processes and tools for annual operational planning and...

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Processes and tools for Annual Operational Planning and review

Acronyms used in this brief

What is this technical brief?

This brief summarises Malaria Action Program in States’ (MAPS) support for AOPs in nine Nigerian states.

What is the purpose of this brief?

To share MAPS’ experience in annual operational plans with other institutions developing malaria control and elimination programs.

Who is this brief for?

Planners and managers working with national or state malaria control and elimination programs, particularly in Nigeria.

What other information is available on AOPs?

This brief is part of a series, including:

Case studies, which provide a picture of AOP in one particular state:

People and processes: Annual Operational Planning for malaria control in Ebonyi State

Planning for results: Annual Operational Planning for malaria control in Oyo State

Success stories, which provide brief examples of how AOP has improved delivery of malaria programs.

ACSM = Advocacy, Communication, Social Mobilization

ANC = Antenatal Care

AOP = Annual Operational Plan

DHIS = District Health Information System

HSS = Health System Strengthening

IPTp = Intermittent Preventive Treatment in Pregnancy

LGA = Local Government Authority

LLIN = Long Lasting Insecticidal Net

MAPS = Malaria Action Program in States

MoH = Ministry of Health

mTWG = Malaria Technical Working Group

NMEP = National Malaria Elimination Program

NMSP = National Malaria Strategic Plan

PHC = Primary Health Care

PMI = Presidents Malaria Initiative

RDT = Rapid Diagnostic Test

SMART = Specific, Measurable, Attainable, Relevant, Time-bound (objective)

SMEP = State Malaria Elimination Program

Contents

1 Introduction 3

2 Aligning program objectives to the national strategy 3

3 Developing a capacity building strategy for state malaria programs 3

4 Steps in the Annual Operational Planning process 4

Step 1: National AOP Development Planning Workshop 5

Step 2: Pre-preparation in states 5

Step 3: Meet stakeholders to prepare workshop 5

Step 4: Phase 1 workshop – situation analysis, objectives and targets 6

Step 5: Phase 2: Generating activities and costs 7

Step 6: Clean up draft AOP 7

Step 7: Verify AOP and obtain consensus 7

Step 8: Finalize AOP, write report and hand over 7

Step 9: Adoption and dissemination 7

5 Establishing a review cycle 8

Providing a means for review 8

The review meeting 8

Proxy indicator tool 9

Performance measurement tool 9

Force field analysis 9

Feedback 10

6 Results 11

Does planning make a difference? 11

Pregnant women receiving LLINs and IPT2 11

Diagnosis and treatment of malaria 12

Monthly reporting of facility activities 12

Conclusions 13

7 Key lessons for AOP in states 13

Annexes 14

Annex 1 Learning from the literature 14

Annex 2 Aligning national goals and strategy 15

Annex 3 Sample state AOP preparation plan 16

Annex 4 Sample objectives and targets 19

Annex 5 Performance measurements 20

Annex 6 Example of force field analysis 21

Annex 7 States supported by MAPS in annual operational planning 22

Annex 8 Interventions supported by MAPS and other malaria control programs 23

M A P S T E C H N I C A L B R I E F A O P 3

1. IntroductionThis Technical Brief draws on experience of stakeholders and advisers in malaria programming in nine Nigerian states. This experience was gained between 2009 and 2014 in Akwa Ibom, Benue, Cross River, Ebonyi, Kebbi, Kogi, Nasarawa, Oyo and Zamfara states. The processes and tools are relevant to malaria programming in other Nigerian states and elsewhere where governments and partners want to bring malaria control and elimination within a sustainable publicly managed framework.

Malaria Action Plan for States (MAPS) set out to increase the quality, access, and uptake of malaria control interven-tions in Nigeria by helping implement and scale-up proven malaria control methods, while strengthening capacity at the national, state, and local government levels.

2. Aligning program objectives to the national strategyMAPS was designed to support the goal of the National Malaria Strategic Plan (NMSP) 2009-2013 of reducing malaria-associated mortality by 50% from 2010-2014. MAPS supported the new vision of Nigeria’s NMSP 2014-2020 of a malaria-free Nigeria. Its goal is to bring malaria-related mortality to zero.

The new NMSP’s Objective 7 sets out its plans for improved governance and coordination. To improve planning, it aims to ‘develop and implement annual unified costed operational plans and conduct periodic reviews at the state level’.

MAPS’ five result areas, agreed with the National Malaria Elimination Programme (NMEP), were:

� Increased household access to LLINs and IPTp

� Improved malaria diagnosis and treatment at state and LGA levels

� Increased knowledge of malaria control interventions at state level

� Improved monitoring and evaluation of malaria programs at national, state and LGA levels

� Increased malaria management capacity at national and state levels

The last two areas reflect the need to ensure that malaria program staff and others are equipped to lead, manage and sustain the drive for malaria control and elimination.

3. Developing a capacity building strategy for state malaria programsThe approach to capacity building used in MAPS focused on the programming and management skills in state and local governments to control and prevent malaria in their communities.

Working with state officials, MAPS supported a rapid situation analysis and needs assessment in each state. The assessment covered:

� Policies, guidelines, frameworks and plans

� Institutional arrangements and integration

� Mechanisms for planning, budgeting and supervision

5. Supply Chain Management

2. Supportive Supervision

1. State Coordination of

Malaria Activities

Improved state and LGA capacity for malaria control

4. Training Mentoring and

Coaching

3. Annual Operational

Planning

Figure 1: State Capacity Building Strategy

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� Existing systems and infrastructure for supervision

� Process for coordination, harmonization and linkages

� Resources (human, financial, material)

These assessments found that program management was very weak in most states, and that malaria funding was inadequate and erratic. It was therefore important to focus on state and local government planning and budgeting, specifically Annual Operational Planning (AOP) matched to the public sector planning cycle. It was essential to include costing and budgeting within this to address the funding problem.

MAPS used the assessment to develop a Capacity Building approach for states and local government which included five components illustrated in Figure 1:

1. Enhancing state coordination of malaria activities helped officials to coordinate and improve planning and implementation, to review and allocate resources and to increase links and collaboration between development partners and programs. This ensured that critical gaps were addressed.

2. Introducing or strengthening Malaria Integrated Supportive Supervision (MISS) helped improve routine supervision of both malaria and general health services. Linked to the annual planning process and performance, this ensured that experience on the ground fed into planning and implementation, so that plans were realistic and achievable.

3. Annual Operational Planning strengthened planning, budgeting, implementation and performance review.

4. Training, mentoring and coaching using NME-approved training modules helped build program management skills at national, state, LGA and facility levels. Topics included planning and budgeting, resource management, procurement, supportive supervision and monitoring and evaluation.

5. To strengthen malaria commodity supply chain management, MAPS worked with partners to ensure that the right commodities were available in the right place, in the right quantity and at the right time.

4. Annual Operational Planning processThe AOP development process strengthens capacity by establishing a regular annual cycle of planning and budgeting, implementation and review (see Figure 2). The advantages of the initial state AOP process are that it:

� Brings together stakeholders across state ministries, local government and partners

� Builds these stakeholders into an ongoing team for planning and review of performance and budgets

� Provides a baseline of malaria control and services which are used for measuring subsequent progress

� Provides the main tools for setting objectives and activities used for planning and regular review

� Provides the main costing and budgeting tools for planning and regular review

� Harmonises malaria planning and budgeting with wider state planning and budgeting processes

� Establishes clear annual objectives, activities and budgets for managers to implement and report on

� Provides a basis to advocate for costed interventions to improve prevention and treatment

Figure 2: National cycle for development and review of state Annual

Operational Plans

National Workshop to

Plan State AOP Process

States Review AOP Performance at Mid and End of Year

National Review of

AOP Process

States Develop and Agree AOPs


non-availability of policy makers and participants, and simple logistical failures can frustrate or delay planning and review, and greatly reduce their value.

Clear arrangements and allowances for travel and subsistence are essential.

Step 3: Meet stakeholders to prepare workshop

The AOP planning session sets out the process for the workshops ahead and brings together key stakeholders to ensure that both the AOP process and the plan itself are properly owned.

The key advisory body at state level is the mTWG bringing together the Ministry of Health, development partners, implementation agencies and other branches of government and the Development Partners’ Forum.

The SMEP is the main executive body, part of the State Ministry of Health, reporting to the state’s Director of Public Health. In addition to a small team at state level, this oversees the work of Malaria Focal Persons in each LGA.

There may also be groups working on particular aspects (or ‘thematic areas’) of the program, such as Advocacy Communication and Social Mobilization (ACSM).

In practice high turnover in some SMEPs and other offices presents continuity challenges, but it remains important for MAPS to work through these government officials and institutions to enable ownership of the process and plan, support continuous and on-going capacity development and for future sustainability of the process.

Harmonising malaria plans/budgets with the state planning and budgeting frameworkAlthough the NMEP requires a specific malaria workplan, it should reflect the wider frameworks for a state malaria control program. These include:

– Annual state planning cycles for health

– State budget frameworks for capital and recurrent expenditure

SMEP and MAPS staff engaged with colleagues outside the malaria sector and the state Ministry of Health, particularly in planning and finance, to ensure consis-tency and adherence to key dates in the annual state planning and budgeting cycle. Some states such as Zamfara had well established planning and budgetary frameworks, while others such as Ebonyi, had less developed frameworks but nonetheless still found the malaria AOP process applicable to other areas of health service planning.

There are nine steps to produce Annual Operational Plans discussed in more detail below. MAPS worked with NMEP to build state ownership of both process and documents. MAPS achieved this by creating a thorough and transparent process for AOP development and review.

Step 1: National AOP Development Planning Workshop

The annual national planning workshop brings together the state mTWG and state representatives from the State Malaria Elimination Programme (SMEP)to review progress against previous national opera-tional plans and develop a planning process that each state can tailor to its needs.

Supporting the AOP processMAPS supported the NMEP in coordinating an overview of state AOP planning. First, the NMEP reviewed the previous year’s national plan with help from the UK aid-funded Support to the Nigeria Malaria Programme (SuNMaP). MAPS then conducted a national AOP Development Planning Workshop with the NMEP to plan the state AOP process, including developing state AOPs and reviewing AOP progress.

MAPS worked with the NMEP to support states in preparing up to three consecutive AOPs in each state (see Annex 7 States supported by MAPS in annual opera-tional planning). MAPS provided technical assistance in the first year both to guide the national workshop and to facilitate the process in states, building a network of national consultants and local facilitators to enable future sustainability. Since then, states have needed less external support as the mTWG and SMEP have provided more leadership, and have been able to draw on local facilitators.

Step 2: Pre-preparation in states

Following the national workshop, the local (SMEP) prepares the state AOP process.

The SMEP develops a State AOP Preparation Plan (see Annex 3 Sample state AOP preparation plan) proposing the participants, dates, program, budget and documents for AOP development. Documents need to be specified at this stage so that SMEP staff and others have time to prepare them before the workshop. Plans are also made for any skills development sessions which may be required such as using Excel, or more advanced topics such as extracting reports from DHIS, or an aspect of epidemiology.

Both the planning and review processes need good prepara-tion. Poor timetabling, budgeting, competing state activities,

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Conducting a situation analysis

Before AOPs, stakeholders had very limited access to state-level data about either disease prevalence or its control, which greatly limited effectiveness.

The situation analysis draws both on the experience of participants and on the documents from the prepa-ration stage. The focus is on analysing problems and developing priorities to address them.

Problem Analysis uses a ’but why’ method. This traces the origins of a problem (e.g. a low rate of diagnosis) to their intermediate and root causes, as illustrated by the example in Figure 3.

From this analysis, priorities emerge, and are used to form objectives and activities. However, there is no clear process of option appraisal in this or at the objective and activity stages, which often results in the develop-ment of ambitious plans that are not realistic.

Step 4: Phase 1 Workshop: Situation analysis, objectives and targets

The Phase 1 workshop has a comprehensive agenda including:

� Forming effective working groups for each thematic area of the plan

� Familiarisation with the national malaria elimination strategy and work plan

� Developing a situation analysis

� Identifying problems and their root causes

� Developing options to address them

� Drafting objectives and targets for each them

� Presenting and agreeing targets for all the themes

Access to data for effective planningImproved quality and availability of information for planning is essential to improve the situation analysis. Although SMEPs had access to some information from facilities supported by particular partners, there was very limited state-wide data on coverage, use or quality of service, so situation analysis relied largely on national sources of data, such as the Nigerian Demographic and Health Survey 2008 and Malaria Indicator Survey 2010. However, these do not provide the annual state level data needed for each state either to analyse its current situation, or to measure improvement on a quarterly or annual basis.

MAPS provided technical assistance to the NMEP by supporting the use of Nigeria’s District Health Information System (DHIS) which provides monthly data from facilities on use, coverage and quality of care. DHIS was introduced in Nigeria in 2003, but has needed extra support from MAPS and others for effective adoption. DHIS covers all aspects of health services, and was supported in preference to systems dedicated to malaria, so that improvements in malaria could benefit the wider health system – and vice versa.

After the first year, SMEPs became more adept at drawing on new sources of evidence for re-assessing the current situation, including:

– Data and projections on commodity distribution and stock levels

– Service delivery performance in the current and previous year

– New research findings

Not enough diadnostic test kits

Low rate of diagnosis

Unreliable supply of test kits

Weak communications between SMEP

and supplier

But why?

But why?

Why?

Figure 3: Example of problem analysis

Evident Problem:

Intermediate cause

Intermediate cause

RooT causE


Setting objectives and targets

Setting objectives and targets is the second and final major exercise of the Phase 1 workshop.

The exercise is conducted according to thematic areas agreed in the preparatory workshop. Each thematic team drafts objectives and targets based on the strategic objectives set by the NMEP, its situation analysis, its problem analysis and priorities. These are then shared with the workshop participants and revised based on comments.

These objectives and targets provide the essential framework for program objectives. They are the central tool by which managers set objectives, monitor perfor-mance, and are held accountable to stakeholders. Teams are supported to develop SMART objectives (Specific, Measurable, Attainable, Relevant, Time-bound) for the year ahead, by following a simple template as demon-strated in the example below.

Example of a SMART objective

Strategic objective

80% of population use LLINs by 2020

Current situation

30.9% of women attending ANC received LLINs in 2013

Objective

increase percentage of women attending ANC who receive LLINs

Target

60% of women attending ANC in 2015 receive LLINs

In this example, the objective is clearly specified and is measured by the DHIS on a monthly basis. The theme team believes the target to increase the percentage of women receiving LLINs from 30% to 60% is attainable, and will demonstrate this by the activities and budget proposed in the second workshop. It is relevant to the strategic objective and is time-bound because it has to be achieved in 2015. See Annex 4 Sample objectives and targets for further details.

Step 5: Phase 2 Workshop

Generating activities and costs

The Phase 2 workshop is a data-intensive exercise drawing on the same team as Phase 1. Activities and costs are developed in a two-stage process. Once potential activities are identified, unit costs are used to develop activity costs, and alternative activities are considered according to cost-effectiveness. These activities and costs are presented in a summary table following the objectives established in the Phase 1 workshop. The development is a ’reality check’ on the objectives stated, challenging groups to confirm that they are achievable and affordable. An example is illustrated in Table 1.

In the first year, this took a full five days, because some participants had little experience of planning activities and budgeting, and all needed to adopt a common approach to planning activities and costs. In subsequent years, some states opted for 2-3 days.

Step 6: Clean up draft AOP

The consultants or facilitators conduct a ’clean-up’ after the two workshops. This includes drafting or editing text for the situation analysis and overall statement of objectives, harmonising the theme groups’ outputs, identifying and following up technical queries, and producing summaries of costs and activities by theme.

Step 7: Verify AOP and obtain consensus

Rather than circulating for comments and corrections, it’s been found necessary to conduct an additional day’s exercise with stakeholders in the state capital to obtain consensus on the draft. The AOP is presented to stakeholders, section by section, with opportunities for comment, clarifications and correction.

Both objectives and activities can be challenged for feasibility and alternatives. Depending on the state’s budget, activities may need to be revised to fit budget availability.

Step 8: Finalize AOP, write report and hand over

The consultants finalize the AOP and prepare an accompa-nying report of the AOP process. This sets out the process and reports any issues that need to be taken forward by the SMEP or NMEP. Both the AOP and the process report are handed over to the SMEP for formal adoption.

Step 9: Adoption and dissemination

A formal meeting is held to adopt and launch the plan. High level support is sought for this, including the Health Commissioner, with broad stakeholder involvement.

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Table 1: Example of a costed workplan

5. Establishing a review cycleProviding a means for review

Three tools illustrated in Figure 4 help teams focus on their progress towards goals, asking the key question ‘but why?’ to help understand the reasons for successes and difficulties.

Two of these tools examine progress on objectives and activities:

1. Progress towards AOP objectives, as represented by proxy indicators

2. Progress on AOP activities, as represented by perfor-mance measurements

The third tool encourages teams to look at the factors behind these results:

3. A force field analysis to identify the factors that enhance or inhibit progress.

Together these tools help participants see why partici-pants have experienced success or difficulties with activities and objectives and enable them to amend their current plans and inform future AOPs.

The review meeting

Like the development process, the review meeting requires careful planning. The process is planned well in advance, to ensure that the same stakeholders and resource people are available if possible, and are properly prepared for a two-day meeting. Officials provide written evidence so the team can confirm proxy and performance measurement results. Following force field analysis, recommendations are made for the revision of activities or objectives.

Following the meeting a brief Summary Review Report is prepared for state officials.

MAPS found that quarterly reviews made heavy demands on both state and MAPS resources, and therefore adapted to supporting mid-year and year-end reviews, leaving policy makers time for other priorities, including planning for basic health services and other programs.


Proxy indicators show progress towards AOP objectives, and are measured in-year through DHIS and other tools

Performance measurements report in-year progress on completing AOP activities

Force field analysis identifies the forces that enable or inhibit progress on activities and objectives

Progress towards elimination of malaria is measured by long term studies such as DHS and MICS

Goal: Elimination of Malaria

1. Proxy indicators

2. Performance measurements

3. Force field analysis

Why?

Why?

Figure 4: Reviewing progress against objectives

Proxy indicator tool

Both the development and review of the plan need to focus on the objectives of the program. Standard proxy indicators were developed to help states see changes in-year that reflect their objectives before they drill down to the activities and resources. These proxy indicators are aligned to the thematic areas for program delivery. All of these indicators use routinely available data from DHIS and other sources. See Table 2 on Page 9.

Performance measurement tool

This tool summarises the performance of the AOP in each of the planned activities. It enables the mTWG to hold the SMEP to account for delivery of the AOP, and highlights successes and areas for improvement. See Annex 5 Performance measurements.

At the review meeting, the mTWG examines records and reports and make decisions on each activity:

� Completely implemented (3 points)

� More than 50% implemented (2 points)

� Less than 50% implemented (1 point)

� Not commenced (0 points)

A summary table is used to derive an overall perfor-mance percentage and a chart. This example compares 2014 with 2013 performance.

Figure 5: Sample State Performance measurement Chart

As in this example, many state programs achieved more of their activities in the second year, as they improved their capacity to achieve realistic objectives.

Force field analysis

Force field analysis is used to visualise the forces driving or restraining progress. Teams use it to understand success or delays in activities, just as performance measurements help explain progress on proxy indicators towards the program’s objectives.

It therefore helps teams to build on success and identify obstacles or bottlenecks in implementation. Figure 6 illustrates an example of visualisation of the analysis.

Teams record these at the review meeting and agree recom-mendations, as in Annex 6 Example of force field analysis.

Objective:

Increased diagnosis rate

Enhancer:

Staff trained Kits available

Inhibitors:

Shortage of medication

Access to facilities

Figure 6: Example of force field analysis

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1. Prevention Documents needed

1. Percentage of pregnant women who received at least 2 doses of SP for intermittent preventive treatment during antenatal care visits

2. Percentage of pregnant women who receive LLIN during antenatal care visits

DHIS

Copy of state quarterly NMEP or HMIS report

2. Diagnosis

Percentage of people with fever at health facility who received a diagnostic test (RDT or microscopy) for malaria

DHIS


3. Treatment

Percentage of people that tested positive for malaria at health facility (uncomplicated or severe) that received antimalarial treatment according to national treatment guidelines

DHIS


4. Advocacy Communication Social Mobilization

Percentage of wards in which community-based organizations (CBOs), civil society organizations or implementing partners are involved in ACSM malaria control activities

ACSM reports

5. Procurement & supply management

1. Percentage of health facilities with stock out of ACTs lasting more than 1 week at any time during the past 3 months

2. Percentage of health facilities with availability of any malaria diagnostic equipment (microscopy or rapid diagnostic testing)

DHIS


6. Monitoring and Evaluation

1. Percentage of health facilities reporting through the DHIS tool/database

2. Percentage of health facilities reporting data in a timely manner

DHIS


7. Program Management

Percentage of cost released by the state out of total pledged SMEP quarterly reports

Table 2: Proxy Indicator Tool

Feedback

Feedback on the review, supported by a briefing note, is given to senior managers in the Ministry of Health and other stakeholders.


6. ResultsDoes planning make a difference?

Evidence shows that MAPS states using the annual operational planning process and receiving technical assistance in other health systems strengthening inter-ventions outperformed other states in the volume of service delivered.

States supported by MAPS received more support in both AOP and other aspects of health systems strength-ening than others. They are compared here with states that received similar levels of support in medical supplies and other commodities, but less support in systems strengthening and none in AOP. Nigeria’s District Health Information System has captured key malaria control indicators since July 2015. See Annex 8 which outlines interventions supported by MAPS and other malaria control programs.

The graphs show the results achieved in these two groups of states between July 2013 and June 20151. This allows us to follow the progress of the first six states supported by MAPS (which started implementing AOPs in Jan 2014), and to compare them with the progress of states with less health systems strengthening and no AOP support.

Also included are three states with no support at all, and all 37 Nigerian states.

Pregnant women receiving LLINs and IPTp

States supported by MAPS show a more consistent and sustained improvement for pregnant women than others in provision of LLINs and two doses of IPTp (see Figures 7 and 8). For example in Figure 7 the percentage of pregnant women receiving LLINs in states supported by MAPS increased steadily from 10% to 28% within 15 months of receiving technical assistance in health systems strengthening. This level was sustained into the following year. Whereas states with reduced health systems support showed an increase from 2% to a high of 23%, this was followed by a decline by half within the same period. Although MAPS only supports services for a limited number of LGAs, more pregnant women benefit across the state as illustrated by comparing data from all states against unsupported states. This suggests that strengthening systems for health provides state-wide improvements.

1 Data extracted from Nigeria’s District Health Information System July 2015 by MAPS

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15

States Supported By MAPS

States With Reduced HSS

All States

Unsupported States

0%

10%

20%

30%

40%

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

10%

20%

30%

40%

Figure 8: Pregnant women receiving IPT2

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

10%

20%

30%

40%

Figure 7: Pregnant women receiving LLINs

Key to Figures 7-12

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Diagnosis and treatment of Malaria

There was widespread over and under-diagnosis, and over and under-treatment, at the start of the period. This suggests poor training and use of diagnostics. All states made strong improvements in these areas as depicted in Figures 9 and 10. MAPS states show consistent improvement.

There is still a tendency to under-diagnose, but treatment of confirmed cases has been sustained close to 100% for over a year.

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

30%

60%

90%

120%

150%

Figure 9: Fever cases tested for malaria by RDT or microspcopy

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

30%

60%

90%

120%

150%

Figure 10: Confirmed uncomplicated malaria cases treated with ACT

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

20%

40%

60%

80%

100%

Figure 11: Expected monthly reports of facility activities received

Q3/13 Q4/13 Q1/14 Q2/14 Q3/14 Q4/14 Q1/15 Q2/15



All States

Unsupported States

0%

20%

40%

60%

80%

100%

Figure 12: Expected monthly reports of facility activities received on time

Monthly reporting of facility activities

States supported by MAPS have shown consistent improve-ment and lead the field in timeliness of reporting (as shown in Figures 11 and 12).

Complete and timely reporting is essential for service improvement. All states have shown improvements both in the rate and timeliness of reporting, reflecting the fact that this is a priority for the national Ministry of Health and a number of programs.


7. Ten lessons for AOP1. Engage stakeholders in the planning process: including the Ministry of Health, wider government, implementation agencies, donors and civil society.

2. Understand national priorities: including those of the National Malaria Strategic Plan and other key policy documents.

3. Coordinate the planning process: this should be coordinated at the national level, and there should be an exchange of ideas and practice between states.

4. Plan and resource the process: do it in depth with facilitators and key stakeholders, and ensure there are resources and time for planning.

5. Set SMART objectives and targets: they need to be clearly Specified, Measurable, Achievable, Relevant, and Time-bound (achieved within a year).

6. Identify indicators for progress towards national objectives and completion of planned activities: use these to monitor and review the success of the plan.

7. Make a realistic assessment of the current situation, problems and priorities: devote enough time in the planning process for appraising the current situation, and understanding the root causes of problems before setting priorities.

8. Plan costs and sources of funding for identified activities: monitor costs in review meetings and the release of government and partner funds.

9. Win state commitment and approval: for the final AOP and monitor its progress through the review process.

10. Build a planning and review cycle: with regular reviews of progress on objectives, activities and budget for the current year, and to feed into next year’s plans.

Conclusion

Annual Operational Planning as a core component of health system strengthening provides a tested way for states to improve the impact and sustainability of state malaria programmes. Data gathered from local health services across Nigeria shows that states which focus on planning and strengthening health systems achieve better results than others. More pregnant women receive mosquito and preventive treatment. Children and adults are more reliably diagnosed and treated. The performance of facilities is more closely monitored through better reporting.In their drive to achieve sustainable elimination of malaria in line with Nigeria’s National Malaria Strategic Plan, states will find that Annual Operational Planning provides an indispensable means for facilitating ownership, planning, accountability and ultimately results.

Annex 1. Learning from the literature Annual planning processes for health services as a whole and for programs such as malaria control have been documented elsewhere. Roll Back Malaria’s Planning and Budgeting for Malaria Control provides a valuable guide for managers on the annual process of planning and budgeting for malaria: it includes reviewing the national context; reviewing achievements; setting objectives based on evidence; setting and approving workplans and budgets (Roll Back Malaria, 2006); it emphasises the importance of engaging stakeholders, using a regular annual planning cycle or spiral linked to the Ministry of Health planning cycle, and introduces tools for reviewing progress from HMIS and other indicators.

A health program focused just on malaria may be justified by the huge public health impact of malaria, but it needs to get the right balance between the focus on ‘vertical’ programs while building mainstream health services to address the whole public health need. It’s well known that vertical programs can detract from basic health services by making inefficient use of staff and resources, generating parallel management and logistical systems, and distorting resource allocation (Gonzalez, 1965). Horizontal programs can provide a more comprehensive and flexible response to the changing public health burden, offer more flexible use of staff and other resources, and be better embedded as permanent institutions in community life. Mills argues that Gonzalez remains relevant: where the public health importance of a single disease is so great, a mass campaign or vertical program can be a way forward, provided it wins the support of stakeholders across the whole health system: vertical programs and integrated services are not mutually exclusive, but can be combined over time, so that vertical programs enrich rather than detract from general health services (Mills, 2005).

Since Gonzalez, epidemiological and economic tools for both vertical programs and general services have greatly improved, including use of Demographic Health Surveys and Malaria Indicator Surveys, as well as economic tools in cost effectiveness. However, authors continued to stress the importance of winning support from political leaders and community beneficiaries, as well as making technical improvements (Abel-Smith, 1994). While the

rational use of evidence is important for planning, it’s just one factor of many that planners need to consider. Other key factors are political considerations and the development of capacity for routine information systems, for decision-making, and political ownership at both local and higher levels.

Health service planners need to take account of political and economic, as well as epidemiological and clinical consid-erations. They need to focus on problems and solutions, as much as technical aspects interventions and desired health outcomes. Writing from Indian experience, Shukla argues that because of inequality of power between citizens, staff, planners and resource providers, community perspectives need to be given special attention. These community voices can only be heard effectively if programs take practical steps to empower these voices, such as structured learning courses and capacity building activities (Shukla 2014). Effective community input also depends on good evidence from the community. Planning is also often hindered by the lack of locally relevant evidence, because of weak routine informa-tion systems (La Vincente 2013).

Building a shared understanding of problems and solutions is at the heart of the planning process. This needs to reflect the diversity of voices in planning, use the evidence available and be realistic about its limitation. Planning for vertical programs needs to respect the need for general health services, looking for ways to enhance general health services and to work towards integration with them, rather than swamping or detracting from them.

Several writers advise caution about technocratic extremes in planning or costing services. A ’logical framework’ or ’theory-driven logical model’ may well be important for planners or development partners, but plans need to use simple concepts and plain language. Thunhurst and Barker applied a set of problem-structuring principles to their approach to health planning in Pakistan: ’non-optimizing’ solutions (aiming for acceptable rather than technically perfect solutions); reduced data demands; simplicity and transparency; conceptualizing people as active subjects; facilitating planning from the bottom up; and accepting uncertainty (Thunhurst and Barker). They focus on the shared analysis of problems through the simple tools of the problem tree, tracing problems from their effects, to the core problem, and finally the root causes, using a succession of ’but why?’ questions.

References

Roll Back Malaria, Planning and Budgeting for National Malaria Control: A Summary of Promising Practices, Roll Back Malaria 2009

Reynolds H.W. and Sutherland E.G. – A systematic approach to the planning, imple-mentation, monitoring, and evaluation of integrated health services, BMC Health Services Research 2013, 13:168

Abel-Smith B. – “Methods of Health Service Planning”

Gonzalez C.L. – Mass campaigns and general health services, Public Health Papers No 29, WHO 1965

Mills A. – Mass campaigns versus general health services: what have we learnt in 40 years about vertical versus horizontal approaches? Bulletin of the WHO 2005

La Vincente et al. – Supporting local planning and budgeting for maternal, neonatal and child health in the Philippines, Health Research Policy and Systems 2013, 11:3

Shukla A. et al – Using community-based evidence for decentralized health planning: insights from Maharashtra, India, Health Policy and Planning 2014; 1–12

Thunhurst C. and Barker C. – Using problem structuring methods in strategic planning, Health Policy and Planning, 1999 14(2): 127–134

14

Annex 2. Aligning national goals and strategy


Theme National Malaria Elimination Programme 2014-2020

Malaria Action Program for States 2009-2015

Prevention At least 80% of targeted population uses appropriate preventive measures by 2020

Increased household access to ownership and use of LLINs and Intermittent Preventive Treatment in Pregnancy (IPTp)

Diagnosis To test all care-seeking persons with suspected malaria using RDT or microscopy by 2020

Improved malaria diagnostic and treatment services at state and Local Government Authority (LGA) areas

Treatment To treat all individuals with confirmed malaria seen in private or public facilities with effective anti-malarial drug by 2020

Increased awareness and knowledge of malaria control interventions at state level

Information and behaviour change

To provide adequate information to all Nigerians such that at least 80% of the populace habitually takes appropriate malaria preventive and treatment measures as necessary by 2020

Increased awareness and knowledge of malaria control interventions at state level

Medicines and commodities

To ensure the timely availability of appropriate antimalarial medicines and commodities required for prevention and treatment of malaria in Nigeria wherever they are needed by 2018.

Within Prevention Diagnosis and Treatment above

Monitoring and evaluation At least 80% of health facilities in all LGAs report routinely on malaria by 2020, progress is measured, and evidence is used for program improvement

Improved capacity for monitoring and evaluation of malaria programs at the national, state and LGA levels

Capacity for governance and management

To strengthen governance and coordination of all stakeholders for effective program implementation towards an ‘A’ rating by 2017 sustained through to 2020 on a standardized scorecard

Increased malaria management capacity at national and state levels

16

Annex 3. Sample state AOP preparation plan

Step Required materials Personnel Output

1. National AOP development planning meeting (Abuja, 3 days)

Flip charts, projector, participants’ laptops

SMEP Managers, MAPS State Capacity Building Officer

MAPs staff, consultants

State AOP development plan

Shared understanding of TOR

Shared understanding of criteria for participants selection

Identification of skill development required at state level

2. Pre-prepare state AOP development workshop (Before preparatory meeting)

Terms of reference SMEP team

Consultants

MAPS State Capacity Building Officer

Confirmed dates for State AOP development process

List of key documents required

Proposed participants

Plans for skill development session

Approved budget

3. State AOP preparatory meeting (State capital, 1 to 2 days)

Agenda: Facilitate understanding of TOR

Draft agenda and timetable

Review participants list

Group participants into thematic areas

Assemble documents required

Plan report writing

Finalize logistics

Conduct skill development session if need identified

Flip chart, projector, laptops, antivirus, flash drives and Copies of key documents:

Terms of reference

National Strategic Plan

Relevant national and state documents

Prevalence and service data

Program progress or evaluation reports

HMIS reports

Commodity distribution plans and reports

Research reports

Skill development resources if required

National Consultants

SMEP team

Selected members of TWG

MAPS State team

Agenda and timetable for Development Workshop

List of participants and assignment to thematic areas

Logistics finalised

Complete folder of national and state documents

Improved skills



4. AOP Development Workshop Phase 1: Draft situation analysis objectives and targets

(Outside State Capital, 6 days)

Agenda: Familiarize with National Strategic Plan

Adopt and adapt target areas from the National Strategic Plan for the state

Draft state situation analysis including: General information, Information on health situation, Malaria situation for each thematic area

In thematic teams, draft objectives and targets: Draft objectives and targets for each thematic area

Discuss and amend objectives and targets

Clean up situation analysis, objectives and targets

As in step 3

Map of the state

State logo

As in step 3

All members of TWG

Representatives of partners

Draft situation analysis

Draft objectives and targets for each thematic area

5. AOP Development Workshop Phase 2:

Draft activities and costs for each thematic area (Outside State Capital, 6 days)

Agenda: In thematic teams, generate major and sub-activities for each objective within the theme

For each sub-activity, identify: Responsible person, Time frame, Cost, Source of funding, Indicator for achievement

As in step 4 National Consultants

SMEP team

MAPS State team

Members of TWG


Draft costed AOP

18


6. Clean up draft (Outside State Capital, 2 days) Agenda: Clean up and harmonize draft AOPs from thematic areas

Summarize cost and funding source for each thematic area

Edit draft AOP documents

Computer

Flash drives

Consultants Clean draft costed AOP

7. Verify and obtain consensus (Capital, 1 day)

Agenda: Present AOP to state stakeholders in the state

Allow for comments, clarifications and corrections

Review and confirm feasibility of objectives

Confirm consensus

Computer

Flash drives

Projector

Flip chart and sheets

Markers


SMEP team

MAPS State team

Members of TWG


Other stakeholders

Verified costed AOP

8. Finalise draft AOP and write report (Virtual, 2 days)

Agenda: Clean up report

Prepare brief report to NMEP/MAPS on AOP development process

Computer

Internet

Consultants Clean draft costed AOP

Brief report on AOP development process

9. Work with state to adopt and disseminate AOP (State Capital, 1 day)

Computer

Flash drives

Projector

Flip chart and sheets

Markers


SMEP team

MAPS State team

Members of mTWG


Other stakeholders

Commissioner of Health and other officials

Adopted costed AOP


Annex 4. Sample objectives and targets

Objective 1: Malaria prevention

Strategic objectiveAt least 80% of targeted populations use appropriate malaria preventive measures by 2020.

Current situation in the state

1. 13.5% of the required LLINs for the state have been distributed among children under 5, pregnant women, the community and schools.

2. 2.2% of children under 5 have received LLINs.

3. 69.7% of pregnant women attended ANC in 2013.

4. 30.9% of pregnant women who attended ANC received LLINs in 2013.

5. 37.7% of pregnant women who attended ANC received 2nd dose of Sulfadoxine/Pyrimethamine (SP) in 2013.

6. Two LGAs have had pilot IRS.

Specific objectives for 2015

1. Children in public primary, boarding secondary and tertiary schools receive LLINs.

2. Children under 5 who complete immunization receive LLINs.

3. Increase the number of pregnant women attending antenatal clinic (ANC) in public health facilities who receive LLIN.

4. Increase the number of pregnant women attending ANC who receive a second dose of SP.

5. Sustain IRS where it has been piloted.

State targets for 2015

1. At least 60% of pregnant women who attend ANC receive LLINs.

2. At least 50% of pregnant women who attend ANC receive 2nd dose of SP.

3. At least 50% of the total population receive LLINs.

4. At least 30% of children under 5 receive LLINs.

5. At least two LGAs sustain IRS.

20

Annex 5. Performance measurementsTh

eme

Activ

ities

pl

anne

dCo

mpl

etel

y im

plem

ente

dM

ore

than

50%

im

plem

ente

dLe

ss th

an 5

0%

impl

emen

ted

Impl

emen

tatio

n no

t com

men

ced

Tota

l Sc

ore

Perf

orm

ance

(T

otal

/Max

)%N

o.M

ax

Scor

eN

o.Sc

ore

X3N

o.Sc

ore

X2N

o.Sc

ore

X1N

o.Sc

ore

X0

Prev

entio

n25

7510

305

103

37

043

57.3

Dia

gnos

is18

540

03

612

123

018

33.3

Trea

tmen

t 6

180

02

41

13

05

27.8

Advo

cacy

Co

mm

unic

atio

n an

d So

cial

M

obili

zatio

n (A

CSM

)

2163

13

714

77

60

2438

.1

Proc

urem

ent

& su

pply

mgt

1957

515

36

22

90

2340

.4

M&E

1442

26

12

44

70

1228

.6

Prog

ram

M

agem

ent

Ove

rall

103

309

1854

2142

2929

350

125

40.5


Annex 6. Example of force field analysis

ThemeInfluencing factor

RecommendationEnhancers Inhibitors

Ad

vo

cacy

C

om

mu

nic

ati

on

an

d S

ocia

l M

ob

iliz

ati

on

Support from malaria implementing partners and cooperation of stakeholders

Reproduction of national malaria advocacy kits not done because it was not a perceived priority by

the state

ACSM mTWG should tag this as an aspirational activity in future AOPs

Dia

gn

osi

s &

Tre

atm

en

t

Technical support from partners

Timely fund release by partners

Expertise on the part of state officials

Delays in procurement process of commodities by the state and

some partners

Fear of parenteral Quinine wastage due to expiration of

some of the previous purchases especially as National guidelines

now recommends the use of parenteral Artesunate over

parenteral Quinine

DPS/ Program Officers should ensure that future procurement

processes commence early in the year

National treatment guideline dictates a reduction in future

procurement of parenteral Quinine

He

alt

h S

yst

em

s S

tre

ng

the

nin

g

Availability and prompt release of fund

Redeployment of staff from other departments to SMEP unit to fill

staffing gaps

Multimedia projector and scanner are already available at DPHC/DC therefore not a perceived priority

for malaria program

Although ISS activities commenced in the first two months of the year, funding

constraints slowed down activities subsequently.

To make request from DPH/DC when needed

DPRS should organize an ISS dissemination meeting to

showcase the relevance of ISS activities

Mo

nit

ori

ng

&

Evalu

ati

on Technically skilled personnel in

SMEP and HMIS unit

Support from partners and good state collaboration

Funding constraints has hindered DPRS from implementing some

M&E trainings

DPRS should organize a dissemination meeting to

showcase the relevance of these trainings

Pre

ve

nti

on

Good partner commitment and collaboration with the state

Late commencement of routine distribution of LLIN to ANCs by a partner such that state had to

come in to fill the gap

Commencement of LLIN distribution activity rescheduled

for last quarter of the year due to inequitable distribution of

community volunteers across the wards in the state

SMEP should ensure that funding for distribution of commodities is

clearly identified

SMEP should put in place structure to sustain distribution of

LLINs across all the wards

22

2013 2014 2015

Benue X X X

Cross River X X X

Ebonyi X X X

Nasarawa X X X

Oyo X X X

Zamfara X X X

Kogi X X

Akwa Ibom X

Kebbi X

Annex 7. States supported by MAPS in annual operational planning


Annex 8. Interventions supported by MAPS and other malaria control programs

States supported by MAPS

States with reduced HSS

Prevention

Distribution of Long-Lasting Insecticidal Nets (LLIN) YES YES

Training of health workers on Malaria in Pregnancy (MIP) YES NO

Provision of sulfadoxine-pyrimethamine (SP) for Intermittent Preventive Treatment in Pregnancy (IPT2)

YES NO

Diagnosis

Training health workers on Rapid Diagnostic Tests (RDTs) YES Limited

Training of laboratory microscopist on malaria microscopy

YES NO

Training of laboratory microscopist on quality assurance and control

YES NO

Training of laboratory microscopist on supervision YES NO

Treatment

Training health workers on case management YES Limited

Training health workers on severe malaria YES NO

Provision of Artesunate Combination Therapy (ACT) YES YES

Provision of injectable Artesunate YES NO

Behaviour change communication

Advocacy YES YES

Intermittent Parasite Clearance (IPC) at community level YES NO

Program management

Annual Operational Plan (AOP) development YES NO

Annual Operational Plan review YES NO

Integrated Supportive Supervision (ISS) YES NO

coordination platform YES NO

Training health managers on malaria program management YES NO

Monitoring and evaluation

Provide NHMIS tools YES YES

Training on the data tools YES YES

MAPS is funded by the USAID through the President’s Malaria Initiative (PMI), implemented in nine states (Benue, Cross River, Ebonyi, Kogi, Nasarawa, Oyo, Kebbi, Akwa Ibom and Zamfara) across Nigeria between 2010 and 2016. FHI 360 is collaborating with Health Partners International and Malaria Consortium to support the implementation of the National Malaria Strategic Plans (2014–2020).

Cooperative Agreement Holder: Implementing Partners: Supporting:

malaria consortiumdisease control, better health

September 2015

MAPS is funded by the USAID through the President’s Malaria Initiative (PMI), implemented in nine states (Benue, Cross River, Ebonyi, Kogi, Nasarawa, Oyo, Kebbi, Akwa Ibom and Zamfara) across Nigeria between 2010 and 2016. FHI 360 is collaborating with Health Partners International and Malaria Consortium to support the implementation of the National Malaria Strategic Plans (2014–2020).