In response to a request from the Ministry of Health and Family Welfare (MOHFW), this provider focused cost analysis of the Bangladesh Essential Health Service Package (ESP) was conducted during January to September 2017 by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) with the funding support from WHO and technical assistance from the USAID-funded Health Finance & Governance (HFG) project. The MOHFW updated the ESP in 2016 for its fourth Health, Nutrition, and Population Sector Programme (HNPSP, 2016-22). The primary objective of this analysis was to estimate the costs of the updated Bangladesh ESP for 2016 to 2022 by interventions and delivery channels in public sector. The results of the study are expected to be used in advocacy for domestic resources required to implement the updated ESP during the target years. Approach: The One Health Tool (OHT) was used to project resource needs and costs of providing the updated ESP. OHT is used globally to support medium- to long-term (3-10 years) strategic planning in the health sector, and has been used to inform strategic planning processes in over 30 low and middle income countries. It provides a unified framework to strengthen integrated planning by supporting the planning, costing, and budgeting of health sector priorities, including health system strengthening strategies. The study team adopted a collaborative and consultative approach to engage all partners in the costing process. Key partners included: Health Economics Unit, Programme Management and Monitoring Unit (PMMU), Planning Wing of MOHFW, Directorate General of Health Services (DGHS), Directorate General of Family Planning (DGFP) of the MOHFW, Urban Primary Health Care Service Delivery Programme under the Ministry of Local Government and Rural Development, Institute of Health Economics Dhaka University, and representatives from HFG and WHO. A seven-member National OHT Resource Pool was formed to develop expertise in cost analysis using the OHT. In addition to the resource pool, an international OHT consultant and an external reviewer from HFG, as well as two external reviewers from WHO, assisted the icddr,b team. Methodology: The team identified the scope of investments required for ESP implementation, including the costs of services and health system (human resources, infrastructure, and logistics) required to enable this implementation in the public sector health facilities. The team applied an ingredients-based costing method using OHT. This costing approach was used to cost all ESP services except those for malaria, tuberculosis, HIV/AIDS, and neglected tropical diseases (which were costed using aggregate budget line items obtained from program implementers). The tool was customized for the updated Bangladesh ESP, and members of the OHT resource pool and the study team jointly reviewed the default data in the OHT. The team collected secondary data (e.g., coverage data from the Bangladesh Demographic and Health Survey, etc.), followed by primary data (e.g., required drugs/supplies and provider time for certain interventions for which there were no treatment guidelines) from purposively selected ESP delivery facilities under the MOHFW in Jhenaidah (Kotchandpur and Harinakunda UHCs) and Dhaka North City Corporation (Urban PHC Clinic [UPHCC] and Comprehensive Reproductive Health Care Centre [CRHCC]) under the MOLGRD. The team collected data through physical inventories and key informant interviews with officials and service providers at the selected public facilities, national and sub-national levels. An exit survey at Jhenaidah District Hospital was also conducted to estimate the proportion of patients receiving the ESP (i.e., the percentage of patients from upazila level and urban areas accessing ESP care at district hospitals). The data input into the OHT to estimate the cost of ESP services was based on current practice, standard treatment protocols, assumptions, and coverage levels in 2016 (see Appendix B). The team also derived assumptions from key informant interviews with qualified physicians/service providers for interventions that were not yet available but planned for the future. Data inputs used for ESP delivery in 2016 (base year) included those inputs directly associated with ESP service delivery (e.g., medicines, supplies, and health personnel time), in addition to the health system inputs necessary to support these services (e.g., human resources, infrastructure, equipment, logistics etc.). These base year data inputs were also used for 2017-2022 (target years) including any additional health system costs (e.g., construction of new health facilities, purchase of new equipment, vehicle etc.) and program activity costs (e.g., human resource training, supervision, etc.). These were identified, quantified, and valued in local currency (Bangladesh Taka, hereafter referred to as BDT) by delivery channels to estimate the total cost of the ESP in public sector. The quantity and unit price of these inputs were organized into the related OHT modules (health services or health system module). The unit price of material inputs was collected from government and market sources. Staff time, drugs and supplies required per intervention was collected from physicians/supervisors expert opinion. Service coverage data for target years (2017-2022) was derived from the respective Operational Plan and Programme Implementation Plan. Coverage data for the base year (2016) was gathered through document review, using for example, the Health Bulletin, Bangladesh Demographic and Health Survey (BDHS), Bangladesh Health and Morbidity Status survey, Urban Health survey, FP Management Information System (MIS), and other sources (see references). Consultative meetings with government program officials and policy planners were held on monthly basis to validate/cross-check data collected from the field settings. Using treatment input data (drugs, tests, supplies, & labor cost), the cost per intervention or service per person (unit cost) at public sector delivery channels were estimated for each of the listed ESP interventions. As the cost per service per person varied by delivery channel, a weighted average cost for each intervention was calculated. In 2016, coverage of ESP services varied from 2.2% (for female sterilization) to 82.5% (for BCG vaccination) by delivery channel, with an estimated weighted average of 20.4% coverage in the public sector. This is consistent with a 2015 Bangladesh national health accounts (BNHA) estimate that approximately 23% of the total healthcare expenditures are borne through the public sector. As ESP services are rolled out from 2017-2022, the estimated weighted average ESP coverage is expected to increase in public facilities to approximately 33% by 2022. The study team calculated an average cost per beneficiary by dividing the total cost of providing ESP in public sector by the population that actually received ESP services during the base year (using the estimated weighted average coverage in 2016) and is expected to receive ESP in the target years (using the estimated weighted average coverage in 2022). For local and international comparisons, the public per capita cost was estimated dividing the total cost of providing the ESP by Bangladesh’s total population irrespective of their coverage status. Key Findings: Based on the 2016 data inputs (i.e., coverage levels, necessary medicines/supplies and labor for interventions, health system costs, etc.), the estimated total cost of the ESP in the public sector in 2016 was BDT 76,195 million. This higher estimated cost of ESP services in 2016 is due to several factors, including the costing approach used, which involved costing ESP interventions as per current practice, as well as using standard protocols and assumptions for those interventions (primarily non-communicable diseases services including hypertension, diabetes, etc.) which were supposed to be available through the ESP but were not found to be fully operational at the time of data collection. The cost of ESP services is expected to increase to BDT 103,194 million in 2022, based on planned increase in service coverage and resources committed for 2017-2022 in Operational Plans, the cost of current and new services, standard protocols and assumptions. The study team calculated an “average cost per beneficiary (or service user)” in 2016 in public facilities as approximately BDT 2349 (29.8 USD)- which would be reduced to BDT 1805 (22.4 USD) in 2022 due to planned increase in coverage and expected efficiency gain through using fixed assets (Appendix E).This figure does not include inflation, but includes health system costs, it was calculated from the specific ESP interventions that were costed for that particular year at the specified coverage level, and it does not represent the average cost for a single client – who would typically need a mix of these services. The study team used the OHT to calculate the unit costs of 132 interventions across 10 delivery channels in the public sector. These recurrent costs represent the cost per service per person (including drugs, supplies, and labor cost) for each intervention provided through each delivery channel in public sector. As expected, these costs vary significantly by type of service and delivery channel for difference in service providers and infrastructure. The team therefore; calculated a weighted average cost for each intervention to provide an estimate of the approximate cost of ESP interventions without focusing on the channel at which it is delivered, which is anticipated to be used for overall planning purposes (Appendix C). The public per capita cost for the ESP was BDT 475 (6.1 USD) in the base year 2016, increasing over the target years to BDT 596 (7.4 USD) in 2022. This per capita cost has been estimated for local and international comparison. In 2001, Tim Ensor et al. showed that the public per capita cost of ESP for 2001 was BDT 115 (inflation adjusted for 2016). Our per capita estimate for 2016 was four times higher than 2001 estimate. However; this increase in per capita cost is attributable to increase in number of services e.g. non-communicable diseases (NCD) under updated ESP and its coverage. ESP services at district hospitals and upazila health complexes (UHCs) accounted for the highest proportion of total costs in 2016, a trend that continues from 2016 to 2022. This is attributed to several things including that these facilities provide most ESP services, overall accessibility to services at these facilities, the size of the facilities and the required supplies and staffing. MNCAH services were the most costly at UHCs, where the costs of child health and maternal health ranked the highest. Compared to other service delivery channels in public sector, NCD services were the greatest cost contributors at district hospitals, where most NCD services listed under the updated ESP are provided. The cost of ESP services at community clinic level was greater than in urban primary health care clinics in 2016. This is due to the greater number of community clinics and the larger volume of patients receiving ESP services compared to urban primary health care clinics RECOMMENDATIONS * These results provide an estimate of the annual investment required for delivering ESP effectively. Policy planners may consider these estimates and use them to advocate for increased funding for health to match the costs. * The National OHT Resource Pool should work under an institutional framework of the MOHFW to conduct additional costing exercises, including using standard treatment protocols for all services; these scenarios will be useful for the mid-term review of the 4th HPNSP and for planning of the next sector program. Using these estimates for future development of ESP: * These estimates should be used by policymakers for further development of a feasible and efficient ESP package and for setting target of the coverage through public delivery channels for next sector programme and also to increase fiscal space for health. * Future ESP cost estimates should also use standard protocols (normative costs) for all interventions, or WHO guidelines if Bangladesh-specific guidelines are not available, to identify the gap between current practice and protocols, and to provide planners with evidence to advocate for increase funding for the provision of quality ESP services across all relevant delivery channels. * As the country moves towards UHC by 2030, future analyses should look at the cost of current and projected coverage of ESP by both public and private sector and cost for service delivery by level of care(primary, secondary and tertiary) . That exercise will help the government to plan and extend ESP coverage by both sector in a coordinated approach. * Further studies should be conducted based on these cost estimates to generate evidence for gaining efficiency and promoting equity in the health sector.