Guide through the reference case
For whom is the Reference Case intended?

The Reference Case is intended for use by multiple constituencies, including policy makers, program managers and staff, health service managers and analysts who support them, working in national ministries, international donor and multilateral organizations, private foundations, research institutions, and non-governmental organizations. It is intended to provide an overview/reference document of costing methods that can be applied in different documents and tools to support costing, depending on the audience and purpose. It does not replace the need for these tools, such as intervention-specific costing manuals. The one ‘tool’ it does provide is reporting standards.

For those who fund cost estimation, the Reference Case provides a minimum standard that can help funders design Terms of Reference (ToR), including specific reporting requirements.

For those who use cost data, the Reference Case provides guidance that can be used to assess whether a cost estimate is ‘fit for purpose’. These users may be economic analysts, modelers, or financial experts in government and non-government organizations, who wish to use the data collected by others to conduct economic and financial analyses. These readers are also advised to focus on the introductory sections, and on the reporting matrix contained in Appendix 2 that provides quality indicators according to purpose.

For those who produce cost data, all sections of the Reference Case should be of interest, as a background reading into the main principles and methods behind costing studies. This is the primary target group for the Reference Case. However, the Reference Case does not provide a ‘how to’ manual for costing any specific health intervention; instead it provides the principles required for study design and methods development. The sections on methodological specifications provide detailed guidance to achieve best practice in cost estimation. The Reference Case can be used to design detailed tools and guidance for those leading the costing of specific services and interventions, but it does not include data collection or analysis tools. The GHCC website is expected to include selected examples of data collection and analysis tools that are ‘Reference Case compatible’ at, in addition to both downloadable Word and HTML versions of the full Reference Case.

Structure of the Reference Case

In line with the IDSI Reference Case on economic evaluation, the technical content of the Reference Case (both costing and reporting) is presented by defining principles and methodological specifications. Principles provide a set of rules that are sufficiently broad to gain consensus and apply in multiple settings. While the application of principles may vary depending on the purpose of the costing, they should be universally applicable to any cost estimate.

Principles provide the conceptual framework for more specific methodological standards, where they are possible to define as they are supported either by evidence or theory. Principles also provide the basis for standardized cost reporting. Methodological specifications are a set of methods that enable the analyst to adhere to the principles. They may not be exhaustive, in that there may be other means to achieve the same principles. The methodological specifications presented here are a work in progress and will be further refined by the GHCC over the course of the project.

The Reference Case includes a reporting standards checklist, aligned to the principles, to support generalizability of cost estimates across settings and diseases. The final section provides additional specifics around the application of the Reference Case for all tuberculosis (TB) interventions and services.

The process of Reference Case development

The approach to developing the Reference Case was based on previous work developing reporting guidelines15. These outline the following stages of standards development.

Box 1 – Summary of iDSI Reference Case guidance on cost

It is important to identify the need for a guideline and examine whether existing guidelines can be extended. While the purposes of costing go beyond economic evaluation alone, we decided to ‘extend’ the Reference Case developed by iDSI on economic evaluation. We did this for two reasons.

Firstly, costs are used for a range of purposes in addition to economic evaluation. Secondly, the Reference Case for economic evaluation does not provide guidance on cost data collection. While in some settings cost data used in economic evaluation are produced by routine systems, in many countries globally this is not the case, and analysts need to estimate costs using primary data collection. There is a wide range of tools available to do this, but no single comprehensive document that summarizes the ‘state of the art’ in the methods used to inform these costing tools.

The next stage is to review the literature to confirm the gap and to identify current evidence on methods. We conducted a bibliometric review (forthcoming) of methodological literature on global health costing. We then organized a meeting identifying participants through our networks, but also identifying authors from the bibliometric review. We conducted a survey among participants on the need for a Reference Case and current methodological gaps prior to the meeting.

The GHCC core team wrote the first draft of this Reference Case as an explanatory document. It was then circulated to a list of technical advisors and stakeholders for review. In November 2016, a meeting was held to discuss the Reference Case and receive feedback. During the meeting, a review of the current quality of cost estimates and a systematic review of the literature on costing methodology were presented. In the latter case, the review included both academic papers and current costing guidance for global health. The meeting did not use a formal method to reach consensus, but all participants were asked to comment on the principles and suggest amendments. All suggestions were considered. Small groups met to discuss methodological specifications. In this case, some of the suggestions were incorporated, but where there was no agreement on methods specified, further working groups were established and the guidance has been left open. The Reference Case was then sent for review to all meeting participants. A list of all who contributed is contained in Appendix 4, including those who provided detailed comments on earlier drafts of this document.

A publication and communication strategy will be developed to accompany the Reference Case. Both producers and users of cost data will also pilot the recommended guidance described in the Reference Case during 2017. The Reference Case will be made available on the GHCC website and updated as methods are further refined and developed.

Finally, it should be noted that several updates for the Reference Case have been identified and will be further developed later in 2017/2018. These topics were identified during the November 2016 meeting by participants. These are:

  • a) Sampling for cost estimation (principle 8)
  • b) Methods guidance on ‘within country’ cost functions (principle 15)
  • c) Methods guidance on how to identify the most important resource use to measure (principle 6)

The scope of the Reference Case

The Reference Case on global health costing provides guidance on estimating costs using primary data collection. Routine program monitoring systems, such as hospital cost accounting systems that estimate expenditures on specific procedures or diagnoses, can often provide useful information for costing analyses. As will be highlighted later in this document, such expenditure information may not be adequate for costing analyses. Where routine systems are used to estimate unit costs, the Reference Case can help assess the quality of the estimates produced, as the quality of routine systems can vary considerably16. The Reference Case can thus help determine whether additional data collection is required.

Currently, this Reference Case focuses on the costs of providing services. These can include items paid for by clients/patients. However, we do not include methods to estimate access costs (which can include direct expenses such as transportation, and opportunity costs from time spent accessing and receiving services), nor do we address the measurement of productivity losses from the symptoms of illness and/or death.

This Reference Case does not provide standards and methods for conducting secondary analyses, such as programmatic budgeting by individual organizations, investment cases required by certain funding organizations, or estimating global price tags for a specific health technology or package of interventions. The results of costing analyses are, however, often useful inputs for these other types of analyses.