Supporting the effective management of maternal, … Program of Immunization : ... (GAVI-HSS) which aims to roll out ... exhibit a number of key principles are more

Supporting the effective management of maternal, neonatal and child health services in Myanmar Lessons from Merlin and Save the Children’s support to township health planning processes

September 2014

Township Health Planning Learning Paper

AMW Auxiliary Midwife BHS Basic Health Staff CHW Community Health Worker CSO Civil Society Organisation CBO Community Based Organisation CTHP Comprehensive Township Health Plan DOH EPI

Department of Health Expanded Program of Immunization

GAVI Global Alliance for Vaccination and Immunization HA-1 Health Assistant-1 HSS Health System Strengthening IPs Implementing Partners INGO International Non-Governmental Organisation JIMNCH Joint initiate Maternal, Newborn and Child Health LNGO Local Non-Governmental Organisation MNCH Maternal, Newborn and Child Health MOH Ministry of Health MS Medical Superintendent PONREPP Post Nargis Response, Preparedness and Plan THD Township Health Department THN Township Health Nurse TMO Township Medical Officer VHC Village Health Committee VHW Village Health Worker

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Background The ability to assess the health needs within a population, to organise services to address these needs, and to ensure access and use of services by all groups, particularly those most vulnerable, are vital functions of health planning to deliver health outcomes and ensure equity. Within Myanmar, plans to support health services are developed at multiple levels - Township, State and Regional levels as well as Central level. The aim of the township plan is to provide an opportunity to harmonise and align various national and international investments in a coordinated plan. Within the overall health service, townships are therefore a key link between the delivery of services in communities and decisions and support from State and Regional Health Departments, and the Department of Health (DOH). The Township Health Department (THD) is the key decision-making body in this process with responsibility for implementing all activities related to public health in the Township. A number of externally funded programmes are currently supporting a township health planning approach. These include Global Alliance for Vaccination and Immunization-Health System Strengthening (GAVI-HSS) which aims to roll out support to township planning in 180 townships, and the 3MDG Fund which has the development of a township health plan as a central tenet of its support to townships under Component 1 support to Maternal, Newborn and Child Health (MNCH) services, in more than 40 townships in five States and Regions. Most recently the Ministry of Health, with support from the World Bank through its Universal Health Coverage project, has signalled its commitment to strengthen the township planning processes; building on the efforts by other programmes, and ensuring a streamlined and simple system, which allows effective planning, and implementation.

Merlin and Save the Children have supported the development of township health plans in nine townships to date under the 3MDG Fund. Experiences from these processes provide important learning for both organisations as well as the wider roll out of health planning activities. This short learning paper outlines the lessons from Merlin and Save the Children’s programmes in supporting these township health-planning processes. It identifies a number of key lessons learnt from the current planning processes and a number of recommendations to support improved planning outcomes in the future.

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Introduction to townships included in the review Merlin and Save the Children are currently supporting nine townships under the 3MDG Fund. Five of these townships are in Chin State (Hakka, Thantalang, Falam, Tedim and Ton Zang); two are in the Delta Region (Laputta and Nga Pu Daw) and two townships are in Magwe Region (NgaPe and Gangaw). The Delta townships have been supported in the delivery of MNCH services in partnership with THDs since late 2008, initially under the Post Nargis Response, Preparedness and Plan (PONREPP) programme, which laid the foundation for the Joint Initiate Maternal, Newborn and Child Health (JIMNCH), and subsequently the 3MDG Fund. The THDs in these townships have a number of years of experience of working in partnership with Implementing Partners (IPs) and in township planning processes.

In Chin State, support to date in townships, prior to inclusion into the 3MDG programme, has been varied. Two townships have received support from Merlin in the delivery of disease specific as well as more comprehensive primary health community based activities, with some limited links to the wider township health system. In the three other townships there has been no previous engagement by Merlin or Save the Children. All five Chin townships are now supported under 3MDG Component 1 funding and have been supported to develop a township plan. In Magwe Region, NgaPe has received support for community-based MNCH and vertical malaria projects prior to their inclusion in the 3MDG programme; Gangaw had not received support from Merlin, Save the Children or other INGOs in MNCH prior to inclusion in the 3MDG programme. Support to conduct a township planning process was provided in early 2014.

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The townships included in this learning document are therefore starting from different baselines in terms of support to MNCH programmes and in their exposure to township planning processes. In all cases the townships have been tasked with developing a township health plan as the basis for delivering a package of essential MNCH services. In Chin and Magwe, this was within a designated inception phase which was three to four months in Chin townships and nearly five months in Magwe townships under the 3MDG programme. In the Delta, this was part of their continuing engagement with the townships. To support the planning process, 3MDG Fund has provided a standard planning tool based on MoH and GAVI-HSS standards. The tool is focussed on essential MNCH health services. How the township planning process has been supported At the start of support to each township, senior representatives from Merlin and Save the Children met with the respective Chief Minister and State Health Director (SHD) to discuss the 3MDG project activities and funding, and working with THDs, particularly in the development of a township health plan. Following agreement at state/regional level, IPs met with the Medical Superintendent (MS) and Township Medical Officers (TMOs) of the respective THDs to introduce the planning process and the timeframe of the inception period. The IPs developed standard tools to support the rapid assessment of the health situation within the townships. These tools include: 1) an assessment of health services and programmes currently in place, in relation to national plans; 2) an assessment of health system components; 3) collection of all township plans and data available; 4) health facility assessments; 5) knowledge and status of AMWs, CHWs and VHCs in selected villages, and health seeking practices within the community. In addition, IPs discussed the identification of key stakeholders (health and non-health) with THDs.

The information and findings from these assessments have been used in the assessment and planning workshops in the townships facilitated by Merlin and Save the Children, with support from partner organizations (MSH in two townships in Chin) and Burnet Institute (in Magwe). How this review has been conducted The aim of the review has been to collate information from key stakeholders in the township planning processes supported to date, to better understand how the programmes have worked with the townships in the development of township health plans, and to identify how this support can be strengthened to maximise the opportunities for improved planning of MNCH services in the future. A number of sources of information have been used in the review. These include: • Planning documents and assessment responses

generated by the situation analyses and the township planning processes.

• Workshop evaluations at the end of the Comprehensive Township Health Plan (CTHP) Workshops in three townships in Chin.

• Interviews with key participants using a structured questionnaire in all townships.

Technical staff from the respective organisations supported the design of the questionnaires. Information was collected from all nine townships across a range of stakeholders involved in the township assessment and planning processes. One questionnaire was administered to stakeholders from the townships including: THD members; BHS representatives; some members of VHCs from communities as well as AMWs and CHWs, and representatives from INGOs, LNGOs and CBOs who attended and participated in township assessment and planning workshop. A second questionnaire was used to gather information from IP staff. Feedback was collected from a total of 60 key stakeholders at township level and 20 IP staff. The data was reviewed and analysed by technical staff from the respective organisations at the Yangon level with the support of a third party (consultant) in the analysis and writing of the results.

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Experiences from Merlin and Save the Children support to township planning processes While there is no blue print for a township health plan, experiences from a range of contexts support the view that health plans that exhibit a number of key principles are more likely to lead to the desired results in terms of quality outcomes, local ownership, learning and capacity building. These principles are highlighted in the box below.1 1District Planning tool for Maternal and Newborn Health Strategy Implementation.

A practical tool for strengthening health management systems. WHO, 2011. Available at: http://whqlibdoc.who.int/publications/2011/9789241500975_eng.pdf?ua=1

Principles of good township planning

1. Participation 2. Strong leadership and organisation 3. Based on a good situation analysis 4. Designed to address priority needs 5. Involvement of different Stakeholders 6. Outlines clear goals and targets 7. Sets clear objectives and clearly

articulates activities 8. Estimates resource needs 9. Shared with the community for their

support

The following section looks at the experiences of the inception and township planning processes across the nine townships, based on these general principles. Participation The planning process and outcome is more likely to be effective if there is active participation of key stakeholders involved in the process. Key actors at the township level include: the THD and other departments under the township authority, key service delivery actors including private sector, INGOs, LNGOs and CBOs; basic health staff, users of services, community representatives. The methodology of the workshops has been geared to ensuring participation of all stakeholders. For example, all participants were involved in the presentation of the situation analysis and identifying and prioritising the main health needs within the individual townships. Participants were actively engaged in contributing to the detailed activity plans with associated timeframes and staffing. The THD members provided information on the focus of MNCH service areas, especially in hard to reach areas and funding sources from GAVI and other government sources. INGOs and LNGOs shared their funding sources and support on relevant thematic areas.

Feedback from both the THDs and the other participants, suggests good participation by a range of stakeholders in the planning processes to date. In particular the THDs have been fully involved in the assessment and planning processes and in supporting and providing inputs related to the local situation analysis and information on the delivery of essential health services. The level of interest within the THDs however has been mixed. In some townships, it is clear that the MS and TMO have been less involved, in part due to staff turnover. This has been especially the case in Chin state. In all cases, the THN and HA-1 staff appear to have been most involved in supporting the planning processes.

http://whqlibdoc.who.int/publications/2011/9789241500975_eng.pdf?ua=1

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Beyond the THD, the level of participation has varied among different stakeholders and appears to relate to their experience in different thematic areas and their level of knowledge regarding their organisation’s activities. However, even where the level of participation has been weak, especially from non-health actors, there has still been a sense of contributing to the general understanding of the local context, within the process. Acceptance of the role of stakeholders in the planning process was perceived as generally high across NGOs, CSOs, VHW and THD respondents. The THD and BHS recognise the importance of active participation throughout the planning process and the insights that different stakeholders can bring to an understanding of the actual situation. Participants also recognised the importance of representation of the community in providing feedback on the planning process to communities to strengthen transparency and accountability. Strong leadership and organisation The planning process and outcome requires strong leadership and organisation to ensure that the process is both effective and transparent. Strong leadership ensures that key stakeholders are included, and that the process allows all views to be heard. It also keeps the process on track in terms of timeframes and quality outcome. Feedback suggests that in many cases the MS and TMO have taken ownership of the CTHP workshop processes and have led and participated in the discussions, supported coordination among stakeholders, and ensured that discussions have been in line with national policy. However in some townships, where the TMO has been less engaged because of competing priorities such as meetings at the State/Regional level or providing hospital care, IPs have taken on more of the facilitation role albeit under the guidance of MS or TMO. In some cases IPs have sensed that the THD is not able to fully take-on the role of leading the planning process at this time due to time and capacity constraints.

Feedback on the inception phase processes highlights the considerable organisation required to ensure a successful planning process and the range of activities needed to ensure that all elements are in place to bring the information and stakeholders together. In particular, preparatory discussions with THDs are highlighted as being critical to ensure that townships are fully aware of the purpose of the township planning process and the information needed to support the process. In many townships, the THD has limited capacity and resources to organise a comprehensive planning workshop and sharing this responsibility with IPs has been crucial for the success of the processes to date. One of the challenges relating to the current process is the time constraint of three months for the inception phase. Ensuring the completion of the situation analysis and the planning process within this time period has been a struggle for many townships. For townships where IPs are new, without the systems in place for organisation, it has been more difficult to set up the operation and build the relationships needed to undertake an effective and inclusive planning process in this short time. Based on a good analysis An effective plan needs to be based on a good analysis of the current situation within the township. This assessment needs to cover all levels of the system – from community to township as well as ensure that all population groups are incorporated. All townships have used the information collected from the assessments in the CTHP workshops to develop their respective township plan. Feedback from participants has confirmed that THDs have been generally supportive of the assessment and planning activities. This has included sharing township health information with IPs; supporting the selection of villages for the community assessment aspects, and facilitating the use of the assessment tools. The THDs have also supported the development and agreement of the workshop agenda and methodology in many townships to ensure appropriate sharing of the data and facilitate analysis.

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Feedback also suggests that the assessment of the townships across all levels of the system from community to township has been very helpful in ensuring that all participants are fully aware of the major needs and gaps in essential services within the township. Assessment data has included information on the township health profile, available service packages, infrastructure and essential equipment, THD capacity, current community based health activities and existing stakeholders supporting services within the township. Data for the assessments has been collected using a range of assessment tools and at all levels. However, feedback from the THDs on the assessment process, reflect its rapid nature. The IP staff from two townships in Chin suggested that sample sizes for the volunteer and community assessments to inform the situation analysis prior to the workshop were very small and they would have liked to have conducted assessments in additional villages from a more representative sample of RHC and SRHCs. The timeframe for the data collection before the workshop did not allow this, however over the full inception period, the volunteer assessments were conducted in all

villages and plans were amended to reflect the actual numbers and knowledge of volunteers. In some townships in Chin, the MS also suggested that it would be useful to collect information on other factors such as economic status, availability of electricity and transportation, as these are seen as key contributing factors in the implementation of health activities. Feedback also suggests that the information collected has helped to highlight gaps in current township health information. The THN and HA 1 staff from one township of Chin in particular seem to have been aware of the reviews and analysis of the township health data and their findings. The THD involvement in the stakeholder analysis has on the whole been limited to providing the list of key implementing partners in the township, leaving the bulk of the analysis to the IPs. Feedback from IP staff using the stakeholder analysis tools has highlighted the time needed to the collect the information requested by 3MDG and the challenges in obtaining some of the information sought. In some cases complete information could not be collected from stakeholders due to the time constraints.

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Addressing priority needs Based on the assessment of the current health needs within a township, it is important that the plan addresses priority needs and ensures that available resources, human and financial are directed to addressing priority issues. The nature of the current plans mean that rather than being a comprehensive plan for the township, the focus is on the key areas needed to deliver on MNCH goals, although participants did identify three priority programmes/areas and develop activity plans for each. Within these given parameters, feedback suggests that the plans developed are generally satisfactory and meet the needs of the township, and are in line with state and national plans. In three of the townships in Chin State information is available from the workshop evaluations. This feedback shows that 92% of participants felt that the objectives of the workshop were achieved and that the discussion topics including prioritization areas were relevant. There is evidence from the Delta townships that the level of discussion around priorities has developed over time. For example, in townships where support is new, the focus of the discussions has been on looking at the timetables and mapping the package of essential services and planning by BHS, referral flow, the condition of infrastructure and detailed costing for transport. In contrast, in those townships previously supported by JIMNCH, most of the participants are already familiar with the services for MNCH. Here the focus of the discussions has been on reviewing and reflecting on current and previous activities, such as delivery of MNCH services by BHS, and on reviewing support to hard-to-reach villages. However most of the townships had very high expectations and stated a frustration that the township health plans could only focus on limited priority areas when there are multiple needs. Guidelines and facilitator notes encourage the identification of three priorities in order to make the plan more manageable and provides space for participants to articulate these top priorities, some of which are interrelated (such as MNCH

and EPI and nutrition, which also raises expectations of the range of needs it will be possible to address). This is exacerbated in some cases by both overly ambitious plans when all three priority work plans are combined as well as a lack of clarity with respect to the parameters of funding from 3MDG or changes in these parameters between township planning processes. The result is that in many townships, the initial plan drafted at the workshop is ambitious and different to the plan that is finally approved by 3MDG. This was noted by participants. Includes a range of perspectives In the assessment and planning process, it is important that the perspectives of different stakeholders are reflected. However, stakeholders also need to come to a common understanding of the key health issues. Feedback from participants in the workshops to date has highlighted the different perceptions and understanding on the health needs within the township, particularly between the THDs and administrative departments. From the administrative viewpoint, the priority areas identified relate to WASH and the selection and recruitment of AMWs/CHWs in one township, while THDs identify the delivery of essential MNCH services, upgrading of health facilities and the provision of essential equipment, as the priorities. In some cases these differing perspectives have led to difficulty in negotiating and gaining agreement on the priority areas between stakeholders during the workshops. While quarterly and other regular coordination meetings take place among line departments and other stakeholders in the townships, it is clear that it has not been until the inception period and the planning workshops that the relationships between these stakeholders developed due to the necessary sharing of information on project activities. One of the principles of stakeholder involvement in the workshops has been to ensure the participation of community level stakeholders in

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the planning process and ensure that plans reflect the reality of their needs. Feedback suggests that the planning processes created the space for sharing information and analysis of the local situation, and the identification of priority needs with different stakeholders. For many of the townships, this kind of planning workshop has never been undertaken before. The participation of AWMs/CHWs in the planning workshop was also found to be particularly helpful in bringing community concerns into the discussions. In addition the participation has also meant they learnt about the overall health system, including the main challenges and needs within the township. Unsurprisingly, communication between stakeholders within the process is identified as critical to the success of the planning workshops, particularly in relation to being able to communicate in the discussions in their preferred local language. During the workshops, local health staff and local IP staff have assisted in translation and communication between participants helping to minimise language barriers. This has been highlighted as a crucial factor in the feedback from Chin State. In Laputta, the participation of the Deputy Regional Director of the Regional Health Department in the CTHP workshop was particularly welcomed in providing insights into national policy and guidelines. The support from the regional level by a senior professional was seen as providing a bridge between the township and the region and encouraging the THD and BHS in their leadership of the planning workshop. The planning workshops also facilitated engagement between CSOs, LNGOs, IPs and the THD, particularly around working in partnership to deliver MNCH services (e.g. taking shared responsibility for the ambulance service; emergency referral support). A range of suggestions were received from participants to facilitate increased involvement at all levels by key stakeholders in the future, including the following: providing information on assessment activities and specific tools in advance; providing time for BHS and the THD to consider and discuss the specific

areas needed to support from various health actors before the CTHP workshop; and to further involve the THD in discussions on the workshop methodology, agreeing the outputs and result of the planning workshop, prior to the process. Clear goals and targets; sets clear objectives and activities A good plan will ensure that there is a clear goal (or goals) and that targets are set which will allow the goal to be realised and measured, that clear objectives are set to help achieve the goal, and that activities to support the objectives are logical. There is no specific feedback from respondents on goals and targets in the current processes as the questionnaires did not specifically address this. However 3MDG has a predefined logical framework covering impact, outcomes and outputs and IPs must fill in targets agreed with TMOs. The CTHP budgeting tool includes components, detailed activities linked to the priority areas identified in the workshop. In the business case as well as the log frame, the 3MDG Fund mentions objectives with specific MNCH core indicators. This is taken forward in the CTHP workshops, with the articulation of the detailed activities under each priority area and discussion on the detailed targets or quantities with specific frequency and time line for each activity. Feedback suggests that participants have taken great interest in discussing the detailed activities conducted by BHS under each of the thematic areas of EPI, MNCH and Nutrition. BHS appear aware of what needs to be improved for the effective delivery of MNCH services within townships to reach the MDG goals four and five. Estimation of resources The township plan will only be realised if there is an accurate estimation of all the resources needed to achieve the activities, and thus goals. This includes a sufficient estimation of time, financial needs, capacity needs and staff. The THD is currently the main decision maker in estimating volunteer staffing requirements: VHWs recruitment, other resources needed within the

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townships, and training needs for volunteers and BHS. The VHW assessments also help to inform the need for new volunteers and retraining, as well as training staff capacity. There is limited exposure within THDs of calculating unit costs and estimating resources for budgeting purposes. In many townships the estimation of resources has thus fallen to the IPs. Where a township is funded by GAVI-HSS, the MS or TMO is currently managing the budget for MNCH support through a dedicated bank account and some TMOs have been trained by GAVI and MOH in fund management. However this training does not extend to developing the skills needed to match needs with resources and develop the budgets to support. In the current township planning processes, THDs have in many cases identified all resources needed without any reference to their capacity to deliver, although IP staff tried to facilitate discussions on capacity. In some townships previous experience in other programmes, such as WASH led to the wish to include such elements in the budgets. However, the subsequent absence of these areas in the final versions of the budget has left townships with the sense that the main needs have not been covered. Clearly identifying and articulating the parameters of the funding prior to the workshop discussions is critical and linking the development of budgets to the planning of activities is a vital aspect of the process with THDs. Shared with the community An effective plan needs to be transparent and shared with those whom it seeks to serve in terms of decisions on the resources allocated to support health services within the township. Effective sharing of the process as well as the plan includes providing simplified versions of the narrative in a language which can be easily understood and ensuring effective distribution of this information within the population. Currently the CTHP planning tools are too complicated to be used effectively with the BHS, THDs and the community. The format of the final plans and budgets also makes them difficult to share. Consideration therefore needs to be given

by IPs and the 3MDG Fund to how greater sharing of the process and plans can be supported in the future. Linking with other health planning initiatives Among the nine townships, six are also implementing MNCH health services under GAVI-HSS. This includes Nga Pu Daw in the Delta and all five townships in Chin state. Thus, these townships are also being supported in planning processes. This presents the opportunity as well as the need to coordinate across programmes and to learn from their respective support. At the beginning, existing township plans such as GAVI-HSS was requested to be shared for review and discussed with THD so that township planning process could build on the existing plan rather than duplicate. Following the planning process in the townships under GAVI-HSS and 3MDG Fund, Merlin and Save the Children held regular coordination meetings to ensure discussion on the sharing of activities between programmes. There was also detailed discussion on division of activities between programmes within the township health plan. Key representatives from GAVI and 3MDG were part of these implementation meetings at township level in some cases. Other health actors in the townships also participated. However despite these efforts, gaps remain for some activities, and there is also overlap in the support provided across the programmes, including the training for BHS. Feedback suggests that the coordination mechanisms between programmes and key actors need to be strengthened, particularly around the planning processes. This is vital to ensure the optimum use of all resources at the township level and to promote best practice in future planning activities.

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Key learning points from the implementation of township planning processes to date Based on the feedback on the processes to date, a number of key learning points have been highlighted. These include:

• The level of interest and participation among THD members and stakeholders differs across townships. In many cases the THN and HA-1 have acted as the key focal points for day- to-day communication and interaction with IPs. To promote maximum involvement across the THDs, significant investment is needed in sensitising townships on the 3MDG Fund and the township planning process in particular.

• The organisation of the township assessment and planning process is a complex undertaking involving the coordination of multiple activities and stakeholders. In 3MDG funded townships IPs are available to provide support, but identifying the resources and processes necessary for townships to undertake planning without external support should be a long term aim.

• The timeframe allocated for the assessment and planning process is short and townships currently struggle to complete within the designated three months. Consideration needs to be given to increasing the timeframe for future townships to promote increased involvement of THDs in all aspects and provide the opportunities for IPs to work with townships to build the skills necessary to take full ownership of the process in the future.

• It is clear that the joint planning processes bring different perspectives to the dialogue

as well as challenges for gaining agreement among stakeholders on the priority actions to address township needs. Facilitating these interactions and exchanges requires mutual flexibility and commitment from all parties to take advantage of the insights that these different perspectives bring.

• The availability of a range of data and information through the initial assessment is critical for the planning process. Merlin and Save the Children have developed their own tools to support the assessment processes to date. It would be useful to ensure the standardisation of tools across all 3MDG townships based on the learning from those already developed and utilised. This will facilitate future learning on a wider scale.

• The process of the rapid assessment has provided the opportunity to look at the wider township health information system. All participants have appreciated this opportunity. In particular THDs have recognised the importance of good data in the planning process and the need to strengthen the health information system at township level. There is need for THDs and BHS to be provided with specific training and feedback on data quality issues as part of the 3MDG programme’s health system strengthening component.

• The assessment and planning processes have highlighted the lack of exposure of THDs to multi-stakeholder assessment processes and to undertaking a stakeholder analysis in particular. The stakeholder analysis tool provided by 3MDG Fund is complex and has presented some challenges to IPs and THDs in its application. Consideration should be given to providing orientation on the stakeholder analysis tool to all IPs and THDs at the start of the inception phase.

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• Multiple stakeholders welcomed the participatory methodology of the planning workshops. It is seen as providing the opportunity to share individual experiences and perspectives and reflect on the local context.

• The multiple health system needs at township level present a challenge for facilitating a planning workshop with a very specific focus. This is particularly the case when the specific parameters of 3MDG Fund support have not been clarified or communicated well in advance. It is important for all participants are fully sensitised on the nature of support from 3MDG Fund in advance of the assessment and planning activities to avoid raising expectations within township staff that result in large differences between the plans developed during the workshop and those that are ultimately funded.

• The planning processes have highlighted the multiple opportunities that these exercises present for key stakeholders such as BHS and community representatives. These include the opportunity to contribute their knowledge and experiences on the local context to the process; the opportunity to link up different stakeholders in the provision of services (e.g. activities such as emergency referral support between local CSOs, LNGOs and THDs, as well as the opportunity to build the capacity of key stakeholders in planning activities). This includes local CSOs and LNGOs as well as THDs.

• The involvement of representatives from the State/Regional Health Department is a vital contribution to the process. It supports the development of capacity of township health teams in planning processes in particular in thinking through the implementation of services in line with

national strategic and operational plans. Technical assistance from the Regional/State Health Department in all township planning processes should therefore be sought and existing township and state health plans must form the basis on which to build in planning

• It is critical for all stakeholders, and in particular the THD and BHS to be fully familiar with the format of planning and budgeting tools prior to the workshops to ensure their buy-in and ownership of both the process and the outcome and for instigating the process of planning, budget calculation and regular review in townships in the longer term.

• The activities in the inception phase benefit from good relationships across stakeholders. These relationships are built on trust. Turnover of staff within the IPs can undermine this trust. It is important that there is continuous involvement, support and guidance through the entire process by the IPs and other professionals to strengthen the important relationships with the THDs and other stakeholders, and ensure a quality outcome.

• There is need to ensure effective coordination between major programmes at township level (e.g. GAVI- HSS and 3MDG Fund) to support the optimum use of all resources at this level.

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Conclusions and key recommendations for future processes This review has highlighted the positive nature of the township assessment and planning processes to date as well as areas where there is room for improvement. In particular, there is an understanding of the positive contribution that a range of participants bring to these processes. In many cases this is the first time that key stakeholders have participated in such a meeting. The review has also shown that the process of capacity development in township assessment and planning takes time. Ensuring that the organisation of the process supports the engagement of all actors, and in particular promotes the leadership of the THDs and staff and their ownership of the plans, is crucial. This is particularly the case for ensuring improved delivery of health services at township level in the future. Some consideration also needs to be given to ensuring that the process, currently focussed on MNCH, strengthens the capacity to develop comprehensive plans for the delivery of wider health outcomes at township level in the future. This will be important for equity and ensuring that all population groups feel that the health system is working for them. Finally ensuring that the time available to work with THDs and staff to ensure that the necessary capacity is developed through the process is key. The IPs have a role to play in facilitating the learning and capacity development and must put this at the centre of their support. This focus needs to be supported through realistic timeframes and tools.

The following recommendations are suggested to support this conclusion:

1. Ensure that townships are adequately sensitised on the 3MDG Fund and the township planning process at the earliest opportunity, including ensuring a thorough understanding of the assessment and planning process, the tools to support, and the specific parameters of the 3MDG township funding.

2. Ensure that the focus of IP support is on building the understanding of the THDs in township assessment and planning processes.

3. Extend the time available for township assessment and planning processes to allow adequate opportunities for THD involvement in the process and the development of capacity to lead on future processes.

4. Ensure the workshop processes provide the space and opportunities for different perspectives to be voiced and the capacity to bring these perspectives together in an agreed plan.

5. Support the development of particular skills in health information at township level as part of the 3MDG Fund health system strengthening support in all townships.

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6. Support the understanding of all townships in stakeholder analysis through a thorough orientation on the use and purpose of stakeholder analysis tools before the start of the inception phase.

7. Ensure that all tools and guidelines to support the township assessment and planning process are standardised between IPs and available in Myanmar language with summaries in local languages where possible, prior to the start of the inception phase. Ensure that all workshops provide the opportunities for all participants to engage in their preferred language through appropriate translation services.

8. Ensure the involvement of State/Regional representatives in the township planning processes to encourage future support for the THDs and their plans.

9. Provide opportunities to review the township health plans on a regular basis with the THDs and other key stakeholders, including new donors, to support the plan as a “living document.”

10. Ensure on-going discussions between key donors supporting township planning processes across the country to share lessons and promote the development of a streamlined and effective planning process, including the standardisation of tools, for all townships.

Merlin and Save the Children would like to thank all township stakeholders for sharing their views with us and the 3MDG Fund for the financial support that made this work possible. Our

organisations are solely responsible for the analysis of findings and recommendations presented in this paper.

We hope that this learning paper will support discussions between all stakeholders involved in township planning processes.

Documents

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