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REVERSING THE TRENDS

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REVERSING THE TRENDS Powered By Docstoc
					  THE SECOND ANNUAL
OPERATIONAL PLAN (AOP 2)
  JULY 2006 – JUNE 2007

      DRAFT REPORT
    Presentation to Stakeholders,
  Kenya School of Monetary Studies
           2ND MAY 2006
        Presentation format
• AOP2 development process- RRI
  Team Leader
• Example of DHP development
  process-Machakos District Health
  Plan – DMOH
• AOP2 as a consolidation of DHPs-
  RRI Team Leader
             Presentation Stakeholder Meeting   2
THE PROCESS

   Presentation Stakeholder Meeting   3
PROCESS OF DEV. OF AOP 2
• Development of Planning Tools and
  Format
• Training of districts, provinces, and
  programmes/divisions
• District consensus building on draft DHP
• Submission of draft DHP to Planning
  Team
• Appraisal of DHP
• Consolidation into AOP 2
              Presentation Stakeholder Meeting   4
         DISTRICT PLANNING
• Each district participated in a five day planning
  workshop to develop draft DHP
• Focus was on service delivery outputs linked to
  district priorities, resources available, and
  contributing to overall national targets
• Support provided to districts
  –   Planning tools and format
  –   Resource envelop (GOK, some Prog & Partners)
  –   Technical Assistance
  –   Resource materials

                  Presentation Stakeholder Meeting    5
      PROVINCIAL PLANNING
• Each province participated in a five day planning
  workshop
• Focus was on support supervision, coordination,
  monitoring and skills upgrading responding to
  DHPs and linked to available resources
• Support provided
  –   Planning tools and format
  –   Resource envelop (GOK and some prog)
  –   Technical assistance
  –   Resource materials

                 Presentation Stakeholder Meeting   6
  PROGRAMMES/DIVISIONS
       PLANNING
• Invited to 2 day planning workshop
• Focus was on systems support to the
  districts and provinces
• Support provided
  – Planning tools and format
  – Technical assistance
  – Resource materials


               Presentation Stakeholder Meeting   7
          DHP APPRAISAL
• Each DHP was appraised by selected
  group of programmes/divisions (10 in
  number)
• Comments and suggestions were
  discussed with each district individually
• On the basis of discussions/negotiations
  districts finalised their plans


               Presentation Stakeholder Meeting   8
          CONSOLIDATION
• Developed DHP consolidation tools
• All DHPs consolidated into AOP 2
  (ongoing)
• District targets determining national
  targets. For the first targets will be;
  – Linked to resources
  – Set and owned by the districts


                Presentation Stakeholder Meeting   9
DISTRICT HEALTH
   PLANNING

 MACHAKOS DISTRICT
  MOH, MACHAKOS
   DHP Development Process
• Five day workshop for DHMT to develop initial
  working draft plan
• Sensitisation of full DHMT on planning process
• DHSF sensitisation
• Development of draft plan by DHSF Steering
  Committee
• Consensus by full DHSF
• Appraisal of the draft DHP
• Finalisation of DHP
                Presentation Stakeholder Meeting   11
        Machokos DHP FOREWORD

The Machakos District health plan for the year 2006/2007
  is the result of a process which involved consultations
among the health workers, DHMT, and the stakeholders.
  The workplan represents the health needs of the vast
Machakos district. It was a challenging experience for the
 DHMT and the stakeholders in developing the workplan.
  However the challenge was well taken and there was
  participation of everybody. The plan is geared towards
reducing the burden of disease in the district by providing
 quality health care in curative and preventive fields. The
   Machakos DHMT and the stakeholders are up to the
challenge of implementing the plan. It is our sincere hope
 that after implementing the plan the health status of the
     Machakos community will improve tremendously.
                   Presentation Stakeholder Meeting           12
              EXECUTIVE SUMMARRY

The workplan contained herein reflects all DHMT and
  DHSF planned activities for the year 2006/07. there are
  174 health facilities with immunisation coverage of
  71.6%. The leading cause of outpatient morbidity is
  malaria accounting for 36.2% of the total new cases
  reported, and an HIV/AIDS prevalence of 6.7%. The
  major causes of mortality are from HIV/AIDS related
  complications. The DHMT has developed a workplan
  with a budget of KES 206,357,210.00 to address all
  identified needs in the year 2006/07.



                   Presentation Stakeholder Meeting         13
Demographic and Health Indicators
•   District size                            6281 sq km
•   Pop (projected 2006)                     1,102,934
•   HIV Prevalence                           6%
•   CBR                                      38/1000
•   IMR                                      56/1000
•   U5MR                                     84/1000
•   MMR                                      200/100,000
•   Contraceptive Prev. Rate                 51%
•   Immunisation coverage                    71.6%
•   Poverty                                  66%
•   Nutritional status
     – Stunted                               33%
     – Wasted                                4%
     – Underweight                           24%

                       Presentation Stakeholder Meeting    14
      DISTRICT HEALTH SERVICE AND
         CAPACITY ASSESSMENT
•   Demographic profile
•   Population by cohort
•   Population by service category
•   Morbidity pattern by cohort
•   IP mortality by cohort
•   Workload (service delivery)
•   # health facilities by level
•   Catchment population per facility
•   Human resource (medical and technical)

                 Presentation Stakeholder Meeting   15
DISTRICT HEALTH SERVICES
   ANALYSIS: AN OUTLINE




       Presentation Stakeholder Meeting   16
               MATERNAL HEALTH
• KEY ISSUES
  – Malaria in pregnancy
  – HIV/AIDS
  – High maternal death rate
• CONSTRAINTS AND CHALLENGES
  –   Community ignorance
  –   Poor accessibility to health facilities
  –   Inadequate staff and equipment
  –   Negative attitude by health personnel
  –   Delivery by unskilled birth attendants
• PRIORITIES
  –   Train HCW in FANC
  –   Provision and use of ITN
  –   Community sensitisation
  –   Start community services
  –   Equip facilities
                        Presentation Stakeholder Meeting   17
               EARLY CHILDHOOD
• KEY ISSUES
  – Low immunisation coverage
  – Malnutrition
  – Child mortality
• CONSTRAINTS AND CHALLENGES
  –   Poor access to health facilities
  –   Competing priorities for mothers
  –   Vaccine stockouts
  –   Inadequate cold chain
  –   Low ITN coverage
• PRIORITIES
  – Start outreach activities
  – Senstise community on vaccination and ITN
  – Procure cold chain equipment


                       Presentation Stakeholder Meeting   18
              LATE CHILDHOOD
• KEY ISSUES
  –   malnutrition
  –   Malaria
  –   Worm infestation
  –   School dropout
  –   Drug abuse
• CONSTRAINTS AND CHALLENGES
  – Poor sanitation
• PRIORITIES
  – School health programme
  – Counselling and guidance
  – Community sensitisation
                   Presentation Stakeholder Meeting   19
          ADOLESCENT HEALTH
• KEY ISSUES
  –   Drug abuse
  –   Teenage pregnancy
  –   Abortions
  –   HIV/AIDS
• CONSTRAINTS AND CHALLENGES
  – One youth centre
  – Peer pressure
• PRIORITIES
  – Integration of youth friendly services into health
    facilities

                   Presentation Stakeholder Meeting      20
     ADULT (GENERAL HEALTH)

• KEY ISSUES
  – HIV/AIDS
  – Malaria
  – TB
• CONSTRAINTS AND CHALLENGES
  – Behaviour change
  – Low ITN coverage
• PRIORITIES
  – Community sensitisation on ITN and behaviour
    change

                 Presentation Stakeholder Meeting   21
                      ELDERLY

• KEY ISSUES
  – Hypertension
  – Diabetes
  – Abandonment
• CONTRAINTS AND CHALLENGES
  – High cost of drugs
  – Poor eating habits
• PRIORITIES
  – Health education
  – Sensitise community to care for elderly

                   Presentation Stakeholder Meeting   22
  COMMUNITY STRENGTHENING

• KEY ISSUES
  – Scarce resources
  – Poor prioritisation
• CONSTRAINTS AND CHALLENGES
  – Low utilisation of available resources
  – Political interference in management of facilities
  – Low capacity of RHF Committees
• PRIORITIES
  – Community mobilisation
  – Capacity building for RHF Committees

                   Presentation Stakeholder Meeting      23
        SRENGTHNING REFERRAL
• KEY ISSUES
  – Poor referral system
• CONSTRAINTS AND CHALLENGES
  –   Poor communication
  –   Lack of ambulances
  –   Inadequate personnel
  –   Low community awareness of the referral system
• PRIORITIES
  – Avail ambulances
  – Provide radio calls, mobile phones etc
  – Sensitise community and health workers on early
    referral
                   Presentation Stakeholder Meeting    24
          CURATIVE SERVICES

• KEY ISSUES
  – Poor quality of services
  – Poor access to services by the community
• CONSTRAINTS AND CHALLENGES
  – Inadequate staff and skills
  – Lack of equipment, drugs and supplies
  – Inaffordability of services
• PRIORITIES
  – Recruit and train more staff
  – Equip facilities and procure drugs and supplies

                  Presentation Stakeholder Meeting    25
  NON-COMMUNICABLE DISEASES
• KEY ISSUES
  –   Diabetes
  –   Hypertension
  –   Malnutrition
  –   Gynaecological conditions
• CONSTRAINTS AND CHALLENGES
  – Lack of community awareness
  – High cost of treatment
  – Lack of updates to health workers
• PRIORITIES
  – Create community awareness
  – Refresher courses for health workers

                      Presentation Stakeholder Meeting   26
  INFRASTRUCTURE AND EQUIPMENT

• KEY ISSUES
  – Poor infrastructure
  – Lack of maintenance
• CONSTRAINTS AND CHALLENGES
  – Poorly maintained buildings and equipment
  – Inadequate infrastructure
  – Inadequate equipment
• PRIORITIES
  – Renovation of infrastructure
  – Maintenance of existing equipment/infrastructure

                  Presentation Stakeholder Meeting     27
HUMAN RESOURCE MANAGEMENT

• KEY ISSUES
  – Poor services
• CONSTRAINTS AND CHALLENGES
  – Inadequate staff
  – De-motivated staff
  – No regular updates
• PRIORITIES
  – Adequate staff
  – Regular updates
  – Motivate staff

                    Presentation Stakeholder Meeting   28
DRUGS AND OTHER MEDICAL SUPPLIES

• KEY ISSUES
• Inadequate drugs and other supplies
• CONSTRAINTS AND CHALLENGES
   –   Irregular supplies from KEMSA
   –   Inadequate number of vehicles for drug distribution
   –   Inadequate number of staff
   –   Insufficient funding
   –   Irrational use of drugs
• PRIORITIES
   – Timely supply from KEMSA
   – Purchase vehicle for drug distribution
   – Train health workers on rational use of drugs

                        Presentation Stakeholder Meeting     29
              GOVERNANCE

• KEY ISSUES
  – Bureaucracy
• CONSTRAINTS AND CHALLENGES
  – Lack of dissemination of policy guidelines
• PRIORITIES
  – Dissemination of policy guidelines



                Presentation Stakeholder Meeting   30
             WORKPLAN
• Defines activities to be undertaken and the
  responsible actors (stakeholders)
• Provides budget estimates and identifies
  the source of funding by stakeholder

• The plan is linked to the resources
  available and involves all stakeholders in
  its development, funding and
  implementation (see handout)
               Presentation Stakeholder Meeting   31
AOP2 - THE PRODUCT
 RESOURCE BASED, BOTTOM UP
           AOP 2
       (FIRST DRAFT)


        Presentation Stakeholder Meeting   32
        TABLE OF CONTENTS
              AOP 2
• SECTION I: PRINCIPLES AND PRIORITIES
  – Introduction
  – Key principles AOP 2
  – Goals, objectives and key priorities
• SECTION II: WORK PLANS
  – KEPH Service Delivery
  – KEPH inputs and support systems
  – Governance of AOP 2 implementation
• SECTION III: FINANCE AOP 2
  – Budgetary requirements
  – Financing AOP 2

                  Presentation Stakeholder Meeting   33
               INTRODUCTION
• NHSSP II 2005 – 2010 approved and launched;
• AOP 1 July 2005 – June 2006 outputs partly achieved:
  see index of AOP 2;
• SWAp Coordinating Committee (SCC) and RRI teams
  inputs; dialogue among departments and divisions is
  strengthened;
• Lessons learned during development of AOP 2:
   – Guidelines for KEPH implementation need to be finalized;
   – AOP 2 bottom-up planning process initiated, but resource
     envelope should be communicated earlier;
   – Systems have been developed, but still need wide application
   – Performance monitoring needs to be put in place;
   – Partners have become involved.


                      Presentation Stakeholder Meeting              34
  KEY PRINCIPLES AOP 2 (1)
1. Norms and Standards have been defined; they
   are the basis for planning and provide
   framework to uniform delivery of services;
2. SWAp development process has allowed joint
   planning and joint implementation of KEPH
   and its support systems; For the first time there
   is a common vision where to go with the sector
3. Results Based Management (RBM) implies
   responsibility AND accountability; Performance
   contracts will be signed by managers at all
   levels to allow the achievement of the defined
   outputs / targets;
                 Presentation Stakeholder Meeting   35
  KEY PRINCIPLES AOP 2 (2)
4. Bottom-up resource based planning by 80
    districts, 8 provinces and all divisions /
    programmes has allowed AOP 2 to be owned
    by MOH and stakeholders. AOP 2 is therefore
    a full part of the Kenyan SWAp;
5. JPWF and AOP 2 are aligned. They have the
    same format and content but differ in time-
    frame and emphasis:
JPWF: 4 years, resource / funding oriented
AOP 2: 1 year, more operational and output
    oriented.

               Presentation Stakeholder Meeting   36
      Norms of key staff by level of care
Level   population   Service delivery staff                    Support staff
I       5,000        50 CORP
                     2 Community health worker
II      10,000       2 comprehensive nurses                    2 attendants
                     1 PHO                                     1 watchman
III     30,000       1 community health worker                 2 statistical clerks
                     2 clinical officers                       1 clerk/cashier
                     14 nursing staff                          2 attendants
                     1 COHO                                    1 cook
                     1 Lab Tech                                2 watchmen
                     1 Pharm Tech

IV      100,000      1 community health worker                 2 statistical clerks
                     6 medical officers                        1 clerk/cashier
                     1 dentist                                 10 attendants
                     7 clinical officers                       2 drivers
                     60 nursing staff                          4 cooks
                     1 lab technologist                        3 watchmen
                     2 lab technicians
                            Presentation Stakeholder Meeting                     37
                     2 Pharm Techs
               KEY PRIORITIES
• Sector intends to focus on a few essential priorities,
  rather than to try to address all the problems. These
  are:
   – Initiate level 1 services and strengthen public health;
   – Strengthen facility based health service delivery (lev
     2–4);
   – Facilitate availability of funds at point of use through
     improved FMS, linked with PME and RBM;
   – Continue to strengthen stewardship, partnership and
     coordination (Dev SWAp governance structures and
     institutionalise sector responsibility and
                      for inputs and outputs).
     accountability Presentation Stakeholder Meeting       38
   GOALS AND OBJECTIVES
• Goals and objectives of AOP 2 are derived from
  the NHSSP II. They are closely related to the
  ERS/MDG
  – Access to health through expansion of level 1
    activities and strengthening service delivery in levels
    2–4
  – Change of attitudes and practices of clients to
    improve utilisation of services
  – Improve absorptive capacity of gov systems through
    strengthening PFM, RBM, and PME
  – Foster stewardship and partnership through
    expanding dialogue with all stakeholders
                   Presentation Stakeholder Meeting           39
   KEPH SERVICE DELIVERY
           (Ch 4)
• Service delivery baseline (2005/06) and
  targets (2006/07) from 80 districts have been
  brought together (bottom-up process);
• Baseline and targets from programmes
  harmonized with those from the districts;
• Work plans from several central level
  programmes detailing system support to be
  provided to the districts;
• Table with interventions / activities by level
  of care and for all the cohorts (handout).

                Presentation Stakeholder Meeting   40
Interventions and activities by level
         of care (example)
Cohort     Result       Output              Targets Interventions
Pregnancy Mothers are Improved      Next               -Strengthen
and NB    kept healthy maternal and slide              capacity of staff
          during       NB health                       levels 1-4
          pregnancy                                    -Awareness
                                                       creation on
                                                       HIV/AIDS level 1
                                                       -Provision of PMCT
                                                       services levels 2-4
                                                       -Provision of 2 free
                                                       SP levels 2-4
                                                       -Distribution of
                                                       ITNs levels 1-4

                    Presentation Stakeholder Meeting                     41
        SERVICE DELIVERY TARGETS
Indicator                                National Average (from districts)
                                 Baseline       District ERS     National
                                                   Targe   Targe    Target
                                                   t       t
% del by skilled birth           9%             24%         -        -
  attendants
% preg women sleeping            14%            45%         50%      80%
  under LLITN
% preg women receiving           18%            53%         -        60%
  IPT x 2
% NB receiving BCG               90%            100%

% child fully immunized at       48%            71%         85%      -
   1 yr
% child <1yr immunized           42%            68%         85%
   measles
# VCT clients                    230,228        707,463     -        2,000,000
# pts starting ART                                Meeting
                         Presentation Stakeholder403,258
                                 39,585                     -        190,000     42
                Support central level divisions
                   (Reproductive Health)
     Result            Outputs               Interventions / Activities            Time Frame      Responsibility
                                                                               Q    Q     Q   Q
                                                                               1    II    III IV
Demand for RH   Community level        Develop IEC and BCC materials           X    X     X   X
Services are    interventions          Support the community level
created and     strengthened and new   interventions
services are    midwifery model
                                       Community MDR guidelines                X
scaled up       started to be
                                       disseminated and are in use
                implemented
                                       Community midwifery model tested in     X   X    X     X
                                       10 districts
Commodity       Contraceptive          Procuring of commodities (Depo          X   X    X     X
security is     commodities and        Provera, implants, condoms,
ensured         equipment are          combined pill and progesterone only
                available              pill, emergency contraceptive pill
                                       Procurement and distribution of basic   X
                                       equipment for RTI services
                                       Procurement and distribution of basic   X   X    X     X
                                       and comprehensive obstetric care
                                       equipment
                                       Presentation Stakeholder Meeting                                     43
KEPH Inputs and Support Systems
• Inputs:
  – Human Resources for Health
  – Infrastructure;
• Support Systems:
  –   Regulations and standards,
  –   Planning,
  –   Financial Management Systems,
  –   Procurement systems,
  –   Commodities and supply management,
  –   Performance based M&E

                 Presentation Stakeholder Meeting   44
      KEPH SUPPORT SYSTEMS (1)
         (inputs, example HRH)
Current challenges
• Shortage of staff to meet present needs and future needs of delivering
  KEPH
• High staff attrition rates without visible programme of replacement
• Inequitable distribution of staff
• Skills imbalances, especially between rural and urban areas
• Poor working environment
• Lack of national database of health sector staff

Results AOP 2
• Adequate numbers of skilled staff to deliver KEPH at levels 1, 2 and 3 in
  place

Outputs AOP 2
• National database of staff in health sector established;
• After three years, Level 1 will have 160,000 CORPs trained (as per norms);
• 50% of Health Facilities in level 2 - 3 will have adequate numbers of staff;
• Adequate numbers of motivated staff is present in levels 2 and 3.
                           Presentation Stakeholder Meeting                 45
 GOVERNANCE OUTPUTS (1)
• Leadership outputs
  – Effective coordination mechanisms in place
     • Governance and Management structures at district
       level strengthened
     • New PH legislation prepared
  – Partnership arrangements up-dated
     • MOH-FBO arrangements formalized
• Equity and rights related outputs
  – GOK financial contribution increase to 12%
  – Resource allocation criteria reviewed
                 Presentation Stakeholder Meeting     46
 GOVERNANCE OUTPUTS (2)
• Efficiency related outputs:
  – PFM improvement plan implemented
  – Outputs AOP 2 measured against inputs
• Effectiveness related outputs
  – Result Based Management (RBM) initiated
• SWAp related outputs
  – SWAp strategy developed
  – DP resources harmonized with GOK
    procedures
               Presentation Stakeholder Meeting   47
FINANCING AOP 2




   Presentation Stakeholder Meeting   48
           District Budget
Service Delivery                 2,862,608,403


Support Systems                  2,523,565,545


Governance                       68,082,777


Total                            5,454,256,725


              Presentation Stakeholder Meeting   49
    District Budget by level

Level 1                    8%

Level 2                    14%

Level 3                    16%

Level 4                    62%
          Presentation Stakeholder Meeting   50
       Fig. 7.1b: Districts budget by Cohort


                               1%

                  28%
                                              42%


                  4%
                   3%

                          22%


Cohort 1   Cohort 2   Cohort 3      Cohort 4         Cohort 5   Cohort 6


                  Presentation Stakeholder Meeting                         51
Resource requirements (service, systems,
Governance)

                                 FBO/
System     District         Prov NGO          Central           Total

Service
delivery    2,862,608,403     na               16,022,429,931    18,885,038,334

Support
Systems     2,523,565,545     na               18,811,981,582    21,335,547,127

Governan
ce             68,082,777     na                           0            68,082,777



Total       5,454,256,725     na        na 45,639,168,888        51,093,425,613
                        Presentation Stakeholder Meeting                    52
FINANCING GAPS




   Presentation Stakeholder Meeting   53
  Strategy for Financing Gaps
• Joint Programme of Work and Funding
• Strengthening NHIF
  – Coverage beyond traditional groups
  – Review of contribution rates
  – Review accreditation of facilities
• User Fees
• Prepayment Schemes
• Public-Private Partnerships
               Presentation Stakeholder Meeting   54
               Summary
The AOP 2 as conceived and developed is
a product of;
   - bottom up process
   - involving all stakeholders
   - linked to the resources

Its priorities, interventions, outputs and
targets have been determined by the
districts.
              Presentation Stakeholder Meeting   55
 What do we require from this
         meeting?
An appraisal of the draft AOP 2 with
comments and suggestions in regard to
the following;
 1.   Comprehensiveness
 2.   Technical feasibility
 3.   Financial feasibility
 4.   Institutional capacity and feasibility




                Presentation Stakeholder Meeting   56
THANK YOU


  Presentation Stakeholder Meeting   57

				
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