Cost analysis of MyChild Solution, HMIS Forms, and an alternative EHR solution

for Afghanistan

July 2017

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This report is written by Timothy Anderson 1, Shahnoza Eshonkhojaeva 2, Dr. Humayon Safi 3, Suraya Yousufzai 3

Authors’ affiliation: 1 - Tallinn University , 2 - Shifo Foundation, 3 - Swedish Committee for Afghanistan

Cover photo: Lennart Berggren/Axiom Film

This document can be freely used for educational and non-commercial purposes.

Table of contentsAbstract 4 .............................................................................................................................................

1. Introduction 5 ...................................................................................................................................

2. Methods 5 ........................................................................................................................................

3. Results 6 ..........................................................................................................................................

Cost comparison between MyChild Solution, HMIS Forms, and an alternative EHR solution 6 ..........

Return on investment with MyChild Solution 9 ..................................................................................

4. Conclusions 10 .................................................................................................................................

5. References 11..................................................................................................................................

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Abstract Background:  As part of a wider pilot study of MyChild Solution based on Smart Paper Technology in Afghanistan, this cost analysis aims to estimate the financial impacts of implementing MyChild Solution (MCS) on a national level in Afghanistan. Printing costs of the current healthcare system and running costs of an alternative point-of-care electronic solution (EHR) are also considered for comparison.

Methods:  All printing costs have been provided by UNICEF based on purchase orders to the printing company which is currently supplying the Health Management Information System (HMIS) forms. Running costs for MCS are based on results from pilot studies in Afghanistan, and costs for a comparable point-of-care electronic solution have been sourced from a case study in Bihar, India.

Results: Compared to the current child health system (HMIS), we estimate that the operating costs of MyChild Solution will be similar, potentially yielding financial gains over a 15-year period. EHR solutions, by contrast, are likely to come with a significantly higher cost. However, there are significant benefits in terms of time-savings, data accessibility, and child health monitoring that can come with both MCS and EHR. In this light, we contend that MyChild Solution is the most cost-effective solution for strengthening preventive child health in Afghanistan.

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1. Introduction This paper details a comparative cost analysis of preventive child care systems in Afghanistan, represented via a series of tables. Specifically, we compare  printing costs  of the current Health Management Information System  (HMIS) forms to projected running costs of proposed MyChild Solution  based on SmartPaper Technology.  In addition,  these costs are  compared with the running costs of an alternative point-of-care electronic health record system (EHR) (Borkum et al. 2015). We further provide an estimation of potential cost-savings related to reduced administration time if MyChild Solution is nationally implemented across Afghanistan. A more comprehensive evaluation of MyChild Solution and its related benefits can be found elsewhere (Shifo Foundation 2016a; 2016b; 2017a; 2017b; 2017c).

2. Methods In this study, we have compiled the costs of three operating healthcare systems to determine which one might be most cost-effective (and beneficial) for Afghanistan. With the exception of the HMIS printing costs, all figures listed in this paper are estimations based on other publications, previous fieldwork with MCS, and price quotes. All HMIS printing costs and quantities shown in this paper have been provided by UNICEF based on purchase orders made to the printing company that currently supplies the HMIS forms. Two of these figures (the printing costs for Birth Registration Cards and MyChild Card) are estimations based on the experience in the field (see Tables 1 and 2 for more details). All data given regarding the point-of-care electronic health record system has been sourced from Borkum et al. (2015). Details for each data source can also be found in its respective table. Annual costs re calculated considering the national scope of Afghanistan, which contains a total of 1800 health facilities providing immunisation services and experiences 1,300,000 newborns per year. Number of health facilities and newborns re provided by  the national Expanded Programme on Immunisation (EPI)  team, Ministry of Public Health (MoPH).

We have chosen to compare the HMIS forms and MCS to a point-of-care electronic system. The point-of-care electronic health record system assessed in this text (EHR) is the system detailed by Borkum et al. (2015) in their post-intervention study of an electronic healthcare system in Bihar, India. This example was selected for its focus on child health, recent publication date, socio-economic setting, and its prominence as a case study (funded by the Bill and Melinda Gates Foundation). EHR represents a common strategy for health interventions in low-income countries, one that is distinct from both MyChild Solution and the HMIS forms currently being used in Afghanistan. We consider this study an important point of comparison. All costs listed for EHR in this analysis have been sourced from Borkum et al. (2015).  

In addition to printing and maintenance costs (found in Tables 1, 2, and 3), we also estimate changes in  administration time  (found in Table 4) from MyChild Solution. Based on a previous post-intervention MCS study in Afghanistan (Anderson et al 2017) and Uganda (Mikaelsson et al 2016), we can approximate how much administration time (related to filling in HMIS forms) can be saved by switching from HMIS to MCS. This has been calculated in terms of hours saved per year, additional children served per year, and costs saved per year (in the form of health workers' salaries).

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3. Results Cost comparison between MyChild Solution, HMIS Forms, and an alternative EHR solution

The full cost-analysis has been broken down in a series of tables below, each focusing on the components of a single system. In Table 1, the printing costs for Afghanistan's current HMIS forms are shown. In Table 2, the running costs (including both printing costs and maintenance costs) for MyChild Solution are detailed. Table 3 places the costs from both HMIS forms and MCS in comparison with EHR costs. 

This comparison is not entirely complete, as the cost we have for HMIS forms only cover printing costs and do not include the auxiliary running or maintenance costs. The figures for MyChild Solution and EHR, by contrast, are holistic measurements that do include maintenance costs.

Table 1. Yearly printing costs with current HMIS forms

Name of the document/form

Unit price Afghani

Quantity printed nationally per year

Total costs/Afghani

Total costs/USD

Source Remarks

Birth registration cards

1.5 1 300 000 x 3 6 045 000 88 136 The price for this form was not available, therefore price and quantity are estimated.

We assume that the price of the Birth registration cards are similar (slightly lower) to the vaccination card, as paper quality and paper consumption are comparable.

The quantity required of this document is similar to vaccination card as the birth registration card should be provided to every child. The quantity is multiplied by three, as three copies of the card are filled per child: one copy is provided to the family, one copy is kept in the health facility, and one copy is sent to the Bureau of Statistics.

Monthly vaccination report

300 7 200 2,160,000 31 493 Prices and quantity is provided by UNICEF based on purchase order made to Strength Innovation Printing Press

Quantity required during one year per health facility is four. There are 1800 health facilities that provide vaccination services.

Expanded Programme on Immunisation (EPI) register of child immunisation

150 7 200 1,080,000 15 746 Prices and quantity is provided by UNICEF based on purchase order made to Strength Innovation Printing Press

Quantity required during one year per health facility is four. There are 1800 health facilities that provide vaccination services.

Vaccination and other supply request form

14 1 800 25,200 367 Prices and quantity is provided by UNICEF based on purchase order made to Strength Innovation Printing Press

Quantity required during one year per health facility is one. There are 1800 health facilities that provide vaccination services.

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*Average exchange rate of 0.01458 USD per 1 Afghani is applied. Source: oanda.com and yahoo finance Jul 2017.

Table 2. Yearly running costs (printing, maintenance and replacement) of MyChild Solution

Vaccination card 2 1 300 000 2,600,000 37 908 Prices and quantity is provided by UNICEF based on purchase order made to Strength Innovation Printing Press

Population under one year is 1,300,000 children 

Daily tally sheet 200 7 200 1,440,000 20 995 Prices and quantity is provided by UNICEF based on purchase order made to Strength Innovation Printing Press

Quantity required during one year per health facility is four. There are 1800 health facilities that provide vaccination services.

Stock and delivery record

150 7 200 1 080 000 15 746 Estimated based on already obtained costs of similar forms

Quantity required during one year per health facility is four. There are 1800 health facilities that provide vaccination services.

Temperature monitoring sheet

365 1 800 657 000 9 579 Estimated based on already obtained costs of similar forms

Quantity required during one year per health facility is 365. There are 1800 health facilities that provide vaccination services.

Total $ 219 971

Item Quantity per year

Unit cost/Afghani

Unit costs/ USD

Total costs/ USD

Source Remarks

MyChild Card 1 300 000 10 0,145 188 687 Price estimated considering national scale. Currently in small scale (10 000) MyChildCard costs 16 Afg, we expect that on large scale of 1 300 000 price should decrease to 10 Afg.

Population under one year is 1 300 000 children.

Maintenance of scanners

34 50 1 700 Based on costs of operations in Uganda, Gambia and Afghanistan.

Thirty-four provinces in Afghanistan (OCHA 2015); one scanning station is needed in every province.

Scanner rollers are replaced on a yearly basis based on recommendations from the manufacturer.

Smart Paper Technology Engine operations and continuous development

1 300 000 0,1 130 000 Based on costs of operations in Uganda, Gambia and Afghanistan.

Replacement of scanners

34 800 27 200 Based on costs of operations in Uganda, Gambia and Afghanistan.

Scanners last for at least seven years if not physically damaged. Costs of amortisation to replace scanners once in seven years is applied.

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*Average exchange rate of 0.01458 USD per 1 Afghani is applied. Source: oanda.com and yahoo finance May 2017. 

Yearly printing costs of HMIS forms are $219,971 and yearly running costs of MyChild Solution are $383,113. Our cost analysis indicates that running costs of MyChild Solution are higher by  $163,141  per year when compared to printing costs of the current HMIS forms. However, comparing these costs alone does not take into account the additional values, services, and improvements to data collection that come with MCS. Universal birth registration, additional health education and SMS reminders for parents, and potentially significant reductions in administration time with MCS mean that a direct comparison of printing costs does not provide a complete basis for evaluating these systems.   

Like MCS, point-of-care electronic health record systems also provide significant benefits in terms of data collection and child registration. Governments, funding organisations, and implementing partners should therefore be aware of the costs of alternative point-of-care electronic health record systems in comparison to MyChild Solution. Running costs of point-of-care EHR are detailed by Borkum et al. (2015) in their post-intervention study of an electronic healthcare system in Bihar, India. The study indicates that running costs of point-of-care EHR are $4.79 per child. Thus, for 1,300,000 newborns yearly, annual running costs of point-of-care EHR in Afghanistan would be $6,227,000. This EHR system, although it provides benefits comparable to MCS, is a dramatically more expensive option.

Table 3. Cost comparison of HMIS forms, MCS and EHR for 1,300,000 newborns

Replacement of laptops

34 300 10 200 Based on costs of operations in Uganda, Gambia and Afghanistan.

Amortisation costs to replace computers every five years is applied.

HMIS forms that will remain after implementation of MyChild Solution

Stock and delivery record

150 7 200 1 080 000 15 746 Estimated based on already obtained costs of similar forms

Quantity required during one year per health facility is four. There are 1800 health facilities.

Temperature monitor sheet

365 1 800 657 000 9 579 Estimated based on already obtained costs of similar forms

Quantity required during one year per health facility is 365. There are 1800 health facilities.

Total annual running costs of MyChild Solution

USD 383 113

Item Current HMIS forms (printing costs only)

MyChild Solution Point-of-care Electronic Health Records

Yearly running costs $ 219 970 $ 383 112 $ 6 227 000

Costs per child $ 0.17 $ 0.29 $ 4.79

Total running costs over period of 15 years $ 3 299 571 $ 5 746 688 $ 93 405 000

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Graph 1. Cost comparison of HMIS forms, MyChild Solution and point-of-care EHR

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Return on investment with MyChild Solution

This analysis is done to quantify reductions in administration time for frontline health workers in the Expanded Programme  on Immunisation (EPI) in Afghanistan (Table 4). Figures for vaccinators' salaries have been taken from the Swedish Committee for Afghanistan, who are the employers of the health workers in several provinces (2015). Table 4 displays a potential 15-year trajectory from the introduction of MyChild Solution. Results from a pilot study in Afghanistan (Anderson et al 2017) indicate a reduction in administration time of 00:09:42 (or 73%) per child fully immunised when using MyChild Solution instead of the current HMIS system. 

During the national implementation of MyChild Solution in Afghanistan, the target is to reach all children under the age of two during the first year, and all newborns starting from the second year onwards, which total approximately 2,772,483 and 1,053,000 respectively (Unicef 2013). For estimating the population under the age of 2, we use 8% of the total population (in line with SCA guidelines).

This quantification also takes into account a time span of fifteen years and the total value brought to frontline health workers in terms of time and money saved from reduced administration. This should be seen as a measure of efficiency - it means that more children can be served in the same amount of time. A population growth rate of 2.8% (from World Bank 2017) is included in this calculation, which is shown in the rising number of children reached within MCS with each new year. The increasing numbers of newborns also affect time and cost savings for each consecutive year. 

Based on this analysis, in 15 years, the total savings in administration time for frontline health workers in EPI would be approximately 3,317,836 hours, an equivalent of $2,462,656 in cost savings for the Afghanistan health sector. Per year, this breaks down to an average of $164,177  in savings. This significant increase in efficiency means that these resources could be utilised to serve more children, provide more personalised care, or attend to health education.

$ 6 227 000

$ 383 113$ 219 971

HMIS forms MyChild Solution Point of care EHR

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Table 4: Time and cost savings with MyChild Solution over fifteen years due to reductions in administration

*Numbers for the first year are higher because they include initial deployment of services for all children under the age of 2 years old

4. Conclusions Within this comparison of HMIS forms, MyChild Solution, and an alternative point-of-care EHR system, this assessment reveals that it costs approximately $219,971 to print HMIS forms for nationwide use in Afghanistan. Comparatively, the yearly running costs of MyChild Solution are $383,113. At a cost of $6,227,000 per year, the running costs of point-of-care electronic systems are approximately sixteen  times more expensive compared with MyChild Solution and twenty-eight times more expensive when compared with existing HMIS forms. 

There are significant gains in terms of reduced administration and other unquantifiable values which are brought by implementation of MyChild Solution in Afghanistan (summarised in Table 4). Taken together, these findings are evidence that some savings could be achieved (especially over a 15-year period and beyond) by switching from HMIS forms to MyChild Solution in Afghanistan. Given the significantly higher cost carried by EHR solutions, they appear to provide a less cost-effective option for Afghanistan than MyChild Solution. Based on existing HMIS printing budgets and cost-savings related to MCS, results indicate that the government of Afghanistan can sustain MyChild Solution. However, we contend that the real value of MCS comes in the form of the additional benefits it could bring to Afghanistan's healthcare system. These include the ability for health workers to register every child, to easily track a child's vaccination schedule, and to get reliable, consistent data based on individual records. For parents, SMS reminders and personalised child IDs can also make appointments easier to track. Moreover, there are likely to be more 'hidden' savings for the healthcare sector that stem from more robust preventive care and better vaccination compliance. Any direct changes in cost related to MCS implementation, by contrast, are minor.

From a different perspective, we can say that MyChild Solution provides the administrative/data accuracy benefits of EHR and other 'e-health' solutions, but at a dramatically lower cost. Results from the pilot study in Mehterlam (Anderson et al 2017) indicate that MCS has been positively received by staff and parents, and has already delivered significant improvements in child health data quality. We estimate that expanding this system throughout Afghanistan will be affordable and effective as a national child health system.

Indicator Year 1 Year 5 Year 10 Year 15 Total for 15 years

Number of children reached

2 772 483* 1 143 952 1 313 278 1 507 725 22 713 667

Time saved for one Vaccinator (hours)

448 218* 184 941 212 323 243 761 3 317 836 hours

Costs saved for one Vaccinator (USD)

332 698* 137 274 157 593 180 927 $ 2 462 656

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5. References 1. Anderson, T.,  Eshonkhojaeva, S., Dr. Safi, H., Dr. Hamidi, S., Mikaelsson, M. 2017. Improving Child

Healthcare in Low-Resce Settings: A Pilot Study of MyChild Solution in Afghanistan. Shifo Foundation.

2. Borkum, E., Sivasankaran, A., Sridharan, S., Rotz, D., Sethi, S., Manoranjini, M., Ramakrishnan, L., Rangarajan, A. 2015.  Evaluation of the Information and Communication Technology (ICT) Continuum of Care Services (CCS) Intervention in Bihar.  Mathematica Policy Research.  Available at: <https://www.mathematica-mpr.com/-publications-and-findings/publications/evaluation-of-the-information-and-communication-technology-ict-continuum-of-care-services-ccs>.

3. Mikaelsson, M., Rahimi, N., Ogwok, K., Anderson, T., Ojok, S., Aboce, S., Ewanu, E., Ebiru, J., Kkonde, A.. 2016. 'Too many books to write' - An evaluation of administration for health workers before and after MyChild Card in Uganda. Shifo Foundation. Available at: <https://shifo.org/doc/toomanybookstowrite.pdf/>.

4. OCHA. 2015. Afghanistan: Population estimate. Available at: <http://www.refworld.org/pdfid/55eedf694.pdf>.

5. Shifo Foundation. 2016a. Child Vaccination Follow-up List (Example). Available at: <https://shifo.org/doc/FollowupListforCHW.pdf/>.

6. Shifo Foundation. 2016b. MyChild Card Evaluation Report. Available at: <https://shifo.org/doc/MyChildCardEvaluationReport.pdf/>.

7. Shifo Foundation. 2017a. Every Child Counts: Sample report. Available at: <https://shifo.org/doc/EveryChildCountsReport.pdf/>.

8. Shifo Foundation. 2017b. Leaving no child behind – closing equity gaps and strengthening outreach performance with MyChild Outreach. Available at: <https://shifo.org/doc/MyChildOutreach.pdf/>.

9. Shifo Foundation. 2017c. Values to Key Actors from MyChild Card. Available at: <https://shifo.org/doc/MyChildCardValues.pdf/>.

10. Unicef. 2013. Afghanistan: Statistics. Available at: <https://www.unicef.org/infobycountry/afghanistan_statistics.html#118>.

11. World Bank. 2017. Data: Afghanistan. Available at: <http://data.worldbank.org/country/afghanistan>

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