Health Planning and Resource Mobilization

By

Dereck Chitama, MBA (Finance), MPH (Health Economics)

Health Planning

What is planning?Is a systematic method of trying to attain explicit objective for the future through the efficient and appropriate use of resources available now and in the future?What is health? (Ambiguous because it has different interpretations and sometime inaccurately interchanged with health care)Health- state of either an individual or community influenced by a number of factors. e.g health care, poverty, education levels etc

Health definition cont.

Narrowest concept- See it as state of the physical bodily organs (Unhealthy if there is malfunctioning of a part of a body eg lung or kidney)Broader but related: See health as not only the mechanics of the different bodily organs but in the ability of the body as a whole to function.

WHO definition of HEALTH (Widely applied)

More holistic view It shift away from the organic and functionally based definitions.It consider not only physical and mental states but also social and economic relationship.

The state of physical, mental and social well being and not merely the absence of disease or illness.

TYPES OF PLANNING

Activity planningRelate to setting of monitorable timetables and schedules for the implementation of pre-set activitiesExample: Flow chart or Gant charts, Critical path analysis etcAllocative planningThe making of the decision on how resources should be spent-Which this topic is primarily concern

Important questions in planning process

Where are we going? (Objectives)With what? (Resources)How? (Efficient and Appropriate implementation)When? (Future)Degree of formalization (Explicitness, systematic)

Basis for planning

Scarcity and choicesBased on recognition that resources are limited.At individual level: not difficult to recognize as most of us have wants outstripping our income, hence we have to make choices between different wants.At organization level: Choices are needed eg. Need to decide whether to grow, contrast or consolidate.

Basis for planning

Economist would say resources are scarce in comparison to the use to which a society /organization wishes to put them.Within the health sector, resources available are insufficient to meet all the health care needs or demands that society would like satisfied.Note: Planning is not confined to the public sector alone: even private hospital/sector need to plan.

Basis for planning cont..

It is increasingly recognized that no health care system can meet all the health care needs of its peopleThere is a need to successfully channel resources away from low priority use to high priority ones. That means choices have to be made

Example of Choices to be made

Approaches to planning

Comprehensive rationalismThe approach suggest a chronologically ordered cycle of events, each leading to unavoidable next event. Such events are often depicted in a form of a continuous cycle.The first event analyses the current position or the problem to be solves( Situation analysis)Next, the aim are decided (where we want to be)List all the possible alternatives course of actionAssess their feasibility and capability of achieving themImplementation

Comprehensive rationalism

Approaches to planning

Mixed scanningThe difficulties of operating comprehensive system are recognized by proponent of mixed scanningHence decision taken to narrow down the comprehensive rationalism by focusing planning attention on selected area of interest.

Mixed scanning

It involve determining the priority areas of planning and it is within this the examination of options occurs.It called mixed scanning because it involve a broad sweep or scan of the whole health sector which form the basis for the more detailed examination of selected areas.Criteria need to be set as to what constitute the problem ,priority and therefore deserve special attention.

Mixed scanning

Approaches to planning

IncrementalismRecognizes the political nature of planning than in the previous approaches.The term political nature is used here in a wide sense to refer to effects of various interest groups and not party politics.It is a series of disjointed steps moving in an incremental manner toward the set goals, the degree of movement at any time being determined by the political context.

Incrementalism

It recognizes that a planning that deals with social issues affecting groups of people, there can be no objectivity or shared assumptions.Hence a plan that can be viewed sensible by decision maker may be viewed with suspicious, if not opposition by some groups.Consequently planning can rarely proceed in a straight line toward set goals.The degree to which can proceed smoothly in a straight line toward desired goals without deviation depends largely on the degree to which plan has sufficient direct political support to overcome countervailing forces

Incrementalism

Realistic rational health planning

What is happening in reality?No health planning conform to any of the above models in its pure formA successful planning must combine strong technical skill with recognition of the political process.It perhaps more accurate to describe planning as a cyclical set of activities (planning spiral), with the end point of each cycle forming the start of the next cycle but in a higher plane

Planning cycle

Planning cycle

Situational analysis - This involve assessment of the present situation.Examine current and projected characteristics of the population.Examine physical and social-economic characteristics of the populationAvailable infrastructure Analyse policy and political environment including existing health policies.Analysis of health needs of the populationServices provided

Planning cycle

Priority setting -determining the hierarchy of goals, objectives and targets of the organization It will be influenced by situational analysis, especially the health needs and broad policy objectivesPriorities need to be feasible and set within the context of social and political climate , available resourcesClear criteria for selection of priorities are needed

Planning cycle

Options appraisal -Generation and assessment of various options for achieving the set objectives or targets.Each option is assessed in terms of Its impact on health target (when and how much)Resource implications e.g cost effectiveness, affordability given the resource constraintsFeasibility of each option- examine if there are other barriers to its success (such as technical and political constraints).

Planning cycle

Programming and Budgeting This translate the result of option appraisal into series of programmes, each with budget.This process is carried for each priority area and its associated targets.The result of this stage is a plan document

Implementation and monitoring-

This involve implementation of the plan.Transforming the broad programmes into more specific and budgeted set of tasks and activities.Involve the drawing up of operational plan or work plan

Planning cycle

Evaluation: Analysis if success or failure in attaining the objectives, its impact etc.It provide basis for the next situational analysis and hence fresh lead into the planning spiral.

Planning as a political process

It is important to bear in mind that planning is a political process.It is highly influenced by the context and actor with a stake in the policy outcome.It is concerned about changes therefore brings supporters and opponents.Many plan have failed because of over attention into bureaucratic formalities and ignore the its political process.The relationship between planers, donners policy makers, service-managers, communities, NGOs, CSOs and other stakeholders is important to the success of a plan.

Case study

Examine the following case (do it in groups and present findings to each other)In a country heavily dominated by curative hospital based care, the health plan calls for a switch in resources from such activities to community based health promotive activities. In particular the plan calls forA slow down of hospital building programmeThe creation of community health workers cadre, supervised by nurse from nearby clinicA training programme for nurses in diagnostic skillsThe development of community health committeeA variety of health promoting activities, including a ban on smoking in public placesDiscussion questionsWhich groups are likely to support/oppose the plan and why?How could analysis of this help in ensuring the implementation of the plans?

Private and Public sector planning

Is there any difference??Different aims of the two sectorPublic sector aim at Improvement of the health status of the community by meeting their health needs WHILE have the objective of making profit by responding to individual health demandDifferent roles

- Private sector operate within the context and environment controlled by regulatory functions of public sector/state. Hence public sector have influence on the activities of private sector.

Private and Public sector planning

Comparison of planning in private and public sector reveal strong similarities (though terminology employed may differ)They both require similar combination of technical skills and political analysisThe differences reflect the deferent organizational culture of the two providers.

Private and Public sector planning

Private sector planningPublic sector planningDetermination of mission statementSetting of goalsSWOT analysis incl. MarketingSituational analysis. Incl. need assessmentDetermination of strategyOptional appraisal and monitoringOperational plansOperational plansImplementationImplementationFeedbackEvaluation and Monitoring

Levels of planning

Within the public, private for profit and NGOs there are likely to be different levels of planning.At each level, planning may occur and may be different as well.However, principles and broad process may be the similar,As one move down the plan will be more specific with central plan providing broad strategic directionsEach level need to take account of plan being developed both in other organizations working in the same horizontal level and higher level in the system (vertical dimension)

Levels of planning

Resource mobilization in health sector

DefinitionRefers to the way in which a country FINANCES its HEALTH CARE SERVICES or Collection of funds from various sources to finance health care and using them to purchase services from public and private providers of health careGoals of health care financingon the supply side by ensuring that essential services are adequately financed and delivered;on the demand side by reducing financial barriers to access and by making sure that funds are raised and services delivered in ways which are affordable to all.

Introduction cont

In a typical low income country revenues are raised from TaxesGeneral taxEar marked taxes/sin taxInsurances

-Social insurance

-Private insurance

-Community based insurance

User feesOverseas development assistance (ODA

Resources mobilization in Tanzania
( NHA, 2001).

*

Tax revenue

Often the main source of fundingLow income countries- 15% of GDP as per Abuja declaration High income countries 31% of GDPPossible to increase but depends on political will and competition from other sectors.Can be used to provide services directly through state institutions or contracting services with private providers.Create moral hazards for consumers and providersNo adverse selection- All citizen are covered

*

Tax revenue cont

Constraints of tax funding

it is difficult to increase tax revenue in African countries (in order to cover the ongoing increase in health expenses) due to the limited tax base and it is often not feasible or advisable to increase tax rates any further.

The high level of external debt experienced in many countries consume a considerable share of government revenue from taxes to go cover these debts. Vastly improved debt relief, and indeed debt cancellation (as has begun to happen), should be advocated for, which would enable governments to devote more of their limited tax funding to the provision of health and other social services

Discussions on issues around tax revenue

Why we have failed to reach the Abuja declaration target?

Spending 15% of GDP

What are the advantages and disadvantages

Insurance

Private insurance-Private health insurance simply means that individuals purchase policies from private (either for-profit, not-for-profit) insurers. Or employers to offer health cost cover to its employeesIn many countries the private sector plays an important role in providing health insurance e.g South AfricaThere is a clear link between payment of a premium and entitlement of services (actuarially based)

Private insurance cont

Actuarially based- Pricing premiums according to the individual risk of a person seeking insurance.The voluntary nature of commercial health insurance makes it especially liable to problems of adverse selection and, to a lesser extent, moral hazardIn order to combat the former, insurers will tend to refuse to cover pre-existing conditions (cream skimming)To combat moral hazard- Co-payment is normally used.

Moral Hazard

Behaviour that increase the probability of the event to occur (patient moral hazard- Lead to over utilization of service.Doctor moral hazard??? Leads to .Measures to preventCo-paymentCapitationLimit of benefitTreatment guidelines

Adverse Selection (AS)

Is a result of information asymmetry.

-Individuals are able to buy insurance at a rate that are not actuarially fair because of information asymmetry.

-Those who are ill most of the time go for the scheme

-Big family in size (number) go for the scheme

Discussion

The concept of market for health insurance in Tanzania , is it new?

Social health Insurance (SHI)

German classical example of SHI: One of the first country to institute SHI nationally(1883).Started as small sickness funds for defined employment groups i.e guild funds, regional funds; national structure gradually phased in (Incremental approach i.e regional to national, optional to compulsory, gradual inclusion of population groups, gradual expansion of benefit package).

SHI cont

SHI Key features

Mandatory membership of formal employees

Supported by legislative and institutional frameworks

Standard payroll deduction from employees

Contributions are not risk based but on ability to pay.

Insured have access to benefit package

Aims of SHI

To improve access to health care- Ultimate goal is universal coverage.To reduce the financial barriers to care.

Community based insurance (CBI)

Any not for profit insurance scheme that is aimed primarily at the informal sector and formed on the basis of a collective pooling of health risks and members participate in its management (Atim,1998)Referred by a range of names: micro-insurance, community financing, mutual funds etc.Variety of design and administrative organizations and procedures within and across countries and regions.In Tanzania: CHF,UMASITA,VIBINDO etc

CBI characteristics

Objective: Improve financial protection and access.Member pay premium at the beginning (cash or In-kind to insurer)Community participation in design and managementProne to adverse selection and moral hazardLow coverage- low revenue if not well designedSustainability???

Out of pocket expenditure/User fee

Direct payment by user to health service providerOften single largest source of financing health careWide spread in developing countries60% of low middle countriesThere is policy concern about user fees/OOP

as it may lead to catastrophic health spending and impoverish people (estimate that up to 178million people suffer from financial catastrophe and 104million are forced into poverty.)-Medical poverty trap???

Deters access to health care service especially for poor /vulnerable

Self treatment and irrational prescription and usage

On the other side easy to collect, generate resources for non-salary portion

Donor Funding

Are funds donated in kindnessAre usually for specifically designed health projects/programmes Have a variety of contributions I.e both monetary and technical assistanceProvides almost the same proportion of funds for health as the Government

*

Donor funding cont

Constraints of donor funding

Donor funding could potentially undermine the role of the Ministry of Health in crucial areas of health policy, particularly in relation to health care financing. That the ministry of health would be more responsive to donor demands, and it is possible that donors could attempt to impose their health sector priorities than our priorities.

There are also concerns about the unreliability of this particular source of financing and a growing awareness of the need to find sustainable domestic financing alternatives.

Sector wide approach (SWAP)

New approach to development aid. Health sector partners pool their funds contributed for healthIncrease role of donor in national sectoral strategyReplace project specific funding with pooled funding for the entire sector.Include reforms to health management systems and priority settingEmphasis on national ownership of of reforms and the role of governmentWide range of stakeholder are involved eg NGOs, Private sector, Civil society etc

END

THANK YOU FOR LISTENING

Regional healt

h organization

Regional plan

District

healt

h

organization

District

plans

Private

healt

h

organization

Business

plans

sector org

Business plan

Primary health care

Service plans

Primary health care

Service plans

Health Ministry

National

Strategic

plan

NGOs

Organizational

Plans

Government Expenditure on Health as Percentage of Total Government Expenditure 2002

0

5

10

15

20

25

BurundiNigeriaAngolaGuineaMoroccoLibya Arab JamahiriyaLiberiaEritreaCongoEgyptMadagascarMauritiusGhanaKenyaGuinea BissauMaliAlgeriaUgandaMalawiEquatorial GuineaSenegalZambiaGambiaChadZimbabweNamibiaRwandaTanzaniaDem. Rep. CongoMozambique

Percentage

Regional AverageAbuja Target