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COUNTDDOWN TO 2015: Health Systems and Policy and Finance Workshop Windsor Hotel, Nairobi, Kenya

25-28 February, 2014

WORKSHOP REPORT

I. BACKGROUND

Countdown to 2015 (CD) is currently supporting in-depth Country Case Studies in six countries —

Afghanistan, Pakistan, Ethiopia, Malawi, Tanzania, and Peru. The aim of the case studies is to better

understand the complex factors contributing to or detracting from progress in reproductive, maternal,

newborn, and child health (RMNCH) in each of the selected countries. This involves assessing the policy,

systems, and financial factors influencing the development and implementation of RMNCH programs. A

second aim of the case studies is to build country-level capacity to conduct rigorous research and to engage

in ongoing monitoring and analyses of progress in RMNCH. An overview of the Country Case Studies is

available in Annex 1.

Each Country Case Study builds on data evaluating changes in RMNCH results. The IHP Evaluation

framework (Figure 1) has been used to guide RMNCH policy implementation, and outlines steps for

measuring reactions of a healthcare system to the implementation of each RMNCH policy. A CD capacity

building workshop held in June 2013 in Pelotas, Brazil provided training on the coverage, equity and LiST

analyses needed for the case studies. These analyses focused on outcome and impact measures in the IHP

Evaluation framework. The workshop in Nairobi built on the previous workshop to improve the capacity of

Country Case Study teams in conducting health systems and policy (HSP) and finance analyses, which are

critical pieces of Country Case Studies and cross-country analyses. These analyses focused on assessing the

inputs and outputs components in the IHP Evaluation framework.

Figure 1: Evaluation Framework for CD Country Case Study

Contextual factors including non-health system determinants- Economic growth, education, transport & communication -

NMR

MMR

Under 5 Mortality Rate

Total Fertility RateCoverage along the continuum of care

- Demand for family planning- Antenatal care visits - Delivery in a health facility- Caesarean section rate- Postnatal care- Exclusive breastfeeding- Vaccine coverage

Equity- Urban/rural residence- Socioeconomic status- Maternal education

Stillbirth Rate

INPUTS OUTPUTS OUTCOMES IMPACT

Health service readiness

Health service quality

Health service utilisation

Health Information Systems

Legislative framework

Health workforce

Infrastructure & commodities

Health system financing

Governance & leadership

WH

O H

ea

lth

Sy

ste

m B

uil

din

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lock

s

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The workshop provided training to Country Case Study teams on a standard set of three CD HSP tools that

were developed as part of the qualitative analysis for Country Case Studies. The aims and objectives of the

three HSP tools are provided in Annex 2. Prior to the workshop, CD HSP facilitators held webinars on the

HSP tools with participants from CD Country Case Study teams. Participants were requested to start filling

CD HSP tools 1 and 2 prior to attending the workshop.

CD Finance facilitators also shared country-specific Official Development Assistance (ODA) data and a

briefing note with participants prior to the workshop. Participants were requested to review their country

ODA data and begin compiling basic tables and graphs. Additionally, participants were requested to bring

any National Health Accounts (NHA) data as well as any other studies on tracking RMNCH spending that is

available for their country.

II. WORKSHOP OBJECTIVES

The workshop aimed to meet the following overall objectives:

1. Build capacity for analyses of factors that have an impact on progress for RMNCH for:

– HSP

– Resource tracking (RT) analyses through tracking of resource flows

2. Increase comparability of analyses and results presentation across CD Country Case Studies

3. Integrate HSP and RT analyses within the overall CD Country Case Studies

Specific HSP objectives were as follows:

1. Develop a standardized CD policy and program timeline to assess national story for context

change and technical, health sector, and multi-sectoral policies relevant to RMNCH (HSP Tool 1)

2. Use the CD RMNCH policy & systems tracer indicators dashboard to assess policy status and

change over time (HSP Tool 2)

3. For identified or proposed foci of the case study, evaluate the extent to which policies have

been translated into effective program implementation (HSP Tool 3)

4. Identify facilitating factors and bottlenecks for access, quality and coverage of interventions,

story of change for that country and implications

Specific RT objectives were as follows:

1. Review available RT data relevant to country case studies and complete, refine or plan the

following analyses:

a. ODA

b. NHA

c. Other special studies in some countries e.g. of household costs

d. Refine analysis plans especially linked to the focus of case study

2. Work in country teams to develop a plan of action for the Country Case Study and identify needs

for technical assistance

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III. PARTICIPANTS

There were a total of 41 participants at the workshop, including 25 CD Country Case Study team

members from the six countries, 3 representatives from the Kenya CD team, 2 representatives from the

Rwanda CD team, 6 facilitators from the CD HSP Technical Working Group (TWG), and 4 facilitators from

the CD Finance TWG. The list of participants is available in Annex 3.

Supporting partners included Evidence for Action, Harvard University, London School of Hygiene &

Tropical Medicine, World Health Organization, Save the Children, UNICEF, USAID and Futures Group.

IV. AGENDA

The agenda for the 4-day workshop was as follows:

Day 1: Introduction & workshop overview (1st half); and overview and country team work on CD HSP

Tools 1 and 2 (2nd half)

Day 2: CD country team summaries on Tools 1 and 2 (1st half); and overview and country team work on

CD HSP Tool 3 (2nd half)

Day 3: CD RT Analyses - Overview, country presentations and plenary discussion (1st half) & country

team work (2nd half)

Day 4: Country team work and country-specific technical assistance (1st half) & wrap-up/conclusion (2nd

half)

The detailed agenda is available in Annex 4. All presentations from the workshop were made available to

participants.

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V. PARTICIPANT FEEDBACK

On the final day of the workshop, participants answered a feedback questionnaire which included 14

questions regarding workshop content and organization (see Annex 5). Some questions required

participants to indicate their level of satisfaction using a score from 1 (strongly disagree) to 4 (strongly

agree).

The questionnaire was completed by 29 out of 30 country team participants, who held qualifications in

public health/epidemiology, clinical medicine, statistics, or economics/finance. Major findings of this

evaluation are summarized below.

The majority of participants provided positive assessments of the introductory, HSP and RT sessions in

the workshop. However, a few participants (< 10%) gave low scores to the talks, facilitation and group

work relating to HSP Tool 3 and RT analyses.

57.1%

42.9%

Has this workshop fulfilled your expectations?

agree strongly agree

3.4%

48.3%

20.7%

20.7%

3.4% 3.4%

What is your current field of work?

Clinical practice Public health Epidemiology

Health economics Research Finance

7.4

6.9

0.0

0.0

59.3

55.2

48.1

48.1

33.3

37.9

51.9

51.9

0 10 20 30 40 50 60 70

RT analyses

HSP Tool 3

HSP Tools 1 & 2

Introduction & overview ofCD Country Case Studies

%

How do you rate the talks for the following sections of the workshop?

strongly agree agree neither disagree nor agree strongly disagree

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Overall, participants reported being pleased with the workshop pace. Additionally, over one third of

participants reported that a writing workshop and data analyses workshop would be useful before

finishing the country case study.

3.7

4.0

0.0

0.0

0.0

0.0

63.0

52.0

44.0

40.7

42.3

34.6

33.3

44.0

56.0

59.3

57.7

65.4

0 10 20 30 40 50 60 70

RT analyses

HSP Tool 3

HSP Tools 1 & 2

RT analyses

HSP Tool 3

HSP Tools 1 & 2

Gro

up

W

ork

Faci

litat

ion

How would you rate the facilitators and group work for the following sessions?

strongly agree agree neither disagree nor agree

%

0.0

0.0

3.7

26.9

11.5

18.5

73.1

88.5

77.8

0 20 40 60 80 100

Well-paced

Breaks weresufficient

A good mix betweenlistening & activities

%

How do you rate the workshop pace?

strongly agree agree neither disagree nor agree strongly disagree

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Participant comments

Participants were asked to provide comments about workshop preparation and content. Select

comments that are representative of the feedback received are transcribed below.

Workshop preparation

“The webinars before the workshop were good, but we need other webinars to share ongoing progress

in the case studies.”

“It was good receiving Tools 1 and 2 prior to the workshop to allow for necessary preparation. I feel it

would have been useful to receive Tool 3 earlier. Furthermore, if Tool 3 could be simplified I feel it could

be more useful.”

Overall

“I really enjoyed my time with the Countdown group and other countries as well. This is such a dynamic,

motivated and passionate group! Feeling everyone's excitement motivated and propelled me forward!

Thanks.”

“It was very participatory and presentations on the group discussions were relevant.”

“Overall, it was a good workshop. I was able to better understand and apply the tools, present our

achievements so far, get feedback, define what is still missing, & plan next steps.”

“The workshop provided an opportunity to understand the process and learn from other countries.”

38.70%

12.90%

32.30%

12.90%

3.20%

Would an additional workshop before you finish your country case study be useful?

Writing workshop LiST Data analyses Finance analyses Peer review workshop for country case study

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“It was a great opportunity to have key members of the team focusing on the case study for 4 days. A lot

was achieved on many levels - analysis and process!”

“What I liked least about the workshop is that not all partners involved in the case study were involved.”

Participants also expressed interest in having a RT/financial analyses protocol and/or tools.

VI. NEXT STEPS

CD global level

The following next steps were identified at the CD global level:

• Coordinated support for crosscutting analyses, i.e. mortality, coverage, equity, HSP and RT

• Consider a joint publication, e.g. PLoS series collection, and a linked writing workshop

• Further develop HSP tools and protocols, in particular:

• More standardized graphic displays for HSP Tools 1 and 2

• HSP 3 tool on implementation needs more work and also to link to output

visuals. Participants expressed a particular interest in GIS mapping

• Finance/RT:

• Consider developing protocol and/or tools relevant to CD case studies

• Some countries requested more technical support

CD country case study teams

The following next steps were identified at the CD country case study team level:

• Ongoing work to identify the overall story and focus of CD case study

• Increased technical support in collaboration with partners in-country

• Each country is likely to need an analysis and/or writing workshop

• Plan links to CD events, national accountability, and/or score cards

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ANNEX 1 – OVERVIEW OF CURRENT COUNTDOWN TO 2014 CASE STUDIES

COUNTRY MAIN FOCUS LEAD IN COUNTRY ADDITIONAL

SUPPORT STATUS

Peru Health systems, financing Universidad Peruana Cayetano Heredia

University of Pelotas

Lancet Every Newborn case study completed, May 2014, Also planning detailed papers

Tanzania 1. Family planning 2. Care at birth

National RMNCH partnership (E4A, WHO, MoH, UNICEF, IHI, etc.)

LSHTM and E4A Event expected April 2014 Submit paper, possibly for June Partners Forum event

Afghanistan Midwifery scale up (stunting reduction and immunization increase)

UNICEF, MoPH, NIPH AKU Mid/late 2014

Pakistan Lack of progress for neonatal, devolution

Mother & Child Care Trust AKU Late 2014

Malawi District performance variation National Stats Bureau, WHO and MoH

JHU and WHO March 2015

Ethiopia Health extension worker package and selected changes e.g. CPR and ICCM

Ethiopia FMOH and EHNRI Harvard (started as JHU) and LSHTM

TBD

Rwanda TBD Rwanda Biomedical Center TBD Application in process

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ANNEX 2 – OVERVIEW OF CD HSP TOOLS

The webinars and workshop and provided training to Country case study teams on a standard set of

three CD HSP tools that were developed as part of the qualitative analysis for Country Case Studies. The

aims and objectives of the three HSP tools are as follows:

Tool 1: CD HSP Policy & Program Timeline

CD HSP Tool 1 aims to understand through a standardized process with standardized content, what HSP

factors have contributed to change (or the lack thereof) in RMNCH in each of the countries conducting a

CD Country Case Study. Specific objectives are as follows:

Describe: To use a chronological timeline to document and analyze what policies, programs,

implementation strategies and pivotal moments have changed for RMNCH from 1990 to the

current year (i.e. “telling the story”)

Analyze: To use the timeline to assess variation for RMNCH policies and strategies at the national

level, highlighting periods of policy intensity for given topics and gaps.

Apply: To describe the story of RMNCH attention in policy change, and what is missing.

Tool 2: CD HSP Dashboard for Tracer Indicators

CD HSP Tool 2 aims to assess tracer RMNCH policy and systems indicators reported by the Countdown to

2015 in the country profiles to produce the CD Policy & Systems Dashboard for the country. Specific

objectives are as follows:

To systematically assess the development and tracking over time of selected RMNCH tracer

policy indicators and related health systems tracer indicators reported in CD Country Profiles

To visually represent policy and system tracers in the form of the Policy & Systems Dashboard to

bring about further interpretation and analysis

Tool 3: CD HSP In-Depth Policy to Action Assessment

CD HSP Tool 3 aims to guide Country Case Study teams in assessing the strength of policy formulation

and implementation related to the focus of their case study. Specific objectives are as follows:

To assess the readiness of policy or program formulation for specific RMNCH relevant policies

or program(s) that have been selected for further assessment in the Country Case Study

To assess the completeness and strength of policy/program implementation related to each of

the selected RMNCH policy foci of the Country Case Study

Countdown used the policy heuristics of (i) agenda setting; (ii) policy formulation; (iii) policy

implementation; and (iv) policy evaluation as guiding principles in the development and analysis of the

three CD HSP tools. Figure 2 shows the CD HSP tools within this policy heuristic — Tool 1 focuses on

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assessing agenda setting, Tool 2 focuses on assessing policy formulation, and Tool 3 focuses on assessing

policy formulation and strength of program implementation.

Figure 2: CD HSP Tools within the Policy Heuristic

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ANNEX 3 – PARTICIPANT LIST

COUNTDOWN HSP & FINANCE WORKSHOP: NAIROBI, 25-28 FEBRUARY 2014 PARTICIPANT LIST

PARTICIPANT EMAIL AFFILIATION FACILITATOR(S)

AFGHANISTAN

1 SM Moazzem Hossain smhossain@unicef.org UNICEF

Neha Singh 2 Khawza Mir Ahad Saeed hefd.khahad@gmail.com LSH&TM/HEFD, MoH

3 Nadia Akseer nadia.akseer@gmail.com SICK KIDS

4 Mohammahd Hafez Rasooly dochafez@yahoo.com MoH

ETHIOPIA

5 Tewodros Bekele Endailalu tedrosmoh@gmail.com

Deb Sitrin

6 Helina Kebede Demisse helukebede@gmail.com MoH

7 Mekonnen Tadesse Balcha mekonnta@yahoo.com

8 Teshome Desta destawolde@who.int WHO

9 Sirak Hailu sirakk@who.int

MALAWI

10 Humphreys Nsona hnsona@gmail.com MoH

Tim Colbourn & Bernadette Daelmans

11 Malumbo Kausi malukausi@yahoo.co.uk

12 Andrew Jamali andrewjamali4@yahoo.com National Statistical Office

13 Susan Kambales kambales@who.int WHO

14 Rufus Ferrabee r.ferrabee@ucl.ac.uk Consultant

PAKISTAN

15 Zulfi Bhutta zulfiqar.bhutta@aku.edu

Agha Khan University Neha Singh 16 Zaid Bhatti zaid.bhatti@aku.edu

17 Muhammad Ashar Malik ashar.malik@aku.edu

PERU

18 Luis Huicho lhuicho@gmail.com Cayetano Heredia University

Patricia Hernandez 19 Eddie Segura eddysegura@gmail.com

20 Jessica Niño de Guzmán jninodeguzman@mef.gob.pe Ministry of Economy & Finance

TANZANIA

21 Hoviyeh Afnan-Holmes hoviyeh.afnan-holmes@lshtm.ac.uk LSHTM

Joy Lawn

22 Theopista John kabutenit@who.int WHO

23 Moke Magoma m.magoma@evidence4action.net E4A

24 Clement Kihinga kihinga@yahoo.com MoH

25 Arin Dutta adutta@futuresgroup.com Futures Group

RWANDA

26 Felix Sayinzoga felix.sayinzoga@gmail.com MoH

Carlyn Mann , Blerta Maliqi, Joy Lawn & Bernadette Daelmans 27 Alypio Nyandwi nalypio@gmail.com

KENYA

28 Rebecca Njuki rnjuki@familycareintl.org FCI Carlyn Mann, Blerta Maliqi, Joy Lawn & Bernadette Daelmans

29 Joyce Lavussa lavussaj@who.int WHO

30 Anne Karim Njeru anne_k_njeru@yahoo.com MoH

FACILITATORS – Health Systems & Policies

31 Tim Colbourn t.colbourn@ucl.ac.uk E4A

32 Bernadette Daelmans daelmansb@who.int WHO

33 Joy Lawn joylawn@yahoo.co.uk LSHTM

34 Blerta Maliqi maliqib@who.int WHO

35 Neha Singh neha.singh@lshtm.ac.uk LSHTM

36 Deb Sitrin DSitrin@savechildren.org SNL/Save the Children

FACILITATORS - Financing

37 Patricia Hernandez patricia.hernandez.consultancy@gmail.com Consultant

38 Carlyn Mann cmann@hsph.harvard.edu Harvard

39 Melisa Martinez-Alvarez Melisa.Martinez-Alvarez@lshtm.ac.uk LSHTM

40 Nirmala Ravishankar nravishankar@gmail.com Consultant

LOGISTICAL SUPPORT

41 Nacer Tarif tarifn@who.int PMNCH

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ANNEX 4 – WORKSHOP AGENDA

DAY 1 – Tuesday, 25 February 2014

Time Topic / Activity Facilitator

9:00 - 9:30

Chair: Zulfiqar Bhutta

Welcome and introductions

CD HSP TWG Co-Chairs

(Bernadette Daelmans & Joy

Lawn)

9:30 - 10:00 CD case study overview and approach Joy Lawn

10:00 – 10:30 Workshop objectives and approach Bernadette Daelmans & CD

Finance TWG

10:30 - 11:00

Coffee/Tea Break

11:00 - 13:00

Chairs: Bernadette Daelmans & Joy Lawn

Presentations on analyses and focus for workshop from

the following country teams (10 minutes presentation

from PowerPoint template + 5 minutes discussion per

team):

Afghanistan

Ethiopia

Malawi

Pakistan

Peru

Tanzania

Rwanda

CD Country Case Study

Teams

13:00 – 14:00

Lunch

14:00 – 14:30

Chair: Tim Colbourn & Humphreys Nsona

CD HSP Tool 1 – Policy & Program Timeline

Joy Lawn & Neha Singh

14:30 – 15:30

CD Country Case Study teamwork on Tool 1drafts

(brought to the workshop)

Country Case Study teams

15:30 – 15:45

Coffee/Tea Break

15:45 – 16:45

Chair: Tim Colbourn & Humphreys Nsona

CD HSP Tool 2 – Dashboard for Tracer Indicators

Neha Singh & Blerta Maliqi

16:45 – 17:30 CD Country Case Study teamwork on Tool 2 drafts

(brought to the workshop)

Country Case Study teams

Evening Dinner at the Windsor Hotel

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DAY 2 – Wednesday, 26 February 2014

Time Topic / Activity Facilitator

9:00 - 10:30

Chairs: Luis Huicho & Neha Singh

CD Country Case Study Team summaries of Tool 1 and

Tool 2

Country Case Study

teams

10:30 - 11:00

Coffee/Tea Break

11:00 – 13:00

CD Policy Tool 3 – Context Specific Policy to Action

Assessment

Bernadette

Daelmans, Blerta

Maliqi & Tim

Colbourn

13:00 – 14:00

Lunch

14:00- 16:00 CD Country Case Study teamwork on Tool 3 Country Case Study

teams

16:00 – 16:15 Coffee/Tea Break

16:15 – 17:30 CD Country Case Study teamwork on Tool 3 (contd.) Country Case Study

teams

17:30 – 18:00

Summary / closing remarks CD HSP TWG

DAY 3 – Thursday, 27 February 2014

Time Topic / Activity Facilitator(s)

9:00-10:30 Overview of RT Analyses for the Countdown

Case Studies and Q&A:

Domestic expenditure analysis

Analysis of Development Assistance

Country team updates on the status of the

health financing/RT component of their

country case study

Nirmala Ravishankar, Country teams

10:30 – 11:00 Coffee Break

11:00 -11:30 Country Presentation 1: Afghanistan Afghanistan Country Case Study team

11:30 – 12:00 Country Presentation 2: Tanzania Melisa Martinez-Alvarez

12:00-13:00 Plenary Discussion:

Q&A on country presentations

Identification of common themes

Nirmala Ravishankar, Carlyn Mann,

Melisa Martinez-Alvarez, Patricia

Hernandez

13:00-14:00 Lunch

14:00 –

onwards

Group Work Nirmala Ravishankar, Carlyn Mann,

Melisa Martinez-Alvarez,

Patricia Hernandez

17:30 – 18:00 Summary / closing remarks CD Finance TWG

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DAY 4 – Friday, 28 February 2014

Time Topic / Activity Facilitator

9:00 – 12:00

Chairs: Bernadette Daelmans & Joy Lawn

Welcome and working plans

CD Country Case Study teamwork and

country-specific technical assistance on

policy and finance tools and analyses and

interpretation

12:00 – 13:00

Presentations on progress made in workshop,

and next steps, requests for specific TA from

the CD Country Case Study teams:

Afghanistan

Ethiopia

Malawi

Pakistan

Country Case Study Teams

13:00 – 14:00

Lunch

14:00– 15:00

Presentations from CD Country Case Study

teams (contd.):

Peru

Tanzania

Rwanda

Kenya

Country Case Study Teams

15:00 - 16:00

Feedback on/adaptations to CD policy tools

and RT analyses

Conclusions

Evaluation forms

16:00 – 16:30

Coffee/Tea Break and close

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ANNEX 5 – EVALUATION FORM

Countdown to 2015: Health Systems and Policies, and Financing Workshop for Country Case Studies

25-28 February, 2014

Participant Feedback Form

We ask that you take a few moments to provide your feedback. Your responses are anonymous and will be

used to improve the quality and the organization of our future workshops. Your feedback is very important

to us.

On a scale of 1-4 where 1 is strongly disagree and 4 is strongly agree, please circle the appropriate answer:

1. Has this workshop fulfilled your expectations? Please indicate your level of satisfaction

1 2 3 4

Comments:

2. What are your qualifications? (please tick all that apply)

Clinical medicine

Natural science/biology

Mathematics/statistics

Nutrition

Economics/Finance

Public Health/Epidemiology

Other

If other, please specify: __________________

3. What is your current field of work?

Clinical practice

Public health including MoH or UN

Epidemiology

Health economics

Other

If other, please specify: __________________

4. How do you rate the talks for the following sections of the workshop:

a) Introduction and overview of CD Country Case Studies 1 2 3 4

b) HSP Tools 1 & 2 (Tuesday) 1 2 3 4

c) HSP Tool 3 (Wednesday) 1 2 3 4

d) Financial analyses (Thursday) 1 2 3 4

5. How would you rate the CD Case Study Country group work for the following sessions

a) HSP Tools 1 & 2 (Tuesday) 1 2 3 4

b) HSP Tool 3 (Wednesday) 1 2 3 4

c) Financial analyses (Thursday) 1 2 3 4

6. How would you rate the facilitators for the following sessions

a) HSP Tools 1 & 2 (Tuesday) 1 2 3 4

b) HSP Tool 3 (Wednesday) 1 2 3 4

c) Financial analyses (Thursday) 1 2 3 4

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7. Were there any topics that were not included that would have been useful? If yes, please specify:

8. Were there any topics that were not useful among those included? If yes, please specify:

9. Did the workshop help you to advance your country case study, including other parts of the

evaluation in addition to HSP and financing? Please specify.

10. Would an additional workshop before you finish your country case study be useful? Yes/No

If yes, please specify the purpose, e.g. an analysis and/or writing workshops:

11. The workshop was:

a) Well-paced 1 2 3 4

b) Breaks were sufficient 1 2 3 4

c) A good mix between listening and activities 1 2 3 4

Comments:

12. How could this workshop be improved (use this space if you did not provide comments above)?

Preparation & webinars:

Handouts and materials (including on USB stick):

Other:

13. What did you like best about this workshop? ___________

14. What did you like least about this workshop?

THANK YOU!