Evidence based policy, planning and budgeting

1. Evidence based policy, planning and budgeting Agnes Soucat (World Bank); Susie Villeneuve (UNICEF) Africa Flagship Workshop on Health Systems Strengthening – Financing for Results July 1, 2010, Kigali, Rwanda

2. Objectives • Overview: areas of support and countries supported so far and planned • Brief highlight: concept and methodology of the MBB tool and how it fits into the broader health system strengthening and health sector planning process • Some examples: what has been the product of this evidence-based planning approach?

3. Evidence based policy, costing, planning and budgeting • Support national HNP strategic plan development • Analysis of health systems bottlenecks or constraints • Development of strategies to address bottlenecks • Simulating scaling up strategies of high impact interventions • Costing strategic plans and estimating impact with multiple scenarios • Help country level compact between Government and DPs • Defining roles, responsibilities and commitments of Government and DPs to implement one national strategic plan • Developing one results framework • Entering one Joint Financing Arrangement • Undertake financing gap analysis and resource mapping for HNP MDGs & implementation of national strategic plan • Support evidence based national policy and strategy development • National child survival strategy • National maternal, newborn and child health strategy • Health financing policy

4. HHA mechanism is used to coordinate support to countries • Technical support is country based and demand driven • When requested by countries HHA put together a team from AfDB, UNAIDS, UNFPA, UNICEF, WHO, World Bank (USAID has joined HHA) • Based on expertise and availability of staff • Team members are drawn from regional or country or HQ staffs • HHA has created a Community of Practice on evidence based policy, planning and budgeting

5. Countries with completed or ongoing MBB applications (48)

6. Concept and methodology: Marginal Budgeting for Bottlenecks (MBB) tool

7. Why focus on system wide bottlenecks? Increasing evidence on efficacy of maternal, newborn and child health & nutrition interventions Enhanced global commitment to MDG 1,4,5,6,7 Implementation bottlenecks: inadequate supplies, human resource constraints, poor access to healthcare, low demand for and/or continuity, and quality of services Increased Govt. Health Spending in context HIPC Budget Support and SWAPS Insufficient improvement in Malnutrition, AIDS, U5MR,NMR,MMR

8. MBB tool used for sector level support including national and sub-national strategic plans MBB is …. • a tool developed by Unicef, World Bank and national Ministry of Health of many countries • a tool for a country specific policy dialogue, planning and budgeting • helps identify bottlenecks in health system performance • promotes result driven expenditures by linking health budgeting to outcomes and impact • EXCEL based, open source, flexible to customize to country situation …. over 30 African countries have used MBB since 2003

9. … a tool developed over time to respond to requests from countries Milestones: • Results-oriented health sector reforms, HIPC and PRSP • how to cost and budget additional allocations to health services? • health MTEF • National Child Survival Strategy • following the Lancet 2003 series on child survival … global partnership established and countries start developing national child survival strategy • MDGs needs assessment • with the support of Millennium project, many countries start to assess and analyze the resource requirements for all the MDGs (2004 onwards) • Harmonization and alignment • the Paris declaration in 2005, reiterated the SWAp principles and the need for evidence based national health sector strategic plans • IHP+ • following the signing of the global compact in 2007, IHP+ countries started a process of developing country level compact • Further re-enforcing the need for evidence based one costed national health sector strategic plan, funding gap analysis and joint financing arrangement towards one budget … the scope and technical sophistication of the MBB tool evolved with these milestones and needs of countries for an analytical tool

10. MBB assist countries to analyse and answers three major questions • What are the major health system bottlenecks hampering delivery of health services? • How much resources (additional) are needed for expected results? • How much can be achieved in health outcomes by removing the bottlenecks?

11. MBB follows a horizontal approach to analyze health system constraints and estimate cost Malaria EPI RH Child TB etc. HIV Family oriented community based services Population oriented schedulable services Individual oriented clinical services Note: System or shared costs are not attributed to individual disease or conditions “not a unit cost approach” 11

12. The tool can help make analysis for the following MDG targets: MDG 1: Reduce the prevalence of underweight children under 5 MDG 4: Reduce the two thirds ,between 1990 and 2015 , the under 5 mortality rate MDG 5: • Reduce MMR by three quarters between 1990 and 2015 the • Achieve universal access to reproductive by 2015 MDG 6: • Have halted by 2015 and begun to reverse the spread of HIV AIDS by 2015 • Achieve by 2010, Universal access to treatment for all HIV AIDS for all those who need it • Have halted by 2015, and begun to reverse the incidence of Malaria and other major diseases

13. Step1 Setup & Inputs • Start year, duration of the plan • Analysis Options (Compare Scenarios: overtime, compare groups) • Default range • Baseline data (epi,Demo,HS, coverage,Eco Step 2: Bottleneck analysis • Selecting tracers, • Defining indicators • Baseline coverage • Causes and solution • Target setting Step 5;Outputs • Impact : mortality reduction (MMR, IMR, NMR, U5..); morbidity reduction (HIV AIDS, TB, Malaria) • Additional budget (capital/recurrent, level of service delivery…) • Health system: additional infrastructure, additional HR Step 3: Policy scenarios • Coverage targets • Health service delivery organization • Service packages • Implementation strategies (CCT, etc.) Step 4: Budgeting and Financing • Select budget items • Mapping budget items to National program, national chart of accounts … • Select implementation curves (phasing assumptions) • Define funding source Steps of an MBB-assisted analysis

14. Family preventive/WASH services Family neonatal care Infant and child feeding Community management illnesses Preventive care for adolescents and adults Preventive pregnancy care HIV/AIDS prevention and care Preventive infant and child care Clinical primary level skilled maternal & neonatal care Management of illnesses at primary clinical Clinical first referral illness management Clinical second referral illness management Over 100 HNP interventions organized into three service delivery modes to facilitate the bottleneck analysis as well as development of scaling up strategies Family oriented community based services Population oriented schedulable services Individual oriented clinical services

15. High impact interventions family oriented community

16. High impact interventions population oriented schedulable

17. High impact interventions individual oriented clinical

18. Analyzing and removing bottlenecks Objective: to increase effective coverage rate of health services ‘effective population coverage rate of health services (C), is defined as population effectively covered with quality services (actual delivery and actual utilization) How? By removing demand and supply side bottlenecks at the three service delivery modes:

19. Six coverage determinants, from both supply and demand side, applied to analyze health system bottlenecks and develop strategies Effective coverage -quality Adequate coverage - continuity Initial utilization – first contact of multi contact services Accessibility – physical access of services Availability – human resources Availability – essential health commodities Target Population Adapted from Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2) http://whqlibdoc.who.int/bulletin/1978/Vol56-No2/bulletin_1978_56(2)_295-303.pdf

20. Example of health system constraints, strategies and ITN scaling up results

21. Inputs Bottlenecks Health Output MDGs Outcome Essential drugs, commodities, safe water system, human resources. .. Availability ∆Cof health interventions delivered by Family/Community Support for community meeting, inputs for a mobile team, construction of health post etc. Impact on MDG health indicators: Reduction in U5MR and MMR Accessibility ∆Cof health interventionsdelivered by Outreach team Drugs and supplies, subsidies for insurance for referral care per user etc. Utilization Demand side subsidy, performance-based incentives for health workers, doctors, and IEC inputs etc. ∆C of health interventionsdelivered by Clinics/Hospitals Continuity Cost of removing bottlenecks to achieve certain MDG target Training, supervision and monitoring of community mobilizers, primary and referral clinical care etc. Quality Aggregate cost of inputs Overview of the MBB tool

22. MBB is designed to support 3 sets of analyses • Compare alternative strategies/ scenarios (e.g. MTEF, NHSSP) • Compare over time (e.g. MDG needs assessment over 5yr time period) • Compare groups (e.g. equity analysis, comparing urban, rural and pastoral)

23. Recent developments: peer reviewed with UNFPA, WHO and UNAIDS • Interventions included in MBB reviewed with various program departments of UNAIDS, UNFPA and WHO • Number of interventions have increased since the review • Adjustments also made on where interventions are delivered, i.e. community, schedulable, clinical • MBB Impact estimation methodology reviewed and updated with recent evidence • Two models to estimate impact for MDG 4 I, (MBB Impact and LiST) • Same dual interface for MDG 5 once LiST is ready • MDG 6 recent consultation with TB and HIV programs in WHO and UNAIDS • Input-output interface between the MBB and program-specific planning tools such as FP (with UNFPA RH costing tool), TB (with WHO stop TB costing tool) and HIV (with the resource needs tool) introduced • Expanded cost line items for program management activities for EPI, RH, Malaria, nutrition and WASH as well as non-MDG services Similar peer review with Consortium of Australian Universities and University of Tokyo

24. Recent developments cont… Costing tools external review 2007 (Bitran and PATH): • 13 tools developed by UN and bilateral agencies • Contracted out by the PMNCH • User's meeting Senegal January 2008 • Review report and tools available in PMNCH website Following the Senegal meeting the six UN agencies (UNAIDS, UNDP, UNFPA, UNICEF, WHO and WB) committed to harmonize and subsequently form an informal inter-agency working group on costing A modular Unified Health Model under development by the inter-agency working group on costing. High Level Taskforce for Innovative International Financing – “more money for health, and more health for the money” Ongoing Africa Investment Case “investing in health for Africa”

25. Country examples

26. Some examples of product supported with the MBB tool ACSD strategy: 11 African countries supported by CIDA Five year national health sector strategies: • Ghana - Third five year national program of work (POW 2007 – 2011) • Ethiopia • Third five year Health Sector Development Program (HSDP 3 2005/06-2009/10) • Fourth five year Health Sector Development Program (HSDP 4 2010/11 – 2014/15) – on going • Nigeria on going • Rwanda • Health sector strategic plan (HSSP 2 2008 – 2012) • Zambia • Fifth five year national health sector plan (midterm revision 2007 – 2010) • Sixth five national health sector plan (2011 -2015 on going) Health sector MTEF • Benin, Cameroon, Madagascar, Mali, Mauritania, Rwanda

27. Some examples ….. Sub-national strategic planning • South Africa in three provinces • Madagascar • Ethiopia all woredas/districts • Zambia in 9 districts one from each province • Rwanda preparing to start with two districts Funding gap analysis and joint financing arrangement for Compact • Burundi, Ethiopia, and Mali • Ongoing: Nigeria, Rwanda, Zambia, Ghana Cost and impact estimate for 49 low income countries included in the High Level Taskforce for International Innovative Financing “more money for health, and more health for the money”

28. On-going and planned • Kenya – national maternal, newborn child health; sub-national strategic planning • Ethiopia –fourth national strategic plan and MTEF • Zambia – sixth national strategic plan • Nigeria – national and sub-national strategic plan as well as Compact • Ghana – MTEF • Rwanda – sub-national annual planning • Sierra Leone – costing analysis for free health care policy

29. Ethiopia: Cost of scaling up health services incremental cost per capita 2005-2015 for reaching the MDGs

30. Ethiopia: HSDP 3 resource mapping (domestic and external) for health sector

31. Ethiopia: HSDP 3 overall financing gap by scenario

32. Ethiopia: HSDP 3 estimated financing gap by programmatic area

33. Thank you