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22-6-2010Dr. Nilar Tin

Service Delivery Gaps Many areas of the country have low service access to MCH and other services due to a range of management, infrastructure, logistics and security barriers.

Program Coordination Gaps Lack of organizational capacity, guidelines and strategic framework on how to coordinate immunization, nutrition, environmental health and RH services is leading to fragmentation and inefficiencies in health service delivery

Human Resource Gaps There is lack of clarity in the roles and functions of basic health staff, and inequities in the distribution of staff, resulting in lack of access to health services in hard to reach areas.

Theme 1 Service Delivery Reaching communities with essential health system delivery components of MCH, nutrition, immunization and environmental health, with emphasis on hard to reach areas

Theme 2 Health Program Coordination and Capacity Building Strengthening coordination, management and organization of the health system at all levels with a focus on the Township Level

Theme 3 Human Resource Management and Development Improving distribution, skill, number and mix of health workers with emphasis on hard to reach areas

HSS Goal: Achieve improved service delivery of essential components of Immunization, MCH, Nutrition, Environmental Health by strengthening programme coordination, sub-national micro-planning, and human resources management and development in support of MDG goal 2/3 reduction in under 5 child mortality between 1990 and 2015.

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By the end of year 4, 180 selected townships with identified hard to reach areas will have increased access to essential components of MCH-EPI and HSS as measured by increased DPT from 70% to 90% and SBA from 67.5% to 80%

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Activity 1.1: SURVEY: Survey to establish base line indicators & outcome, impact and research for operation (including mapping)

Activity 1.2: SUPPLIES: Increase availability of Essential Supplies and equipment based on needs identified in Coordinated Township Health Plan (CTHP).

Activity 1.3: INFRASTRUCTURE: 540 RHCs and 324 sub-RHCs in 180 HSS-targeted Townships will be renovated/constructed by year 4, based on needs identified in CTHP.

Activity 1.4: TRANSPORTProvision of essential transport for township and BHS to reach hard-to-reach areas, based on needs assessment analysis in CTHP: Transport Allowance + capital for vehicles, bicycles, trolley jeeps

Activity 1.5: PARTICIPATION Involving NGOs, local authorities and Community Health Workers in developing and implementing CTHP

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By the end of year 4, 180 selected townships with identified hard to reach areas will have developed and implemented CTHP.

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Activity 2.1: GUIDELINES DEVELOPMENT:

Develop national guidelines for CTHP (including financial management and health financing) & supervision at all levels (including checklists)

Activity 2.2: HEALTH FINANCING RESEARCH

Complete a research program on financial management capacity and feasibility and effectiveness of health financing schemes in HSS targeted townships by year 2.

Activity 2.3: OPERATIONAL RESEARCH:

Pilot community based health initiative (financing schemes) according to national guidelines in 50 townships by year 4

Activity 2.4: TRAINING

Implement the training program on coordinated management through the modified MEP program

Activity 2.5: PLAN DEVELOPMENT:

Develop and monitor coordinated health planning of HSS-targeted tsps

Activity 2.6: EVALUATION:

Assess process and impact of coordinated State & Township coordinated health planning, and then disseminate findings

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By the end of year 4, 20 selected townships with identified hard to reach areas will be staffed by midwives and PHS2 according to the National HR Standards.

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Activity 3.1: RESEARCH: Conduct Research program for HR planning focusing on distribution mix function and motivation and management capacity (including financing), by year 3.

Activity 3.2: HR PLAN: Develop HR Plan recommending strategies for retention and deployment of staff in hard-to-reach areas, based in part on research from activity 3.1

Activity 3.3: HR PROPOSAL: Development of Proposal to MOH recommending appropriate deployment number and pattern of MW and PHS2 in hard-to-reach areas, assessing retentions scheme options that include financial incentives.

Activity 3.4: CONTINUING TRAINING: Conduct coordinated MCH, EPI, Nutrition & EH training programs applying the principles of MEP

Impact and Outcome Indicators (morbidity, mortality and program coverage)

1. National DTP3 coverage (%) 2. Number / % of districts achieving ≥80% DTP3 coverage (National) 3. Under five mortality rate (per 1000) (national) 4. Delivery by Skilled Birth Attendants (HSS targeted Townships) 5. Rate of ORT Use of <5 children (National) 6. % of 6-59 months children having Vitamin A during past 6 months (National)

Output Indicator (health system capacity)

1. % of townships have developed and implemented coordinated plans according to national framework 2. Number/% of RHC visited at least 6 times in the last year using a quantified checklist (supervision) 3. Number of managers/ trainers / BHS trained for MEP at each level per year (management training) 4. Proportion of RHCs with no stock out of essential supplies in the last 6 months (availability, service access, utilization, quality) 5. No of RHC and sub RHC renovated and/or constructed per year, including improved drinking water and sanitation facilities 6. Percent of selected Townships with identified hard to reach areas staffed by midwives and PHS2 according to the National HR Standards.(In one RHC, 5 midwives and 5 PHS 2, 1 Lady Health Visitor and 1 Health Assistance. Each rural sub centre should have one midwife and 1 PHS2) 7. % of Townships implementing Community based health insurance scheme 8. % Townships with active health committees 9. % Townships have coordinated MCH package of services (ANC, TT, Nutrition, BF, BS and VCCT) and IMCI

States & Divisions

Kachin

Kayah

Kayin

Chin

Mon

Rakhine

Shan(East), (North), (South),

Sagaing

Mandalay

Magway

Bago(East), Bago(West)

Yangon

Ayeyawady

Taninthayi

Year 1 -20 townshipsYear 2- 40Year 3- 60Year 4- 60

Myanmar GAVI HSS Budget by System Level

Township Level & Below

85%

International8%

Central and State7%

% Allocations to Coordinated Township Health Plan

UN AGENCY, $34,500 , 20%

NGO, $12,700 , 7%

GAVI HSS, $54,775 , 31%

GOVT., $73,580 , 42%

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Activities initiated after approval of GAVI HSS Proposal in July 2008

TWG and Consultant

January 2009 Development of guidelines and tools for Baseline

Health System Rapid Assessment (township survey)

February 2009 Development of guidelines for Coordinated Township

Health Plan

19th -20th March 2009 Health Assessment conducted in Lewe township by

DOH/DHP

4th -7th May 2009 Health Assessment conducted in Ngaputaw township

by DOH/WHO/consultant

13th -15th May 2009 Workshop on sharing findings of Township Health

Systems Assessment in Lewe and Ngaputaw townships- conducted at NPT

Finalization of the Health Assessment Tool for HSS townships

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10th September 2009 One day workshop for Township coordinated Plan

was held by TWG with consultant

11th -13th December 2009 Conducted experimental costed Township

Coordinated Health Planning at Lewe township

Need-based, bottom-up approach was sensitized to providers in providing package of health care (EPI+ANC+Nutrition+EH) to mother and child

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From GAVI Board

November 2009 Dr.Ranjana Kumar and Dr.Mercy Ahun from GAVI Board,

Geneva visited NPT (GAVI HSS & ISS)

18th -19th January 2010 Mr. Joe Martin Consultant GAVI Transparency and

Accountability (TAP) came to NPT for Financial Management Assessment of both HSS and ISS

23rd February 2010 FMA Questions to MOH/WHO/UNICEF was sent by Mr.

Joe Martin (TAP) from Geneva

25th March 2010 MOH able to send back the FMA document

TAP asked for Clarifications –Final FMA able to send back on 18-6-10

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Recent progress with funds from SEARO Surveyor teams had conducted HSS

Assessment in 10 townships according to GAVI HSS plan (20 Year 1) in 1st week of May

Surveyors: DOH Planning, PH, EPI DHP DMS (Teaching staff and MPH students from

UOPH)

Still in analysis stage

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1. Cover sheet2. Health Management and Planning 3. Mapping Hard to reach4. Human resources5. Health Finance and Financial Management 6. Community participation 7. Essential drugs and equipment8. Infrastructure9. Data and Service Quality10. Summary Report

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Figure 8 Making a Summary Report

Summary Report Township

Availability of ServicesWhat is the general analysis of availability of services in this Township?What are the main factors effecting availability?

Accessibility of ServicesWhat is the general analysis of accessibility of services in this Township?What are the main factors effecting accessibility?

Utilization of ServicesWhat is the general analysis of utilization of services in this Township?What are the main factors effecting utilization?

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Figure 8 Making a Summary Report

Summary Report Township X

Utilization of Quality ServicesWhat is the general analysis of quality of services in this Township?What are the main factors effecting quality?

Main conclusions and RecommendationsWhat are the main health system bottlenecks for improvement of maternal and child health services?

What strategies and investments are best placed to remove these bottlenecks?

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Health system analysis examines gaps in operations across health programmes and service delivery units

Making the transition from “management by project” to “management through systems” is a critical step in achieving:

◦ Equity: in distribution

◦ Efficiency through coordination and reduction of overlap of resources in favour of hard to reach areas

◦ Effectiveness: improved health coverage

◦ Sustainability: strengthening self reliance and management capacity

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Hospital Care Public Health Disease Control

Systems Analysis Planning & management

Human Resources Finance & Financial Management

Infrastructure Data and Service Quality

Essential Drugs & Equipment Community participation

Hard to reach (equity analysis)

SERVICE DELIVERY FOR COMMUNITIES Township Coordinated Health Plan

With funds support as well as technical support from SEARO

Feasibility Study on Effectiveness of Community Based Health Initiatives (CBHI): Maternal Voucher Scheme in Township Health System

(May -October 2010)

(DHP/DOH)

This activity will evaluate the effectiveness of community based schemes in shorter term and in longer term will lead to development of national guidelines for management of health financing.

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