MDG Needs Assessment Training Workshop May 9-12, 2005 Health Module

MDG Needs AssessmentTraining Workshop

May 9-12, 2005

Health Module

2 www.unmillenniumproject.org

To present the Millennium Project approach to conducting a health needs assessment

Purpose


1. Choosing interventions2. Defining and setting targets3. Estimating resource needs4. Checking results

MDG Needs Assessment Approach


Interventions should be seen not as isolated programs but as an integrated set of health services provided through a strengthened system of health care delivery.

1. Choosing Interventions



Infectious Diseases

Child Health, Maternal Health, and Reproductive Health

• IMCI package• Immunization• Neonatal package• Antenatal care• Skilled attendance and clean delivery • Emergency obstetric care (EmOC)• Contraception and family planning services• Safe abortions and care of complications of abortion

• Antiretroviral therapy • UNAIDS HIV prevention and care package• Artemisinin combination treatment for malaria (as appropriate)• Insecticide treated nets and IRS as appropriate (other vector control as appropriate)• DOTS and DOTS Plus (as required)



• New infrastructure and O&M of existing infrastructure at district level• Adequate health personnel salaries• Pre- and in-service training• Community demand interventions• Management systems and monitoring & evaluation• Research and development

Health System

•Interventions to ensure availability, e.g.:

•Incentives to direct research and development

•Establishment of national essential medicines lists, including preventive, curative, and reproductive health commodities, equipment, and supplies

•Ensuring reliable procurement and distribution systems

•Interventions to ensure affordability, e.g.:

•Equity pricing

•Reduction of tariffs and duties

•Reduction of mark-ups

•Interventions to ensure appropriate use, e.g.:

•Programs to improve the way drugs are prescribed, dispensed, and used

•Public media campaigns and education of providers

Access to Essential Medicines


Category Intervention Package Description

Child health Neonatal integrated package

Clean delivery, newborn resuscitation, prevention of hypothermia, kangaroo care (skin-to-skin contact to promote parent/infant bonding especially for premature babies), antibiotics for infection, tetanus toxoid, breastfeeding education, hygiene education

Immunization Vaccines for polio, diptheria, pertussis, tetanus, measles, hepatitis B, Hib and yellow feverIntegrated Management of Childhood Ilnness (IMCI)

Integrated approach to child health that focuses on the well-being of the whole child. IMCI aims to reduce death, illness and disability, and to promote improved growth and development among children under 5 years of age. IMCI includes both preventive and

Maternal health Antenatal care Visits with skilled personnel during pregnancy to check that all is well with mother and baby. It includes being offered a range of tests and should be implemented in accordance with the new WHO antenatal care model

Skilled attendance and clean delivery

Presence of trained and registered midwives, nurses, nurse/midwives or doctors at birth

Emergency Obstetric Coverage (EmOc)

Treatment for ecclampsia, haemorrhage, obstructed labor and sepsis.

Reproductive health Contraception and family planning services

Universal access to family planning counselling and all forms of contraception.

Safe abortions Provision of safe abortions and counseling as well as post-abortion care.

1. Choosing Interventions:More Detail on MCH and SRH


Category Intervention Package Description

HIV/AIDS Prevention:Behavior change programs

Programs to encourage safer sexual behavor including condom social marketing, peer-based education, mass media campaigns and school based AIDS education.

STD Control Routine screening and effective treatment of sexually transmitted diseases (e.g., syphilis, gonorrhea, vaginitis)

Voluntary Counseling and Testing (VCT)

VCT includes both pre and post test counseling and is available to people testing positive or negative

Harm reduction for injecting drug users

Actions to prevent transmission of HIV and other infections that occurs through sharing of non-sterile injection equipment and drug preparations. Specific programs include provision of sterile syringes and needles and drug substitution treatment.

Prevention of Mother to Child Transmission

Prevention of transmission of the HIV virus from infected women to their infants during pregnancy, labour and delivery, as well as during breastfeeding. Includes short-term antiretroviral prophylactic treatment, infant feeding counselling and support, and

Blood safety interventions (e.g., HIV antibody screening, exlcuding high risk donors)

Measures to reduce the risk of receiving infected blood through a transfusion. Includes HIV antibody screening, avoiding unnecessary blood transfusions and excluding high risk donors.

Care and Treatment:Antiretroviral therapy Combination of protease inhibitors taken with reverse transcriptase inhibitors used in treating

AIDS and HIV.Treatment of opportunistic infections

Treatment of any infection caused by a microorganism that would not normally cause disease in individual but occurs in persons with abnormally functioning immune systems (as in AIDS patients)

Orphan support Provision of support to orphans to minimize the impact of AIDS on their lives. Includes school fee support, provision of orphanages and community support.

1. Choosing Interventions:More Detail on HIV/AIDS


Category Intervention Package DescriptionTB BCG vaccine Bacillus of Calmette and Guérin vaccine for TB in high prevalence settings.

Directly Observed Treatment Short Course (DOTS)

Internationally-recommended TB control strategy combining five elements: political commitment, microscopy services, drug supplies, surveillance and monitoring systems, and use of highly efficacious regimes with direct observation of treatment.

Malaria Insecticide treated nets Mosquito nets that are treated with insecticide, which can provide a physical and chemical barrier to mosquitos. The chemical halo that extends beyond the mosquito net itself also shortens the mosquito's life span.

Artemisinin combination therapy

Combination of drugs used to treat multi-drug resistant falciparum malaria, which is now widespread in Africa.

Access to Essential Medicines

Interventions to ensure availability, affordabilty, and appropriate use

Provision of procurement and distribution facilities, adequate transportation, monitoring systems to assure drug quality; elimination of user fees for essential medicines; programs to improve the way drugs are prescribed, dispensed, and used, including development and implementation of national essential medicines lists and clinical treatment guidelines, public media campaigns and education of providers.

Health Systems Interventions to strengthen health system

Includes, human resources, improving management capacity, enhancing monitoring and evaluation, increasing capacity for R&D, enhancing community demand, and improving infrastructure

1. Choosing Interventions:More Detail on TB, Malaria





• Some health MDGs have quantified targets, e.g.:– Child Mortality: Reduce by two-thirds, between 1990 and 2015,

the under-five mortality rate – Maternal Health: Reduce by three-quarters, between 1990 and

2015, the maternal mortality ratio

• Others allow for interpretation of targets, e.g.:– HIV/AIDS: Have halted and begun to reverse the spread of

HIV/AIDS– Malaria and other major diseases: Have halted and begun to

reverse the incidence of malaria and other major diseases

2. Defining and Setting Targets: Outcome Targets

Each country will need to adopt specific numeric outcome targets to guide its MDG health strategy.


Health MDGs offer no specific guidance on coverage levels for health services. Overall aim should be to achieve universal coverage of essential health services (or “essential health package”)

2. Defining and Setting Targets:Coverage Targets





3. Estimating Resource Needs

To assist countries in undertaking a Needs Assessment, the Millennium Project suggests the following four-point approach:

A.Direct intervention costs

B.Human resources

C.Infrastructure

D.Health systems strengthening


3. Estimating Resource Needs:A. Direct Intervention Costs

•Recurrent costs for the essential health interventions in the areas of maternal health, child health, HIV/AIDS, TB, and malaria include:

Drugs

Supplies

Hospital beds

Diagnostic tests

•Costs for each area of health are calculated as follows:

Total cost = Unit cost X Population in need

Note, that drug costs will not usually need to be inputted as international drug prices for essential drugs are coded into the models.


NO. OF CASES

COST PER CASE

Country epidemiological data

Country demographic data

Target coverage rates

Intervention components and quantities

Unit costs of components• Drugs• Hospital bed and food• Laboratory costs• Other supplies

TOTAL COSTS

3. Estimating Resource Needs:A. Direct Intervention Costs


3. Estimating Resource Needs:B. Human Resources

Countries need to calculate the number and cost of health workers at all levels of the health system needed to deliver the interventions at scale. Health workers include (among others):

• doctors

• nurses and midwives

• clinical officers

• lab technicians and technologists

• pharmacists and pharmacy technicians

• community health workers

• health managers



Human resource cost categories include

• salary and benefits

• in-service training

• pre-service training

• retention and distribution incentives

Human resource needs should be carefully estimated by each country for the desired level of service

coverage



Suggested costing methods

• Health workers per facilities

• Doctor or nurse to population ratio

• Conducting a comprehensive human resources needs survey

Country example: Yemen Human Resources Needs, 2015


3. Estimating Resource Needs:C. Infrastructure

Number and cost of building or refurbishing health facilities from health posts to first level referral hospitals (including capital costs, maintenance, and overhead).

Country example: Ethiopia Infrastructure Needs, 2015


3. Estimating Resource Needs:D. Health Systems Strengthening

Two methods:

1. Bottom-up costing of health system components

• Costs of managers at all levels (training and salaries)

• Quality control and audit systems

• Basic financial and accounting systems

• Health information systems (and required ICT)

• Public health functions (such as epidemiologic surveillance)

• Enhancing community demand for services (health education and community mobilization)



2. Overhead mark-up to direct cost of services

• Estimate a percentage of direct cost of services as follows:

Strengthening management systems (including financial management)

20% of direct health costs including salaries

Improving monitoring, evaluation, and quality assurance


Building capacity for basic research and development




Example:

If the costs of interventions, infrastructure, salaries, and community education equal $30 per capita annually, the additional three health systems “overhead” items would add another 37% percent of that total or $11.1 per capita for a total health system cost of $41.1 per capita.


3. Estimating Resource Needs:Adding it All Up

Direct costs of all

interventions +

Infrastructure and HRH costs

Costs ofhealth systemstrengthening+

Total health costs


4. Checking Results

Review all results to ensure that numbers are robust. Here are some sample health costs from Tanzania:

Per capita total cost estimates in 2000 US$ 2005 2010 2015% of total

in 2015 Average 2005-15

% of total over

period

HIV/AIDS Prevention 1.93 2.75 3.25 7% 2.7$ 8%HIV/AIDS Care 1.06 1.38 1.46 3% 1.4$ 4%HIV/AIDS Treatment 0.70 6.00 9.59 22% 5.8$ 17%TB 0.33 0.33 0.33 1% 0.3$ 1%Malaria Prevention 0.28 0.51 0.73 2% 0.5$ 1%Malaria Treatment 1.98 2.03 1.58 4% 1.9$ 6%Maternal Heath 1.04 1.56 2.05 5% 1.6$ 5%Child Health 4.40 4.51 4.50 10% 4.5$ 13%Management 2.34 3.82 4.70 11% 3.7$ 11%Quality improvement 1.76 2.86 3.52 8% 2.8$ 8%Human resources (salary incr.) 4.69 7.64 9.40 22% 7.5$ 22%Community demand 0.40 0.86 1.31 3% 0.9$ 3%R&D capacity 0.23 0.38 0.47 1% 0.4$ 1%Infrastructure recurrent costs 0.78 0.72 0.66 2% 0.7$ 2%

Total cost per capita ($) 22 35 44 100% 35 100%


4. Checking Results

Sample health costs from Uganda:


in 2015 Average 2005-15

% of total over

period

HIV/AIDS Prevention 1.8$ 2.4$ 2.8$ 7% 2.4$ 7%HIV/AIDS Care 0.5$ 0.6$ 0.7$ 2% 0.6$ 2%HIV/AIDS Treatment 0.6$ 3.2$ 6.0$ 15% 3.4$ 11%TB 0.4$ 0.4$ 0.4$ 1% 0.4$ 1%Malaria Prevention 0.2$ 0.5$ 0.7$ 2% 0.5$ 1%Malaria Treatment 0.9$ 1.0$ 0.8$ 2% 0.9$ 3%Maternal Heath 1.3$ 2.0$ 2.8$ 7% 2.1$ 7%Child Health 6.4$ 6.7$ 6.8$ 17% 6.7$ 21%Management 2.4$ 3.4$ 4.2$ 11% 3.4$ 11%Quality improvement 1.8$ 2.5$ 3.1$ 8% 2.6$ 8%Human resources (salary incr.) 4.8$ 6.8$ 8.4$ 21% 6.8$ 21%Community demand 0.4$ 0.9$ 1.3$ 3% 0.9$ 3%R&D capacity 0.2$ 0.3$ 0.4$ 1% 0.3$ 1%Infrastructure recurrent costs 1.3$ 1.1$ 0.9$ 2% 1.1$ 3%



4. Checking Results

Sample health costs from Ghana:


in 2015 Average 2005-15

% of total over

period

HIV/AIDS Prevention 2.1$ 2.9$ 3.3$ 11% 2.8$ 11%HIV/AIDS Care 0.4$ 0.5$ 0.6$ 2% 0.5$ 2%HIV/AIDS Treatment 0.3$ 2.4$ 3.8$ 13% 2.3$ 9%TB 0.5$ 0.5$ 0.5$ 2% 0.5$ 2%Malaria Prevention 0.4$ 0.6$ 0.8$ 2% 0.6$ 2%Malaria Treatment 0.4$ 0.4$ 0.3$ 1% 0.4$ 2%Maternal Heath 1.5$ 2.2$ 2.8$ 9% 2.3$ 9%Child Health 2.7$ 3.5$ 3.8$ 12% 3.4$ 14%Management 1.7$ 2.6$ 3.2$ 10% 2.6$ 10%Quality improvement 1.2$ 2.0$ 2.4$ 8% 1.9$ 8%Human resources (salary incr.) 3.3$ 5.2$ 6.4$ 21% 5.1$ 21%Community demand 0.4$ 0.9$ 1.3$ 4% 0.9$ 4%R&D capacity 0.2$ 0.3$ 0.3$ 1% 0.3$ 1%Infrastructure recurrent costs 1.3$ 1.1$ 1.0$ 3% 1.1$ 5%


Documents

MDG Needs Assessment Training Workshop May 9-12, 2005 Health Module