The Boma Health Initiative Costing and Investment Case Analysis April 2019 Report citation: Gilmartin C., Collins D., and Driwale A. South Sudan Boma Health Initiative Costing and Investment Case Analysis. 2019. Management Sciences for Health. Arlington, USA. Photo credits: UNICEF South Sudan/Kealey: Front Page and page 11,12,13,14,15,16,22,34,35,46,55, UNICEF South Sudan/Holt: Page23 and 24 UNICEF South Sudan/Ryeng: Page 26 UNICEF South Sudan/Irwin: Page 27 UNICEF South Sudan/Martel: Page30,31,52 UNICEF South Sudan/Rich: Page 54 Correspondence: Colin Gilmartin ([email protected]) and David Collins ([email protected]). 4 South Sudan - Boma Health Initiative Costing and Investment Case Analysis Table of Contents Foreword ...........................................................................................................................................2 Acknowledgements............................................................................................................................3 Table of Contents ...............................................................................................................................5 List of Tables ......................................................................................................................................7 List of Figures .....................................................................................................................................7 Acronyms ..........................................................................................................................................9 Executive Summary .......................................................................................................................... 11 1. Introduction ............................................................................................................................. 17 1.1. Context of the study ................................................................................................................... 17 1.2. Objectives of the analysis ........................................................................................................... 19 1.3. Methodology ............................................................................................................................... 19 2. Country context and situation analysis ...................................................................................... 23 2.1. Priority challenges for community health in South Sudan ......................................................... 25 2.2. Community health policy and programmes ............................................................................... 28 2.3. Bottlenecks in the community health system ............................................................................ 31 3. Package of services and coverage scenarios ............................................................................... 32 3.1. Provision of services .................................................................................................................... 32 3.2. Coverage assumptions ................................................................................................................ 36 4. Cost of interventions ................................................................................................................ 38 4.1. Cost of implementation .............................................................................................................. 38 4.2. Total costs by category .................................................................................................................... 40 4.3. Total costs by programme ............................................................................................................... 42 4.4. Costs per capita ................................................................................................................................ 44 4.5. Cost per service ................................................................................................................................ 44 4.6. Quantities and costs of medicines ................................................................................................... 44 4.7. CHW time utilisation ........................................................................................................................ 44 5. Current financing and financing gaps ......................................................................................... 45 6. Impact of investment in community health on deaths averted ................................................... 45 7. Limitations of the analysis ........................................................................................................ 52 8. Discussion ................................................................................................................................ 54 9. Conclusions and recommendations ........................................................................................... 57 Annexes........................................................................................................................................... 58 Annex 1. Initial package of services .................................................................................................... 58 Annex 2. List of key data assumptions and sources............................................................................ 59 Annex 3. Discussion panel participant list .......................................................................................... 64 Annex 4. Bottlenecks .......................................................................................................................... 66 5 South Sudan - Boma Health Initiative Costing and Investment Case Analysis Annex 5. Expected utilisation rates and CHW minutes per service .................................................... 75 Annex 6. Coverage numbers ............................................................................................................... 78 Annex 7. Total costs by input type ...................................................................................................... 81 Annex 8. Total costs by programme ................................................................................................... 82 Annex 9. Impact analysis methodology using the Lives Saved Tool (LiST) ......................................... 83 Annex 10. Health impact coverage assumptions ................................................................................ 89 Addendum 1 - Revisions to BHI cost models ...................................................................................... 94 Addendum 2 - SRH/FP services package .......................................................................................... 107 References ..................................................................................................................................... 111 6 South Sudan - Boma Health Initiative Costing and Investment Case Analysis List of Tables Table 1. Major bottlenecks in the community health system .................................................................... 32 Table 2. Boma Health Initiative package of services .................................................................................. 33 Table 3. Coverage assumptions .................................................................................................................. 37 Table 4. Recurrent cost per capita (US $) ................................................................................................... 44 Table 5. Amount of resources (US $ million) needed for the BHI ............................................................... 45 Table 6. Mortality rates by impact year ...................................................................................................... 48 Table 7. Lives saved by impact year ............................................................................................................ 49 Table 8. Package of services - utilisation rates and CHW time per service ................................................ 75 Table 9. Numbers of services under low coverage scenario ...................................................................... 78 Table 10. Numbers of services under medium coverage scenario ............................................................. 79 Table 11. Numbers of services under high coverage scenario ................................................................... 80 Table 12. Total cost by input type – low coverage scenario (2018-2028) (US $) ....................................... 81 Table 13. Total cost by input type – medium coverage scenario (2018-2028) (US $) ................................ 81 Table 14. Total cost by input type – high coverage scenario (2018-2028) (US $) ...................................... 81 Table 15. Total costs by programme – low coverage scenario (2018-2028) (US $) ................................... 82 Table 16. Total costs by programme – medium coverage scenario (2018-2028) (US $) ............................ 82 Table 17. Total costs by programme – high coverage scenario (2018-2028) (US $) .................................. 82 Table 18. Key assumptions for impact analysis .......................................................................................... 85 Table 19. LiST coverage scenarios ..............................................................................................................