Resource

FINAL REPORT MOTS Costing Exercise

Executive Summary

In an effort to minimize the future impact of Ebola in Africa, numerous donors and stakeholders have worked together to develop an Ebola vaccine, to disseminate information and training to health workers and populations in communities at risk of an Ebola outbreak, and to reinforce communication and trust between national health systems and the broader population. The Ebola Vaccine Deployment, Acceptance and Compliance project (EBODAC, www.ebovac.org/EBODAC) carried out by a consortium in Sierra Leone from 2016 to 2019 tested a mobile-based IVR refresher training, known as the Mobile Training and Support (MOTS) service to strengthen the knowledge, skills, and attitudes of community health workers (CHWs) in Sierra Leone following their in-person foundational training with the Ministry of Health and Sanitation (MOHS) on Ebola readiness and vaccination. As part of the MOTS implementation, a costing study was commissioned, which is the subject of this report. The key questions analyzed through the MOTS costing study are:

• What will be the regular, ongoing cost to the MOHS of providing mobile-based refresher training to CHWs throughout Sierra Leone?
• How does the expected cost to MOHS of offering MOTS refresher training compare to that of the alternatives—in-person refresher training or no refresher training at all?
• What are the benefits of the mobile-based refresher training for the MOH (or another implementing organization), and what are the tradeoffs compared to in-person refresher training?

What are the costs (as well as benefits and drawbacks) to CHWs of mobile-based refresher training? In investigating the costs and benefits of MOHS implementing mobile-based refresher training, based on the MOTS pilot project, the costing study finds that:

• The cost for MOHS to provide mobile-based refresher training to all CHWs in a single district within one year would be about $25,000, compared to $52,000 for in-person refresher training—a savings of $27,000;
• The annual cost for the MOHS to extend a mobile-based refresher training to all 16,000 CHWs nationwide is estimated to be around $190,607, which amounts to approximately $12 per year per CHW, and $1.19 per household reached;
• CHWs incur low opportunity cost when attending in-person training and incur low/no opportunity and airtime costs in accessing the mobile-based IVR refresher trainings, which are available according to their schedule and preferences;
• This mobile-based refresher training mechanism is a game-changing innovation in contexts with widespread and hard-to-reach rural populations; MOTS enables a dramatically more efficient and widespread community health outreach, builds sustained engagement with decentralized health workers and can provide a critical safeguard in the case of health emergencies;
• The MOHS could put in place the foundation for mobile-based refresher training and CHW communication for a low, fixed annual fee (under $14,000 for the technology infrastructure and translation and recording of the IVR audio content), and then disseminate education modules selectively according to available funds to cover the variable expenses;
• Although implementing the mobile-based refresher system entails significant annual expense, the potential benefits of enhancing CHW performance and by extension community health and readiness—thereby reducing the occurrence and impact of various diseases including Ebola— 3 appear to outweigh the marginal cost1 of implementing the mobile-based refresher system and should be supported by donors.

This report provides an overview of the costing data collection, analysis, and findings, presents a discussion of the assumptions, considerations, implications, and conclusions with the goal of informing decision-making and budgeting for mobile-based refresher training in Sierra Leone, as well as other sub-Saharan African countries.

CONCLUSION

The study reached the conclusion that implementing MOTS (mobile-based training) is likely to yield net benefits for both the MOHS and CHWs. Assuming even a small positive impact on CHWs’ performance and health indicators in their communities, the system would pay for itself, in terms of community health protection, related government expenses, and broader economic impacts. The alternative of not implementing health refresher training for CHWs appears ill-advised, given WHO guidelines and health sector findings; and the alternative of implementing in-person refresher training appears prohibitively expensive. The best choice among these three options, therefore, seems clear: instituting a mobile-based communications and refresher training channel for CHWs would be a sound and promising investment.

The estimated additional, annual budget for MOHS to implement mobile-based refresher training comes to approximately $191,000 to disseminate one refresher module per year to every CHW across the country (about 16,000 CHWs), including the cost of transforming health content into IVR audio modules in five languages and the national and district level support and monitoring necessary to ensure quality roll-out, uptake and backstopping. This expense for annual mobile-based refresher training dissemination thus equates to $12 per year per CHW, or about $1.19 per household reached—a level of expense that many donors should be willing to help cover.

This investment in refresher training is likely to reinforce the MOHS’ existing investment in its network, training, and management of CHWs, while also enhancing CHWs’ knowledge, skills, attitudes, and performance of their duties with benefits accruing to the communities served. The analysis of CHW-level impacts shows that the flexibility and brevity of the mobile-based refreshers, in combination with in-person foundational training that will continue to be provided, does not incur a high cost to participants in terms of lost income and may in fact increase status and authority of CHWs in their communities. In light of the sharp economic losses realized due to the past Ebola crisis and other endemic, preventable, and containable diseases, this investment in an efficient and cost-effective CHW communications channel with the potential to reduce the occurrence and impact of future disease appears justified and recommended for Sierra Leone.

Although this study focused on the case of MOTS in Sierra Leone, the results may also help inform investments in mobile-based Ebola and other health-related refresher training in similar contexts. When considering this cost analysis for application in another country, it is important to note the key cost drivers that will directly affect the expense:

• The cost of translation, IVR recording, and configuration (including the number of languages and local fee rates of relevant service providers
• Technology costs including local license fees, choice of platform and related management costs, the going rate for mobile network airtime and data usage
• Local training-related costs for national and district/regional level training, impacted by distances and market rates for transportation, lodging, and refreshments

In many markets, the costs for these line items could differ significantly from those in Sierra Leone, and negotiation of these cost drivers could potentially lower the expected cost of mobile-based refresher implementation.