evidence-based planning budgeting and monitoring bottleneck analysis dr. ruth kitetu policy and...
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Evidence-based planning budgeting
and monitoringBottleneck Analysis
Dr. Ruth KitetuPolicy and Planning
Ministry of Health August 2014
Overview
Introduction
In devolved system of governance, counties are set to engage in routine health planning and evaluation cycles to contribute to the County policies, Health Strategic Plans, County Integrated Development Plans and AWPs (CGA 2012).
If evidence is not used to guide the development of the policies and plans, implementation is likely not to achieve expected MNH results, particularly among vulnerable populations (women and new-borns).
The Opportunities and challenges of devolution in Kenyan health care system
Opportunities taking resources closer to the people, promoting accountability, improving equity and efficiency improve management systems, provide closer supervision to staff, generate information for better evidence based planning, County-
specific prioritization of health interventions and allocative efficiency
allow closer interactions between community members, local leaders and county governments.
Challenges embracing evidence based planning, budgeting and monitoring to
respond creatively to health systems challenges to execute the limited resources responsibly;
Regular assessment of health systems i in identifying key bottlenecks and prioritizing interventions to strengthen the systems and contribute to achievement of key MNH results/targets;
Accounting for tangible MNH results with allocated resources
Policy DirectionPOLICY ORIENTATIONS
& Principles POLICY OBJECTIVES
& strategiesPOLICY GOAL
Health Financing
Health Leadership
Health Products & Technologies
Health Information
Health Workforce
Service Delivery Systems
Health Infrastructure
Effi
ciencyM
ulti se
ctora
lSocia
l acco
unta
bility
Equit
yPeople
centr
ed
Part
icip
ati
on
Eliminate Communicable
Conditions
Halt, & reverse rising burden of NCD’s
Reduce the burden of violence & injuries
Provide essential medical services
Minimize exposure to health risk factors
Strengthen collaboration with
health related sectors
Physica
l and fi
nancia
l acce
ss
Qualit
y a
nd s
afe
serv
ices Attaining
the highest possible
standard of health in a Responsive
Manner
KHSSP strategic direction
GOAL
Attaining Equitable, affordable, accessible and quality health care for all Kenyans
IMPACT TARGETS
Reduce, by at least half, the infant, neonatal and maternal deaths
Reduce, by at least 25%, the time spent by persons in ill health
Improve, by at least 50%, the levels of client satisfaction with services
Reduce by 30%, the catastrophic health expenditures
Key service delivery targets
Reduce Maternal Mortality Rate (MMR) from 488/100,000 to 150/100,00
Reduce under five mortality rate from 74/1,000 to 35/1,000
Reduce infant mortality rate (IMR)from 52/1,000 to 30/1,000
Reduce percentage of HIV/AIDS prevalence from 5.6% to 4%
Improve under one immunization coverage from 83% to 90%
Reduce Malaria in-patient case fatality from 15% to 5%
Health Sector planning framework
CONSTITUTION, LEGAL & REGULATORY FRAMEWORK
KENYA HEALTH POLICY (2014 - 2030)Long Term policy directions
KENYA HEALTH POLICY (2014 - 2030)Long Term policy directions
KENYA HEALTH SECTOR STRATEGIC PLAN (5 YEARS)Medium Term Objectives, Investments, and Programs
KENYA HEALTH SECTOR STRATEGIC PLAN (5 YEARS)Medium Term Objectives, Investments, and Programs
INVESTMENT PLANS (5 YEARS)Counties, and National Referrals
INVESTMENT PLANS (5 YEARS)Counties, and National Referrals
ANNUAL / MID TERM SECTOR BUDGET
ANNUAL / MID TERM SECTOR BUDGET
National Annual
work plan Plan
National Annual
work plan Plan
County annual work Plan
County annual work Plan
Facility Annual work Plan
Facility Annual work Plan
GLOBAL HEALTH DEVELOPMENT AGENDAGlobal health commitments
GLOBAL HEALTH DEVELOPMENT AGENDAGlobal health commitments
Ministerial(National) strategic plan
Ministerial(National) strategic plan County strategic plansCounty strategic plans SAGA/programs strategic
planSAGA/programs strategic
plan
ANNUAL SECTOR TARGETS
ANNUAL SECTOR TARGETS
Program / SAGA Annual work plan
Plan
Program / SAGA Annual work plan
Plan
VISION 2030Country Development vision and commitments
VISION 2030Country Development vision and commitments
Purpose of the EBPBM
Overview of EBPBM presents a six-step process to support more equitable, evidence-based health service delivery , particularly in an adaptive programming-context counties profiles;
Collectively, referred to this approach as “evidence-based planning, budgeting and monitoring;”
EBPB Overview
2. Data collection
3. Health system
assessment
4. Identification of systems
strengthening priority strategies
5. Estimation of resources required and new coverage
targets
6. Implementation: Work plans and
monitoring frameworks
1. Advocacy for evidence-based planning and monitoring
Expected results
The expected outcomes of evidence-based planning and monitoring processes are:
1. The production of health plans that are efficient in their pursuit of strengthening service delivery through a “continuum of care” approach;
2. Improved capacity of health managers at all levels of a system to quickly pinpoint the most critical healthcare delivery challenges and respond to them with evidence- based strategies and clear lines of accountability;
3. Improvement of health systems to respond to the needs of all citizens, but particularly the most vulnerable women and children, and produce more results towards the health- related MDG 4 and 5.
Bottleneck analysis
A bottleneck analysis is a structured way of determining whether the essential components of health service delivery are present, quantifying constraints, and assessing and prioritizing the underlying causes of these constraints.
It makes use of routinely collected data (in most cases) and, once the data are on hand, can be conducted by any type of health personnel, with minimal orientation, in the course of less than a week.
What is a bottleneck? Cont..
A single constraint or problem in service delivery that blocks the performance of the entire system.
If you can relieve the bottleneck, the system should start working much more efficiently.
For example…
A well-meaning NGO donated $200,000 of brand-new supplies for emergency maternal and newborn services in an ASAL sub-county.
Four years later, these supplies were collecting dust in the sub-county store.
Why? This sub-county still has only 2 midwives, who were last trained in 2002!
Example Cont…
14
Guiding principle of bottleneck analysis
In order to deliver a given health service effectively (i.e. meeting health quality standards), the service must be consistently available and the target population must be willing and able to access it.
Expected results of a bottleneck analysis - Methodology
Identify where the bottlenecks are, why they exist, and how they affect different populations.
Prioritize your bottlenecks (which ones are the most serious).
Propose strategies and realistic new coverage targets, along with the budget items associated with each strategy.
Create a work plan and monitor whether your activities are relieving bottlenecks as planned
Bottleneck analysis concept # 1
Progress generally occurs at different rates for different populations, and for different services in a county. In order to develop efficient health plans, you must “unpack” your county averages.
****Health systems analysis tool available (programmed)
Concept # 2
Each health system has a maximum performance level. We call this a “performance frontier/target.”• Different populations may or may not enjoy the
maximum performance of the system.• The first goal should be to ensure that all
populations enjoy the same health system performance (i.e the same range and quality of services).
• The second goal is to shift the “performance frontier/target” of the health system: to improve it, so that it can achieve better results
Concept # 3
In order to deliver any given service effectively, services must be available, the population must be interested in and able to use them, and they must be delivered with a certain level of quality.
We have broken these three areas into 6 simple variables… we call these the 6 determinants of coverage
To understand why a service isn’t achieving its targets, you must look methodically at each of these 6 determinants of coverage.
We call this type of analysis bottleneck analysis
6 Determinants of coverage
In order to deliver high-quality services, you need:
1. Medical supplies/supply chain management
2. Human resources
3. Physical, financial and socio-cultural access (to facilities or outreach services)
4. Population awareness/ knowledge/demand
5. Health information/monitoring & evaluation
6. Efficient leadership and governance
The 6 determinants of coverage: detailed definitions
1. There must be quality drugs, equipment, and other key supplies available as per need (“commodities”)
2. There must be enough trained health workers who know how to use the drugs and supplies properly (“human resources”)
3. The health facility must be accessible to community, or the service must be present regularly in the community (“access”)
4. Patients must know the services are available and be interested in using them (“initial utilization”)
5. Patients must use the services repeatedly, when indicated (“continued utilization”)
6. The services must be delivered properly and completely, meeting quality standards (“effective quality coverage”)
Sample Bottleneck analysis preview and proposed targets
21% 30%
60%
32%17%
5%
47%7%
24%
5%
7%9%
0%
20%
40%
60%
80%
100%
Proportion ofclinical primary
health centre withno stock-outs of
delivery kits
Availability of nursesand midwives
compared to need(national norm)
Proportion ofwomen not
reporting distance asa problem for access
to health care
Proportion of birthsassisted by a skilled
provider
Proportion of livebirths delivered by a
SBA in a healthfacility
Proportion of livebirths delivered by a
SBA in a healthfacility and receivinga post natal check-up within 24 hrs.
Skilled delivery
Base Line Frontier
A quick “snapshot” view of an entire health system’s
performance
Health systems deliver hundreds of different services
Each service could be analyzed with a bottleneck analysis, but that would be very time consuming and quite repetitive.
As a time-saver, you can select a few services delivered through different parts or levels of the health system and extrapolate the results to similar services.
Major groups of interventions-KEPH
Community based services
Family preventive / WASH services
Family neonatal care
Infant and child feeding
Community illness management
Population oriented schedulable services
Preventive care for adolescents and adults (Family planning)
Preventive pregnancy care
HIV/AIDS prevention and care
Preventive infant and child care
Individually oriented clinical services
Maternal & neonatal care at primary clinical level
Management of illnesses at primary clinical level
Clinical first referral care
Clinical second referral care
Select 1 service representing
each category for bottleneck
analysis
Conclusion
A bottleneck analysis is one effective way of assessing a health system’s performance in order to make prioritized, evidence-based, manageable plans.
Almost any type of health worker, at any level of the health system, can conduct a bottleneck analysis, using data that are generally already available.
Bottleneck analyses can either be conducted prospectively (to prepare a new plan) or retrospectively (to assess the appropriateness of an existing plan, or to investigate why a plan did not produce the expected results).
AHSANTENI SANA
GROUP WORK METHODOLOGY
County groupings classified thematically
Nomadic –Mandera, Wajir, Marsabit,Isiolo,Turkana Garrissa (Dr. Bashir and Dr.Josephine)
Urban – Nairobi, Kakamega, Mombasa, Nakuru (Ms. Kidula, Terry Watiri)
Agrarian – Homabay, Kisumu, Siaya, Taita Taveta (Dr. Ayah, Dr. Kitetu)
Plenary discussions on thematic areas
Way forward
Reference materials Include :
A list of high impact, evidence-based interventions for maternal, newborn and child health that may or may not be provided through the health system. Use this sheet to help "inventory" health services. 2)
A data collection sheet for the organization of the health system: key information needed on how the system is organized, which will be used for both the bottleneck analysis and strategy identification process
Bottleneck analysis indicators: A data entry template for bottleneck analysis, using 12 tracer interventions.
Case study counties using bottle neck analysis to inform planning and budgeting
Every newborn Lancet Series May 2014
Communique
County presentation template
Current total maternal deaths
Strategic and annual targets
Major bottleneck/challenge
Most critical opportunity
Highest key intervention
WAY FORWARD
Develop technical assistance plan on evidence based planning-timelines to be agreed
Capacity building on bottleneck analysis including costing of health services
Mentorship program