Strategic Planning for NTPs
EMRO NTP Managers’ Meeting 2004
Holger Sawert
TB budget data 2003
Making a plan: a general framework
GOALS
OBJECTIVES
PRODUCTS
ACTIVITIES/PROCESS
INPUT
The general framework in TB control
Goal
–
Eliminate TB as a public health problem
Objectives
–
Detect and cure cases
DOTS Training, supervision, supply of drugs/reagents etc staff, equipment, drugs, reagents etc.
Products
–
Activities/Process
–
Inputs
–
Stages of NTP development
Cure rate coverage Case detection rate II. Expanded DOTS network Cure rate e.g., MDR level, TB/HIV coIII. Additional, countryspecific TB control-activities infection level
Program stage
Key outcome indicators
I.
DOTS within MOH system
Determining the program stage
Cure rate at MOH sites
MOH coverage Case detection rate yes Average cure rate yes >85%?
no
no
Stage I
100%?
yes
no no
Stage II
>70%? >85%?
yes
Stage III
‘DOTS’ and ‘Beyond DOTS’
Most NTPs are in stage I or stage II, i.e., cure rate is below 85%, detection below 70% For these programs, ensuring quality implementation of the five DOTS components is the absolute priority Quality DOTS will ensure high cure rates and may also be sufficient to achieve high case detection
TB Control: The 5 components of DOTS
Political commitment Diagnosis by microscopy Adequate supply of SCC drugs Directly observed treatment Monitoring, Management
TB Register
Setting the standards
Commitment
–
sufficient funding for all activities available at all levels labs well equipped, QA system in place drugs of good quality available at all centers at all times all patients have appropriate supervisor all training, supervision, monitoring according to guidelines records complete, reports adequate and timely
Diagnosis
–
Drugs
–
DOT
–
Quality
– –
Example of Task Analysis
1.0 Estimate Needs / Prepare Procurement Plan 1.1 Estimate amounts of drugs NDT districts will need. 1.2 Estimate amounts of drugs rest of country will need for first year. 1.3 Estimate amount of TB-related supplies needed for NDT districts and rest of country
2.0 Obtain Financing
2.1 Obtain and compare drug price information.
2.2 Calculate real cost of drugs.
2.3 Prepare a sound budget.
3.0 Purchase / Ensure Quality
3.1 Implement system of quality control and regulations for drugs.
3.2 Identify technical specifications for drugs.
3.3 Identify technical specifications for syringes, needles and sterile water.
4.0 Distribute / Store
4.1 Establish distribution procedures
4.2 Establish storage procedures
5.0 Monitor Usage
5.1 Ensure proper usage of standard chemotherapy
5.2 Manage drug stocks
The management cycle
Planning
Strategic evaluation
Implementation
Monitoring
Strategic evaluation
Goals achieved? yes No change! yes
no
Objectives achieved? no Products produced? no New activities to improve products ! yes No change! No change!
Indicators for strategic planning
Goals achieved?
–
Prevalence, mortality
Objectives achieved?
–
Cure rate, case detection rate
Planned activities and products produced?
–
‘Process indicators’ for DOTS components
Interaction: planning and monitoring
Monitoring GOALS
Planning
OBJECTIVES Process indicators PRODUCTS
ACTIVITIES/PROCESS
INPUT
Process indicators for DOTS
Commitment:
• •
Proportion of total financial requirements met Proportion of implementation units with adequate budget
Diagnosis:
•
• •
Proportion of units adequately equipped and supplied Proportion of symptomatics examined with 3 smears Proportion of units with adequate QA results
Proportion of treatment units with stockouts Proportion of drugs that concur to standard quality criteria Proportion of cases receiving adequate DOT Proportion of staff trained Proportion of planned supervision and monitoring activities actually performed Proportion of units with accurate, complete and timely reports
Drugs:
•
•
DOT
• • • •
Monitoring, development, management
Example of a ‘Problem Tree’
Low cure rate
Late Diagnosis
Drug shortages
Lack of awareness about tuberculosis
High health services fees
Budget insufficient
Poor drug supply system
Turning problems into actionable objectives
Low cure rate Cure rate increased
Late diagnosis Early diagnosis
Drug shortages Drugs available
Low awareness about TB Increase awareness
High fees for diagnosis TB diagnosis free of charge
Insufficient budget Budget sufficient
Poor supply system Drug supply system adequate
Actionable objectives
Increase
cure rate!
Ensure
uninterrupted drug supply!
new drug logistics system!
Design
Simple analysis
Treatment centers not supervised
Supervise all centers!
No money for per diems
Provide per diems!
NTP budget too low Money: MOH / donors!
Thinking more deeply…
Treatment centers not supervised
No money for per diems
No transport
No time for supervision
NTP budget too low
No vehicles/ No priority ?
No staff/ No priority ?
Thinking more deeply…
Ensure supervision
Provide per diems
Provide transport
Ensure staff availability
Money from MOH/donors
Buy cars/
Employ staff/
Advocacy ?
Advocacy ?
The management cycle
Planning: buy drugs for 20,000 pts.
Strategic evaluation
Implementation: Drug procurement, distribution
Monitoring:
Drug stockouts in 30% of all centers
Interaction: Planning, monitoring, problem analysis
stockouts No buffer stock No central warehouse District orders Not appropriate Drug prices Too high MOH exclusive supplier
Provincial warehouses No national Not functional Logistics system
Obtaining actionable objectives
No stockouts buffer stock Central/provinces Timely orders Based on case finding Drug prices As international NTP can chose cheapest supplier
Central warehouse Provincial warehouses National logistics available functional System available
Strategic activities based on problem analysis
NTP can chose cheapest drug supplier
–
–
obtain drug price quotes from several suppliers Advocacy to minister to allow alternative procurement
construct new warehouse at central level renovate warehouses at provincial level Hire consultant to design new drug logistic system revise national training material to include new drug logistic system (print separate brochure?) print and distribute new drug order forms hold training course on drug logistics with PTCs/DTCs include drug logistics in PTC supervision checklist
Central level warehouse available
–
Regional warehouses functional
–
National drug logistics system available
– – – – –
The management cycle
Planning: •obtain drug for 20,000 several Buy drugsprice quotes from pts. suppliers
•Advocacy to minister to allow alternative procurement •construct new warehouse at central level •renovate warehouses at provincial level •Hire consultant to design new drug logistic system •revise national training material to include new Implementation: drug logistic system (print separate brochure?) Drug •print and distribute new drug order forms … procurement, •hold training course on drug logistics with distribution PTCs/DTCs •include drug logistics in PTC supervision checklist
Strategic evaluation
Monitoring: Drug stockouts in 30% No stockouts of all centers
Challenges
Making planning an important NTP activity
–
E.g., annual planning workshop with staff from peripheral levels, in time for MOH budget submission
Including process indicators in NTP monitoring system
–
–
– –
WHO indicator manual Little experience Collect actionable data Avoid data drowning
Group exercise
Each group to consider one DOTS component Are there problems with this component? Identify process indicators Analyze problems with ‘problem tree’ Convert ‘problem tree’ into ‘activity tree’ Do the same exercise for other DOTS components!