From Aggregate Costing To Costing the Scale-Up: Kenya s Experience. TERRIE WEFWAFWA Ministry of Health Nutrition Unit
Presentation outline Background Information Previous Costing Methods Costing for Scale Up The Costing Tool Achievements Challenges Opportunities and Way Forward
Kenya nutrition situation Demographic Data (Projection for 2013) Population 43.8 million Children Under Five 6.7 million Population Growth Rate (2010) 2.7 % New constitution launched Devolution to 47 counties
% Children Prevalence of undernutrition 40% 30% MDG 2015 target for stunting: 16.8% Stunting, 35.30% 20% 10% Underweight, 16.10% 0% Wasting, 6.70% 1993 1998 2003 2008 Sources: DHS & WHO
Nutrition practices and vitamin and mineral uptake Good Nutrition Practices - Exclusive Breastfeeding 32% - Complementary Feeding with at 54% least 4 groups per day Vitamin and Mineral Intake - Zinc Treatment for Diarrhea 0.2% - Pregnant Women receiving Iron Folate Supplementation 12.0% - De-worming (12-59 months) 37.5% - Vitamin A Supplementation (6-59 months) 30.3% - Presence of Iodised Salt in the House 97.6%
Previous costing methods Kenya has implemented nutrition program in last five decades with the coverage being at less that half the targeted population for most interventions. The budgets were determined from the resources available. The allocation of finances would be made on a ratio basis as determined by severity of the problem, proportion population, geographical and administrative considerations giving rise to inequities During the last five years two levels of annual workplans for national and regional levels were prepared and costed at the national and district levels but difficult to isolate nutrition costs for the country Kenya became the 30 th country to join SUN movement and committed to scale up high impact nutrition interventions
Costing for SUN The National Nutrition Action Plan(NNAP) 2012-2017 is Kenya s roadmap for SUN. Government and stakeholders agreed on set of high impact nutrition interventions(hini) for scale up. Has 11 strategic objectives that focus on the priority areas for nutrition problems facing the country. Scale up was defined as increasing coverage of current baselines by at least 80% of present figure( increasing by 16-20% annually) and then costing that out Clearly defines the indicators, baselines, targets and timelines for each intervention. Determined the resources required to reach targets. Aligned to the government development and financial planning cycle for sustainability
Strategic objectives to cost Subjected the priority areas to costing model : 1. Improve nutritional status of women of reproductive age (15-49 years): 2. Improve nutrition status of children under five 3. Reduce the prevalence of micronutrient deficiencies in the population 4. Prevent deterioration of nutritional status and save lives of vulnerable groups in Emergencies 5. Improve access to quality curative nutrition services 6. Improve prevention, management and control of diet related NCDs 7. Improve nutrition in schools and other institutions 8. Improve knowledge, attitudes and practices on optimal nutrition 9. Strengthen the nutrition surveillance, monitoring and evaluation systems: 10. Enhance evidence-based decision-making through operations research 11. Strengthen coordination and partnerships among the key nutrition actors
Costing of the NNAP The costing was application of the WHO Onehealth costing model for delivery of health services Kenya had completed the adaptation process of determining the actual costs of all resources needed for delivery of a treatment or health service(kenya Health Strategic Plan Two) The costing involved stakeholder participation at all levels
Process of calculating costs for each strategic objective Determine affected population and proportion Determine indicators and targets Determine baseline and annual targets Select HiNi Identify activities, required commodities, and HR Identify service delivery channels Break activities into tasks Determine unit costs associated with each task Calculate costs and scale-up
Data collection sheet - Population Percent of target population requiring interventions Population Targets Values are in percentage points Nutrition Indicator 2013 2014 2015 2016 2017 Supplementation (Folic acid, multivitamins, calcium, ferrous sulphate) Routine Body Mass Index (weight and height) measurement for all outpatients # of pregnant women who received iron and folic Supplements 62 64 65 67 69 # OPD cases 5 7 10 12 15 Food demonstrations (at community and facilities) Management of nutritional disorders (micronutrient deficincies, Kwashiorkor, Marasmus, Obesity, Iodine and Vitamin A deficiency ) # facilities with food demonstrations # under 5 s with acute malnutrition accessing care 5 10 15 20 25 40 42 45 47 50
Nutrition Supplementation (Folic acid, multivitamins, calcium, ferrous sulphate) Routine Body Mass Index (weight and height) measurement for all outpatients Data collection sheet Service Delivery Values are in percentage points Community Outreach Clinic Hospital WASH Curren t year Target year Curren t year Target year Curren t year Target year Curren t year Target year Curren t year Target year Other nonhealth Curren Target t year year Private sector Curren t year Target year Curren t year 0 0 0 0 0 0 0 0 0 0 0 0 100 100 100 100 50 50 25 25 25 25 0 0 0 0 0 0 0 0 100 100 Total Target year Food demonstrations (at community and facilities) Management of nutritional disorders (micronutrient deficincies, Kwashiorkor, Marasmus, Obesity, Iodine and Vitamin A deficiency ) 0 0 0 0 100 100 0 0 0 0 0 0 0 0 100 100 0 0 0 0 100 100 0 0 0 0 0 0 0 0 100 100
Achievements For the first time the country has a costed national nutrition plan indicating the resources required to make progress on the indicators The scaling up planning provided for prioritization of the most immediate nutrition needs The actual costing has provided a realistic quantification of the what is needed and the budget deficit that needs to be raised to address the nutritional problem The linking of budget to an indicator displays transparency and accountability which is an important component of good governance The Scaling Up Action plan has provided an implementation matrix, performance monitoring and evaluation plan and financial resource inputs needed for achievement of indicators
Challenges Experienced Costing for human resource for nutrition interventions e.g. counseling and growth monitoring.there is no set standard for time duration per cadre per session and therefore difficult to estimate cost. Transport costs are usually significant but difficult to estimate as they are spread out in many health interventions Monitoring and evaluation data expected to be obtained from DHIS but substantial amount of nutrition data is obtained from periodic surveys and this was not provided for in the tool Food fortification costs were only for ministry requirements for capacity building, monitoring and enforcement but not what is needed for scale up as this cost is borne by private sector The costing requires accurate data which was not available in some cases The costing is detailed and time consuming
Opportunities and way forward The costing for SUN provided an opportunity to determine the resources required to change the nutrition indicators. The NNAP is being used to mobilize resource from government, partners and donors at national and international level Kenya has decentralized the governance system and the counties are using the NNAP to develop county specific plans for scaling up and use the plans to resource mobilize for the devolved funds. There is need to modify this health service delivery costing tool to include nutrition sensitive interventions for costing of the nutrition program. There is urgent need to develop a cost tracking tool. Strengthen the nutrition M&E system at national and sub national levels to provide accurate data for planning and budgeting Develop standards for nutrition practice