Costing of Community Health Service Packages - The Malawi Social Action Fund (MASAF) Experience

Introduction

The Malawi Government designed a 12 year project as one of the policy instruments in achieving the Millennium Development Goals. The project is managed by the Malawi Social Action Fund (MASAF). MASAF was designed as a platform for the implementation of multi-sectoral community Driven Development (CDD) interventions in the areas of Education, Health, Water, Transport, Communication, Natural Resources, Energy, Agriculture, Irrigation and Community Services. These interventions have been placed in five Community Service Packages (CSP) such that community demands to meet local needs must be within these Service Packages in order to get funding from MASAF. Each of the Service Packages has elements that are meant to address specific Millennium Development Goals (MDGs) and the Malawi Growth and Development Strategy (MGDS). The five Service Packages are health, education, water and sanitation, transport and communication and household food security^1,2,3.

The design of MASAF was to cost the Service Packages within the first three years so that in the subsequent nine years of implementation, the costs of the various interventions would be predetermined and thereby improve on planning and implementation of the sub projects. The costing of service packages was preceded by establishing baseline data for each of the 12 MDG indicators selected for the MASAF project as impact indicators.

The objective of this costing exercise was to estimate the average costs for health service packages to estimate funding requirements to meet local authority health care needs. This paper describes the process that was followed in costing subprojects and service packages and also presents the costs of community health packages by each local authority (LA). This paper follows a previous paper⁴ where baseline data for health related MDGs for each LA were reported. The results of this paper could therefore be used to estimate resource requirements that could among other behavioural changes lead to the attainment of the MDG targets at LA level⁵.

Methodology

This study was done in the year 2005 over a six months period. The Malawi Kwacha Exchange rate was MK135 to $1. The projects used to estimate the costs had been under implementation for close to two years.

The costing tool had four columns which captured the service package component/item, its unit of measure, cost of its community contribution (if applicable) and cost provided by MASAF. The total cost was then arrived at and converted in dollars.

Costing of Sub projects and Service Packages

In MASAF 3, communities do preliminary costing of subprojects, which are reviewed and improved at the LA by the District Executive Committee (DEC). MASAF assisted Project Management Committees (PMCs) and LAs in this process through the provision of lists of activities, materials, labour and services, Bills of Quantities (BoQs), as requirements to provide services required by the community.

Communities are expected to understand the inputs required to benefit from a service that is required in their local areas. Costing by communities involves providing local costs for materials, labour and services that can be acquired within their community. For services that are not locally available, communities apply prices they pay for such services elsewhere or are assisted by LA officials. The community, through this process, has an idea of the total cost for the service they are demanding. The community then isolates the items that will be provided by the community as their contribution towards the cost of the service. The total community contribution is then compared with the total cost for the service to check if the contribution meets the MASAF funding requirements.

At LA level, the costing of the subprojects are reviewed and improved through use of BoQs provided by MASAF and using an LA Price List which is maintained by each Local assembly. This study therefore used micro-costing. Micro costing was the default methodology due to the set up of the MASAF project which funds at community level. Micro costing was also appropriate because the objective of the exercise was to estimate actual project costs at community level.

Costed Service Packages

Once funded, communities implement subprojects as approved by the LA or MASAF Board. During implementation, the cost of these subprojects will be different depending on local costs where the subproject is implemented. This means that completed projects will end up with different final costs, although the initial budgets were the same.

Costing Service Packages involved determining actual costs of the individual elements that have been funded and completed per subproject. These costs are a combination of both MASAF and Community contributions to come up with total costs for the subproject that was funded. Costs of similar elements are then averaged to come up with one cost of a service element. For example, an LA may have 6 boreholes funded in different locations within the LA. Once all these are completed, the LA will take an average cost of the final costs of the 6 boreholes to be the average cost of a borehole within that LA. Fully Costed Service Packages are, therefore, costed elements of a Service Package using fully completed elements and having full eligible costs of both Community and MASAF contributions as implemented in a particular LA.

Process of costing of Service Packages

The various Service Packages are costed to determine the costs of each of the elements making the service package. To achieve this, the cost in terms of how much was spent on the structure is determined by going through financial records kept by the community, referred to as the MASAF contribution. Communities also determined how much worth were the construction materials and time input they had contributed to the project and this was computed into monetary terms, referred to as community contribution.

The total of the MASAF and community contribution made up the total cost of the element. An average of a number of similar elements was computed to come up with the Local Assembly average cost for that particular element. Costs of several elements in the same Service Package make up the total Service Package cost.

Results

The community essential health service was costed. This service packages comprises of various components (see Tables 1a–3). The service package was costed in the three administrative zones/regions of Malawi. Tables 1a–3 show the costs per each LA in each zone.

Table 1a.

Southern Zone

		Chiradzulu DA	Mangochi Town	Mangochi DA	Balaka Town	Balaka DA	Machinga DA	Liwonde Town	Zomba	Phalombe
Component	Unit of Measure	Total	Total	Total	Total	Total	Total	Total	Total	Total
Training of TBAs	TBA Trained	$592.59	$641.67	$604.63	$555.56	$555.56	$610.37	$610.37	$539.13	$555.56
Training of HSAs	HSAs	$888.89	$740.74	$740.74	$740.74	$740.74	$740.74	$925.93	$740.74	$740.74
Drug Revolving Fund	Revolving Fund	$1,962.96	$1,982.22	$1,982.22	$1,856.30	$1,856.30	$2,111.11	$2,162.96	$1,851.85	$2,111.11
Anti-malaria Program	Program	$740.74	$6,315.56	$6,315.56	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74
Family Planning Services	Service	$4,818.52	$4,803.70	$4,803.70	$4,819.63	$4,819.63	$4,796.30	$4,796.30	$4,796.30	$4,709.19
Rehabilitation of dispensary	Dispensary	$6,296.30	$18,154.81	$18,154.81	$18,984.85	$18,984.85	$6,876.25	$6,824.07	$19,840.37	$5,555.56
Construction of dispensary	Dispensary	$51,487.78	$54,093.52	$51,589.26	$64,019.92	$64,019.92	$57,996.12	$58,737.97	$50,671.11	$39,322.82
Construction of Health Centre	Health Centre	$237,821.11	$256,446.30	$256,446.30	$242,970.84	$242,970.84	$227,083.54	$242,862.80	$246,051.85	$217,301.26
Construction of Underfive Clinic	Under Five Clinic	$33,333.33	$25,893.70	$20,412.04	$21,548.17	$21,548.17	$29,309.99	$30,051.85	$24,740.74	$20,967.93
Construction of Maternity Unit	Maternity Unit	$68,118.52	$47,510.74	$47,510.74	$64,296.30	$64,296.30	$51,917.78	$51,917.78	$41,118.52	$30,521.15
Construction of Guardian Shelter	Shelter	$14,814.81	$21,927.78	$18,524.44	$23,671.11	$23,671.11	$16,317.78	$16,317.78	$25,925.93	$14,674.18
Drilling a Borehole, 45m Deep	Borehole	$3,253.28	$3,688.89	$3,298.12	$3,147.11	$3,147.11	$3,290.17	$3,290.17	$3,820.04	$3,620.16
Construction of a Double VIP Latrine	Double VIP	$2,918.52	$2,917.22	$2,714.44	$3,599.74	$3,599.74	$2,970.37	$2,970.37	$1,981.91	$2,140.74
Construction of a Single VIP Latrine	Single VIP	$1,841.22	$2,017.41	$1,432.59	$2,525.81	$2,525.81	$1,929.63	$1,929.63	$1,392.59	$40,377.63
Training of Medical Assistants	MA Trained	$5,555.56	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$5,333.33
Training of Nurse Midwives	Midwife Trained	$1,962.96	$5,555.56	$5,555.56	$5,555.56	$5,555.56	$5,555.56	$5,555.56	$5,555.56	$5,555.56
Training of Nurse Midwives	Nurse Trained	$3,555.56	$5,333.33	$5,333.33	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,555.56
Training of Midwives	Midwife Trained	$1,855.56	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85
Home Based Care Kits	Kits Procured	$240.74	$237.04	$237.04	$248.15	$248.15	$237.04	$237.04	$207.41	$247.56
Home Based Care Training	Volunteers Trained	$222.22	$255.56	$255.56	$222.22	$222.22	$311.11	$311.11	$222.22	$222.22
Health Centre Statistics on Community Day	Day	$3,111.11	$33,333.33	$33,333.33	$33,333.33	$33,333.33	$33,333.33	$33,333.33	$2,650.19	$3,333.33
Bicycle Ambulance	Bicycle Ambulance	$133.33	$144.44	$144.44	$137.04	$137.04	$137.04	$137.04	$137.04	$148.15
Growth Monitoring Training	Volunteer Trained	$111.11	$133.33	$133.33	$111.11	$111.11	$111.11	$111.11	$111.11	$3,333.33
Community Health Service Package	TOTAL COST	$445,636.73	$469,497.22	$456,892.57	$473,824.96	$473,824.96	$427,302.01	$444,564.65	$443,836.08	$406,919.64

Table 3.

Northern Zone

		Karonga Da	Likoma Da	Mzuzu City	Karonga Town	Chitipa Da	Nkhatabay Da	M'mbelwa Da	Rumphi Da
Component	Unit of Measure	Total	Total	Total	Total	Total	Total	Total	Total
Training of TBAs	TBA Trained	$461.85	$479.46	$455.84	$461.85	$503.74	$455.84	$455.84	$455.84
Training of HSAs	HAS Trained	$487.09	$479.01	$441.98	$487.09	$441.98	$487.09	$441.98	$487.09
Drug Revolving Fund	Revolving Fund	$399.89	$633.31	$548.53	$399.89	$638.37	$622.61	$609.22	$593.99
Anti-malaria Program	Program	$829.63	$979.22	$964.75	$829.63	$926.59	$965.43	$1,005.59	$876.69
Family Planning Services	Service	$441.56	$319.43	$338.85	$441.56	$351.85	$332.60	$336.60	$347.47
Rehabilitation of Dispensary	Dispensary	$7,760.74	$5,703.70	$2,825.89	$7,760.74	$4,038.70	$2,825.89	$2,825.89	$3,457.77
Construction of Dispensary	Dispensary	$14,969.26	$16,376.17	$15,212.14	$14,969.26	$14,841.77	$14,804.40	$15,582.51	$15,212.14
Construction of Health Centre	Health Centre	$140,740.74	$185,185.19	$155,555.56	$137,037.04	$148,148.15	$125,925.93	$13,333.33	$133,333.33
Construction of Under Five Clinic	Under Five Clinic	$14,220.54	$13,622.74	$13,480.26	$8,047.70	$8,453.06	$16,196.31	$13,974.08	$12,484.74
Construction of Maternity Unit	Maternity Unit	$12,392.47	$24,154.81	$18,962.96	$12,392.47	$20,451.11	$19,539.63	$21,191.85	$21,191.85
Construction of Guardian Shelter	Shelter	$11,385.88	$6,367.86	$5,929.48	$11,385.88	$8,019.19	$8,699.64	$8,714.67	$9,520.00
Drilling a borehole, 45m Deep	Borehole	$3,600.46	$14,573.96	$3,068.56	NIL	$222.22	$3,576.42	$3,099.31	$3,342.89
CBM Training	Water point committee	$611.11	$611.11	$666.41	$611.11	$611.23	$619.94	$665.78	$664.89
Construction of a Double VIP Latrine	Double VIP	$1,189.31	$1,709.78	$1,494.31	$1,189.31	$1,464.50	$1,681.61	$1,346.17	$1,372.94
Construction of a Single VIP Latrine	Single VIP	$511.20	$1,180.14	$918.14	$511.20	$936.59	$1,089.52	$857.17	$650.90
Training of Medical Assistants	MA Trained	$5,970.37	$6,762.96	$6,744.44	$5,970.37	$5,970.37	$5,970.37	$6,762.96	$5,970.37
Training of Nurse Midwives	Midwife Trained	$8,955.56	$8,955.56	$9,992.59	$8,955.56	$8,955.56	$8,955.56	$8,955.56	$8,955.56
Training of Nurse	Nurse Trained	$8,955.56	$8,955.56	$9,992.59	$8,955.56	$8,955.56	$8,955.56	$8,955.56	$8,955.56
Training of Midwives	Midwife Trained	$2,985.19	$2,985.19	$3,330.86	$3,330.86	$2,985.19	$2,985.19	$2,985.19	$2,985.19
Home Based Care Kits	Kits procured	$228.77	$275.56	$296.14	$228.77	$300.00	$285.38	$281.87	$299.69
Home Based Care Training	Volunteers trained	$181.85	$179.07	$174.68	$181.85	$166.53	$187.48	$183.46	$187.43
Health Centre Statistics on Community Statistics Day	Day	$97.82	$279.04	$254.52	$97.82	$333.33	$298.67	$260.52	$354.42
Bicycle Ambulance	Biccyle Ambulance	$222.22	$222.22	$162.96	$222.22	$118.52	$296.30	$162.96	$162.96
Growth Monitoring Training	Session	$1,259.26	$1,259.26	$1,259.26	$1,259.26	$1,259.26	$1,259.26	$1,259.26	$1,259.26
Community Health Service Package	TOTAL COST	$238,858.32	$302,250.29	$253,071.70	$225,726.99	$239,093.36	$227,016.60	$114,247.32	$233,122.96

Table 1b.

Southern Zone

		Luchenza Town	Thyolo DA	Neno DA	Mulanje DA	Mwanza DA	Nsanje DA	Chikwakwa DA	Blantyre City	Blantyre DA
Component	Unit of Measure	Total	Total	Total	Total	Total	Total	Total	Total	Total
Training of TBAs	TBA Trained	$480.56	$480.56	$518.52	$518.52	$518.52	$518.52	$480.56	$3,740.74	$3,740.74
Training of HSAs	HSAs	$888.89	$888.89	$888.89	$925.93	$888.89	$888.89	$888.89	$13,000.00	$1,037.04
Drug Revolving Fund	Revolving Fund	$1,282.04	$1,282.04	$1,282.04	$2,111.11	$1,282.04	$1,289.44	$1,282.04	$11,111.11	$6,481.48
Anti-malaria Program	Program	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74
Family Planning Services	Service	$4,931.85	$4,931.85	$333.33	$4,796.30	$333.33	$4,969.19	$4,931.85	$4,796.30	$9,766.67
Rehabilitation of dispensary	Dispensary	$1,481.48	$1,481.48	$1,481.48	$5,814.81	$1,481.48	$1,300.37	$4,615.93	$22,222.22	$17,596.22
Construction of dispensary	Dispensary	$43,962.96	$46,574.81	$25,925.93	$25,925.93	$46,555.56	$46,730.22	$46,030.73	$35,286.98	$35,286.98
Construction of Health Centre	Health Centre	$235,185.19	$255,555.56	$251,481.48	$211,111.11	$255,185.19	$212,962.96	$226,952.55	$296,296.30	$296,296.30
Construction of Underfive Clinic	Under Five Clinic	$18,571.74	$18,571.74	$18,518.52	$19,259.26	$18,518.52	$18,148.15	$21,211.13	$27,880.24	$27,880.24
Construction of Maternity Unit	Maternity Unit	$44,444.44	$48,000.00	$22,222.22	$22,222.22	$48,074.07	$14,674.18	$46,698.61	$38,888.89	$38,891.48
Construction of Guardian Shelter	Shelter	$26,596.67	$26,226.30	$25,925.93	$15,037.04	$25,925.93	$8,835.00	$22,175.16	$15,880.30	$15,651.08
Drilling a Borehole, 45m Deep	Borehole	$3,118.94	$3,118.94	$3.090.56	$3,241.38	$3.090.56	$3,304.49	$4,474.88	$4,793.06	$4,793.06
Construction of a Double VIP Latrine	Double VIP	$2,999.44	$2,999.44	$3,259.26	$3,217.41	$3,259.26	$2,835.12	$2,999.44	$3,216.55	$3,216.55
Construction of a Single VIP Latrine	Single VIP	$1,924.64	$1,924.64	$1,622.22	$1,844.44	$1,622.22	$1.326.17	$1,924.64	$1,472.32	$1,472.32
Training of Medical Assistants	MA Trained	$5,426.10	$5,426.10	$5,518.87	$5,523.31	$5,518.87	$5,333.33	$5,426.10	$5,333.33	$5,333.33
Training of Nurse Midwives	Midwife Trained	$5,555.56	$5,555.56	$5,555.56	$1,851.85	$5,555.56	$5,555.56	$5,555.56	$3,555.56	$5,555.56
Training of Nurse Midwives	Nurse Trained	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$4,419.75	$5,703.70
Training of Midwives	Midwife Trained	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$3,175.31	$3,175.31
Home Based Care Kits	Kits Procured	$237.04	$237.04	$237.04	$237.04	$237.04	$240.37	$237.04	$400.00	$274.07
Home Based Care Training	Volunteers Trained	$444.44	$444.44	$355.56	$340.74	$444.44	$444.44	$444.44	$3,207.41	$259.26
Health Centre Statistics on Community Day	Day	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$2,543.21	$3,333.33
Bicycle Ambulance	Bicycle Ambulance	$133.33	$133.33	$144.44	$144.44	$144.44	$144.44	$133.33	$125.93	$125.93
Growth Monitoring Training	Volunteer Trained	$3,333.33	$3,333.33	$3,333.33	$111.11	$3,333.33	$3,333.33	$3,333.33	$111.11	$111.11
Community Health Service Package	TOTAL COST	$410,480.12	$436,647.53	$381,176.64	$333,752.47	$431,450.72	$342,315.67	$409,277.70	$502,197.34	$486,722.50

Table 2a.

Central Zone

		Dedza Town	Salima DA	Nkhotakota DA	Salima Town	Lilongwe DA	Lilongwe DA	Dowa DA	Ntcheu Town
Component	Unit of Measure	Total	Total	Total	Total	Total	Total	Total	Total
Training of TBAs	TBA Trained	$453.37	$453.37	$426.52	$426.52	$524.69	$524.69	$453.37	$453.37
Training of HSAs	HSAs	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$888.89	$888.89	$5,333.33	$5,333.33
Drug Revolving Fund	Revolving Fund	$888.89	$888.89	$888.89	$888.89	$888.89	$888.89	$888.89	$888.89
Anti-malaria Program	Program	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74	$740.74
Family Planning Services	Service	$333.33	$333.33	$333.33	$333.33	$333.33	$333.33	$333.33	$333.33
Rehabilitation of dispensary	Dispensary	$9,395.33	$6,278.29	$6,130.50	$6,278.29	$7,499.08	$7,499.08	$7,407.41	$7,570.44
Construction of dispensary	Dispensary	$16,935.17	$15,496.58	$57,074.50	$15,496.58	$66,658.17	$66,658.17	$15,781.26	$16,935.17
Construction of Health Centre	Health Centre	$49,081.50	$59,305.62	$197,389.91	$59,305.62	$152,926.61	$152,926.61	$50,607.85	$52,933.97
Construction of Underfive Clinic	Under Five Clinic	$8,703.70	$5,705.57	$13,833.51	$5,705.57	$9,380.61	$9,380.61	$5,705.57	$9,373.05
Construction of Maternity Unit	Maternity Unit	$14,909.81	$16,225.20	$24,185.61	$16,225.20	$16,551.54	$16,551.54	$10,293.29	$16,935.17
Construction of Guardian Shelter	Shelter	$7,259.26	$18,370.37	$13,185.14	$18,370.37	$15,055.74	$15,055.74	$18,370.37	$8,312.46
Drilling a Borehole, 45m Deep	Borehole	$3,960.76	$3,563.47	$3,334.37	$3,563.47	$4,685.66	$4,685.66	$3,594.81	$3,842.63
CBM Training	Water Committee	$540.56	$622.22	$581.39	$622.22	$540.56	$540.56	$540.56	$540.56
Construction of a Double VIP Latrine	Double VIP	$1,273.56	$921.69	$1,633.27	$921.69	$2,255.35	$2,255.35	$1,168.52	$1,228.29
Construction of a Single VIP Latrine	Single VIP	$636.78	$507.56	$963.74	$507.56	$1,605.50	$1,605.50	$591.98	$614.15
Training of Medical Assistants	MA Trained	$5,333.33	$5,333.33	$5,333.33	$5,333.33	$3,392.59	$3,392.59	$5,333.33	$5,333.33
Training of Nurse Midwives	Midwife Trained	$5,555.56	$5,555.56	$5,555.56	$5,555.56	$7,407.41	$7,407.41	$5,555.56	$5,555.56
Training of Nurse Midwives	Nurse Trained	$3,555.56	$3,555.56	$3,555.56	$3,555.56	$3,333.33	$3,333.33	$3,555.56	$3,555.56
Training of Midwives	Midwife Trained	$1,851.85	$1,851.85	$1,851.85	$1,851.85	$4,296.30	$4,296.30	$1,851.85	$1,851.85
Home Based Care Kits	Kits Procured	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15
Home Based Care Training	Volunteers Trained	$320.52	$320.52	$320.52	$320.52	$320.52	$320.52	$320.52	$320.52
Health Centre Statistics on Community Day	Day	$1,333.33	$1,333.33	$1,333.33	$1,333.33	$1,333.33	$1,333.33	$1,333.33	$1,333.33
Bicycle Ambulance	Bicycle Ambulance	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15	$148.15
Growth Monitoring Training	Volunteer Trained	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33	$3,333.33
Community Health Service Package	TOTAL COST	$142,025.88	$156,326.01	$347,614.54	$156,326.01	$304,248.48	$304,248.48	$145,391.06	$149,615.33

Table 2b.

Central Zone

		Ntchisi DA	Kasungu DA	Kasungu Town	Dedza DA
Component	Unit of Measure	Total	Total	Total	Total
Training of TBAs	TBA Trained	$237.04	$518.52	$518.52	$453.37
Training of HSAs	HSAs	$888.89	$888.89	$888.89	$5,333.33
Drug Revolving Fund	Revolving Fund	$888.89	$740.74	$740.74	$888.89
Anti-malaria Program	Program	$4,444.44	$44.44	$44.44	$740.74
Family Planning Services	Service	$251.85	$333.33	$333.33	$333.33
Rehabilitation of dispensary	Dispensary	$6,296.74	$9,453.77	$9,453.77	$9,395.33
Construction of dispensary	Dispensary	$51,544.91	$63,952.04	$63,952.04	$16,935.17
Construction of Health Centre	Health Centre	$263,592.76	$128,240.74	$128,240.74	$49,081.50
Construction of Underfive Clinic	Under Five Clinic	$17,597.78	$9,218.44	$9,218.44	$8,703.70
Construction of Maternity Unit	Maternity Unit	$35,230.56	$25,915.11	$25,915.11	$14,909.81
Construction of Guardian Shelter	Shelter	$14,080.32	$10,462.59	$10,462.59	$7,259.26
Drilling a Borehole, 45m Deep	Borehole	$3,619.04	$3,441.84	$3,441.84	$3,960.76
CBM Training	Water Committee	$540.56	$540.56	$540.56	$540.56
Construction of a Double VIP Latrine	Double VIP	$1,633.27	$1,633.27	$1,633.27	$1,633.27
Construction of a Single VIP Latrine	Single VIP	$963.74	$963.74	$963.74	$636.78
Training of Medical Assistants	MA Trained	$5,333.33	$5,333.33	$5,333.33	$5,333.33
Training of Nurse Midwives	Midwife Trained	$5,555.56	$5,555.56	$5,555.56	$5,555.56
Training of Nurse Midwives	Nurse Trained	$3,555.56	$3,555.56	$3,555.56	$3,555.56
Training of Midwives	Midwife Trained	$1,851.85	$1,851.85	$1,851.85	$1,851.85
Home Based Care Kits	Kits Procured	$148.15	$2,814.81	$2,814.81	$148.15
Home Based Care Training	Volunteers Trained	$320.52	$320.52	$320.52	$320.52
Health Centre Statistics on Community Day	Day	$3,333.33	$3,333.33	$3,333.33	$3,333.33
Bicycle Ambulance	Bicycle Ambulance	$148.15	$148.15	$148.15	$148.15
Growth Monitoring Training	Volunteer Trained	$3,333.33	$3,333.33	$3,333.33	$3,333.33
Community Health Service Package	TOTAL COST	$425,390.56	$282,594.47	$282,594.47	$142,025.88

Discussion

Malawi is a signatory to the millennium declaration of 2000 where countries have undertaken to achieve targets in eight Millennium Development Goals (MDGs). The Malawi government has set up various instruments to help in achieving these goals. One of the instruments in the Malawi Social Action Fund (MASAF). MASAF funds interventions in the areas of Education, Health, Water, Transport, Communication, Natural Resources, Energy, Agriculture and Irrigation at community level through local assemblies. It is not clear however what are the required resource envelopes to provide community health care costs in the LAs. In addition, it is not clear what resource envelope is required, in addition to other behavioural changes, to achieve MDGs at each of the local assemblies.

This paper has documented a costing process and the costs required to achieve community health care at each LA. This is the first time that health related costs have been reported and therefore can be used as “standards” for estimating community health care costs in each LA.

As expected with a study of this nature, some costs were missing. This was resolved by using community project costs incurred by projects similar to MASAF. These were mostly project implemented by donor agencies at community level.

Lessons Learnt in costing of Service Packages

Community subproject costing

Through costing of Service Packages, there has been a general appreciation of subproject costs (MASAF contribution and Community contribution) by those communities that participated in project implementation in the first three years of MASAF 3. Communities' estimation of subprojects cost have generally been very unrealistic. However after the costing of Service Packages, particularly for those communities that have implemented subprojects, communities have understood the whole exercise of costing and the costings are now more realistic.

Costs variations

The exercise revealed that there are cost variations between structures of the same type in different Local Assemblies. These variations can be attributed to differences in transportation of materials costs and the actual costs of materials from LA to LA. The general trend is that LAs that are closer to the major cities and towns have lower transportation costs and subsequently end up with lower subprojects costs. Assemblies that are far from the major cities and towns have higher transportation costs and end up with higher subprojects costs.

Poor Record keeping

During the costing exercise, some data for costing subprojects was sourced from Local Assemblies. It was noted that not all Local Assemblies were keeping adequate data. In some LAs, where sector ministries were able to provide data, the data was not up to date; the sector ministries struggled to provide the data of projects which they had implemented previously. In some cases, sector ministries could not provide the data; this proved that record keeping was very poor and not reliable.

Rehabilitation of subprojects

The implementation of rehabilitation of subprojects indicates that structures of the same type may be implemented with varied amounts of funding requirements. This is basically because the structures may require different rehabilitation levels resulting from different levels of state of dilapidation. As a result it became slightly difficult to get an indication of the average cost of rehabilitating structures of the same type. Therefore variance of costs of rehabilitation of subprojects is high

Community contributions

The costing of Service Packages has assisted in enhancing the understanding of subproject costs at both community and LA level. This has also assisted communities to understand the level of their community contributions in relation to the MASAF funding. It is important to note that when communities cost projects and give an indication of the materials that they will contribute towards the project, communities rarely look at those materials in financial terms, however through the costing of Service Packages exercise, the communities have come to realize how much their contributions are in financial terms.

Project completions

To adequately carry out costing of Service Packages, data needs to be collected from completed projects. This means communities have to aggregate costs of materials for both community contribution and from MASAF funds after a project is completed. In essence this implies that this activity has to largely await the completion of a project in order for the data to be complete. This therefore means that data can only be collected from completed projects only, and therefore makes the costing of the Service Packages a slow activity.

Limitations

The study used costs kept both at local authority and community level, some of the costs may not be accurate and that may affect the results. Due to the set up of the MASAF project, the costing exercise can be referred to as “micro-costing”. Costing tools developed globally for health MDGs (e.g., Marginal Budgeting for Bottlenecks, MBB) were not used and this may affect comparability with other studies. Most of the global tools however were developed for national level interventions and not community based interventions. In some instances, there were missing project costs. Costs from other comparable community interventions by donor agencies were used. The limitation with this is that MASAF had a labour intensive community contribution component which would make its project total costs lower than those implemented by donor agencies without a community contribution.

There are variations in costs for various reasons. Projects far away from urban centres had higher transportation costs. This distorted the average costs per LA. This has been taken care off by splitting the costs between district assemblies (DAs), town assemblies, municipalities and cities with decreasing transport costs in that order. The Project Management Committees (PMCs) also had different management styles and that tended to vary costs. For example some PMCs would send more people to obtain quotations. That increased administrative costs through travel and other allowances.

Conclusion

After costing the Service Packages, it is now clear how much each intervention will cost the Local Assemblies and communities to implement. The costed service package will also enable LAs to estimate the resource envelope to require achieving LA specific Millennium Development Goals in addition to other behavioural changes. Baselines for health related MDGs in all LAs are available⁴. These costed Service Packages will also help other stakeholders to estimate resources required to effectively implement projects in the various LAs. These costs can be used as “Standards”. Local assemblies will also be able to use the costed Service Packages in developing their socio- economic district profiles. The Service Packages will also help communities to judge and know in advance the complexity and levels of community contributions demands of any subproject that the community may wish to implement.