1. DHPI Approach at a Glance Facilitators’ Workshop on District Health Performance Improvement Lilongwe, 25 th – 27 th March 2015

2. The context

3. Challenges in reaching the MDGs In Malawi, despite the significant achievements of the last two decades, maternal and neonatal mortality are still high Maternal mortality ratio 574 deaths per 100,000 births (MDGs Endline Survey 2014 ) In 2012 neonatal mortality rate 21 deaths per 1,000 live births ( still deemed very high)

4. Childhood Mortality Levels (MDGs Endline Survey 2014 ) Deaths per 1,000 live births for the 5-year period before the survey 1 month1 year5 years

5. Stagnation in coverage of key interventions

6. Trends in coverage vary widely by intervention, national, 2000-2013 Sources: 2000, 2004, 2010 DHS, 2006 MICS, 2013/14 MDGE

7. Coverage levels for some key interventions ANC 4 – 45% ITNs – children 66%, pregnant women 61% Full immunization – 72% Exclusive Breastfeeding – 70% Early Breastfeeding– 75% SBA – 87% (quality!) MDGs Endline Survey 2014

8. Equity has not improved over time Changes in under-5 mortality by wealth quintiles, 1990-2009

9. Persistent inequities In Malawi, although coverage for some interventions is relatively high, there is still a part of the population that is not reached (equity) There are important differences among districts, and the DHPI exercise in the districts so far has highlighted important differences within districts

10. Priorities for action Increase coverage of high impact interventions Focus on reaching the unreached Strengthen Health Districts through: – Capacity building for better planning, implementing and monitoring – Improving health information system for timely use of data for action at decentralized level

11. The DHPI Approach

12. What is DHPI? DHPI is a systematic outcome-based approach to equitable programming and frequent monitoring that strengthens the health system, complementing and building on what exists. DHPI helps to do things in a better way, it does not set new priorities or strategies.

13. Main objectives 1.To increase coverage of RMNCH high impact interventions, particularly for underserved populations. 2.To track progress towards equity of access for the most underserved populations. 3.To strengthen local systems by: increasing the capacity of decentralized management teams monitoring in real-time and local data use for timely course correction engaging communities and stakeholders as key partners in improving the health of children and women.

14. The DHPI approach is… Flexible to fit the local context and address local challenges Integrated into district planning and review cycles of on-going programs Builds local ownership through The MoH (Planning Division and HZOs) owning and leading the process, mainstreaming it into long-term national processes and strategies District Health Authorities developing an annual operational plans and monitoring its implementation Works efficiencies into planning and monitoring: planning period becomes a more manageable process; real-time monitoring helps to quickly identify priorities for next year’s planning

15. DHPI builds on previous experience: equity oriented management approaches Bamako Initiative in 1987 – PHC facility-centered approach – Focused on access to essential drugs – Community participation in PHC management – Included user fees and cost recovery IMCI in 1990 – Has focused on improving skills of HCW in hospitals and PHC facilities – Proven effective in improving quality of care – Weak on systems strengthening and changing family practices RED Strategy in 2002 – EPI-centered and focused on planning, monitoring, supervision, outreach and community involvement Marginal Budgeting for Bottlenecks (MBB) in 2002 – Planning and advocacy tool – No implementation follow up

16. DHPI applies elements of effective and proven methods, such as: quality improvement (QI), performance improvement, Participatory Learning Action Quality Assurance; WHO’s tools for district situation analysis; World Bank’s analysis of organisational performance; the Triple A cycle of assessment, analysis and action; MSH’s Managing Performance Improvement of Decentralized Health Services. DHPI builds on previous experience: quality improvement approaches

17. DHPI approach: scope and applicability Health WASH Nutrition HIV/ AIDS Health System Interventions from different sectors, provided through the HS

18. Key steps in DHPI Bottleneck and Equity Analysis at district level Operational Planning for bottleneck resolution at local level Monitoring of local health system performance through: – strength of implementation – bottleneck reduction – coverage increase

19. DHPI Approach: its steps

20. Steps Preparation Diagnose Intervene Verify Adjust

21. Preparation 1.Ensure that the analysis and planning exercise informs district plans and budgets 2.Ensure leadership of local health authorities and that coordination mechanisms are in place 3.Map stakeholders to be involved at local level

22. Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks

23. Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation

24. Adjust Monitor frequently using existing opportunities Verify Take corrective actions immediately to ensure impact

25. Steps Diagnose Select interventions Define indicators Identify information sources and collect data Identify the bottlenecks Identify areas lagging behind Analyse the root causes of bottlenecks Intervene Prioritize solutions with all stakeholders Define an implementation and monitoring plan Support implementation Verify Monitor frequently using existing opportunities Adjust Take corrective actions to ensure impact