Health planning approaches hahm 17

1. Prof. Kyawt Sann Lwin
Professor/Head
Health Policy and Management Department

2.  Green A., An Introduction to Health
Planning for Developing Health Systems, 3rd
Edit., Oxford University Press, 2007
 Merson M. H., Black R. E., Mills A. J.,
Global Health: Diseases, Programs,
Systems, and Policies : Chapter 12:
Management and Planning for Public Health,
Green A. & Collins C., 2007
 Sakharkar BM (2009) Principles of Hospital
Administration and Planning, 2nd
Edit,
Chapter 7. Jaypee brother Publishing2

3.  Planning concepts/ importance
 Types of planning – strategic / operational
 Planning spiral/ cycle
 Situation analysis
 Priority, goal and objective setting
 Option appraisal
 Programming
 Implementation and monitoring
 Evaluation
 Different levels/ time scales of planning
 Decentralization
3

4.  Essential element in management
 Concern with making decisions today to
influence the future
 Plans – Statements of intent concerning how
resources will be used to achieve the
organization's objectives
 must be written down and copies passed on to all
concerned because a plan has no value if it
remains only in the mind of the planner - there
are many others in the organisation who will
have to be associated in putting the plan into
practice and understanding the plan
 Plans provides an opportunities for the
institution to be proactive rather than reactive
4

5.  The process is one of forecasting, because
forecasting seeks to provide the manager
with information about the future, and
involves considering the six questions
 1. What we expect to do?
 2. Why will it be done?
 3. Where will it be done?
 4. When we expect to do it?
 5. Who are going to do it?
 6. How will it be done?
 The function of planning cannot be
delegated
5

6.  should be made as far ahead as the maximum lead
time—the period of time it will take to implement a
decision
 For forecasting - past data as well as future based
forecasting techniques are used, analysis of factors
which are likely to cause expected change - complex
techniques such as multiple regression, simulation,
multivariate equations
 E.g., change in the demographic characteristics,
attitude and behaviour patterns of user population
 changes in medical care patterns (e.g. ambulatory vs
inpatient care, new technology), and
 changes in the concurrent factors affecting utilisation
(e.g. medical insurance, employee health
programme)
6

7.  Great help in many a problem in the health
care field, because
 They can balance the views of the
 governing board,
 medical staff,
 administration and other
 key groups both inside and outside the institution
 Gives formality to the programme decision
 Have important influences on implémentation
of strategies
7

8. 1. Plans should be based on a thorough study
of the end results desired
2. Planning should involve participation of the
medical staff, other concerned service
representatives
3. Plans should be comprehensive
4. Plans should be flexible
5. Plans should be continually updated
6. Plans should be realistic
7. Plans should be time phased
8

9.  Changing nature of health and health care
strategies
 Change in health needs
e.g. new diseases, relative prevalence of
diseases/problems due to epidemiologic or
demographic transition
 Change in resources
e.g. financial forecasts and availability of key resources
(e.g. professionals)
 Technology developments and their impacts
9

10.  Decisions about priorities depend on social and
political context of country or region
 Current allocation of resources within health
sector is not optimal – plan needs to address
them
10

11. Misperception
 About production of plans
(document)
 About capital budget
 Only concern with projects
 A highly technical &
specialist activities
 Carried out only by
specialist planners
 An objective and neutral
activities
But
 concerned with change, not
document
 also focus on recurrent
budget
 Projects are only one way of
achieving change
 is a common sense
 needs to be shared by a wide
group of actors
 involve value judgments
11

12.  Strategic / Allocative planning
Making decisions relating to how resources will be
used and which strategies/activities will be
undertaken
Carries a wider perspective for the whole
organization at the highest organization level
 Activity / operational planning /work plan
Focus on detailed implementation by setting out
time frames for activities in the short term
Setting of monitorable implementation schedules
Done at the lower organizational level
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13. 13
Sub-nationalNational
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+++++
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Implementation level
Economic appraisal
Management focused
Strategic directions
Long term vision
Activity planning
Allocative planning
OperationalStrategicCharacteristic

14.  Means of giving Ministries of Health’s strategic
direction;
 Process for developing intersectoral collaboration
for health development;
 Means for constructive public-private partnership;
 Means for streamlining donor assistance;
 Means for bringing about institutional change
 Introducing discipline and minimizing external
influences
14

15. 15
Indicators/Sources of
Information
How do we get to
know that we have
gotten there?
Strategies/
Intervention /Activities
How do we get
there?
Objectives/TargetsWhere do we want
to be?
Situation Analysis &
priority setting
 Where are we?

16. 16
Situation Analysis
Implementation and
Monitoring
Evaluation
Option appraisal
Priority, goal, and
objective setting
Programming

17.  Assess the current situation and projected
future changes to it
 Key components of situational analysis
 Population characteristics
 Area characteristics and infrastructure
 Policy and political environment
 Health needs
 Efficiency, effectiveness, equity and quality of
current services
 Services provided by non health sector and their
resources
17

18.  Determination of ‘what it wants to achieve’
(hierarchy of objectives)
 To ensure feasible within - the social and political
climate, available resources
 Clear criteria for selection are needed
 Allow broad view of health
 Balance decision making at national and local
 Transparent process
 Needs to end up with objectives that are feasible
18

19. Health for all by 2020
Reduction in
child mortality rates ..
Reduction in MMR
By 2015
Reduction in HIV
Incidence …..
Increase in Family
Planning Service outlets
by 30% by 2010
Extension of access to
safe obstetric care to 70%
of pregnant women by 2010
Increase in level of
Female literacy by 10%
by 2010
Milestone: Introduction of
20 referral ambulances
by 2007
Milestone: Training of 200
Birth attendants by end of
2007
Milestone: Increase in
Maternity beds by 10%
by 2007
19

20. 20
Health for all by 2020
Reduction in
child mortality rates ..
Reduction in MMR
By 2015
Reduction in HIV
Incidence …..
Increase in Family
Planning Service outlets
by 30% by 2010
Extension of access to
safe obstetric care to 70%
of pregnant women by 2010
Increase in level of
Female literacy by 10%
by 2010
Milestone: Introduction of
20 referral ambulances
by 2007
Milestone: Training of 200
Birth attendants by end of
2007
Milestone: Increase in
Maternity beds by 10%
by 2007
Goal
Aims
Objectives
Targets

21.  End result of priority setting process
 Structured in a hierarchy:
1. Broad overall health goals
2. Specific health aims related to particular
health problems
3. Health sector activity objectives
4. Targets that are milestone
21

22.  Should be SMART:
1. Specific
2. Measurable
3. Attainable
4. Relevant
5. Time bound
 WHAT is to be done, HOW MUCH is to be
done, WHEN and WHERE it is to be
completed
22

23. 23
c
b
d
Professionally determined needs=a +b +c
Needs as perceived by community or individual = b + c + d + e
Economic demand of individual or community = b + d

24.  Economic appraisal
 Combine consideration of health gain &
resources
 Use cost per DALY
 Applicability ?? Lack appropriate data in
developing countries
 Multivariable decision matrices
 Delphi technique
24

25. 25
Priority
ranking
1
2
3
4
5
6
In-patient
Morbidity
Family
disruption
Economic
Consequen
-ces
Public and
potential
demand
Technical
feasibility
of solution
Social
Consequen
ces
Suffering
and
disability
Enteric
diseases
Complication
of pregnancy
Respiratory
diseases
TB
Malnutrition
Measles
Alcoholism
Psychiatric
disorders
Skin diseases
inc. Leprosy
TB
STD
Alcoholism
TB
Bilharazia
Trauma
Polio
Leprosy
LeprosyLeprosy
TB
TB Trauma
Malnutrition
Malaria
Complication
of pregnancy
Alcoholism
TB
Measles
Polio
Water borne
diseases
Alcoholism
STD
Psychiatric
disorders
Polio
Eye
diseases

26. 26
Weighting of
criteria
Criteria
Cost per
DAILY
2
Public
demand
1
Mortality
rates
2
Disability rates
1
Allocated
score
4
Measles AIDS AIDS Polio
3 TB Alcoholism TB Alcoholism
2 Malaria Malaria
1 Gastro-enteritis
Scoring
AIDS 12
TB 12
Measles 8
Malaria 8
Alcoholism 6

27.  Generation and assessment of various options for
achieving the set objectives and targets (e.g. ↓
child malnutrition by 25%)
 Determine which is most appropriate
 First brainstorm to emerge creative ideas than
reduce to short list of options
 Criteria
 Economic appraisal
 Equity
 Feasibility
 Acceptability
27

28.  Translate the results of earlier decision into
a series of programs, each with a budget
(plan document)
 Level of detail, regarding the budget and
time frame depends on types of plan
(strategic or operational)
 Logframes – a means of ensuring logical
approaches to project design is followed and
providing a means of monitoring a progress
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29. 29
Hierarchy of
Objectives
Objectively
Verifiable
indicators
Means of
verification
Assumptions
Goal
Improve RH
(impact)
MMR by 20%
Morbidity by 20%
IMR by 15% -----
Evaluation
report
mortality,
morbidity and
fertility is due to
lack of Knowledge
and access to
quality services
Objectives
use of RH
services
(outcomes)
Clinic attendance
by women 30%, by
adolescent 60%
Contraceptive
prevalence rate
30%
Monthly
report

30. 30
Hierarchy of
Objectives
Objectively
Verifiable
indicators
Means of
verification
Assumptions
Outputs
12 existing
RH facilities
upgraded
Program
monthly
report
Activities
Secure
funding
Appoint
contractor
Ensure
standard
Inputs
Staff salary
Training
Equipment cost

31.  Situational analysis, including the health
needs or problem being tackled
 Objectives of the plan
 Strategies/activities to meet these
objectives
 Resources required, including finance to
provide the services, and from where these
are to be provided
 Timetable
 Foreseeable constraints or risks
31

32.  Penultimate stage of planning
 Reasons cited for poor implementation
 Lack of funds/ relevant resources
 Poor timing of inputs / coordination
 Resistance to change
 Neglect of institutional or legal requirement
 Unforeseen circumstances / unexpected results
 Real cause - Poor planning design
 failure to recognize the political nature of planning
 overoptimistic objectives
32

33.  Key activity to improve Implementation is
monitoring
 Require explicit time frame for well
specified activities and a clear
understanding of who is responsible for it
(e.g. GANTT chart)
 Choose minimum no. of indicators
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34.  Ask questions about outcomes, outputs and
inputs
 Provides the basis for the next SA
34

35.  What were the objectives of the activities
being evaluated? Were they appropriate?
 Were the objectives set achieved? If not, why
not?
 Were any health improvements the direct
result of the activity?
 Were there any other effects of the
activities?
35

36. Outputs
 Were the services provided?
 Appropriate, relevant, and adequate?
Inputs
 Did the resources planned arrived?
 Sufficient, turned into services?
36

37.  Concerned with change and each change has its
opponents/ proponents
 Highly influenced by the context, stakeholders’
power, value and attitudes (e.g. PHC Vs curative
care)
 Planning process should:
 Open consultation
 Develop cohesive support for proposal
 Be pragmatic and look for compromise proposals
37

38. 38
Health ministry
National strategic plans
Regional health organizations
Regional plan
District health organizations
District plans
Private sector
organization
Business plan
NGO
Organizational
plan
Primary care
Service plans
Primary care
Service plans
Managerial control
Regulatory control

39. Greater approval role by MOH
39
National strategic
Health plans
District strategic health plan
District operational health
Plan and budget Plan relationship
Responsibility
National Ministry of
Health
District Health
team

40. MOH – advisory technical role
40
National strategic
Health plans
District strategic health plan
District operational health
Plan and budget Plan relationship
Responsibility
National Ministry of
Health
District Health
team
District development
plan
District
authority

41. 41
Central Government
MOH other
Ministries
Central Government
MOH other
Ministries
Local Government
MOH other
Ministries
Specialist
H service
General
H service
Devolution
Specialist
H service
District Health Officer
General
H service
Deconcentration
Line management
Other relation (fund,
Technical, regulatory)

42.  Low and middle income countries – health care
structure are highly centralized
 In terms of decision making structure – delegation
of powers and devolution – greater local control
and flexibility
 Setting broad policies and strategies at central
and leaving the detailed implementation to lower
lever and other non-state agencies
 Central - needs to develop regulatory and quality
assurance role
42

43.  Central to periphery budget allocation
- based on population characteristics to reflect need
and equity such as pop. age, sex, social class,
mortality, morbidity
 Need strong central human resource planning
– local areas set their own salary level – Health Staff
may move freely between areas in response to
labor market
43

44. Greater efficiency in service provision
 Decision making closer to community served –
accords with community participation principle
 Decision making closer to the field level service
providers –more appropriate services
 Greater potential for multisectoral collaboration at
lower service delivery level
 Enhance the ability to tap into new forms of
finance generation
44

45.  Inequity between different areas –
particularly in resource generating
mechanism
 Lead to different levels of technical
standards between different areas
 Rapid decentralization – lack of sufficient
skilled staff e.g., financial mgt.
 If handled inappropriately – decision making
by elites
45

46. Advantages Disadvantages
 Clear program focus
 Staff specialization
and expertise
 Ability to attract
specific funding
 Inconvenience to
users
 Inefficiency arising
from duplication
 Competition for
funding
 Lack of local control
46

47.  Five years has been taken as the standard
time frame – ? too rigid
 Rolling process of planning – each year the
plan period is rolled on by a year and often
combined with a long term perspective plan
Process
 Take account time needed for consultation
at different stages / each level
 Link with higher and lower level plan and
overall system
47

48. 48
Detailed
Operational
Plan and
budget
Year 1
Less
Detailed
Plan and
budget
Broad
Plan and
budget
Year 2 Year 3
Rolling plan
Year 1
Detailed
Operational
Plan and
budget
Year 2
Rolling plan
Less
Detailed
Plan and
budget
Year 3
Broad
Plan and
budget
Year 1 Year 2 Year 3
Perspective plan
Yr. 3 Provide broad outline info.
e.g. overall no. of HCs to be
Constructed
Yr. 2 More detailed info.
e.g. breakdown no. of HCs by region
Yr. 1 The most detailed info.
e.g. An operational plan with info.
On precise location, start & finish
date for construction of HC

49. 49