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