Vitamin A supplementation (VAS) for children under five years of age has been a cornerstone of global child survival programs for decades, and VAS has been shown to have positive impacts on reducing child mortality. The World Health Organization recommends all children 6-59 months receive high-dose VAS every 4 to 6 months in areas where the prevalence of vitamin A deficiency is ≥ 20% in young children, and more than 80 countries currently have universal VAS programs in place. In SSA, VAS has mainly been provided through National Immunization Days (NID) and polio Supplemental Immunization Activities. As these involve providing essential childhood vaccines through door-to-door delivery, coverage has generally been high (> 80%) for both immunizations and VAS,[v] compared to the much lower coverage typically achieved through health facility-based delivery. More recently, semiannual Child Health Days or Child Health Weeks (CHWs), which utilize a fixed-site community-based approach rather than household visits, have become a key delivery platform for VAS in SSA. However, funding constraints and successful polio eradication efforts are shifting the policy and program focus away from NIDs and CHDs to integration of VAS into routine immunization services. Two examples of this are the six-month and six-monthlycontact points, which enable year-round supplementation and allow for adding-on of additional health services (e.g., family planning counselling) when a parent brings their child to a health facility. Additional approaches are also being tested, such as the use of community-health workers to facilitate campaigns.
The restructuring of vitamin A delivery presents challenges in terms of identifying ways to sustain high coverage while also lowering costs. However, there is limited detailed data available on the costs (or cost-effectiveness) of different models of VAS in different contexts – with some notable exceptions, particularly for the case of Cameroon. A 2007 cross-country analysis found costs to vary widely across contexts. As such, this study seeks to evaluate the costs (overall and per child reached) of three different approaches to VAS: mixed approach in Kenya, door to door in Burkina Faso and routine approach in Mozambique.
Research Objectives: The study in question aims to compare the costs of these three strategies for the delivery of VAS. The results can be analyzed in combination with percentages and number of children reached (as determined through post-event coverage surveys (PECS) and administrative data, respectively), to connect costs to impact.
Methods: The study is designed as a comparative study among three distribution models:
(1) Kenya: A routine strategy that combines routine facility-based delivery of VAS with outreach sessions organized in early child development centers and catch up events twice a year. Services delivered include vitamin A supplements to children 6-59 months (100,000 IU capsules for children 6-11 months and 200,000 IU capsules for children 12-59 months) and deworming tablets (Albendazole) for children 12-59 months. Services are distributed by teams consisting of facility health personnel and community workers.
(2) Burkina Faso: a newly designed campaign approach called Vitamin A Days Plus (JVA+). This campaign is organized using two different delivery models: in urban settings, teams of health workers and community workers deliver services over a five-day period using a door-to-door approach. In rural areas, CHWs paid by the government of Burkina Faso are given up to five weeks to distribute the services in their catchment area (the number of households each community worker covers varies widely between areas). Services delivered are vitamin A supplements to children 6-59 months (100,000 IU capsules for children 6-11 months and 200,000 IU capsules for children 12-59 months), deworming tablets (Albendazole) for children 12-59 months and measurement of mid-upper arm circumference (MUAC) using an insertion tape to screen for child wasting. The urban approach is thus quite similar to that used in Mali.
(3) Mozambique: Routine delivery of VAS is organized at facility level and through outreach sessions supported by community workers. In this case, the study will compare two support programs to identify how much support is needed by the health system to reach high coverage and how much each support system costs. Services delivered include VAS to children aged 6-59 months (100,000 IU capsules for children 6-11 months and 200,000 IU capsules for children 12-59 months) and deworming tablets (Albendazole) for children 12-59 months. Services are delivered by health personnel and CHWs.
All approaches are implemented nationwide by the respective Ministry of Health, with support from HKI in certain areas. For the purposes of costing analysis, urban and rural areas will likely need to be analyzed separately; if feasible, analysis might be done at a finer sub-national level, as well (i.e., the region). All costs associated with the distribution (e.g., planning, awareness-raising, delivery, supervision and monitoring) will be taken into account; results will be reported at the overall cost level as well broken down by cost type (e.g., fixed v. variable; actual v. opportunity; personnel, planning, monitoring, etc.)
HKI currently supports VAS projects in 11 African countries, with expected expansion into additional countries in the coming year. In campaign-based countries, this entails at least two campaigns a year, and HKI expects to continue this work for several years. Though we have not reported on cost per unit impact in the past, we plan to do this on a regular basis in the future. It is thus essential to create standard processes, budget codes, templates, and other reporting tools to facilitate ongoing collection of cost data by HKI staff (technical and financial) and to build the capacity for analysis of this data among select technical staff, including the creation of standard analysis code files, templates, etc. Having comparable cost data across time will permit additional analyses of relative costs of different models and types of support as well as change in cost over time.
The Role of the Costing Analyst
To support this work, HKI is seeking a consultant to act as Costing Analyst to undertake three main areas of work:
(1) Support the review and adaptation of existing tools developed for the study.
(2) Support and participate in selected activities associated with costing data collection, analysis, and reporting.
(3) As an integral part of (1 and 2), help HKI to develop the tools and technical capacity to independently undertake additional costing analysis of VAS approaches in the future.
The Costing Analyst consultant will work with a consultant Costing Analysis Advisor (CAA) and members of the HKI staff to undertake all of this work.
· Adapt existing tools and protocols for countries
· Work with the project team to decide on key choices that relate to the CEA analysis (e.g., specific methods for determining the inclusion of costs, how to deal with partners’ costs, etc.)
· Review existing financial reporting structures (e.g., expense coding) to ensure that the necessary information is collected by the HKI team
· Determine needs for any additional collection of (population or service provider) data via coverage surveys and reporting from partners
· Periodically review the costing data with HKI to ensure appropriate collection and labelling
· Develop a database of relevant costing data, as needed for the analysis
· Undertake costing analysis, in line with the appropriate rigorous methodologies, and align this to coverage / impact data to report on costs per unit of impact
· Train select HKI staff in how to analyze costing data
· Draft a brief report on the costing analysis method and findings, to be included in the project report
· Lead the writing (with HKI staff) of at least one paper reporting on the costing analysis results
As part of this work, it is anticipated that there will be at least one workshop, with the CA and HKI staff. This will focus on the design of the methodology and training of relevant staff on use of reporting tools; a second, smaller workshop may be organized for discussion and training on analytic approaches.