Presentation on theme: "Evidence-based planning budgeting and monitoring Bottleneck Analysis"— Presentation transcript:
1 Evidence-based planning budgeting and monitoring Bottleneck Analysis OverviewDr. Ruth KitetuPolicy and PlanningMinistry of HealthAugust 2014
2 IntroductionIn 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).
3 The Opportunities and challenges of devolution in Kenyan health care system taking resources closer to the people,promoting accountability,improving equity and efficiencyimprove management systems,provide closer supervision to staff,generate information for better evidence based planning, County-specific prioritization of health interventions and allocative efficiencyallow closer interactions between community members, local leaders and county governments.Challengesembracing 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
4 Policy DirectionPOLICY ORIENTATIONS& PrinciplesPOLICY OBJECTIVES& strategiesPOLICY GOALEquityHealth FinancingEfficiencyQuality and safe servicesEliminate Communicable ConditionsPhysical and financial accessAttaining the highest possible standard of health in a Responsive MannerHealth LeadershipHalt, & reverse rising burden of NCD’sMulti sectoralPeople centredHealth Products & TechnologiesReduce the burden of violence & injuriesHealth InformationProvide essential medical servicesHealth WorkforceSocial accountabilityParticipationMinimize exposure to health risk factorsService Delivery SystemsStrengthen collaboration with health related sectorsHealth Infrastructure
5 KHSSP strategic direction GOALAttaining Equitable, affordable, accessible and quality health care for all KenyansIMPACT TARGETSReduce, by at least half, the infant, neonatal and maternal deathsReduce, by at least 25%, the time spent by persons in ill healthImprove, by at least 50%, the levels of client satisfaction with servicesReduce by 30%, the catastrophic health expenditures
6 Key service delivery targets Reduce Maternal Mortality Rate (MMR) from 488/100,000 to 150/100,00Reduce under five mortality rate from 74/1,000 to 35/1,000Reduce infant mortality rate (IMR)from 52/1,000 to 30/1,000Reduce 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%
7 Health Sector planning framework CONSTITUTION, LEGAL& REGULATORY FRAMEWORKGLOBAL HEALTH DEVELOPMENT AGENDAGlobal health commitmentsVISION 2030Country Development vision and commitmentsKENYA HEALTH POLICY ( )Long Term policy directionsKENYA HEALTH SECTOR STRATEGIC PLAN (5 YEARS)Medium Term Objectives, Investments, and ProgramsMinisterial(National) strategic planCounty strategic plansSAGA/programs strategic planINVESTMENT PLANS (5 YEARS)Counties, and National ReferralsANNUAL / MID TERM SECTOR BUDGETANNUAL SECTOR TARGETSNational Annual work plan PlanCounty annual work PlanFacility Annual work PlanProgram / SAGA Annual work plan Plan
8 Purpose of the EBPBMOverview 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;”
9 EBPB Overview 1. Advocacy for evidence-based planning and monitoring 2. Data collection3. Health system assessment4. Identification of systems strengthening priority strategies5. Estimation of resources required and new coverage targets6. Implementation: Work plans and monitoring frameworks
10 Expected resultsThe expected outcomes of evidence-based planning and monitoring processes are:The production of health plans that are efficient in their pursuit of strengthening service delivery through a “continuum of care” approach;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;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 analysisA 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.
12 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.
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!
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.
16 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
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.****Health systems analysis tool available (programmed)
18 Concept # 2Each 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
19 Concept # 3In 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 coverageTo 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
20 6 Determinants of coverage In order to deliver high-quality services, you need:Medical supplies/supply chain managementHuman resourcesPhysical, financial and socio-cultural access (to facilities or outreach services)Population awareness/ knowledge/demandHealth information/monitoring & evaluationEfficient leadership and governance
21 The 6 determinants of coverage: detailed definitions There must be quality drugs, equipment, and other key supplies available as per need (“commodities”)There must be enough trained health workers who know how to use the drugs and supplies properly (“human resources”)The health facility must be accessible to community, or the service must be present regularly in the community (“access”)Patients must know the services are available and be interested in using them (“initial utilization”)Patients must use the services repeatedly, when indicated (“continued utilization”)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 servicesEach 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.
24 Major groups of interventions-KEPH Select 1 service representing each category for bottleneck analysisCommunity based servicesFamily preventive / WASH servicesFamily neonatal careInfant and child feedingCommunity illness managementPopulation oriented schedulable servicesPreventive care for adolescents and adults (Family planning)Preventive pregnancy careHIV/AIDS prevention and carePreventive infant and child careIndividually oriented clinical servicesMaternal & neonatal care at primary clinical levelManagement of illnesses at primary clinical levelClinical first referral careClinical second referral care
25 ConclusionA 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).
27 GROUP WORK METHODOLOGY County groupings classified thematicallyNomadic –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 areasWay forwardReference 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 processBottleneck analysis indicators: A data entry template for bottleneck analysis, using 12 tracer interventions. Case study counties using bottle neck analysis to inform planning and budgetingEvery newborn Lancet Series May 2014Communique
28 County presentation template Current total maternal deathsStrategic and annual targetsMajor bottleneck/challengeMost critical opportunityHighest key intervention
29 WAY FORWARDDevelop technical assistance plan on evidence based planning-timelines to be agreedCapacity building on bottleneck analysis including costing of health servicesMentorship program