Kinghorn AWA1, Schutte C2, Undi M 3, Mwansa FD4 - Amazon Web ...
How can studies of immunization program costs best be used to enhance planning and management for efficiency at district and facility level? Experience in Zambia Kinghorn AWA1, Schutte C2, Undi M 3, Mwansa FD4 ¹Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa. ²Strategic Development Consultants, Pietermaritzburg, South Africa. ³Independent Consultant, Lusaka, Zambia. ⁴ Ministry of Health, Lusaka, Zambia Correspondence: [email protected]
METHOD Systems and practices for service and financial planning and management were appraised through document review and key informant interviews, in order to target the feedback and interpretation of information. EPIC study results for 50 facilities were discussed with 9 district and 3 provincial management teams to validate study conclusions and assess their ability to act on study results.
However, there is limited delegation of authority to manage key resources, particularly staffing and vaccines. These are the largest components of RI costs. District and facility managers have authority over district and service plans, but only over relatively small budgets for maintenance, transport, DSA and supervision. although these are critically important. Despite limited delegations and budgets many managers, particularly more experienced ones, can use costing information to identify realistic opportunities for more efficient use of available resources Fourth Global Symposium on Health Systems Research, November 14-18, 2016 in Vancouver, BC Poster Ref 3029 ACKNOWLEDGMENTS: This work was part of the EPIC2 Project funded by the Bill and Melinda Gates Foundation. Views expressed are those of the authors and not necessarily of the Foundation or Harvard School of Public Health, which managed EPIC2. We are grateful to the service planners and managers in the Zambia Ministry of Health, particularly Mrs Josephine Simwinga, Dr Caroline Phiri and Mr Guissimon Phiri, as well as the 3 Provincial health management teams and 9 District management teams. Collins Chansa, Penelope Kalesha-Musumbu, Stephen Resch and Logan Brenzel gave valued guidance .
cMYP; national plan & budget; Overall coordination; Supervise & support PMO/DMO; capacity building; Data analysis, forecasts; PSM; manage cold chain Facility and vehicle allocation
Provincial Medical Office Plan & budget. Coordinate, supervise & support DMOs; District capacity building; data analysis, forecasts; vaccine stock and logistics; cold chain maintenance
District Medial Office District Plan & budget - maintenance, transport, DSA, training, supervision Supervise & support; capacity building; data collection & analysis Vaccines stock management & issue to facilities; cold chain maintenance
Facility
FIGURE 2: A “Complex Systems” Assessment can Further Pinpoint Priority Opportunities & Constraints for Enhancing Performance
3. Staff Capacity & skills
National ;
nl
2. Systems & system tools Management, planning & performance management
Provincial Medical Office OPPORTUNITIES Plan & budget. Coordinate, supervise & support DMOs;
Experienced managers vaccine stock and logistics; ANDcold chain maintenance x Management & analysis; CONSTRAINTS x Specific vacant posts x Capacity building, supervision District capacity building; data analysis, forecasts;
4. Strategies, plans, policies • Child Health Weeks • Vaccine supply policy
District
5. Shared values, teamwork and support
• Incentives – per dia References: EPI prioritised; Mentorship
6. Other key factors x Unreliable disbursement x Structural constraints on efficiency
Facility
Current effect on performance: Enhance X Limit Vary with context
Some expensive outreach services can, for example be made more efficient by adapting scheduling and use of transport. Even staff allocation and capacity utilization, as well as vaccine wastage, can be influenced to some extent at district and facility level. These capabilities, combined with consistent prioritization of immunization, have helped to protect immunization coverage even when resources have declined.
Figure 2 shows factors that facilitate or limit managers’ ability to use resources to achieve immunization targets. Among other items, more than 15 systems and system tools were identified as important influences on ability to manage RI. These relate to a) planning b) finance, PSM and HR management and c) performance management and incentive systems
Service & community plans & budget- transport, DSA, maintenance; Services; training and social mobilization; collect & analyze data; M&E of EPI activities; help cold chain maintenance
1. Style of leadership & authority e.g. PMO/ DMO can influence staffing
RESULTS (cont)
Nevertheless, a range of factors constrain managers’ ability to obtain and respond to information on cost of services. Unreliable and partial disbursement of budgets is a major impediment to active planning. Other constraints included: information and operational systems; limited capacity and experience in key posts; and structural constraints on service efficiency particularly in remote areas.
Limited delegation: esp staff, vaccines
RESULTS A well established “bottom up”, decentralized planning system facilitates management of resources and efficiency at district and facility level in Zambia.3 At each level there are planning, budgeting and management roles that can be usefully informed by costing data (Figure 1). .
Decentralised “Bottom up” planning
A process was developed to feed back results to district managers to inform their management of RI service costs and efficiency. We used this process to explore factors that affect the ability of district level managers to obtain information on service performance and to manage scarce resources better.
Decentralised “Bottom up” planning
The EPIC study provided extensive information on costs of routine immunization (RI) at district and facility level in Zambia, and determinants of costs and productivity.1,2 Most RI costs are incurred in facility-level activities.
National (CHU; Planning; Finance; HR)
Limited delegation: esp staff, vaccines
BACKGROUND Detailed studies of costs and cost determinants of various primary care services have been conducted in several low and middle income African countries in recent years. Feedback of results to district and facility managers is seldom reported and optimal methodologies for this are not well described.
FIGURE 1: Management Decentralisation and “Decision Space” at each level are key Influences on Efforts to Enhance Immunization Performance
DISCUSSION AND CONCLUSIONS Feedback of costing and other study information to district and service level is often neglected and is welcomed by planners and managers. Many of them can use the information well. But study information, or even improving the systems to produce routine RI, financial and service information, may have limited impact. Better understanding of the systems, constraints and opportunities facing managers is critical for more effective analysis, feedback, learning and action. Various constraints and opportunities have previously been explored with frameworks that assess the degree of decentralization, and “decision space”.4 5 We recommend use of frameworks that allow deeper, wider analysis of “complex systems” (e.g. Boesen & Therkildsen - ROACC; Peters & Waterman - 7Ss).6,7 These can provide critical insight into the many influences at play, and which responses are likely to have most effect on performance in various contexts.. KEY REFERENCES 1. Schutte C Chansa C Marinda E Guthrie T Banda S Nombewu ZC Motlogelwa K Lervik M Kinghorn AWA. Cost Analysis of Routine immunisation in Zambia. Vaccine 33S (2015) A47–A52 2. Kinghorn A, Schutte C, Marinda E Chansa C. What drives Productivity and Costs of Routine Immunization Services in Zambia? Oral Presentation. International Health Economics Association Congress, Milan July 2015 3. Ministry of Health (2009) Action Planning Handbook for District Health Teams (5th Edition). Republic of Zambia Lusaka. 4. Bossert TJ Beauvais JC (2002) Decentralization of health systems in Ghana, Zambia, Uganda and Philippines: a comparative analysis of decision space. Health Pol Plan 17(1) 14-41 2002. 5. Bossert T Chitah MB Bowser D. (2003) Decentralization in Zambia: resource allocation and district performance. Health, Policy and Planning 18(4); 357–369 2003 6. Boesen N Therkildsen O (2005). Results-Oriented Approach to Capacity Change. Ministry of Foreign Affairs Danida www.evaluation.dk 7. Waterman RH Peters TJ Phillips J. Structure is not Organization. Business Horizons. June 1980
METHOD Systems and practices for service and financial planning and management were appraised through document review and key informant interviews, in order to target the feedback and interpretation of information. EPIC study results for 50 facilities were discussed with 9 district and 3 provincial management teams to validate study conclusions and assess their ability to act on study results.
However, there is limited delegation of authority to manage key resources, particularly staffing and vaccines. These are the largest components of RI costs. District and facility managers have authority over district and service plans, but only over relatively small budgets for maintenance, transport, DSA and supervision. although these are critically important. Despite limited delegations and budgets many managers, particularly more experienced ones, can use costing information to identify realistic opportunities for more efficient use of available resources Fourth Global Symposium on Health Systems Research, November 14-18, 2016 in Vancouver, BC Poster Ref 3029 ACKNOWLEDGMENTS: This work was part of the EPIC2 Project funded by the Bill and Melinda Gates Foundation. Views expressed are those of the authors and not necessarily of the Foundation or Harvard School of Public Health, which managed EPIC2. We are grateful to the service planners and managers in the Zambia Ministry of Health, particularly Mrs Josephine Simwinga, Dr Caroline Phiri and Mr Guissimon Phiri, as well as the 3 Provincial health management teams and 9 District management teams. Collins Chansa, Penelope Kalesha-Musumbu, Stephen Resch and Logan Brenzel gave valued guidance .
cMYP; national plan & budget; Overall coordination; Supervise & support PMO/DMO; capacity building; Data analysis, forecasts; PSM; manage cold chain Facility and vehicle allocation
Provincial Medical Office Plan & budget. Coordinate, supervise & support DMOs; District capacity building; data analysis, forecasts; vaccine stock and logistics; cold chain maintenance
District Medial Office District Plan & budget - maintenance, transport, DSA, training, supervision Supervise & support; capacity building; data collection & analysis Vaccines stock management & issue to facilities; cold chain maintenance
Facility
FIGURE 2: A “Complex Systems” Assessment can Further Pinpoint Priority Opportunities & Constraints for Enhancing Performance
3. Staff Capacity & skills
National ;
nl
2. Systems & system tools Management, planning & performance management
Provincial Medical Office OPPORTUNITIES Plan & budget. Coordinate, supervise & support DMOs;
Experienced managers vaccine stock and logistics; ANDcold chain maintenance x Management & analysis; CONSTRAINTS x Specific vacant posts x Capacity building, supervision District capacity building; data analysis, forecasts;
4. Strategies, plans, policies • Child Health Weeks • Vaccine supply policy
District
5. Shared values, teamwork and support
• Incentives – per dia References: EPI prioritised; Mentorship
6. Other key factors x Unreliable disbursement x Structural constraints on efficiency
Facility
Current effect on performance: Enhance X Limit Vary with context
Some expensive outreach services can, for example be made more efficient by adapting scheduling and use of transport. Even staff allocation and capacity utilization, as well as vaccine wastage, can be influenced to some extent at district and facility level. These capabilities, combined with consistent prioritization of immunization, have helped to protect immunization coverage even when resources have declined.
Figure 2 shows factors that facilitate or limit managers’ ability to use resources to achieve immunization targets. Among other items, more than 15 systems and system tools were identified as important influences on ability to manage RI. These relate to a) planning b) finance, PSM and HR management and c) performance management and incentive systems
Service & community plans & budget- transport, DSA, maintenance; Services; training and social mobilization; collect & analyze data; M&E of EPI activities; help cold chain maintenance
1. Style of leadership & authority e.g. PMO/ DMO can influence staffing
RESULTS (cont)
Nevertheless, a range of factors constrain managers’ ability to obtain and respond to information on cost of services. Unreliable and partial disbursement of budgets is a major impediment to active planning. Other constraints included: information and operational systems; limited capacity and experience in key posts; and structural constraints on service efficiency particularly in remote areas.
Limited delegation: esp staff, vaccines
RESULTS A well established “bottom up”, decentralized planning system facilitates management of resources and efficiency at district and facility level in Zambia.3 At each level there are planning, budgeting and management roles that can be usefully informed by costing data (Figure 1). .
Decentralised “Bottom up” planning
A process was developed to feed back results to district managers to inform their management of RI service costs and efficiency. We used this process to explore factors that affect the ability of district level managers to obtain information on service performance and to manage scarce resources better.
Decentralised “Bottom up” planning
The EPIC study provided extensive information on costs of routine immunization (RI) at district and facility level in Zambia, and determinants of costs and productivity.1,2 Most RI costs are incurred in facility-level activities.
National (CHU; Planning; Finance; HR)
Limited delegation: esp staff, vaccines
BACKGROUND Detailed studies of costs and cost determinants of various primary care services have been conducted in several low and middle income African countries in recent years. Feedback of results to district and facility managers is seldom reported and optimal methodologies for this are not well described.
FIGURE 1: Management Decentralisation and “Decision Space” at each level are key Influences on Efforts to Enhance Immunization Performance
DISCUSSION AND CONCLUSIONS Feedback of costing and other study information to district and service level is often neglected and is welcomed by planners and managers. Many of them can use the information well. But study information, or even improving the systems to produce routine RI, financial and service information, may have limited impact. Better understanding of the systems, constraints and opportunities facing managers is critical for more effective analysis, feedback, learning and action. Various constraints and opportunities have previously been explored with frameworks that assess the degree of decentralization, and “decision space”.4 5 We recommend use of frameworks that allow deeper, wider analysis of “complex systems” (e.g. Boesen & Therkildsen - ROACC; Peters & Waterman - 7Ss).6,7 These can provide critical insight into the many influences at play, and which responses are likely to have most effect on performance in various contexts.. KEY REFERENCES 1. Schutte C Chansa C Marinda E Guthrie T Banda S Nombewu ZC Motlogelwa K Lervik M Kinghorn AWA. Cost Analysis of Routine immunisation in Zambia. Vaccine 33S (2015) A47–A52 2. Kinghorn A, Schutte C, Marinda E Chansa C. What drives Productivity and Costs of Routine Immunization Services in Zambia? Oral Presentation. International Health Economics Association Congress, Milan July 2015 3. Ministry of Health (2009) Action Planning Handbook for District Health Teams (5th Edition). Republic of Zambia Lusaka. 4. Bossert TJ Beauvais JC (2002) Decentralization of health systems in Ghana, Zambia, Uganda and Philippines: a comparative analysis of decision space. Health Pol Plan 17(1) 14-41 2002. 5. Bossert T Chitah MB Bowser D. (2003) Decentralization in Zambia: resource allocation and district performance. Health, Policy and Planning 18(4); 357–369 2003 6. Boesen N Therkildsen O (2005). Results-Oriented Approach to Capacity Change. Ministry of Foreign Affairs Danida www.evaluation.dk 7. Waterman RH Peters TJ Phillips J. Structure is not Organization. Business Horizons. June 1980
