The definition of Health Systems encompasses all organizations, institutions, resources and people whose primary purpose is to improve health. Until recently the understanding of this definition was limited to traditional health delivery through facilities and did not encompass communities and households. It is well established that involvement of communities and households improves health outcomes because community actors working through community systems do provide essential health services including demand creation, BCC and treatment support. CS projects routinely engage with elements of the health system and frequently encounter constraints that may limit their effectiveness. Thus a comprehensive definition of health systems and a clear outline of what comprises health system strengthening activities is a welcome and necessary tool for program planning/design, but this has not been available. In 2004, Plan Kenya used sustainability thinking for planning and designing its KIDCARE project, and in retrospect was able to prioritize Health Systems Strengthening activities well enough even though there was not a hard and fast tool for HSS.
Project location within the District
The KIDCARE (2004-2009) project seeks to sustainably reduce child mortality and morbidity in Kilifi. KIDCARE was implemented by the Kilifi community, Plan, MOH, AMKENI, Aga Khan Health Services, KEMRI Welcome Trust and PSI. AMKENI and PSI are projects funded by the local USAID mission in Kenya. The project prioritized six interventions malaria control, prevention of malnutrition, improved immunization coverage, pneumonia case management, control of diarrhea, and HIV/AIDS prevention. Plan applied the Sustainability Framework (SF) to refine the KIDCARE project Results Framework, to clarify Goal and Objectives and to fit its project design. Through application of the SF, Plan hoped to refine indicators and group them within the 6 components of the framework.
The 1 st step of SF is visioning. Visioning helps to profile several strategies, including HS and HSS, as an integral part of realizing the vision and helps stakeholders to define what HS/HSS needs to be within their particular context.
KID-CARE’s definition for sustainability was “To identify and work with existing structures to strengthen and help our children to live until their fifth birthday “= Strengthening the health system They envisioned the healthy child at the center, and graded necessary stakeholders. They also identified actions that need to be taking place in the future if the vision is to be realized.
SF recognizes 6 different components that have been found to contribute to sustainability of health programs.
The visioning process, for both the project and the local system, and involving several actors, helped to frame the important elements the project needed to commit to, but also elaborated other elements other partners needed to contribute to. Some of the tools used for the visioning exercise was drawing a problem tree.
The problem tree for Kilifi District health (local system). It so happened that some of the elements the project could commit to undertake and some of the elements required other partners to do.
5 years later…
The project was able to map the components at baseline (2005) , mid-term (2007) and final evaluation (2009). These results were used by the stakeholders (District Health Stakeholders Forum) to discuss what needed to be done to achieve the vision and what new players needed to be brought on board.
A future vision for health requires households and community involvement Everybody has a part to play although some partners may need to be more involved than others DHC-Dispensary Health Committee
What you plan does not always come to pass. Having a shared vision with your stakeholders usually makes for pleasant surprises. Unforeseen external shocks also affected the program negatively. A famine affecting part of the project area and contested presidential elections made it difficult to accomplish planned activities. CDF-Constituency Development Fund, LATF-Local Authority Tariff Fund, KEPH- Kenya Essential Package of Health
Local Lessons on Sustainability thinking to improve Health Systems Strengthening Core Fall Meeting September 14, 2010 Plan Kenya
Plan Kenya KIDCARE Vision for Sustainability Fathers as active caretakers of sick children Health Services availability right where the communities live Households to be at the forefront of engaging with health benefits and communication INFLUENCERS (CENTRAL MOH) LOCAL MOH CORPS PARENTS GUARDIANS VHCs/DHCs/CBOs PARTNERS FATHERS OLDER CHILDREN
Six components of SF Framework <ul><li>Health Outcomes </li></ul><ul><li>Health System </li></ul><ul><li>Organizational Capacity </li></ul><ul><li>Organizational Viability </li></ul><ul><li>Community Competence </li></ul><ul><li>External/Environmental Factors </li></ul>
STEP 1: Defining the Local System Project thinking : What will the project do? System thinking : A project is only one of many actors that contribute to sustainability of health outcomes in a local system. So, instead we ask “What will the project partners contribute?” And we also ask “What can others contribute?” Project Community Organizations Central MOH/Gov. Private sector Traditional health providers Health facility District Management Team Community Health Workers Local System Civil stability Other development sectors Environment Project
Indicators Baseline Coverage % Endline Coverage % Target % % Children (0-23mths) underweight 26.6 14.4 21.6 % Children (0-23mths) births attended by SBA 12.9 35.4 % Mothers of children (0-23mths)who received 2TT 24.0 66.7 60 % Infants (0-5mths) exclusively breastfed in last 24 hrs 21.1 54.9 31 % Children (0-23mths) fully vaccinated by 12mnths 62.2 76.5 74 % Children (0-23mths) who slept under ITN last night 20.7 76.7 60 % Mothers of children (0-23mths) who know 2 ways of preventing HIV 41.4 66.0 70
Results 1 <ul><li>KIDCARE identified that several elements necessary to achieve her vision were outside her direct mandate. </li></ul><ul><li>With partners, KIDCARE adopted, measured and tracked a number of indicators for these elements across several levels </li></ul><ul><li>KIDCARE used these measurements to initiate stakeholder discussions and identify decisions/decision-makers required to achieve her vision </li></ul>
Results 2 <ul><li>KIDCARE recognized several factors at several levels e.g. household factors - (involvement of fathers), community factors - (caregroups+CHWs v/s CHWs alone), public health system factors -(staffing), national factors - (CCM policy) and external factors - (security) as vital for achieving vision </li></ul><ul><li>KIDCARE recognized importance for inclusive partnership at district level to be custodian for Health Vision/(DHSF was formed and strengthened) </li></ul>
Lessons learned while applying SF 1 <ul><li>CSSA enabled an informal HS assessment (outside of the traditional HFA) that helped map what needs to happen to strengthen the system. </li></ul><ul><li>Further reflection helped the team to define the community at a lower level than the CHW. This is when the need to have care groups was birthed. </li></ul><ul><li>DHCs need to grow from just being “administrator of the dispensary” to “actually managers of health in the entire catchment area.” </li></ul><ul><li>Identifying key indicators for the various SF components frequently needed reflection on the problem tree. This in turn made the project reflect on project strategies. </li></ul><ul><li>With the choice of indicators also came the realization that there was a need to commit to expanding the M/E framework of the KIDCARE project, to work closely with new local partners and to access new sources of information for indicator measures. A good example is the need to work closely with the District Security Council to update on “political stability”. </li></ul>
Lessons learned while applying SF 2 <ul><li>Some planned activities failed to happen because policy changed e.g. temporary hire of nurses on vacation to fill spots in the dispensaries failed because MOH abolished cost-recovery which was the planned financing method. Also shopkeeper training in home management of malaria failed to happen because new Malaria treatment guidelines using ACT were introduced. </li></ul><ul><li>On the flipside some new activities happened because of an enabling environment so created: </li></ul><ul><ul><li>CHW work was easier through caregroups </li></ul></ul><ul><ul><li>Clinton Global Initiative and DANIDA stepped in to recruit extra nurses for dispensaries </li></ul></ul><ul><ul><li>Devolved funds from CDF and LATF used to construct and equip 4 new dispensaries and support access road construction </li></ul></ul><ul><ul><li>Introduction of KEPH by MOH provided official support of level 1 activities at village level </li></ul></ul>
Conclusions: What do we see at the end of the tunnel? <ul><li>HS definition in a local context can be competently constructed by a team of local stakeholders pursuing a common health vision </li></ul><ul><li>Even if it is outside the mandate of an individual project, HSS efforts can be assisted through targeted work with stakeholders. </li></ul>
The preceding slides were presented at the CORE Group 2010 Fall Meeting Washington, DC To see similar presentations, please visit: www.coregroup.org/resources/meetingreports