In Romania, the legislation allows public entities to contract social services provided by NGOs. Nevertheless, some conditions have to be met: the NGO has to be accredited by the Ministry of Labour and Social Protection as a social service provider, the service has to be licensed by the same ministry and the minimum standard cost for the said service has to be approved by a government decision.
NGOs hold back from accessing (and therefore receiving) a license for their social services for numerous reasons. From our experience, most reasons have less to do with the legislation and more with the practices, values and resources of the non-governmental providers. Nevertheless, there is one significant barrier that makes it impossible for a public institution to procure an existing social service from a private provider, be it non-profit or for-profit: if there is no minimum cost standard calculated for the service and included in the government decision regulating standard costs of social services. And this barrier is relevant for most specialized social services targeting groups vulnerable to HIV.
To address this barrier and to provide support for organizations involved into delivering services for key population (DIU, MSM, PLHIV, sex workers), Romanian Angel Appeal implemented under the project #SOS an activity aiming to calculate the minimum standard cost for various HIV prevention and support services. We started the process in July 2019, within #SOS Project, with a workshop during which an APH trainer instructed staff from RAA and other local NGOs on how to use the cost calculation tool. To fill-out and use the tool, RAA collected a lot of information describing in detail an agreed list of HIV prevention services: what types of interventions are provided, how often, for how many clients, what is the cost of every service component etc.
Acording to Fidelie Kalambayi, RAA expert, this was a process that initially was considered to be rather straightforward, proved a bit more challenging and taught us some very useful lessons that we hope could serve others.
The urgent need to have consensus between the team determining the minimum cost standard for a service and the service providers. The minimum cost standard is actually a policy instrument that makes it possible for public institutions to organize the procurement of social services. Since the standard will eventually end up in a government decision in order to be approved, there is significant pressure for it to reflect as well as possible all the expenses that an organization might incur when organizing and delivering a social service. Using the calculation tool proposed by Alliance for Public Health, RAA involved in the process non-governmental organizations and also consulted with the Ministry of Labour and a public provider of similar services (District 5’s Social Care Department).
Relying only on historical costs communicated by service providers is not always enough for the standard cost estimation. Most NGOs are very client-oriented – which is, of course, commendable and in line with their mission. However, this also means that, more often than not, they make every necessary effort to provide the help their clients need: they use voluntary work, invest in their services donations in money or products, they negotiate preferential prices for non-profits with service providers. This realization made us look closer at the historical costs we collected, to see whether they are in line with current market prices and they also reflect the equivalent of the donations.
The minimum cost calculation should properly reflect a variety of constituting costs, at their market level and in line with local regulations. For one, we had to align the staff salaries with an existing reference scale, and we used the one that regulates salaries of the personnel in the public sector. We realized that, for example, as of 2017, a nurse or a social worker in the public sector received a salary at least 15-20% higher than a similar specialists from the NGOs we included in the costing exercise. It is very important that the costs for the salaries to be aligned with the costs from public sector so that to enhance the process of recruiting the personnel. What NGOs are currently facing is the problem of shortage in the number of the people involved in the outreach programs, for example, as a consequence of the salaries that are much lower than in the public sector.
Then, we decided to also apply national regulations that set the minimum or maximum workloads for staff working in social services. In practice, these regulations are mainly observed by services in the public sector and they set limits such as: a social worker should work intensively with no more than 20 clients per month, a GP’s consultation lasts on average 15 minutes, a psychologist should not have more than 6 counselling sessions per day etc.
Finally, we had to identify which interventions can be performed by which type of staff, according to the national legislation. This was particularly important, since in practice, because they have limited staff, NGOs are more inclined to use their employees interchangeably for various tasks. For example, in an NGO a psychologist might perform counselling, outreach and, if needed, will accompany the client to other services; the outreach staff performs many office tasks related to the logistics of the outreach activity (e.g. administering the stocks of health consumables); the social workers are often responsible with the monitoring and reporting activities.
Implementing all the above resulted in a higher cost with human resources for each of the services designed. Nevertheless, we believe that it was necessary to rightly reflect the level of salaries in the market, given the reported shortage of social and medical staff in the country.
The APH cost calculation tool should include a range of very important costs that are usually ignored by many non-profit providers. One is the cost with the amortization of assets. Our experience showed that NGOs do not usually anticipate that that their mobile units, their furniture, the office or medical equipment and supplies they use will need replacing at one point. That is why they omit including amortization cost in their estimations.