Overview of HSDP-III

Planning and budgeting for MDG results in Ethiopia Countdown to 2015 at Women Deliver Nejmudin Kedir June 8,2010 Outline Planning and budgeting for MDG results: The Marginal Budgeting for Bottlenecks Approach (MBB) Key questions The Ethiopia Experience Outline Planning and budgeting for MDG results: The Marginal Budgeting for Bottlenecks Approach (MBB) Key questions The Ethiopia Experience Marginal budgeting for bottlenecks approach (MBB) An approach developed by UNICEF, the World Bank and many national Ministries

with a tool for facilitating a country specific policy dialogue facilitates selection of high impact interventions which can be integrated into existing providers/service delivery arrangements ( eg to accelerate progress towards the MDGs) helps identifying bottlenecks in health systems performance estimates marginal/incremental costs and benefits of overcoming bottlenecks promotes result driven expenditures by linking health budgeting to 4 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 Insufficient improvement in Malnutrition, AIDS, U5MR,NMR,MMR

Increased Govt. Health Spending in context HIPC Budget Support and SWAPS 5 MBB follows a horizontal approach to analyze health system constraints and estimate cost Malaria HIV EPI RH Child TB etc. Family oriented community based services Population oriented schedulable services Individual oriented clinical services

6 Step 1: Define service package into three service delivery modes Family oriented community based services Population oriented schedulable services Individual oriented clinical services 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 7 Outline Planning and budgeting for MDG results: The Marginal Budgeting for Bottlenecks Approach (MBB) Key questions The Ethiopia Experience MBB answers three major questions 1. What are major health system bottlenecks hampering delivery of health services? 2. How much can be achieved in health outcomes by removing the bottlenecks? 3. How much money (additional) is needed for expected results?

9 Step 1: High impact interventions family oriented community Effective interventions 1. Family oriented community based services Insecticide Treated Mosquito Nets Quality of drinking water Use of sanitary latrine Hand washing by mother Indoor Residual Spraying (IRS) Clean delivery and cord care Early breastfeeding and temperature management Universal extra community-based care of LBW infants Exclusive breastfeeding for children 0-6 months Breastfeeding for children 6-11 months Complementary feeding Therapeutic Feeding Oral Rehydration Therapy Zinc for diarrhea management Vitamin A - Treatment for measles Artemisinin-based Combination Therapy for children Artemisinin-based Combination Therapy for adults Antibiotics for U5 pneumonia Community based management of neonatal sepsis

National Coverage Targets Baseline Scenario Scenario Scenario 2008 1 2 3 10 Step 1: High impact interventions population oriented schedulable Effective interventions 2. Population oriented schedulable services Family planning HPV vaccination Antenatal Care Calcium supplementation in pregnancy Tetanus toxoid Deworming in pregnancy Detection and treatment of asymptomatic bacteriuria Treatment of syphilis in pregnancy Prevention and treatment of iron deficiency anemia in pregnancy Intermittent preventive treatment (IPTp) for malaria in pregnancy Balanced protein energy supplements for pregnant women Supplementation in pregnancy with multi-micronutrients

PMTCT Condom use Cotrimoxazole prophylaxis for HIV+ mothers Cotrimoxazole prophylaxis for HIV+ adults Cotrimoxazole prophylaxis for children of HIV+ mothers Measles immunization BCG immunization OPV immunization Pentavalent (DPT-HiB-Hepatitis) immunization Pneumococcal immunization Rotavirus immunization Vitamin A supplementation National Coverage Targets Baseline Scenario Scenario Scenario 2008 1 2 3 11 Step 1: High impact interventions individual oriented clinical Effective interventions 3. Individual oriented clinical services

Normal delivery by skilled attendant Active management of the third stage of labor Basic emergency obstetric care (B-EOC) Comprehensive emergency obstetric care (C-EOC) Resuscitation of asphyctic newborns at birth Antenatal steroids for preterm labor Antibiotics for Preterm/Prelabour Rupture of Membrane (P/PROM) Detection and management of (pre)ecclampsia (Mg Sulphate) Management of neonatal infections Clinical management of neonatal jaundice Universal emergency neonatal care (asphyxia aftercare, management of serious infections, management of the VLBW infant) Antibiotics for U5 pneumonia Antibiotics for dysentery and enteric fevers Vitamin A - Treatment for measles Zinc for diarrhea management Artemisinin-based Combination Therapy for children Artemisinin-based Combination Therapy for adults Management of complicated malaria (2nd line drug) Management of severely sick children (referral IMCI) Detection and management of STI Management of opportunistic infections Male circumcision First line ART for children with HIV/AIDS First-line ART for pregnant women with HIV/AIDS First-line ART for adults with AIDS

Children second-line ART Adult second-line ART Detection and treatment of TB with first line drugs (category 1 & 3) Re-treatment of TB patients with first line drugs (category 2) MDR treatment with second line drugs National Coverage Targets Baseline Scenario Scenario Scenario 2008 1 2 3 12 Step 1: Continuum of care in time and place Source: PMNCH ( www.who.int/pmnch/about/continuum_of_care/en/inde x.htm 13

Step 2: Identifying bottlenecks using coverage determinants 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 14 Step 2: Removing coverage bottlenecks in Ethiopia: scaling up ITN Procurrre d + distri bu te d 20mi l li on ITN's Policy decision: long las ting Trai ne d &

de pl oye d 30.000 HEW 100% 80% 80% 75% 72% 65% 75% 50% 36% 20% 25% 16% 4% 1%

0% ITN in districts HEWs 2005 Fam ilies w ith net Using net 2007 Using tre ated net 2007 2005 15 Step 3: Mortality impact estimation Increase in effective coverage

X Intervention efficacy Controlled for: Double counting by residual summation of disease specific impacts Replacement mortality (lives saved re-added to denominator of children at risk Impact of the baseline coverage X Disease specific attributable mortality 16 Step 4&5: Costing, planning & budgeting, and

fiscal space calculations Inputs I-Economics Modeling/calculations Outputs Input price Input unit price I-Health System Design National norms and standards Input quantity O-Summary I-Epidemiology Demography, disease prevalences & incidences I-Interventions M-Cost

Marginal cost of scaling up interventions to new frontier Average per capita marginal cost by service delivery; average funding need, economic cost/live saved ... Service packages and interventions I-Coverage Baseline coverage of current interventions Increase in coverage O-Coverage New frontier or target coverage levels I-Finance and Budget O-Finance and Budget Investment and recurrent cost phasing, and source of

finance assumptions Yearly additional budget and financing estimates I-Fiscal Space O-Fiscal Space Baseline macroeconomic parameters; economic growth and resource flow assumptions Estimate of fiscal space for health; proportion of marginal cost to fiscal space 17 Steps in MBB application for evidenced based planning and budgeting Step 1: Analyzing health systems and prioritizing high impact

interventions Step 5: Planning, budgeting, and analyzing fiscal space Step 2: Analyzing and removing system bottlenecks to coverage Step 4: Estimating additional cost of removing bottlenecks Step 3: Estimating impact on MDGs 4,5,6 18 Outline Planning and budgeting for MDG results: The Marginal Budgeting for Bottlenecks Approach (MBB)

Key questions The Ethiopia Experience APPLICATIONS OF MBB IN ETHIOPIA Ethiopia at glance 80 million population Federal government : 9 regional states, and 2 city administration 817 Woredas (districts) Health (EDHS 2005): U5M 123 per 1,000 live birth MMR 673 per 100,000 live birth Stunting

Total health expenditure: 16.1 USD/Capita MBB applied in Ethiopia for MSG needs assessment 2004 Child Survival Strategy 2004 HSDP III 20005 IHP+ Compact 2007 Woreda Based Annual Planning 2007-2010 HSDP IV 2010 HSDP with Clear Priorities and strategies aligned with MDGs Bloodlines Priorities Target Vehicles Maternal health

CPR > 60% 30,000 HEWs HRD 15,000 HPs HCSS 3,200 HCs Finance

5,000 HOs HMIS Train GPs Improve QA System Harmonization Child health Immunization > 85% HIV/TB

Malaria Reach every household 263,000 people on ART 20 million ITNs PPD/MOH Linking resource needs to results incremental cost per capita 2005-2015 for reaching the MDGs US$ Scale Up Strategy (2004 constant $) 35 HSDP-3 Further decrease of :

child mortality, maternal mortality, HIV MTC transmission Provision of HAART , multi-drug resistant TB and severe malaria treatment Step 4: Expansion and Upgrade of Emergency Obstetrical care Further decrease of : child mortality maternal mortality HIV MTC transmission Reduced MM by 75% Step 3: First level clinical upgrade Further decrease of: Child mortality Maternal Mortality Malaria, morbidity & mortality TB

Reduced malaria mortality by 50% Increase TB DOTS coverage Step 2: Health Services Extension Program Decrease in child mortality Reduction in HIV Mother To Child Transmission Reduction of deaths due to pregnancy by 40% Reduce malaria mortality morbidity Reduce Child malnutrition Reduced child mortality by two third Step 1: Information and Social Mobilization for Behavior change Decrease in child mortality due to HIV, malaria, diarrhea diseases

Reduced HIV transmission Reduced malaria morbidity and mortality Reversed trend in HIV incidence and stabilized trend in HIV prevalence 30 25 Step 5 20 15 4.1 billion USD Step 4 Step 3 10

5 MDGs reached Step 5 : Expansion and Upgrade of Referral Care HSDP-4 4.6 billion USD Health Outcomes Step 2 3.3 billion USD Step 1 Current Health Expenditures 0

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 25 Ethiopia: HSDP 3 resource mapping (domestic and external) for health sector Ethiopia: HSDP III overall financing gap by scenario Ethiopia: HSDP 3 estimated financing gap by programmatic area UK Scaling Up For Better Health Initiative HPN partners in Ethiopia: Canada UNICEF Catalytic Initiative

GAVI Health System Strenghening Global Fund Health System Window Norway Global Business Plan For MDG 4 and 5 Common Results Framework Gates Results Based Health Financing PBS Component 2 PNMCH

Government of Ethiopia MDGs Performance Fund Joint Consultative Committee (JCC) HPN donor group HSDP PPD/MOH FMOH customized MBB to support evidence based planning at sub-national level Process: Customize MBB for District (Woreda) application Formats for baseline data collection shared with each Woreda Health Office ahead of time Mentors training on the tool and approach Application workshop five to seven days Draft plan shared with respective woreda

administration Budget request and defense with WOFED and Woreda administration Parallel process of aggregation by Zone and Region Health Sector Strategic Plan (HSDP) Regional Health Sector Strategic Plan Health Sector Annual Plan FMOH Detailed Annual Plan Regional Annual Plan Regional Detailed Annual Plan Zonal Health Sector Strategic Plan Zonal Annual Plan Zonal Detailed Annual Plan

Woreda Health Sector Strategic Plan Woreda Annual Plan Health Facility Strategic Plan Health Facility Annual Plan ual Plans at all level reflects HSDPs Activities HSDP Priorities to be reflected at All Level Top down and bottom-up linkages Last three years GoE took to national scale the Woreda planning exercise Year 2008/09 2009/10 2010/11 # of mentors 161 139 191

# of Woredas Total # of participants in the capacity building 803 4,101 803 4,104 817 5,052 In incremental way: 2008/09 only the health system bottlenecks analyses module introduced 2009/10 cost and impact estimation modules added to the Woreda plan process 2010/11 Woredas doing both annual and five year health strategic plan Key Message 1. The tools helped to link local priorities and targets with national and global priorities and targets

2. Helped to develop evidence based planning through a systematic assessment of health system bottleneck and to implement scientifically proven high impact interventions to scale up 3. Application of the tool helped to improve health expenditure from government and DPs 34 Thank you

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