Presentation - Sigrun Mögedal


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Presentation - Sigrun Mögedal

  1. 1. Framework for Strengthening Immunization Services in GAVI Phase 2: Based on the System Barriers Approach GAVI Board meeting Abuja, 4-5 December 2004 [email_address] [email_address]
  2. 2. Solicitation for country interest Tools development Rapid country assessments GAVI Board Dec 04 Oslo Consultation Oct 04 The Gambia Ghana Guyana Rwanda Sierra Leone Uganda Vietnam Zambia GAVI Board Dec 03 Norad has coordinated SWB efforts in eight countries with HeSo, WHO/EIP/SPO and the GAVI Secretariat.
  3. 3. The approach is based on a rapid assessment of system-wide barriers across levels using immunization as a tracer. <ul><li>Barriers classified according to performance drivers (ref. McKinsey & Co. 2003) and the operational level at which they operate. </li></ul><ul><li>Active search for good practices. </li></ul><ul><li>Engagement through WHO of a local research institution to accompany and document the process. </li></ul>
  4. 4. Financial and human resources constraints are key barriers to immunization especially at peripheral level. <ul><li>Financial constraints </li></ul><ul><li>Insufficient level of resources </li></ul><ul><ul><li>Overall allocation to health </li></ul></ul><ul><ul><li>Macro-economic constraints </li></ul></ul><ul><li>Management inefficiencies </li></ul><ul><ul><li>Disbursement to peripheral level </li></ul></ul><ul><ul><li>Coordination and use of available resources </li></ul></ul><ul><li>Human resources constraints </li></ul><ul><li>Work environment not conducive to health worker performance </li></ul><ul><ul><li>Low pay and renumeration </li></ul></ul><ul><ul><li>Limited career prospects </li></ul></ul><ul><ul><li>Inadequate support systems </li></ul></ul><ul><li>Ineffective use of health staff </li></ul><ul><ul><li>Weak management and control </li></ul></ul><ul><ul><li>Staff absenteeism due to high level of training/workshops </li></ul></ul><ul><li>Underlying & compounding problems </li></ul><ul><ul><li>Neglect and under-investment in HR management systems </li></ul></ul><ul><ul><li>Migration </li></ul></ul><ul><ul><li>Triple-threats of AIDS (reduced size of workforce, increased workload, increased psycho-social stress) </li></ul></ul>More funding is needed but money alone will not necessarily improve performance! Some districts handle the constrained environment and perform better than others . Leadership and management capacity is essential for good performance.
  5. 5. Certain system-wide barriers stand out across countries. <ul><li>Available data is not sufficiently used for planning and monitoring purposes. </li></ul><ul><li>Organization of outreach activities are not well planned and vulnerable to disruption in funding flows. </li></ul><ul><li>Inadequate transport especially at district level reduces staff mobility and supply distribution and affects supervision to service delivery level. </li></ul><ul><li>Health sector reforms are generally not perceived to be constraints. However some important reform elements are often weak. </li></ul><ul><ul><li>Engagement of civil society in service planning and provision (e.g. private sector in urban areas), and for advocacy and monitoring purposes. </li></ul></ul><ul><ul><li>Design and implementation of strategies to improve equity. </li></ul></ul>
  6. 6. Countries and districts demonstrate a range of good practices with potential for cross-learning and broader application. <ul><li>Mitigating human resources constraints: </li></ul><ul><ul><li>Training and deployment of lower-level cadres for provision of basic services </li></ul></ul><ul><ul><li>Incentive schemes (car loan, housing loans, deprived area allowances) </li></ul></ul><ul><ul><li>Free provision of anti-retroviral treatment for health staff </li></ul></ul><ul><ul><li>Revision of pre-service training curricula for more relevant skill mix </li></ul></ul><ul><ul><li>Coordination of training workshops to reduce staff absenteeism </li></ul></ul><ul><ul><li>Application of standardised rates for incentives to reduce competition between programs </li></ul></ul><ul><li>Addressing financial constraints: </li></ul><ul><ul><li>Improving aid effectiveness by pooled coordination of priority programs or use of SWAp frameworks. </li></ul></ul><ul><ul><li>Conducting financial tracking studies to identify bottlenecks </li></ul></ul><ul><li>Making better use of health management information: </li></ul><ul><ul><li>Publicising a league table with district indicators in newspapers </li></ul></ul><ul><ul><li>Obtaining information on NGO activities by exchanging monthly reports with vaccines. </li></ul></ul><ul><ul><li>Using district data purposefully to target supervision and additional support </li></ul></ul><ul><li>Overcoming transport constraints: </li></ul><ul><ul><li>Hiring commercial transport from health centres to conduct outreach </li></ul></ul>
  7. 7. There is scope in most countries to review the current set-up and performance of national coordination bodies for immunization. <ul><li>Performance of the traditional ICC is uneven , in part due to </li></ul><ul><ul><li>Incomplete and unbalanced representation </li></ul></ul><ul><ul><li>Ambiguous scope </li></ul></ul><ul><ul><li>Limited capacity to lead and manage coordination </li></ul></ul><ul><ul><li>Redundancies in SWAp settings </li></ul></ul><ul><ul><li>Difficult to linking up with sub-national level </li></ul></ul><ul><li>Several other coordinating frameworks are of increasing importance for immunization: </li></ul><ul><ul><li>PRS processes as overarching frameworks with strengthened link to MDG </li></ul></ul><ul><ul><li>Multisectoral planning and budgeting frameworks (MTEF) </li></ul></ul><ul><ul><li>Sectoral Program Based approaches (PBA) including SWAp-like processes and budget support </li></ul></ul><ul><li>The multitude of partners and mushrooming of coordinating bodies are system barriers in themselves. </li></ul>
  8. 8. One size does not fit all. Non-prescriptive and context-tailored solutions are required to strengthen national coordination . <ul><li>Focus on functions rather than on structural set-up. Strengthen monitoring at national level as an entry point for targeted district level action. </li></ul><ul><li>Distinguish between countries with and without SWAp-like processes. </li></ul><ul><li>Place accountability at highest level with appropriate representation, budget leverage and decision-making authority </li></ul><ul><li>An active technical sub-committee is critical for good performance. </li></ul>
  9. 9. How can GAVI as an alliance of immunization partners contribute to broader global efforts to alleviate system barriers? <ul><li>Promoting harmonization and increasing aid effectiveness </li></ul><ul><li>OECD/DAC Rome Commitments as overarching framework. </li></ul><ul><ul><li>Harmonization among development partners </li></ul></ul><ul><ul><li>Alignment with country priorities and systems </li></ul></ul><ul><li>GAVI considered to be ”relatively light” and system-neutral but more can be done to streamline procedures and practices. </li></ul><ul><li>Targeting specific </li></ul><ul><li>program areas </li></ul><ul><li>Range of activities already in place through individual or joint partner action. </li></ul><ul><li>GAVI can be an advocate and a pathfinder in areas of specific concern to immunization. </li></ul><ul><ul><li>Financial sustainability planning </li></ul></ul><ul><ul><li>Increased productivity of health workers at peripheral level . </li></ul></ul><ul><ul><li>Better use of immunization data as a way to target district support. </li></ul></ul>
  10. 10. Country feedback indicates there is scope to adjust the SWB approach and expand its use. <ul><li>Covers key areas of system wide concerns </li></ul><ul><li>Sensitive and specific to barriers </li></ul><ul><li>Captures good practices </li></ul><ul><li>Useful as a way to engage in policy dialogue at different levels </li></ul><ul><li>Stimulates a deeper understanding of the context </li></ul><ul><li>Issues related to community concerns and demand not sufficiently addressed </li></ul><ul><li>Not suitable for self-administration at sub-national level </li></ul><ul><li>Action planning to address identified barriers needs to be strengthened </li></ul>The use of local research institutions is strongly recommended as a way to build the local evidence base and support policy development.
  11. 11. SWB activities are proposed brought forward in 2005 along three tracks. <ul><li>Complete and document activities in eight countries. </li></ul><ul><ul><li>Final report 4th quarter 2005. </li></ul></ul><ul><li>Pursue harmonization and alignment efforts </li></ul><ul><ul><li>Revision of GAVI country guidelines </li></ul></ul><ul><ul><li>Request countries to assess the appropriateness of current coordination set-ups. </li></ul></ul><ul><ul><li>Promote linkages with initiatives involved in strengthening health information systems and human resources for health. </li></ul></ul><ul><ul><li>Develop a set of ”shared principles” based on good country practices. </li></ul></ul><ul><li>Incorporate approaches and lessons learned from the SWB work into GAVI Phase 2 support for immunization services. </li></ul>
  12. 12. Strengthening immunization services Phase 2 principles <ul><li>Basic principles and procedures for immunization services strengthening support should continue to be : </li></ul><ul><ul><li>Flexible – not earmarked. </li></ul></ul><ul><ul><li>Subject to performance on the basis of agreed indicator(s) to ensure accountability. </li></ul></ul><ul><ul><li>Predictable </li></ul></ul><ul><ul><li>Allocated on a capitation basis to retain equitable approach. </li></ul></ul><ul><ul><li>Subject to regular GAVI review and approval processes </li></ul></ul>
  13. 13. The Phase 2 approach I <ul><li>Invest in overcoming barriers of critical relevance to immunisation but not limited to immunisation </li></ul><ul><ul><li>Traditional project approaches targeting the immunization system “in isolation” will not succeed in bringing sustained improvements </li></ul></ul><ul><ul><li>Barriers that are critical for immunization performance at the peripheral service delivery level are also critical for a number of other priority interventions – adds value to the investment </li></ul></ul><ul><li>Priority to improvements in basic service delivery and barriers critical for increasing access and coverage in the periphery </li></ul><ul><ul><li>sub-national and peripheral level, in particular low-performing areas/districts </li></ul></ul><ul><li>Facilitate broad engagement and expanding the interface with - and involvement of communities </li></ul><ul><ul><li>Predictable and timely flow of funds to peripheral level </li></ul></ul><ul><ul><li>Empowerment and productivity of health staff (skillsstrengthening, mobility, allowances) to support key operations (supervision, outreach) </li></ul></ul>
  14. 14. The Phase 2 approach II. <ul><li>Assessment/ barrier analysis as the basis for a credible action proposal to increase access and expand coverage, </li></ul><ul><ul><li>with indicators for performance </li></ul></ul><ul><ul><li>applying proven operational strategies (ref, RED approach) </li></ul></ul><ul><ul><li>showing complementarity of different funding sources and established links to district health plans and budgets </li></ul></ul>Harmonization <ul><ul><li>A three step allocation system is proposed: </li></ul></ul><ul><ul><ul><li>First step: Action proposal </li></ul></ul></ul><ul><ul><ul><li>Second step: Annual investment based on capitation and </li></ul></ul></ul><ul><ul><ul><li>stratification of countries </li></ul></ul></ul><ul><ul><ul><li>Third step: Continuation (after two years) of annual </li></ul></ul></ul><ul><ul><ul><li>investment, based on performance in relation to action </li></ul></ul></ul><ul><ul><ul><li>plan </li></ul></ul></ul>
  15. 15. Additional components <ul><li>Country proposals could also include </li></ul><ul><li>Operational research, involving local research institutions, to increase the evidence base </li></ul><ul><li>Inputs to central level in support of low-performing districts </li></ul>
  16. 16. The GAVI Board is requested to: <ul><li>Endorse the approach/basic principles for immunization services support in GAVI Phase 2, to use as the basis for developing a comprehensive proposal for GAVI Board consideration. </li></ul><ul><ul><li>This proposal will to the furthest possible extent follow the investment case framework guidelines. </li></ul></ul><ul><li>Endorse the timeline for finalizing this process: </li></ul><ul><ul><li>March/April 2005: presentation of concept paper including key policy issues for a go/no-go for development of a full investment case. </li></ul></ul><ul><ul><li>June 2005: presentation of an investment case for additional infrastructure support </li></ul></ul><ul><ul><li>Later: proposals for support modalities, updated guidelines and documents </li></ul></ul><ul><li>Name a task team of interested partners, coordinated by the GAVI Secretariat, to take this issue forward. </li></ul>