdown of costs by input sheds light on the budget categories, and who will bear the costs

Issues for consideration

Application of the FBT

• Will demonstrate future resource needs associated with a plan

• Could be used to illustrate cost savings:– Treating women in late stages, vs. – Comprehensive preventive screening programmes and treating women in

earlier stages

• Incorporates demographic changes over time– change in population size of various age cohorts– can model an increase or decrease in incidence over time, based on the

local context and expected change in risk factors.

• Waiting times not explicitly addressed but could be taken into account by estimating costs for the activities required to reduce waiting times

Issues for consideration• The financial cost analysis should be based on an analysis of the

current health systems constraints, and how to overcome them (access to care, quality of care), and link to the broader health sector plans.

• If estimated costs are deemed as not affordable, potential strategies include:– Plan for a less ambitious strategy (lower coverage)– Explore innovative ways to save costs (greater integration of

services, shift service delivery to lower level facilities, use generic drugs, etc)

– Explore different options for financing the plan

• Link the implementation plan for Breast Cancer programme to the broader national health strategic plan

Ampliar la cobertura

Reduce la participación de los gastos ye las cuotas

Tres dimensiones de financiamento

Issues for consideration (contd.)

• Equity – e.g., variation in access and quality of care by geography

• The role of public / private providers• Coverage targets/ scale-up phasing aligned with national

health investment plans• National vs. Decentralised level planning• Inflation and price changes over time not yet accounted for

Proposed next stepsStrategic:• Define the overall strategic plan and implementation plan• Link these to broader national plans for the health sectorProgrammatic:• Refine inputs and assumptions for the programmatic investments, including

treatment protocols, and price data.• Define the format of results that are useful in the Mexican context (cost

categories, budget categories)Assess financing policy • Assess financing options• Develop financing strategy (how to ensure moving towards universal financial

access with long-term predictability of funding)

Muchas gracias por su atención