Federal Ministry of Health National Government of Unity/ MDTF Decentralized Health System...

Federal Ministry of Health National Government of Unity/

MDTF

Decentralized Health System Development Project (DHSDP)

Final Project ProposalOC Meeting

August the 28th, 2006

Contents of the presentation

• Project preparation process

• Context and key health sector development issues

• Targeted states and health indicators in the selected states

• Project Description

– Project Development Objective and Key Performance Indicators– Project Components– Performance indicators– Project Costs

• Implementation arrangements– Institutional and Implementation Arrangements – Procurement Arrangements– Financial Management Arrangements– Monitoring and Reporting– Sustainability and Critical Risks

• Next steps

Project Preparation Process• Initial Project Proposal considered by Health

Thematic Group and approved by IOC in February• 2 consultative meeting were convened and provided

invaluable inputs to the project development (February and June (health coordination meeting and HTG)

• More than 20 core team meetings• State-level planning and consultation

– State Ministries of Health consulted on IPP– Field missions to targeted states were completed (all

parts of each state)– Project Implementation Plan developed (1 workshop in

each state 2 workshops in the federal level)– Detailed technical planning to continue during project

implementation

Project Preparation Process

• As part of project planning and consultation, environmental, social and gender assessment in the four target states has been done:– Assessment missions have highlighted

significant social, cultural, financial, and conflict-related barriers to health care facing women and vulnerable groups particularly

– An Environmental and Social Management Framework (ESMF) and a Resettlement Policy Framework (RPF) have been chosen as mitigation instruments

Key health sector issues

Poor PHC infrastructure and performance and low level of access to and utilization of health services

– Overall, but specially in the four target states there are large deficiencies in existing public health services

– Key staff are deficient, poorly deployed, paid and motivated and often have insufficient technical knowledge and skills

– Although early phases of pharmaceutical supply system exists (RDF) the supply of pharmaceuticals to lower levels health facilities is uncertain,

– Basic equipment is lacking and working conditions are poor and quality of care is low,

– In many areas of the target states, there is a basic lack of health facilities and services, with limited support from non-governmental organizations (NGOs)


Large disparities and deficiencies in health services and outcomes– Averages of MDGs health indicators in Northern Sudan are

low, but often better than Sub-Saharan Africa averages;• MMR 509/100,000

• IMR 68/1,000

• U5MR 104/1,000

• Low levels of access to and utilization of health services

– However, these averages masks significant urban-rural and regional disparities, related to conflict, displacement, and poverty;

State LocalitiesPopulation

2005 (million)

IMRUnder-5 MR

MMR RHPI

Blue Nile 5 0.75 101 172 479 81

Red Sea 4 0.77 116 165 415 32

Kassala 12 1.71 101 148 561 64

South Kordofan 12 1.87 95 147 552 75

Total or average (target states)*

33 5.10 101 154 524 66

Northern Sudan average 68 104 509 58


Major financial and social barriers to access to health services

• the Social and gender assessment has shown that:– even in situations where a supply of health services

exists, there are major barriers to access by women, vulnerable groups and the poor in general

– the cost of user fees and medications prevents many poor households from accessing health care,

– many social, cultural, and conflict-related issues have an impact on overall health and access to care


Decentralization, fiscal federalism and the financing of health services– responsibilities for health care services are

decentralized;– the national level commands the bulk of growing

fiscal revenues;– primary and first-referral health care services in the

poorer states suffer from under-financing and inequitable allocation of resources.

– the Federal Government is increasing fiscal transfers to the state governments; and

– committed in its Interim Constitution to emergency and basic health services free to the user.


• Health financing and the MDGs– primary and first-referral health care services in

the poorer states suffer from under-financing and inequitable allocation of resources.

– the (JAM) estimated that additional resources of approximately US$ 215 million would be required annually in the next two to three years in order to achieve significant progress towards the MDGs over all of Northern Sudan

– This project is 19 million US$, targeting 4 states, then leaving a gap of 196 Million US$ annually???

• Bilateral support?• Government investment

Project Description

Project Development Objective (PDO )– Consistent with overall health sector vision to move

towards achieving the MDGs and improve equity

Improve access to quality basic health services by conflict affected populations in conflict-affected and underserved states (4 targeted states, 5.1 Million)

Improving the capacity of the decentralized health system to establish the basis for wider health sector reforms, sustainable financing and sector development

Project Description

2. Project Components• Component1: Expanding access to

primary health care services by underserved populations

• Component 2: Development of the decentralized health system and establishing the basis for wider health sector reform, sustainable financing and development

Component1: Expanding access to primary health care services by

underserved populations

– Objective: to improve access to primary health care services and high-impact health interventions by conflict-affected and underserved populations in the target states in the immediate term,

– Sub-component 1.1. Expansion of coverage of primary health care services and high-impact interventions.

– Key interventions and strategies• injecting new resources into the public system, improving

service quality and allowing reductions in user/consultation fees

• finance mobile and temporary clinics managed and supplied by the State MoHs using government health workers reallocated from better-served areas

• contracting out for some interventions to private providers• provision of high-impact health interventions directly to

communities and households,

Component1: Expanding access to primary health care services by

underserved populations• Sub component 1.2: Pilot experiences to reduce barriers

to access to primary health care services• Key interventions and strategies:

1. Evaluate the implementation, effect on service utilization, and financial feasibility of subsidies for primary health care services with high impact on morbidity and mortality

2. Measure the cost and impact on service utilization of financing the health insurance premiums for all children under-five and pregnant women in an area where the State Health Insurance Fund is functioning

3. Assess the effect on health service utilization by women of interventions designed to address gender-related barriers to access

4. Other pilot experiences will be implemented as needs and opportunities for learning are identified during project implementation

Component 2: Development of the decentralized health system and

establishing the basis for health sector reform

Objective: Increase the capacity of the decentralized health system to establish the basis for sustainable financing, reform and development.

Component 2: Development of the decentralized health system and establishing the basis for health

sector reformSub-component 2.1Capacity building and policy for the development

of the decentralized health system

• Key interventions and strategies1. Health care financing (NHA, TA, policy and strategy

development2. Pharmaceutical supply (TA, studies)3. Health planning, budgeting and management by target

State and Locality health administrations4. Improving the HMIS and Monitoring and evaluation

systems, and other systems (capacity of administrators effectively analyze and use data )

Component 2: Development of the decentralized health system and establishing the basis for health

sector reformSub-components 2.2. human resources for

health development (improvements in the production, quality, deployment and retaining of the PHC workforce. )

• Key interventions and strategies:1. Development and endorsement of health sector-

wide HRH strategies, policies, and practices2. State PHC human resource development strategies 3. Curriculum review and teacher in-service training.4. Rationalization and investment in training schools

and equipment (Health Science Academy)



Sub-component 2.3. Investment in primary health care infrastructure and equipment

• Key interventions and strategies:

1. The aim is to make the provision of the basic package of health services possible

2. Upgrade and expand the PHC infrastructure focusing on the areas where the network of health facilities is weakest

3. Improve the quality of services delivered aiming at improving access and utilization

4. Investment in PHC infrastructure and equipment will be closely coordinated with project’s immediate support to service delivery under sub-component 1.1.



Sub-component 2.4. Project implementation

• Personnel and resources necessary to manage the project and coordinate the project activities at the federal and state levels

• Aims at building needed capacities and supporting the existing institutional structure

Microsoft Word Document

Performance indicatorsComponent Indicator Baseline

Target Phase

1

Target Phase 2

Target Phase 3

Sources

1. Expanding access to primary health care services by underserved populations

Outpatient consultations per person per year in target areas; ratio between highest and lowest wealth quintile

<0.20;5:1

0.30;3:1

0.40;2.5:1

0.50;1.5:1

HMIS & HH survey

% patients who do not receive care due to financial barriers in target areas

100*; 90 70 50 HH survey

Vitamin A coverage in target areas 100* 110 120 130 HMIS & HH survey

Skilled birth attendance in target areas 100* 105 110 120 HH survey

Number of pilot initiatives implemented aimed at reducing financial and gender barriers to care

0 0 2 3 State PIU monitoring reports

2. Establishing the basis for reform and development of the decentralized health system

National Health Accounts completed 0 0 0 1 Study report

% of PHC health facilities included in the investment plan for target areas rehabilitated/constructed and equipped


% of PHC worker training objectives in project plan achieved

(Number of RH trained and deployed)*


Project cost and proposed Budget

(US$ million) MDTF Government Total

Phase 1 6 13 19 Phase 2 8 16 24

Phase 3 9 18 27

Total 23 47 70

Proposed Budget

($US million) Phase 1 Phase 2 Phase 3 Total

1. Expand access to PHC services 6 7 7 20 1.1. Expand coverage PHC & high-impact 5 5 5 15 1.2. Pilots to improve access 1 2 2 5

2. Establish basis for reform & development 13 17 20 50 2.1. Policy & capacity development 4 4 4 12 2.2. PHC human resources development 2 4 4 10 2.3. Investment infrastructure & equipment 6 8 11 25 2.4. Project implementation 1 1 1 3

Total 19 24 27 70

Allocation of budget between states

• Budget allocations to support activities in the four states were determined on a simple per capita basis for Phase1

• Overall increase in public per capita investment 3.33 U$

• Simulations of allocation formulas which include population, federal per capita fiscal transfers to the states, and population per health center, provide results not significantly different from simple per capita allocation

• Allocation within the states will target impoverished and underserved areas (equity)

Proposed Budget

Estimated Population

2005 (million)

Phase 1 per capita

allocation ($US)

Phase 1 Budget (US$

million)

Federal 2.00

Southern Kordofan 1.87 3.33 6.23 Blue Nile 0.75 3.33 2.50 Kassala 1.71 3.33 5.70 Red Sea 0.77 3.33 2.57

Total 5.10 17.00

Annual Planning & Consultation

• To assess progress, adjust planning, reallocated budget

• Broad-based consultation in each state

• Built-into project implementation and M&E

Implementation arrangements

• State consultations and planning– Planning and consultation processes

have been carried out during project preparation at the state level, involving all major stakeholders

– On the basis of this process, a Project Implementation Plan (PIP) was developed and agreed

Implementation arrangements

• Institutional and Implementation Arrangements – The FMoH will be the executing agency, working in close

cooperation with partners and the SMoH of the four target states

– A Federal Project Implementation Unit (FPIU), established in the FMoH will have overall management and coordination responsibilities

– Within the target States, a State PIU (SPIU) will be established within the SMoH for the day-to-day management of project activities

– Federal and State Steering Committees: with representation from the Federal and State Ministries of Health and Finance, as well as other partners (WHO and UNICEF, etc…) will be established and provide overall strategic orientation and oversight for the project

Proposed Implementation Arrangements

Federal SteeringCommittee

Health ThematicGroup

FMoH

Directorates &Programs

MoFNE

FMoH TechnicalCommittee

Federal PIUTarget State

PIUs

Target State Steering

Committees

Target State Stakeholders

Target State MoHs


Target State MoF

Target State Local Authorities & Communities

Line of responsibility

Membership / input

Federal SteeringCommittee

Health ThematicGroup

FMoH


MoFNE

FMoH TechnicalCommittee

Federal PIUTarget State

PIUs

Target State Steering

Committees

Target State Stakeholders

Target State MoHs


Target State MoF

Target State Local Authorities & Communities

Line of responsibility

Membership / input

Procurement Arrangements

• The procurement capacity of the Federal and State Ministries of Health is weak in terms of technical personnel and application of procurement procedures

• The project will recruit qualified Procurement Specialists to carry out procurement functions and build the capacity of the MOH

• In order to enhance early start up of project activities after effectiveness, the Federal PIU will be established as soon as possible so that it can embark on procurement activities identified and listed on the Procurement

Financial Management Arrangements

• PIU will recruit a financial management officer who will be responsible for:

1. putting in place a computerized accounting system;

2. establishment of appropriate procedures for recording all project expenditures and commitments;

3. timely submission of requests of replenishment of funds from MDTF and the Government contributions; and

4. periodic reporting of project expenditures

MDTF

MDTFSpecial

A/C

Federal PIU

KassalaPIU A/C

Blue NilePIU A/C

SouthernKordofanPIU A/C

GovernmentSpecial

A/C

Government

Red SeaPIU A/C

(1) (2)(3) (3)

(5)

(6)

(4) (5)

GovernmentImplementers

ContractorsLocal/

ForeignSuppliers

(4)

(6) (7)

(8)

MDTF

MDTFSpecial

A/C

Federal PIU

KassalaPIU A/C

Blue NilePIU A/C

SouthernKordofanPIU A/C

GovernmentSpecial

A/C

Government

Red SeaPIU A/C

(1) (2)(3) (3)

(5)

(6)

(4) (5)

GovernmentImplementers

ContractorsLocal/

ForeignSuppliers

(4)

(6) (7)

(8)

Monitoring and Reporting• A strong monitoring and evaluation (M&E) function is critical

to this project,

• The Federal PIU will be responsible for overall M&E and reporting on the project, in close collaboration with the FMoH Planning Directorate and Health Management Information System (HMIS)

• Each State PIU is responsible for M&E and reporting on project activities and performance in the states,

• Contracting technical assistance to the Planning Directorates and HMIS of the Federal and State MoH to support project M&E.

• Capacity building in health information management will be a critical component of this technical assistance.

Next steps

• Project Effectiveness planned for September– Requires:

• That consensus on priority activities have been determined for the target states, meeting the objectives of the project, particularly in improving access for conflict-affected and underserved populations

• That project implementation capacity has been put in place (technical, financial management, procurement)

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