Understanding the true costs of health care, particularly those beyond direct service delivery, is a critical, yet often challenging, endeavor for health planners, health technology assessment agencies, and academic groups. Recognizing this challenge, the World Health Organization (WHO) CHOICE programme has released a crucial update to its methodology and global price databases, focusing specifically on disease control programme support costs.
This seminal paper, “Disease control programme support costs: an update of WHO-CHOICE methodology, price databases and quantity assumptions,” by Bertram et al. (2017), offers an indispensable resource for countries seeking to accurately estimate the financial and economic requirements for implementing and scaling health plans.
What are Programme Support Costs? Programme support costs are defined as expenses incurred at an administrative level outside the direct point of health care delivery. These are the costs associated with activities designed to enhance the quality of service delivery or encourage the uptake of specific health interventions, such as training, supervision visits, monitoring and evaluation, administration, and legislation. Crucially, these costs are distinct from both direct patient-level costs (e.g., medicines, diagnostic tests) and general shared health system costs (e.g., supply chain, infrastructure). Ignoring these “above-facility-level” costs can lead to misleading cost-effectiveness ratios, making their accurate estimation vital for comprehensive economic evaluation.
Key Contributions and Updates: The Bertram et al. (2017) article outlines a robust methodology used to update the WHO-CHOICE price database to a 2010 reference year, a significant advance from the previous 2000 reference. Key updates and contributions include:
- Comprehensive Price Databases: The authors collated publicly available databases for 14 non-traded cost variables and a set of traded items, employing statistical and econometric models to estimate prices for all 194 WHO member states. A notable improvement is the provision of prices at the country level, rather than just regional, offering greater precision.
- Detailed Cost Categories: The database covers a wide array of cost components, including:
- Human resources: Identified as the largest driver of programme support costs.
- Travel allowance and per diem rates.
- Vehicle and transportation costs, including per-kilometer operating costs.
- Cold chain storage and distribution equipment, essential for immunization and other programmes.
- Power generation and utility prices (electricity, water).
- Telecommunication data for various services.
- Office supplies, ICT hardware, and furniture.
- Advertising costs for advocacy purposes.
- Updated Quantity Assumptions: The study provides new quantity assumptions for typical WHO-CHOICE generalized cost-effectiveness analysis (GCEA) applications, derived from literature reviews and expert consensus. These cover administrative requirements, materials and supplies, utilities, information, education and communication (IEC), supervision, and training.
- Scaling Factors for Programme Costs: A novel feature is the introduction of scaling factors to account for economies of scale and scope. Programme support costs are scaled based on the number of interventions a programme supports (assuming 30% resources for one intervention, linearly increasing to 100% for ten, with a marginal 3% increase for additional interventions). Additionally, some costs, such as in-service training and supervision visits, are scaled to intervention coverage levels, though human resources and office running costs remain constant irrespective of coverage.
- Addressing Supply Chain Costs: While not strictly programme support costs, the WHO-CHOICE model now incorporates a mark-up ratio for supply chain costs (e.g., 13% for overall commodities, 26% for ITNs, 6% additional for cold chain) to capture these health system costs within economic evaluations.
- User-Friendly Tools: A calculation workbook is available, enabling users to select a country and obtain generic estimates, with the flexibility to modify all prices and quantity assumptions. This tool distinguishes between ongoing and set-up costs and is compatible with the OneHealth Tool.
Limitations and Future Directions: Despite these significant advancements, the authors acknowledge ongoing limitations, including the persistent issue of data scarcity, particularly for low-income countries where accurate cost data is most needed. Gaps remain in global price databases for certain variables (e.g., media, construction), and there is a need for more quantitative evidence on human resource staffing requirements beyond expert opinion. The paper advocates for greater attention to programme support costs in data collection activities, improved reporting standards in costing studies with greater data disaggregation, and further research into integrated approaches to programme delivery.
This updated WHO-CHOICE methodology and the accompanying database provide an invaluable framework for more accurate and standardized health care cost estimations, ultimately supporting better resource allocation decisions and the successful implementation of disease control programmes worldwide.
Reference for this Article:
Bertram, M. Y., Stenberg, K., Brindley, C., Li, J., Serje, J., Watts, R., & Edejer, T. T. (2017). Disease control programme support costs: an update of WHO-CHOICE methodology, price databases and quantity assumptions. Cost Effectiveness and Resource Allocation, 15(1), 21. https://doi.org/10.1186/s12962-017-0083-6