Dr. Nwe Ni Ohn

Health System Strengthening Framework

Service Delivery Gaps Many areas of the country have low service access to MCH and other services due to a range of management, infrastructure, logistics and security barriers.

Program Coordination Gaps Lack of organizational capacity, guidelines and strategic framework on how to coordinate immunization, nutrition, environmental health and RH services is leading to fragmentation and inefficiencies in health service delivery

Human Resource Gaps There is lack of clarity in the roles and functions of basic health staff, and inequities in the distribution of staff, resulting in lack of access to health services in hard to reach areas.

Theme 1 Service Delivery Reaching communities with essential health system delivery components of MCH, nutrition, immunization and environmental health, with emphasis on hard to reach areas

Theme 2 Health Program Coordination and Capacity Building Strengthening coordination, management and organization of the health system at all levels with a focus on the Township Level

Theme 3 Human Resource Management and Development Improving distribution, skill, number and mix of health workers with emphasis on hard to reach areas

HSS Goal: Achieve improved service delivery of essential components of Immunization, MCH, Nutrition, Environmental Health by strengthening programme coordination, sub-national micro-planning, and human resources management and development in support of MDG goal 2/3 reduction in under 5 child mortality between 1990 and 2015.

HSS Objective 1: Service DeliveryBy the end of four years, (180) selected townships with identified

hard to reach areas will have increased access to essential components of MCH, EPI and EH and Nutrition as measured by increased DPT from 70% to 90% and SBA from 67.5% to 80%

Activity 1.1: SURVEY: Access to essential component of PHC

Surveys to establish baseline indicators & outcome, impact and research for operations (including mapping)

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For description and analysis of health system gaps and bottlenecks at the Township level the following system areas were surveyed:

Health Management and Planning, including Mapping hard to reach areasHuman Resource ManagementHealth Finance and Financial ManagementCommunity ParticipationEssential Drugs & EquipmentInfrastructureData Quality and Service Quality

HSS Objective 1: Service DeliveryActivity 1.2: SUPPLIES: (UNICEF)Increase availability of Essential Supplies and equipment based on

needs identified in HSS Assessment and Coordinated Township Health Plan (CTHP).

Essential Drugs supply by UNICEF will be incremental for four years

S&E to be provided to HSS townshipsSub Center drugs (Paracetamol, Septrin, Misoprostol, ORS, ZnSo4)Hospital drugs (Inj Benzyl Pen, Gentamycin, Ampicillin, Metro,

syringes, needle, scalp vein needle)

MW kits/ Sub center kits (23 items)Renewable items for MW/Sub center kits (14 items)RHC kits (28 items)Renewable items for RHC kits (16 items)Clean Delivery Kits (1600/tsp –total 32,000)

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HSS Objective 1: Service DeliveryActivity 1.3: INFRASTRUCTURE: Total Renovation of 540 RHCs (3 per township) Year 1 (60) RHC

Tot Construction of 324 new sub-RHCs (1.8 x 180 townships) Year 1 (36) Sub centers will be constructed

Installation of solar for (63) RHCs at hard to reach townships depends upon need in HSS Assessment surveys

At present-still in negotiation with UNOPS for infrastructure

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HSS Objective 1:Service DeliveryActivity 1.4: TRANSPORT:

Provision of essential transport for township and BHS to reach hard-to-reach areas, based on needs assessment analysis in CTHP:

Reimbursement of recurrent transport cost to (20) townships to meet fuel cost for traveling (through CTHP) US$ 5000/Tsp/yr

Supply of transport capital to (20) townships based on needs identified in CTHP (Motorcycle/ bicycles/ scooters and boats)

(through -RHC Plan prioritization given to most needy)US$ 2500/Tsp/yr

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Activity 1.5: Social mobilization of NGOs, local authorities and VHWs in developing and implementing CTHP

Supportive activities for community involvement (Health Committee's activities) US$ 3,000/yr/Tsp

Training/recruitment of CHW in HTR areas (20 CHW/tsp at 20 townships)

Training/recruitment of AMW in HTR areas(20AMW/ tsp at 20 townships)

Refresher training for CHW (50 CHW per tsp x 20 tsp)

Refresher training for AMW (50 AMW per tsp x 20 tsp)

HSS Objective 2By the end of year 4, (180) selected townships with identified hard

to reach areas will have developed and implemented CTHP.

Activity 2.1: GUIDELINES DEVELOPMENT: Development and implementation of CTHP and financing schemes Guidelines development for CTHP (including financial management and health financing) & supervision

at all levels

Print and production of Guideline for CTHP (English & Myanmar)

Workshop on dissemination of HSS Assessment and sensitization of CTHP to S/R and townships and NHSC meeting

Conduct CTHP at 20 townships with BHS using Assessment results

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HSS Objective 2Activity 2.2. HEALTH FINANCING RESEARCH (mainly by DHP)

Health financing research on financial management capacity and feasibility and effectiveness of health financing schemes in all HSS targeted townships

Development and production of policy brief and guidelines and SOP for initiation of Maternal voucher scheme (MVS)

Advocacy meeting to central level and township on MVS Training to township level personnel on MVS Awareness raising activity for MVS in the township

Actual implementation of piloting MVS in Yedarshay township in two contracts of six months

Administration & supervision cost for MVS 11

HSS Objective 2ACTIVITY 2.3: TRAINING

Training programme on coordinated management through the Management and Leadership program(includes health planning and supervision) in HSS targeted townships

ACTIVITY 2.4: PLAN DEVELOPMENT Management Support includes supervision and planning activities

(from CTHP-for 20 townships) (US$ 10,000/Tsp/Year)

ACTIVITY 2.5: RESEARCH AND EVALUATION

Research and evaluation of process and impact of coordinated State and Township coordinated health planning and dissemination of findings

Annual Programme Review (Central level/townships including responsible persons from States/ Divisions)

HSR training workshop/ and Support for HSR (For HSS focused in targeted townships & For Central & S/D)

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HSS Objective 3: Human ResourceBy the end of year 4, 20 selected townships with identified hard to

reach areas will be staffed by midwives and PHS2 according to the National HR Standards.

Activity 3.1: RESEARCH: Strengthening Health Workforce at hard to reach areas in selected

townships Research Programme for HR Planning with focus on distribution mix,

function and motivation and management capacity (including financing)

Development of conceptual framework and research on performance based systems and motivational factors for retention of Rural Health Workforce (Consultation to Dr Kyawt San Lwin, PhD Student for PH, UOPH)

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HSS Objective 3: Human ResourceMulti-sector Workshop on development of HR Plan recommending

financial/management/other support strategies for retention of health staff in HTR

Development of National HR Strategic Plan including strategies for retention and deployment of health staff in HTR

Feasibility Testing of HR Plan on retention and deployment of staff at township level based on analysis and research findings (one Township)

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HSS Objective 3: Human Resource Continuing training in coordinated MCH, EPI, Nutrition and EH

training programmes applying the principles of MEP Approach (Capacity building from CTHP)

Township level training for Coordinated Action of four programmes applying MEP approach

International Short Course for health financing (HITAP Training-Economic Evaluation and Health communication) 50,000

Asia Region Study Tour on PHC planning & delivery system (Central + S/D + Township)

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HSS Objective 3: Human ResourceHR Finance incentive scheme development for health staff in remote areas - identified in township coordinated plans Financial Support (Per-diem) for health staff in HTR areas (20 Townships) (20 Tsp x 5,775) US$ 115,500

Leadership development programme SSA for 4 Central Medical Officers (Programme management, Training and Research, M&E and Finance)

SSA for 14 HSSOs

Supporting activities for implementing HSS Copier, LCD& Office Equipment, Computer, printer for S/R and township levels

M&E IndicatorsImpact and Outcome Indicators

(morbidity, mortality and program coverage)1. Under 5 mortality (Township)

2. Township DTP3 coverage (%)( Pentavalent coverage)

3. Number / % of districts achieving ≥80% DTP3 coverage (National)

4. Delivery by Skilled Birth Attendants (HSS targeted Townships)

5. Rate of ORT Use of <5 children (Township)

6. % of 6-59 months children having Vitamin A during past 6 months (Township)

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M&E IndicatorsOutput Indicators (health system capacity)

1. % of townships have developed and implemented coordinated plans according to national framework

2. Number/% of RHC visited at least 6 times in the last year using a quantified checklist (supervision)

3. Number/% of sub centre visited at least 6 times in the last year using a quantified checklist (supervision)

4. Number of managers/ trainers / BHS trained for Management and Leadership at each level per year (management training)

5. Proportion of RHCs with no stock out of essential supplies in the last 6 months (availability, service access, utilization, quality)

6. No: of RHC and sub RHC renovated and/or constructed per year, including improved drinking water and sanitation facilities

7. % of selected Townships with identified hard to reach areas staffed by midwives and PHS2 according to the National HR Standards.

8. % of Townships implementing Community based health insurance scheme

9. % Townships holding monthly Township Health Committee meeting

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% Townships have coordinated MCH package of services (ANC, Nutrition, ES, EPI) 18

S/N State/Region Year 1 Townships

1. Kachin 1.Bamaw 2.Shwegu

2. Kayah Demawsoe

3. Kayin Hlaingbwe

4. Chin Hakha

S/N State/Region Year 1 Townships

5. Mon 1.Thaton 2. Mudon

6. Rakhine Maungdaw

7. Shan(East) Kengtung

8. Shan(North) Hsipaw

9. Shan(South) Nyaungshwe

10. Sagaing Ye-U

11. Mandalay 1.Pyinmana 2.Lewe

12. Magway Htilin

13. Bago(East) Yedashe

14. Bago(West) Thayawady

15. Yangon Kawhmu

16. Ayeyawady

Ngaputaw

17. Taninthayi Myeik

FIRST YEAR HSS TOWNSHIPS

State/Region Year 1(2012) 2013-14Kachin (16) Bamaw, Shwegu Moegaung, Mohnyin,Kayah (7) Demawsoe Prusoe, Shadaw, Bawlakhe, MeisaiKayin (8) Hlaingbwe Kawkayeik, Myawady

Chin (9) Hakha Htantalan, Tonzang

Mon (8) Thaton, Mudon Bilin, Kyaikhto

Rakhine (7) Maungdaw Ann, Gwa(replacement of Butheedaung)

Shan(East) (10) Kengtung Mongphyat, Mongpyin

Shan(North) (21) Hsipaw Lashio, Kyaukme

Shan(South) (14) Nyaungshwe Hopone, Loilem, Pinlaung

Sagaing (13) Ye-U Wetlet, Mingin, Kalewa

Mandalay (12) Pyinmana, Lewe (NPT) Thazi , Thabeikkyin,

Magway (15) Htilin Setoktaya, Saw, Pwintbyu

Bago(East) (6) Yedashe Thanatpin (replacement of Taungnoo),Kawa

Bago(West) (6) Thayawady Paukkaung, Moenyo

Yangon (11) Kawhmu Hmawbi, Taikkyi,

Ayeyawady (7) Ngaputaw Laymyethna, Kangyidaunt

Taninthayi (10) Myeik Taninthayi, Palaw, Yebyu

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Figure 8 Making a Summary Report

Summary Report Township X after HSS AssessmentAvailability of services - health services infrastructure, human resources and essential drug and equipment for example exist in adequate supply. Non availability of services - absence of human resources or ED or subRHC in a hard to reach or unreached area of the Township.

Accessibility refers to the capacity of the population to access the service. Thou’ infrastructure and health staff and essential drugs may be available in the area, but the population may not be able to access the services due to physical barrier or financial constraint or inability to communicate with the health staff.

Poor accessibility to health services can lead to low utilization of services. High utilization however does not necessarily mean high impact.

The services are required to be of sufficient quality to ensure that there is public health impact.

Linking HSS Assessment to CTHP

Health System AreasPlanning & Management

Service DeliveryHuman Resources

Community ParticipationInfrastructure

Essential Drugs & Logistics SystemTransport

Finance & Financial Management

COORDINATED TOWNSHIP HEALTH PLAN

STATION HOSPITAL & RHC COORDINATED PLANS

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Health system analysis examines gaps in operations across health programmes and service delivery units

Making the transition from “management by project” to “management through systems” is a critical step in achieving:

Equity: in distribution

Efficiency through coordination and reduction of overlap of resources in favour of hard to reach areas

Effectiveness: improved health coverage

Sustainability: strengthening self reliance and management capacity

Health Systems Strengthening

Thank You