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Evidence-based planning budgeting and monitoring Bottleneck Analysis Dr. Ruth Kitetu Policy and Planning Ministry of Health August 2014 August 2014 Overview.

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Presentation on theme: "Evidence-based planning budgeting and monitoring Bottleneck Analysis Dr. Ruth Kitetu Policy and Planning Ministry of Health August 2014 August 2014 Overview."— Presentation transcript:

1 Evidence-based planning budgeting and monitoring Bottleneck Analysis Dr. Ruth Kitetu Policy and Planning Ministry of Health August 2014 August 2014 Overview

2 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). 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). 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).

3 The Opportunities and challenges of devolution in Kenyan health care system Opportunities Opportunities taking resources closer to the people, taking resources closer to the people, promoting accountability, promoting accountability, improving equity and efficiency improving equity and efficiency improve management systems, improve management systems, provide closer supervision to staff, provide closer supervision to staff, generate information for better evidence based planning, County-specific prioritization of health interventions and allocative efficiency 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. allow closer interactions between community members, local leaders and county governments. Challenges Challenges embracing evidence based planning, budgeting and monitoring to respond creatively to health systems challenges to execute the limited resources responsibly; 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; 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 Accounting for tangible MNH results with allocated resources

4 Policy Direction POLICY ORIENTATIONS & Principles POLICY ORIENTATIONS & Principles POLICY OBJECTIVES & strategies POLICY OBJECTIVES & strategies POLICY GOAL Health Financing Health Leadership Health Products & Technologies Health Information Health Workforce Service Delivery Systems Health Infrastructure Efficiency Multi sectoral Social accountability Equity People centred Participation 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 Physical and financial access Quality and safe services Attaining the highest possible standard of health in a Responsive Manner

5 KHSSP strategic direction GOAL Attaining Equitable, affordable, accessible and quality health care for all Kenyans 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 half, the infant, neonatal and maternal deaths Reduce, by at least 25%, the time spent by persons in ill health 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 Improve, by at least 50%, the levels of client satisfaction with services Reduce by 30%, the catastrophic health expenditures Reduce by 30%, the catastrophic health expenditures

6 Key service delivery targets Reduce Maternal Mortality Rate (MMR) from 488/100,000 to 150/100,00 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 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 infant mortality rate (IMR)from 52/1,000 to 30/1,000 Reduce percentage of HIV/AIDS prevalence from 5.6% to 4% Reduce percentage of HIV/AIDS prevalence from 5.6% to 4% Improve under one immunization coverage from 83% to 90% Improve under one immunization coverage from 83% to 90% Reduce Malaria in-patient case fatality from 15% to 5% Reduce Malaria in-patient case fatality from 15% to 5%

7 Health Sector planning framework CONSTITUTION, LEGAL & REGULATORY FRAMEWORK KENYA HEALTH POLICY ( ) Long Term policy directions KENYA HEALTH POLICY ( ) 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 National Annual work plan Plan County annual work Plan Facility Annual work Plan GLOBAL HEALTH DEVELOPMENT AGENDA Global health commitments GLOBAL HEALTH DEVELOPMENT AGENDA Global health commitments Ministerial(National) strategic plan County strategic plans SAGA/programs strategic plan ANNUAL SECTOR TARGETS Program / SAGA Annual work plan Plan VISION 2030 Country Development vision and commitments VISION 2030 Country Development vision and commitments

8 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; 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;” Collectively, referred to this approach as “evidence-based planning, budgeting and monitoring;”

9 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

10 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.

11 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. 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. 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.

12 What is a bottleneck? Cont.. A single constraint or problem in service delivery that blocks the performance of the entire system. 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. If you can relieve the bottleneck, the system should start working much more efficiently.

13 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!

14 Example Cont… 14

15 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. 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.

16 Expected results of a bottleneck analysis - Methodology Identify where the bottlenecks are, why they exist, and how they affect different populations. Identify where the bottlenecks are, why they exist, and how they affect different populations. Prioritize your bottlenecks (which ones are the most serious). 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. 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 Create a work plan and monitor whether your activities are relieving bottlenecks as planned

17 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. 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) ****Health systems analysis tool available (programmed)

18 Concept # 2 Each health system has a maximum performance level. We call this a “performance frontier/target.” 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. 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 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 The second goal is to shift the “performance frontier/target” of the health system: to improve it, so that it can achieve better results

19 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. 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 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. 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 We call this type of analysis bottleneck analysis

20 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

21 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”)

22 Sample Bottleneck analysis preview and proposed targets

23 A quick “snapshot” view of an entire health system’s performance Health systems deliver hundreds of different services 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. 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. 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.

24 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

25 Conclusion A bottleneck analysis is one effective way of assessing a health system’s performance in order to make prioritized, evidence-based, manageable plans. 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. 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). 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).

26 AHSANTENI SANA AHSANTENI SANA

27 GROUP WORK METHODOLOGY County groupings classified thematically County groupings classified thematically Nomadic –Mandera, Wajir, Marsabit,Isiolo,Turkana Garrissa (Dr. Bashir and Dr.Josephine) Nomadic –Mandera, Wajir, Marsabit,Isiolo,Turkana Garrissa (Dr. Bashir and Dr.Josephine) Urban – Nairobi, Kakamega, Mombasa, Nakuru (Ms. Kidula, Terry Watiri) Urban – Nairobi, Kakamega, Mombasa, Nakuru (Ms. Kidula, Terry Watiri) Agrarian – Homabay, Kisumu, Siaya, Taita Taveta (Dr. Ayah, Dr. Kitetu) Agrarian – Homabay, Kisumu, Siaya, Taita Taveta (Dr. Ayah, Dr. Kitetu) Plenary discussions on thematic areas Plenary discussions on thematic areas Way forward Way forward Reference materials Include : 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 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 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. 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 Case study counties using bottle neck analysis to inform planning and budgeting Every newborn Lancet Series May 2014 Every newborn Lancet Series May 2014 Communique Communique

28 County presentation template Current total maternal deaths Current total maternal deaths Strategic and annual targets Strategic and annual targets Major bottleneck/challenge Major bottleneck/challenge Most critical opportunity Most critical opportunity Highest key intervention Highest key intervention

29 WAY FORWARD Develop technical assistance plan on evidence based planning-timelines to be agreed Develop technical assistance plan on evidence based planning-timelines to be agreed Capacity building on bottleneck analysis including costing of health services Capacity building on bottleneck analysis including costing of health services Mentorship program Mentorship program


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