World Federation of Public Health Conference Ethiopia

23rd -27th April, 2012.

FACTORS ASSOCIATED WITH THE IMPLEMENTATION OF A HEALTH SERVICES PLANNING TOOLKIT: A QUALITATIVE STUDY

OF TWO DISTRICTS IN ZAMBIA, CENTRAL AFRICAEmily Moonze- MPH,DHSM,RM,RN

Dissertation submitted in partial fulfilment of the requirements for the

degree of Master of Public Health.The University of Liverpool/Laureate Online Higher Education

Contact:+260 97 7 798022 / + 260 211 258160/2 email-emilym@zambiaissp.org/ emoonze@yahoo.co.uk

Ministry of Health Zambia

Acknowledgements

• Abt Associates Inc.• The University of Liverpool/Laureate Online Higher

Education• Ministry of Health Zambia, • Dr. Deborah McGill - Dissertation Advisor• Katete District Health Team.• Mazabuka District Health Team. • Chongwe District Health Team .

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Background

• The increasing disease burden in many developing countries influenced development and adoption of new planning initiatives.

• In Zambia, attainment of the health goals and other national health priorities.

• In 2003 Zambia moved away from short term to more result oriented, medium- term Expenditure Framework.

• In 2006 adopted the marginal budgeting for bottlenecks (MBB) tool as a health services planning tool.

• MBB is an analytical costing, planning and budgeting toolkit for evidence based result oriented health services management in developing countries.

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Background

• The MBB concept was piloted at district level as a planning tool.

• This study focused on experiences from two of the nine pilot districts.

• The assumption was that findings from the study would highlight areas requiring improvements in both existing and future MBB implementing districts.

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The Research Question

What are the barriers and enablers associated with the successful implementation of a health services planning toolkit (MBB) in Zambia from the perspective of key stakeholders?

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Study Aim and Ojectives

Aim: To evaluate factors associated with implementation of health services planning tools in order to determine their effectiveness and applicability at district level.Objectives:•To assess the current implementation of the MBB toolkit in the health planning process.•To evaluate strengths/opportunities and weaknesses/barriers of the MBB toolkit.•To make recommendations for future planning tools at district level.

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Methodology

• A qualitative study using semi structured interviews.• An interpretative approach informed the study design. • The researcher developed her own data collection tool in form

of a topic guide.• Pilot was undertaken in one of the MBB pilot districts, and tools

adjusted based on findings.• Study conducted in two of the nine pilot districts: Katete (rural)

and Mazabuka (semi-urban).• Purposeful sampling.• Ethics approval obtained• Consent obtained from each of the study participants before

onset of interview 7

Data Collection

• Nine of the planned 12 participants were interviewed within their work environments.

*Programme Officer: MCH Coordinator, District Accountant, District Health Information Officer, Environmental Health Technician.

• All the interviews were recorded using a digital recorder. • Data downloaded to the computer and each interview was

transcribed.

Category Definition Number

A District Director of Health 1

B Manager, Planning and Development

2

C Programme Officer* 6

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Data Analysis

• Thematic analysis using a manual process and data was coded based on most frequent themes.

• Data was presented as broad themes and illustrated with quotations.

• Five themes emerged from the analysis of data which will guide the presentation of results:o Experiences with using MBB for health services planning;o Successes of MBB implementation;o Challenges of MBB implementation;o Lessons learned from MBB implementation;o Recommendations for improvement

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Data Analysis-Summary of Emerging issues

Theme 1.0: Experience with using MBB for health services planning Community

Funding Human resources

MBB concept/ tool

Capacity building Stakeholders / Partners

1.1 Planning experience in MBB     x      1.2 Exposure to MBB Concept       x    1.3 MBB implementation period       x    Theme 2.0: Successes of MBB implementation            2.1 Changes to planning approach       x    2.2 Improvement in selected health indicators         x  2.3 Increased focus on community x          2.4 Availability of extra funding   x        Theme 3.0: Challenges to MBB implementation            3.1 Inadequate community involvement x          3.2 Inadequate qualified staffing at facility level     x      3.3 Withdrawal /inadequate funding for MBB   x        3.4 MBB concept/tool       x    3.5 Inadequate logistical support         x  3.6 Poor data management         x  Theme 4.0: Lessons learned            4.1 Presence of stakeholders’/partners’ opportunity for successful MBB concept           x

4.2 Capacity building/competencies key to successful MBB         x  4.3 Availability of human resource at facility key to successful MBB     x      

4.4 Extra funds through MBB, opportunity to successful MBB concept   x        

4.5 Community involvement/motivation necessary to successful MBB concept x          

4.6 A plan based on MBB concept can attract donor support       x    Theme 5.0: Recommendations for improvement            5.1 Need for community involvement / motivation in MBB x          5.2 Government to consider issue of human resources for successful MBB     x      5.3 Staff need capacity building and competencies in MBB /training         x  5.4 Need to continue provide funding for MBB   x        5.5 MBB implementation needs further strengthening to be successful         x  5.6 Stakeholder involvement to be strengthened           x

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RESULTS

Experiences with using MBB for health services planning.•Most respondents had been involved in health services planning in one way or another during the annual planning cycle.• Almost all the respondents had been exposed to the MBB tool

and have used the tool for three years in their planning.

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RESULTS

Successes of MBB implementation•Respondents reported that they had become more analytical in every aspect to problem identification. •Improvements in district performance in selected programmes, such as the maternal and child health programmes .•Increased focus on community was identified as a major strength of the MBB concept.•Additional funds from MBB project enabled districts to contract extra staff, such as midwives.

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RESULTS

Challenges of MBB implementation.•Administration of health services by multiple types of service providers in the community.•The high-dropout rate community based volunteers. •Increase in number of clients after the introduction of incentives ( mother-baby packs) at the MBB facilities.•Lack of qualified staff (especially midwives) at the facility level; •MBB programme seen as stand-alone or not harmonized with other existing programmes.•Poor data management resulting in data gaps and discrepancies.

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RESULTSLessons learned•Presence of stakeholders/partners within the districts provide an opportunity for successful implementation of the MBB concept.•Inadequate understanding of the programme by staff could lead to implementation failure.•For programmes to run well every facility should be run by qualified staff. •Raising morale of community volunteers can contribute to successful MBB implementation.

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Recommendations for Policy Makers

• Guidance on payment of incentives to community volunteers necessary.• A sustainable mechanism for funding the MBB programme is necessary.• Address human resources crisis at facility level. • Facility staff need training in the MBB concept.• Partnerships with local partners to be encouraged.

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CONCLUSION

• The study, revealed that MBB can be a useful tool to strengthen and enhance effective achievement of health outcomes.

• The study revealed important findings which are key to successful implementation of MBB tool such as: community involvement in planning; adequate funding; adequate staffing at facility level; harmonization of MBB with existing planning processes; adequate capacities/competencies in the MBB concept by district staff; and stakeholders’ involvement and support.

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Thank you for your attention!

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