Tanzania Ministry of Health / IDRC TEHIP Essential Health Interventions Project Tanzania Essential...

Tanzania Ministry of Health / IDRC TEHIP Essential Health Interventions

Project

Tanzania Essential Health Interventions ProjectTanzania Essential Health Interventions Project(TEHIP)(TEHIP)

Planning with Evidence:Planning with Evidence:TEHIP ExperiencesTEHIP Experiences


Project

TEHIPTEHIP

Tanzania’s Essential Health Interventions Project

A Joint Initiative of A Joint Initiative of

Tanzania’s Ministry of HealthTanzania’s Ministry of Health

AndAnd

Canada’s International Development Canada’s International Development Research CentreResearch Centre

(IDRC)(IDRC)


Project

‘‘Kupanga ni kuchagua”Kupanga ni kuchagua”

“To Plan is to Choose”

Julius K. Nyerere

1965


Project

Objectives and Design of Objectives and Design of TEHIPTEHIP


Project

Broad Objective of TEHIPBroad Objective of TEHIP

• Since 1997, to test the impact of decentralized priority setting, planning, and resource allocation for essential health interventions by:

– Determining the information, management, policy, and implementation requirements for essential health interventions in actual conditions;

– Measuring their costs and evaluating their integrated effectiveness


Project

What does TEHIP test?What does TEHIP test?

A process of decentralized planning which takes more account of evidence

• Which evidence?

– Burden of disease

– Cost-effectiveness

– Community preferences

– Capacity of the health system to deliver


Project

The core questions of TEHIPThe core questions of TEHIPIn the Context of Decentralization….

1. How, and to what extent, can CHMTs do planning which is more evidence based?

» If so, ……..

2. How, and to what extent, can CHMTs implement such evidence based plans?

» If so, ……..

3. How, to what extent, and at what cost, does this reduce the burden of disease?


Project

Why Health Reform?Why Health Reform?“Diagnoses”

• Imbalance of funding toward tertiary care and expensive technologies - rather than primary care and basic interventions

• Inefficiency in use of resources

• Rising costs of health care

• Inequities in access


Project

Why Health Reform?Why Health Reform?“Prescriptions”

• Reallocation of government health resources to areas of greatest priority– ie. Minimum package of public health and clinical

interventions based on burden of disease and cost-effectiveness

• Decentralization of management and budgetary control

• Enhanced but regulated role for private sector– For profit and not for profit– Competitive markets to generate efficiency


Project

Health Sector ReformsHealth Sector Reforms Tanzania

– Ideological Change• All health services no longer free for all

– Managerial Change• improving performance of the civil service• Resetting the role and function of the Ministry of Health

– Organizational Change• Decentralization / Local ownership

– Financial Change• Broadening health financing options; cost sharing

– Public Private Mix• Introducing managed competition

– Health Research• An evidence base


Project


Project

District Health PlanningOn what bases do most CHMTS plan?

• Common sense, but heavily influenced by ……– Status quo?– Budgeting process?– Last year’s plan plus x%?– Pressure from donors or special interest groups?– Contemporary ideology or paradigms?– Health crises?– Political voice?– Opportunities?– Ministry Guidelines…

• But not explicitly a goal to maximize health outcomes


Project

Capacity Building for Capacity Building for District Health Planning and District Health Planning and

Priority SettingPriority Setting


Project

The District Evidence BaseThe District Evidence BaseA tool kit for:

• Burden of Disease Information

• Costs and Cost Effectiveness

• Community Voice

• Systems Analysis and Resource Mapping


Project

Some TEHIP “Interventions”Some TEHIP “Interventions”

• Supportive Interventions and Strategies– District Simulated Basket Funding – Strengthening Health Management & Admin– District Integrated Management Cascade – Community Ownership of Health Facilities – Community Voice (PAR)

• Planning Tools– District Burden of Disease Profile– District Health Expenditure Mapping– District Cost Information System – District Health Service Mapping


Project

Simulated Basket FundingSimulated Basket Funding

A Prerequisite for Decentralized Planning & Priority Setting


Project


Project

Strengthening District Health Strengthening District Health Management & AdministrationManagement & Administration

• CHMT Team building & management skills– WHO SHM Modular Course

• CHMT Planning skills– “Ten steps to a district health plan”

• CHMT Administrative skills– Computerization– Financial management– Communications– Office management– Maintenance concepts


Project

Tools for District Health Tools for District Health Planning and Priority Planning and Priority

SettingSetting


Project

Burden of Disease ProfileBurden of Disease Profile- - A Resource for District Health PlannersA Resource for District Health Planners -

A Graphical Presentation of A Graphical Presentation of Intervention Addressable Shares of Intervention Addressable Shares of

the Burden of Diseasethe Burden of Disease


Project

Tanzania’s “Minimum” Package of Tanzania’s “Minimum” Package of Essential Health InterventionsEssential Health Interventions

• Reproductive & Child Health– Safe Motherhood

• 5 Interventions

– Immunization– IMCI– Family Planning– Nutritional Deficiencies

• 9 Interventions

• Communicable Disease Control– Malaria

• 6 Interventions

– TB / Leprosy– HIV / STDs

• 3 interventions

– Epidemics• Cholera, meningitis

• Non-Communicable Disease Control

– Cardiovascular diseases– Diabetes– Neoplasms– Injuries/Trauma– Mental disorders– Anemia & Nutritional Deficiencies

• Treatment for common Diseases– Skin, ocular, oral conditions

• Community Health Promotion and Disease Prevention

– School Health– Water & Sanitation– IEC (7 interventions)

» 50 Interventions in Minimum Package


Project

Why do we need a District Burden of Disease Profile?

• Burden of disease not intuitively understood;

• Intervention Priorities not intuitively known.

• HMIS statistics for “top 10 diseases” biased by attendance; misleading for household and community problems;

• Interventions and strategies now integrated beyond single diseases;

• Cost effective intervention addressable burdens of disease?

• Objective data now available from sentinel demographic surveillance systems (DSS).


Project

0 100

Kilometers

200

KILOMBEROKILOMBEROKILOMBEROKILOMBEROKILOMBEROKILOMBEROKILOMBEROKILOMBEROKILOMBERORUFIJIRUFIJIRUFIJIRUFIJIRUFIJIRUFIJIRUFIJIRUFIJIRUFIJI

MOROGOROMOROGOROMOROGOROMOROGOROMOROGOROMOROGOROMOROGOROMOROGOROMOROGORO

ULANGAULANGAULANGAULANGAULANGAULANGAULANGAULANGAULANGA

Comparison Districts

IMCINo IMCI

DSS Collaborative Research Platform(AMMP / IHRDC / TEHIP)

TanzaniaComparison Districts230,000 Under Surveillance

Prepared by TEHIP /MOHMay, 2000


Project

Measuring Burden of DiseaseMeasuring Burden of DiseaseSentinel DSS

• DSS - Demographic Surveillance System– A geographically defined population under

continuous demographic monitoring with timely production of data on all births, deaths and migrations (INDEPTH, 1998)

• Characteristics of a DSS:– enumeration of the denominator population by

repeated household visits at regular intervals;– continuous reporting of numerator vital events,

especially deaths, by key informants– causes of death determined by verbal autopsy


Project

Source of Burden of Disease Source of Burden of Disease InformationInformationSentinel DSS

• Tanzania has Demographic Surveillance Sites (DSS) in several districts.

• Total population of 650,000 continuously monitored for health, demographic and poverty indicators.

• Sites have been harnessed into a National Sentinel Surveillance System.

• NSS DSS provides representative annual Burden of Disease Profiles to districts represented by their sentinel.


Project

Measuring the Burden of DiseaseMeasuring the Burden of DiseaseHow can we objectively compare disease burdens?How can we objectively compare disease burdens? • Health service attendance?

• (HMIS “Top 10 Diseases”)

• Prevalence?• (Number of existing cases in the population now)

• Incidence?• (Number of new cases in the population per year)

• Mortality?• Morbidity?• Severity?

– Or

• A time-based measure combining: prevalence, incidence, mortality, morbidity, severity, and duration? The DALY


Project


Project

Rainfall foreshadows mortalityEstimated Rainfall in the Rufiji DSS Area in 2000

0

25

50

75

100

125

150

Jan-

00

Feb

-00

Mar

-00

Apr

-00

May

-00

Jun-

00

Jul-0

0

Aug

-00

Sep

-00

Oct

-00

Nov

-00

Dec

-00

Rai

nfa

ll (m

m)

Season Total = 712 mm


Project


Project

District Health AccountsDistrict Health Accounts

- A Tool for District Planners -- A Tool for District Planners -

A CHMT Graphical Window to A CHMT Graphical Window to the Content of their Annual the Content of their Annual

District Health Plans, Priorities, District Health Plans, Priorities, Budgets and ExpendituresBudgets and Expenditures


Project

Why do we need a Why do we need a District Health Accounts Tool?District Health Accounts Tool?

• reduces complexity of budgets for planners;

• graphical display of complex numeric information;

• summary information on resource source and allocation;

• analyzes budget and expenditure to check against priorities (e.g. burden of disease), norms and standards;

• captures all potential sources of revenue;

• assesses implementation of DHP(budget vs expenditure);

• feeds into the National Health Accounts;

• Assists accountability and transparency.

• Sample output follows…..


Project

What is theDistrict Health Accounts Tool?

• It is:– A budget analysis tool for District Planners

(CHMT and District Council)

– An expenditure analysis tool for District Planners (CHMT and District Council)

– A tool for the MOH to assess and compare Comprehensive Council Health Plans

• It is not:– An accounting tool for accountants!!!


Project

0%

5%

10%

15%

20%

25%

30%

35%S

hare

of Tota

l

Malaria All(I)MCI

Malaria < 5RH Strategy

Malaria >5Immunization

TBOther

Intervention Priority

92-95 YLL Share 96 Budget Share

Morogoro Disease Burden vs 96 Budget


Project

0%

5%

10%

15%

20%

25%

30%

35%S

hare

of Tota

l

Malaria All(I)MCI

Malaria < 5RH Strategy

Malaria >5Immunization

TBOther

Intervention Priority

92-95 YLL Share 98 Budget Share

Morogoro Disease Burden vs 98 Budget


Project


Project

150

Kilometers

30

500450045004500450045004500450045004

500250025002500250025002500250025002

500150015001500150015001500150015001

500650065006500650065006500650065006

500350035003500350035003500350035003

500550055005500550055005500550055005

500750075007500750075007500750075007

Cartography by TEHIP / MOH / DHMT September 2001

Integrated Supervision CascadeMOROGORO RURAL

Integrated Supervision Cascade

DHMT (1)

Duthumi RHC (7)

Kibati RHC (6)Melela Dispensary (RHC) (9)

Mgeta RHC (11)

Mkuyuni Dispensary (RHC) (15)

Mlali (RHC) (5)

Mvomero Dispensary (RHC) (10)

Mvuha (RHC) (7)

Ngerengere RHC (9)

Tawa RHC (8)

Turiani Dispensary (RHC) (9)

Paved RoadMinor Roads & Tracks

Rivers

Railroads

Codan Radio Call Numbers

Radio Location

Integrated Integrated Management Management

CascadeCascade


Project

Integrated Management Integrated Management CascadeCascade

• Includes– 2-way radio communications– Involvement of FLHWs in CHMT activities– Delegation of responsibilities– Supervision & training– Distribution & collection of drugs & supplies– Laboratory services & referral– Personnel management– Emergency response (eg. Cholera outbreaks)


Project

Community Ownership of Health Community Ownership of Health FacilitiesFacilities

Typical Dispensary in Rufiji District – pre TEHIP


Project

Facility Rehabilitation for Community Facility Rehabilitation for Community Ownership of Health FacilitiesOwnership of Health Facilities

• A high demand/high need/high visibility– But

• Conventionally high financial and opportunity costs;• Conventionally vertically planned and implemented;• System not skilled in sub-contracting.

• Community labour based approach– TEHIP basket ceiling capped in CHMT plan;– Promoted community engagement & ownership;

• Expanded scopes of work undertaken with consistency of design;

• 60% lower costs over conventional contracting;• Community skills now expanding to other sectors;• Signs of improved maintenance due to community ownership.


Project

Community OwnershipCommunity Ownership

Before After


Project

Community OwnershipCommunity OwnershipBefore After


Project

Example of IMCIExample of IMCI

Adopting New Cost-Effective Interventions


Project

NoIMCI

0 150

Kilometers

IMCI

300

IMCI MCE: Tanzania Component

Morogoro

Kilombero

Ulanga

Rufiji


Project

Preliminary Cost Results

Compared with non-IMCI districts:

1. IMCI districts did not incur higher costs (per child) of caring for under-fives;

2. There was no change in average cost per under-five visit at IMCI primary facilities;

3. A lower proportion of under-fives were admitted to hospital in IMCI districts;

4. Health workers in IMCI districts spent on average two more minutes per under-five consultation;

5. IMCI facilities spent less on drugs because of more rational use.


Project

Health Mapping Tool

New Appreciation of

District HMIS Data


Project

150

Kilometers

30

Health FacilityUtilization in 1998

Prepared by TEHIP / MOHData Source: DHMT HMIS F005 January, 2000

Minor Road

Railroads

Paved Roads

Villages with no Health Facilities

Morogoro Rural District

HMIS Reported Outpatients446,834 Attendences (31% Under 5)

16,0008,0001,600

Under FivesAll Others

Villages with Health Facilities (87)Registered Facilities (97)

Dispensary - Government (60)Dispensary - NGO (19)Dispensary - Parastatal (6)Dispensary - Private (2)Health Centre - Government (5)Health Centre - Parastatal (1)Hospital - Government (2)

Hospital - NGO (1)

Hospital - Parastatal (1)all others (1)


Project

0

Kilometers

15 30

NambunjuNambunjuNambunjuNambunjuNambunjuNambunjuNambunjuNambunjuNambunju

NdundutawaNdundutawaNdundutawaNdundutawaNdundutawaNdundutawaNdundutawaNdundutawaNdundutawa

KiwangaKiwangaKiwangaKiwangaKiwangaKiwangaKiwangaKiwangaKiwanga

Mbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju MvuleniMbunju Mvuleni

MangwiMangwiMangwiMangwiMangwiMangwiMangwiMangwiMangwi

MkupukaMkupukaMkupukaMkupukaMkupukaMkupukaMkupukaMkupukaMkupuka

KilulatambweKilulatambweKilulatambweKilulatambweKilulatambweKilulatambweKilulatambweKilulatambweKilulatambweRungunguRungunguRungunguRungunguRungunguRungunguRungunguRungunguRungungu

MtawanyaMtawanyaMtawanyaMtawanyaMtawanyaMtawanyaMtawanyaMtawanyaMtawanyaMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / MsindajeMchungu / Msindaje

MkendaMkendaMkendaMkendaMkendaMkendaMkendaMkendaMkendaBumba / MsoroBumba / MsoroBumba / MsoroBumba / MsoroBumba / MsoroBumba / MsoroBumba / MsoroBumba / MsoroBumba / Msoro

Bumba*Bumba*Bumba*Bumba*Bumba*Bumba*Bumba*Bumba*Bumba*

Villages With Health Facility5 Km Catchment Area

Dispenary - Government (44)Dispensary - NGO (4)Health Centre - Government (5)

Hospital - Government (1)

Hospital - NGO (1)

Paved Road

Lakes

Main Road

Minor Road

Track

Nature Reserves

Wetlands

Rivers

Villages Without Services TEHIP / MOH / DHMTApril, 2000

Selous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game ReserveSelous Game Reserve

Mkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMkuranga DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural DistrictMorogoro Rural District

Kilwa DistrictKilwa DistrictKilwa DistrictKilwa DistrictKilwa DistrictKilwa DistrictKilwa DistrictKilwa DistrictKilwa District

Liwale DistrictLiwale DistrictLiwale DistrictLiwale DistrictLiwale DistrictLiwale DistrictLiwale DistrictLiwale DistrictLiwale District

KilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilomberoKilomberoDistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrictDistrict

Indian Indian Indian Indian Indian Indian Indian Indian Indian

OceanOceanOceanOceanOceanOceanOceanOceanOcean

Rufiji District: Health Service Access88% of Villages and 91% of Population

within 5 Km of Health Services

Map produced in TEHIP GIS Lab using MapInfo Commercial Software


Project

Malaria IntensityMalaria Intensity


Project

Process Impacts Process Impacts Leading to Health ImpactsLeading to Health Impacts


Project

Health Facility Utilization by Under Fives Peripheral Health Facilities

Morogoro Rural District Tanzania

Source, Morogoro HMIS/MCH3 MoH/TEHIP


Project


Project

Declining Infant and Declining Infant and Child Mortality in Rufiji Child Mortality in Rufiji

District since 1999District since 1999


Project

Take Home Lessons Take Home Lessons So FarSo Far


Project

Some Take Home Lessons – so farSome Take Home Lessons – so far- Experiences from TEHIP -- Experiences from TEHIP -

• Strengthen decentralized planning and management capacity as a prerequisite for basket funding;

• Ensure practical planning and monitoring tools– Eg. Graphical Burden of Disease Profiles, Expenditure Mapping, etc.

• Tools should steer towards interventions addressing largest disease burdens (eg. IMCI, etc)

• Scale up sequentially (limited absorptive capacity of the system; build on synergies later)

• Engage community only after manifesting improvements in quality;

• Increment of about $0.80 per capita sufficient to start process


Project

More Take Home Lessons - so farMore Take Home Lessons - so far- Experiences from TEHIP -- Experiences from TEHIP -

• Move towards comprehensive DHP’s including all major providers and funding partners

• Identify and deal with technical inefficiencies early• Simplify, strengthen and rationalize HMIS

– Add costing component to HMIS– Add coverage estimation to HMIS– Remove facility based disease surveillance from HMIS– Add household based disease surveillance to HMIS (eg.

National Sentinel Surveillance DSS)– Add poverty indices to the DSS methodology

• Link operational research with development


Project

Going to Scale• Basket funding creates demand for:

– evidence based planning;

– capacity building for health management and administration;

– appropriate planning tools and supportive strategies;

• MoH establishing a National Sentinel Surveillance System for all DSS sites

for Burden of Disease Profiles;

• MoH will use District Health Accounts at National level for 2002 and at

District Level for 2003;

• MoH has a tested Community Rehabilitation / Ownership Strategy;

• MoH has a tested Integrated Management Cascade System;

• MoH has Zonal Training Centres which are being reviewed for use in

National roll out.

Tanzania Ministry of Health / IDRC TEHIP Essential Health Interventions Project Tanzania Essential...

Documents

Transcript of Tanzania Ministry of Health / IDRC TEHIP Essential Health Interventions Project Tanzania Essential...