News and Opinions  –  2018

Costing National Action Plans on AMR: Practical suggestions for simplifying the process

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Costing a country’s National Action Plan on Antimicrobial Resistance (AMR) appears to be a daunting and challenging task. The complexities of the National Action Plans, its multidisciplinary nature, intergovernmental involvement, along with the numerous activities involved in implementation appear to require an entire health system budgeting exercise which can be overwhelming.

As Dr. Kim Faure has solid experience on costing National Action Plans on AMR. In an interview with React Africa, Dr. Faure outlined fundamental steps around costing for National Action Plans on AMR. Once the purpose of the costing exercise is understood along with the activities that are specific for antimicrobial resistance, the costing exercise can be simplified and achieved. Dr. Faure highlight's fundamental practical steps that will help the process of costing.

Photo: Istara, Pixabay.

Dr. Faure is currently the African Coordinator for the Center for Disease Dynamics, Economics and Policy (CDDEP), which is supporting low and middle income countries in Africa to develop a national action plan, strategy and policy to combat antimicrobial resistance.

Dr. Kim Faure, African Coordinator, CDDEP is being interviewed during the ReAct Africa conference in September 2017.

She has more than 14 years experience and knowledge of health services, quality assurance, public health policy and regulatory frameworks in Africa. Having worked in the public and private healthcare sectors in South Africa she understands the various challenges low and middle income countries experience whilst planning the provision of quality health services. She understands the issues around balancing access to, and overuse of, health services to increase health outcomes.

Dr. Kim Faure says:

“Once the purpose of the costing exercise is understood along with the activities that are specific for antimicrobial resistance, the costing exercise can be simplified and achieved.”

Dr. Faure, what do you need to think about as a first step when costing a National Action Plan on AMR?

– You need to find the purpose of costing a National Action Plan on AMR. Many countries require an understanding of what antimicriobial resistance activities within a National Action Plan will cost in order to seek the necessary political approvals for their National Action Plan.

–  Understanding the National Action Plan costs also assists with mobilizing resources – either from within the ministries and treasury structures or from donors who would be willing to support such activities based on an estimated budget.

–  The audience, therefore for the costing, needs to be understood in order to align costing elements, structures and models appropriately.

What do you need to cost in a National Action Plan?

– The financially astute personnel will want to see every single activity – whether it is antimicrobial resistance specific or not – costed with as much detail as possible including estimated costs over a 5 year period.

– Given the multidisciplinary nature of antimicrobial resistance and its overlap with other programs such as public health prevention and promotion, mother and child health, infection prevention and control and general pharmaceutical management of medicines, costing needs to be more focused and simplified to prevent it repeating the entire countries health and agriculture budgets.

Antimicrobial resistance activities in a National Action Plan can be divided into 3 types which each require a different costing methodology:

  • Antimicrobial resistance specific activities which are new or focused on antimicrobial resistance only, such as: antimicrobial resistance committees and structures, antibiotics awareness campaigns and communication events, antimicrobial stewardship and use guidelines for health facilities, regulation of the prescribing of antibiotics, surveillance on antimicrobial resistance and antimicrobial use. These activities should be costed in full taking into account the full needs of each program.
  • Antimicrobial resistance sensitive activities that may be contained within existing programs such as immunization, infection prevention and control and availability of medicines. For example, expansion of the immunization program to include bacterial communicable diseases will reduce infections and therefore by extension antimicrobial resistance.These activities may already be part of existing programs with their own budgets, therefore it is desirable to include any additional costs that need to be incurred in order to improve the focus on antimicrobial resistance or expand the existing programs to include antimicrobial resistance activities.
  • Broad health system type activities – these are mainly the focus of major public health systems strengthening programs such as WASH, regulation of farming methods to improve biosecurity and production, pharmaceutical supply chain management and procurement. Many of these large scale programs with have other objectives than antimicrobial resistance and will most likely be funded from another source already and therefore may be excluded from the costing of the National Action Plan provided it is established that they are budgeted for from another source.

Dr. Faure, could you give examples of what aspects to cost in a National Action Plan on AMR?

– In general terms, most antimicrobial resistance activities are human resource intensive, requiring people’s time to develop guidelines or participate in meetings and workshops. Therefore most of the costs involved in developing new AMR program activities or in expanding existing programs to include antimicrobial resistance activities will be labour cost driven. Most of these costs will be from internal staff within ministries, academic institutions and government agencies –which has in theory a zero cost to it as they are employed – besides travel and logistics expenses. However, in some instances external expertise is required and will incur an additional hourly cost.

Antimicrobial resistance specific activities will require estimates to be made for the following types of expenses:

  • Meetings of committees and task teams – venue hire, food for participants, accommodation and travel logistics. Where possible the ministry should look at existing venues/meeting rooms available within its facilities to host these meetings or use those of academic partners and government agencies.
  • Facilitator support in the form of ministry staff or outsourced/external consulting personnel for specific activities or task teams and functions. A part time co-ordinator should be considered to help drive processes, keep track of deliverable, arrange and facilitate meetings.
  • Most of the technical experts involved in AMR task teams or committees will be employed as academics or within the ministries. However should the country have a policy that allows for the reimbursement of time for members of formal committees to participate, then these costs per hour should also be considered.
  • Media and printing costs – these are sometimes difficult to estimate and include things like the use of professional marketing staff to design awareness and communications materials (if these services are not available in-house) or the printing of posters, leaflets and brochures on awareness on antibiotics. Depending on the type of awareness and communication campaign that is envisaged in the National Action Plan an estimate should also include media releases, radio slots and advertisement or large scale billboards and TV program slots.
  • Situation analysis and studies may be needed to understand the antimicrobial resistance issues before an activity can be implemented, for example understanding public awareness or existing Infection Prevention Control or biosecurity practices or the status of —laboratory services. These should be seen as “discrete projects” which require external support and costs as a consulting initiative which the ministry may need to go out on tender for or approach a donor to fund.

– Antimicrobial resistance sensitive activities need to consider what is already budgeted for by the existing programs, determine whether this is sufficient to include antimicrobial resistance or requires additional funding to expand into antimicrobial resistance. This may mean additional staff or training activities such as expanding infection prevention from academic facilities to all health facilities. In order to cost these activities it is imperative to have discussions with the programs affected to understand how can antimicrobial resistance be integrated, what is budgeted for now and what is that money allowing them to achieve in terms of implementation and coverage and then determine the additional amounts needed. The ministry will have to decide then how these costs are to be apportioned between the different directorates involved to prevent duplication of budgets or funding requests.

– What is challenging regarding time frame over which to cost?

– The challenge with developing a costing for the National Action Plan on AMR for a 5 year period is that many of the initial activities in years 1-2 will be focused on first understanding what the current status is or situation analysis and studies on antimicrobial use and antimicrobial resistance. As the findings of these analysis will not be known at the time of costing, it will be difficult to cost what the implementation activities will be thereafter i.e. years 3–5.

– In these instances, prioritization processes are important – National Action Plans activities are categorized into those that are easy to achieve in short term and require less effort than those that require more effort and longer term focus. Then short term activities are included in the costing in a more detailed manner whilst the longer term ones are mere estimates for the future or can be excluded until such time as their detailed nature becomes apparent.

– Another timing consideration should be that National Action Plans’s should be costed in time with the routine budgeting cycle of the ministries involved. Preparation in advance of these budgeting decision making cycles allows for a better opportunity to incorporate antimicrobial resistance costs into the next years budgets and therefore will speed up implementation actions. This will require a longer timeframe view and include all activities in the antimicrobial resistance costing as in most instances the required budget will not be provided in full.

– However, if the budget cycle has been missed, National Action Plan costing should be used to focus on accessing other sources of funding such as donors or development partners. In this instance the costing should focus on “discrete projects” which donors would see fit to fund in their entirety as specific initiatives.

Methods for prioritization and simplification makes costing of National Action Plan on AMR achievable

“The use of some simple prioritization and simplification methods for costing National Action Plan on AMR activities will allow a daunting task to be achievable with an output that is useful to ensure that antimicrobial resistance activities are implemented and the burden of antimicrobial resistance is reduced sooner rather than later.”

Dr. Kim Faure, African Coordinator, CDDEP