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COUNTDDOWN TO 2015: Health Systems and Policy and Finance Workshop Windsor Hotel, Nairobi, Kenya
25-28 February, 2014
WORKSHOP REPORT
I. BACKGROUND
Countdown to 2015 (CD) is currently supporting in-depth Country Case Studies in six countries —
Afghanistan, Pakistan, Ethiopia, Malawi, Tanzania, and Peru. The aim of the case studies is to better
understand the complex factors contributing to or detracting from progress in reproductive, maternal,
newborn, and child health (RMNCH) in each of the selected countries. This involves assessing the policy,
systems, and financial factors influencing the development and implementation of RMNCH programs. A
second aim of the case studies is to build country-level capacity to conduct rigorous research and to engage
in ongoing monitoring and analyses of progress in RMNCH. An overview of the Country Case Studies is
available in Annex 1.
Each Country Case Study builds on data evaluating changes in RMNCH results. The IHP Evaluation
framework (Figure 1) has been used to guide RMNCH policy implementation, and outlines steps for
measuring reactions of a healthcare system to the implementation of each RMNCH policy. A CD capacity
building workshop held in June 2013 in Pelotas, Brazil provided training on the coverage, equity and LiST
analyses needed for the case studies. These analyses focused on outcome and impact measures in the IHP
Evaluation framework. The workshop in Nairobi built on the previous workshop to improve the capacity of
Country Case Study teams in conducting health systems and policy (HSP) and finance analyses, which are
critical pieces of Country Case Studies and cross-country analyses. These analyses focused on assessing the
inputs and outputs components in the IHP Evaluation framework.
Figure 1: Evaluation Framework for CD Country Case Study
Contextual factors including non-health system determinants- Economic growth, education, transport & communication -
NMR
MMR
Under 5 Mortality Rate
Total Fertility RateCoverage along the continuum of care
- Demand for family planning- Antenatal care visits - Delivery in a health facility- Caesarean section rate- Postnatal care- Exclusive breastfeeding- Vaccine coverage
Equity- Urban/rural residence- Socioeconomic status- Maternal education
Stillbirth Rate
INPUTS OUTPUTS OUTCOMES IMPACT
Health service readiness
Health service quality
Health service utilisation
Health Information Systems
Legislative framework
Health workforce
Infrastructure & commodities
Health system financing
Governance & leadership
WH
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The workshop provided training to Country Case Study teams on a standard set of three CD HSP tools that
were developed as part of the qualitative analysis for Country Case Studies. The aims and objectives of the
three HSP tools are provided in Annex 2. Prior to the workshop, CD HSP facilitators held webinars on the
HSP tools with participants from CD Country Case Study teams. Participants were requested to start filling
CD HSP tools 1 and 2 prior to attending the workshop.
CD Finance facilitators also shared country-specific Official Development Assistance (ODA) data and a
briefing note with participants prior to the workshop. Participants were requested to review their country
ODA data and begin compiling basic tables and graphs. Additionally, participants were requested to bring
any National Health Accounts (NHA) data as well as any other studies on tracking RMNCH spending that is
available for their country.
II. WORKSHOP OBJECTIVES
The workshop aimed to meet the following overall objectives:
1. Build capacity for analyses of factors that have an impact on progress for RMNCH for:
– HSP
– Resource tracking (RT) analyses through tracking of resource flows
2. Increase comparability of analyses and results presentation across CD Country Case Studies
3. Integrate HSP and RT analyses within the overall CD Country Case Studies
Specific HSP objectives were as follows:
1. Develop a standardized CD policy and program timeline to assess national story for context
change and technical, health sector, and multi-sectoral policies relevant to RMNCH (HSP Tool 1)
2. Use the CD RMNCH policy & systems tracer indicators dashboard to assess policy status and
change over time (HSP Tool 2)
3. For identified or proposed foci of the case study, evaluate the extent to which policies have
been translated into effective program implementation (HSP Tool 3)
4. Identify facilitating factors and bottlenecks for access, quality and coverage of interventions,
story of change for that country and implications
Specific RT objectives were as follows:
1. Review available RT data relevant to country case studies and complete, refine or plan the
following analyses:
a. ODA
b. NHA
c. Other special studies in some countries e.g. of household costs
d. Refine analysis plans especially linked to the focus of case study
2. Work in country teams to develop a plan of action for the Country Case Study and identify needs
for technical assistance
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III. PARTICIPANTS
There were a total of 41 participants at the workshop, including 25 CD Country Case Study team
members from the six countries, 3 representatives from the Kenya CD team, 2 representatives from the
Rwanda CD team, 6 facilitators from the CD HSP Technical Working Group (TWG), and 4 facilitators from
the CD Finance TWG. The list of participants is available in Annex 3.
Supporting partners included Evidence for Action, Harvard University, London School of Hygiene &
Tropical Medicine, World Health Organization, Save the Children, UNICEF, USAID and Futures Group.
IV. AGENDA
The agenda for the 4-day workshop was as follows:
Day 1: Introduction & workshop overview (1st half); and overview and country team work on CD HSP
Tools 1 and 2 (2nd half)
Day 2: CD country team summaries on Tools 1 and 2 (1st half); and overview and country team work on
CD HSP Tool 3 (2nd half)
Day 3: CD RT Analyses - Overview, country presentations and plenary discussion (1st half) & country
team work (2nd half)
Day 4: Country team work and country-specific technical assistance (1st half) & wrap-up/conclusion (2nd
half)
The detailed agenda is available in Annex 4. All presentations from the workshop were made available to
participants.
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V. PARTICIPANT FEEDBACK
On the final day of the workshop, participants answered a feedback questionnaire which included 14
questions regarding workshop content and organization (see Annex 5). Some questions required
participants to indicate their level of satisfaction using a score from 1 (strongly disagree) to 4 (strongly
agree).
The questionnaire was completed by 29 out of 30 country team participants, who held qualifications in
public health/epidemiology, clinical medicine, statistics, or economics/finance. Major findings of this
evaluation are summarized below.
The majority of participants provided positive assessments of the introductory, HSP and RT sessions in
the workshop. However, a few participants (< 10%) gave low scores to the talks, facilitation and group
work relating to HSP Tool 3 and RT analyses.
57.1%
42.9%
Has this workshop fulfilled your expectations?
agree strongly agree
3.4%
48.3%
20.7%
20.7%
3.4% 3.4%
What is your current field of work?
Clinical practice Public health Epidemiology
Health economics Research Finance
7.4
6.9
0.0
0.0
59.3
55.2
48.1
48.1
33.3
37.9
51.9
51.9
0 10 20 30 40 50 60 70
RT analyses
HSP Tool 3
HSP Tools 1 & 2
Introduction & overview ofCD Country Case Studies
%
How do you rate the talks for the following sections of the workshop?
strongly agree agree neither disagree nor agree strongly disagree
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Overall, participants reported being pleased with the workshop pace. Additionally, over one third of
participants reported that a writing workshop and data analyses workshop would be useful before
finishing the country case study.
3.7
4.0
0.0
0.0
0.0
0.0
63.0
52.0
44.0
40.7
42.3
34.6
33.3
44.0
56.0
59.3
57.7
65.4
0 10 20 30 40 50 60 70
RT analyses
HSP Tool 3
HSP Tools 1 & 2
RT analyses
HSP Tool 3
HSP Tools 1 & 2
Gro
up
W
ork
Faci
litat
ion
How would you rate the facilitators and group work for the following sessions?
strongly agree agree neither disagree nor agree
%
0.0
0.0
3.7
26.9
11.5
18.5
73.1
88.5
77.8
0 20 40 60 80 100
Well-paced
Breaks weresufficient
A good mix betweenlistening & activities
%
How do you rate the workshop pace?
strongly agree agree neither disagree nor agree strongly disagree
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Participant comments
Participants were asked to provide comments about workshop preparation and content. Select
comments that are representative of the feedback received are transcribed below.
Workshop preparation
“The webinars before the workshop were good, but we need other webinars to share ongoing progress
in the case studies.”
“It was good receiving Tools 1 and 2 prior to the workshop to allow for necessary preparation. I feel it
would have been useful to receive Tool 3 earlier. Furthermore, if Tool 3 could be simplified I feel it could
be more useful.”
Overall
“I really enjoyed my time with the Countdown group and other countries as well. This is such a dynamic,
motivated and passionate group! Feeling everyone's excitement motivated and propelled me forward!
Thanks.”
“It was very participatory and presentations on the group discussions were relevant.”
“Overall, it was a good workshop. I was able to better understand and apply the tools, present our
achievements so far, get feedback, define what is still missing, & plan next steps.”
“The workshop provided an opportunity to understand the process and learn from other countries.”
38.70%
12.90%
32.30%
12.90%
3.20%
Would an additional workshop before you finish your country case study be useful?
Writing workshop LiST Data analyses Finance analyses Peer review workshop for country case study
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“It was a great opportunity to have key members of the team focusing on the case study for 4 days. A lot
was achieved on many levels - analysis and process!”
“What I liked least about the workshop is that not all partners involved in the case study were involved.”
Participants also expressed interest in having a RT/financial analyses protocol and/or tools.
VI. NEXT STEPS
CD global level
The following next steps were identified at the CD global level:
• Coordinated support for crosscutting analyses, i.e. mortality, coverage, equity, HSP and RT
• Consider a joint publication, e.g. PLoS series collection, and a linked writing workshop
• Further develop HSP tools and protocols, in particular:
• More standardized graphic displays for HSP Tools 1 and 2
• HSP 3 tool on implementation needs more work and also to link to output
visuals. Participants expressed a particular interest in GIS mapping
• Finance/RT:
• Consider developing protocol and/or tools relevant to CD case studies
• Some countries requested more technical support
CD country case study teams
The following next steps were identified at the CD country case study team level:
• Ongoing work to identify the overall story and focus of CD case study
• Increased technical support in collaboration with partners in-country
• Each country is likely to need an analysis and/or writing workshop
• Plan links to CD events, national accountability, and/or score cards
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ANNEX 1 – OVERVIEW OF CURRENT COUNTDOWN TO 2014 CASE STUDIES
COUNTRY MAIN FOCUS LEAD IN COUNTRY ADDITIONAL
SUPPORT STATUS
Peru Health systems, financing Universidad Peruana Cayetano Heredia
University of Pelotas
Lancet Every Newborn case study completed, May 2014, Also planning detailed papers
Tanzania 1. Family planning 2. Care at birth
National RMNCH partnership (E4A, WHO, MoH, UNICEF, IHI, etc.)
LSHTM and E4A Event expected April 2014 Submit paper, possibly for June Partners Forum event
Afghanistan Midwifery scale up (stunting reduction and immunization increase)
UNICEF, MoPH, NIPH AKU Mid/late 2014
Pakistan Lack of progress for neonatal, devolution
Mother & Child Care Trust AKU Late 2014
Malawi District performance variation National Stats Bureau, WHO and MoH
JHU and WHO March 2015
Ethiopia Health extension worker package and selected changes e.g. CPR and ICCM
Ethiopia FMOH and EHNRI Harvard (started as JHU) and LSHTM
TBD
Rwanda TBD Rwanda Biomedical Center TBD Application in process
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ANNEX 2 – OVERVIEW OF CD HSP TOOLS
The webinars and workshop and provided training to Country case study teams on a standard set of
three CD HSP tools that were developed as part of the qualitative analysis for Country Case Studies. The
aims and objectives of the three HSP tools are as follows:
Tool 1: CD HSP Policy & Program Timeline
CD HSP Tool 1 aims to understand through a standardized process with standardized content, what HSP
factors have contributed to change (or the lack thereof) in RMNCH in each of the countries conducting a
CD Country Case Study. Specific objectives are as follows:
Describe: To use a chronological timeline to document and analyze what policies, programs,
implementation strategies and pivotal moments have changed for RMNCH from 1990 to the
current year (i.e. “telling the story”)
Analyze: To use the timeline to assess variation for RMNCH policies and strategies at the national
level, highlighting periods of policy intensity for given topics and gaps.
Apply: To describe the story of RMNCH attention in policy change, and what is missing.
Tool 2: CD HSP Dashboard for Tracer Indicators
CD HSP Tool 2 aims to assess tracer RMNCH policy and systems indicators reported by the Countdown to
2015 in the country profiles to produce the CD Policy & Systems Dashboard for the country. Specific
objectives are as follows:
To systematically assess the development and tracking over time of selected RMNCH tracer
policy indicators and related health systems tracer indicators reported in CD Country Profiles
To visually represent policy and system tracers in the form of the Policy & Systems Dashboard to
bring about further interpretation and analysis
Tool 3: CD HSP In-Depth Policy to Action Assessment
CD HSP Tool 3 aims to guide Country Case Study teams in assessing the strength of policy formulation
and implementation related to the focus of their case study. Specific objectives are as follows:
To assess the readiness of policy or program formulation for specific RMNCH relevant policies
or program(s) that have been selected for further assessment in the Country Case Study
To assess the completeness and strength of policy/program implementation related to each of
the selected RMNCH policy foci of the Country Case Study
Countdown used the policy heuristics of (i) agenda setting; (ii) policy formulation; (iii) policy
implementation; and (iv) policy evaluation as guiding principles in the development and analysis of the
three CD HSP tools. Figure 2 shows the CD HSP tools within this policy heuristic — Tool 1 focuses on
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assessing agenda setting, Tool 2 focuses on assessing policy formulation, and Tool 3 focuses on assessing
policy formulation and strength of program implementation.
Figure 2: CD HSP Tools within the Policy Heuristic
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ANNEX 3 – PARTICIPANT LIST
COUNTDOWN HSP & FINANCE WORKSHOP: NAIROBI, 25-28 FEBRUARY 2014 PARTICIPANT LIST
PARTICIPANT EMAIL AFFILIATION FACILITATOR(S)
AFGHANISTAN
1 SM Moazzem Hossain [email protected] UNICEF
Neha Singh 2 Khawza Mir Ahad Saeed [email protected] LSH&TM/HEFD, MoH
3 Nadia Akseer [email protected] SICK KIDS
4 Mohammahd Hafez Rasooly [email protected] MoH
ETHIOPIA
5 Tewodros Bekele Endailalu [email protected]
Deb Sitrin
6 Helina Kebede Demisse [email protected] MoH
7 Mekonnen Tadesse Balcha [email protected]
8 Teshome Desta [email protected] WHO
9 Sirak Hailu [email protected]
MALAWI
10 Humphreys Nsona [email protected] MoH
Tim Colbourn & Bernadette Daelmans
11 Malumbo Kausi [email protected]
12 Andrew Jamali [email protected] National Statistical Office
13 Susan Kambales [email protected] WHO
14 Rufus Ferrabee [email protected] Consultant
PAKISTAN
15 Zulfi Bhutta [email protected]
Agha Khan University Neha Singh 16 Zaid Bhatti [email protected]
17 Muhammad Ashar Malik [email protected]
PERU
18 Luis Huicho [email protected] Cayetano Heredia University
Patricia Hernandez 19 Eddie Segura [email protected]
20 Jessica Niño de Guzmán [email protected] Ministry of Economy & Finance
TANZANIA
21 Hoviyeh Afnan-Holmes [email protected] LSHTM
Joy Lawn
22 Theopista John [email protected] WHO
23 Moke Magoma [email protected] E4A
24 Clement Kihinga [email protected] MoH
25 Arin Dutta [email protected] Futures Group
RWANDA
26 Felix Sayinzoga [email protected] MoH
Carlyn Mann , Blerta Maliqi, Joy Lawn & Bernadette Daelmans 27 Alypio Nyandwi [email protected]
KENYA
28 Rebecca Njuki [email protected] FCI Carlyn Mann, Blerta Maliqi, Joy Lawn & Bernadette Daelmans
29 Joyce Lavussa [email protected] WHO
30 Anne Karim Njeru [email protected] MoH
FACILITATORS – Health Systems & Policies
31 Tim Colbourn [email protected] E4A
32 Bernadette Daelmans [email protected] WHO
33 Joy Lawn [email protected] LSHTM
34 Blerta Maliqi [email protected] WHO
35 Neha Singh [email protected] LSHTM
36 Deb Sitrin [email protected] SNL/Save the Children
FACILITATORS - Financing
37 Patricia Hernandez [email protected] Consultant
38 Carlyn Mann [email protected] Harvard
39 Melisa Martinez-Alvarez [email protected] LSHTM
40 Nirmala Ravishankar [email protected] Consultant
LOGISTICAL SUPPORT
41 Nacer Tarif [email protected] PMNCH
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ANNEX 4 – WORKSHOP AGENDA
DAY 1 – Tuesday, 25 February 2014
Time Topic / Activity Facilitator
9:00 - 9:30
Chair: Zulfiqar Bhutta
Welcome and introductions
CD HSP TWG Co-Chairs
(Bernadette Daelmans & Joy
Lawn)
9:30 - 10:00 CD case study overview and approach Joy Lawn
10:00 – 10:30 Workshop objectives and approach Bernadette Daelmans & CD
Finance TWG
10:30 - 11:00
Coffee/Tea Break
11:00 - 13:00
Chairs: Bernadette Daelmans & Joy Lawn
Presentations on analyses and focus for workshop from
the following country teams (10 minutes presentation
from PowerPoint template + 5 minutes discussion per
team):
Afghanistan
Ethiopia
Malawi
Pakistan
Peru
Tanzania
Rwanda
CD Country Case Study
Teams
13:00 – 14:00
Lunch
14:00 – 14:30
Chair: Tim Colbourn & Humphreys Nsona
CD HSP Tool 1 – Policy & Program Timeline
Joy Lawn & Neha Singh
14:30 – 15:30
CD Country Case Study teamwork on Tool 1drafts
(brought to the workshop)
Country Case Study teams
15:30 – 15:45
Coffee/Tea Break
15:45 – 16:45
Chair: Tim Colbourn & Humphreys Nsona
CD HSP Tool 2 – Dashboard for Tracer Indicators
Neha Singh & Blerta Maliqi
16:45 – 17:30 CD Country Case Study teamwork on Tool 2 drafts
(brought to the workshop)
Country Case Study teams
Evening Dinner at the Windsor Hotel
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DAY 2 – Wednesday, 26 February 2014
Time Topic / Activity Facilitator
9:00 - 10:30
Chairs: Luis Huicho & Neha Singh
CD Country Case Study Team summaries of Tool 1 and
Tool 2
Country Case Study
teams
10:30 - 11:00
Coffee/Tea Break
11:00 – 13:00
CD Policy Tool 3 – Context Specific Policy to Action
Assessment
Bernadette
Daelmans, Blerta
Maliqi & Tim
Colbourn
13:00 – 14:00
Lunch
14:00- 16:00 CD Country Case Study teamwork on Tool 3 Country Case Study
teams
16:00 – 16:15 Coffee/Tea Break
16:15 – 17:30 CD Country Case Study teamwork on Tool 3 (contd.) Country Case Study
teams
17:30 – 18:00
Summary / closing remarks CD HSP TWG
DAY 3 – Thursday, 27 February 2014
Time Topic / Activity Facilitator(s)
9:00-10:30 Overview of RT Analyses for the Countdown
Case Studies and Q&A:
Domestic expenditure analysis
Analysis of Development Assistance
Country team updates on the status of the
health financing/RT component of their
country case study
Nirmala Ravishankar, Country teams
10:30 – 11:00 Coffee Break
11:00 -11:30 Country Presentation 1: Afghanistan Afghanistan Country Case Study team
11:30 – 12:00 Country Presentation 2: Tanzania Melisa Martinez-Alvarez
12:00-13:00 Plenary Discussion:
Q&A on country presentations
Identification of common themes
Nirmala Ravishankar, Carlyn Mann,
Melisa Martinez-Alvarez, Patricia
Hernandez
13:00-14:00 Lunch
14:00 –
onwards
Group Work Nirmala Ravishankar, Carlyn Mann,
Melisa Martinez-Alvarez,
Patricia Hernandez
17:30 – 18:00 Summary / closing remarks CD Finance TWG
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DAY 4 – Friday, 28 February 2014
Time Topic / Activity Facilitator
9:00 – 12:00
Chairs: Bernadette Daelmans & Joy Lawn
Welcome and working plans
CD Country Case Study teamwork and
country-specific technical assistance on
policy and finance tools and analyses and
interpretation
12:00 – 13:00
Presentations on progress made in workshop,
and next steps, requests for specific TA from
the CD Country Case Study teams:
Afghanistan
Ethiopia
Malawi
Pakistan
Country Case Study Teams
13:00 – 14:00
Lunch
14:00– 15:00
Presentations from CD Country Case Study
teams (contd.):
Peru
Tanzania
Rwanda
Kenya
Country Case Study Teams
15:00 - 16:00
Feedback on/adaptations to CD policy tools
and RT analyses
Conclusions
Evaluation forms
16:00 – 16:30
Coffee/Tea Break and close
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ANNEX 5 – EVALUATION FORM
Countdown to 2015: Health Systems and Policies, and Financing Workshop for Country Case Studies
25-28 February, 2014
Participant Feedback Form
We ask that you take a few moments to provide your feedback. Your responses are anonymous and will be
used to improve the quality and the organization of our future workshops. Your feedback is very important
to us.
On a scale of 1-4 where 1 is strongly disagree and 4 is strongly agree, please circle the appropriate answer:
1. Has this workshop fulfilled your expectations? Please indicate your level of satisfaction
1 2 3 4
Comments:
2. What are your qualifications? (please tick all that apply)
Clinical medicine
Natural science/biology
Mathematics/statistics
Nutrition
Economics/Finance
Public Health/Epidemiology
Other
If other, please specify: __________________
3. What is your current field of work?
Clinical practice
Public health including MoH or UN
Epidemiology
Health economics
Other
If other, please specify: __________________
4. How do you rate the talks for the following sections of the workshop:
a) Introduction and overview of CD Country Case Studies 1 2 3 4
b) HSP Tools 1 & 2 (Tuesday) 1 2 3 4
c) HSP Tool 3 (Wednesday) 1 2 3 4
d) Financial analyses (Thursday) 1 2 3 4
5. How would you rate the CD Case Study Country group work for the following sessions
a) HSP Tools 1 & 2 (Tuesday) 1 2 3 4
b) HSP Tool 3 (Wednesday) 1 2 3 4
c) Financial analyses (Thursday) 1 2 3 4
6. How would you rate the facilitators for the following sessions
a) HSP Tools 1 & 2 (Tuesday) 1 2 3 4
b) HSP Tool 3 (Wednesday) 1 2 3 4
c) Financial analyses (Thursday) 1 2 3 4
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7. Were there any topics that were not included that would have been useful? If yes, please specify:
8. Were there any topics that were not useful among those included? If yes, please specify:
9. Did the workshop help you to advance your country case study, including other parts of the
evaluation in addition to HSP and financing? Please specify.
10. Would an additional workshop before you finish your country case study be useful? Yes/No
If yes, please specify the purpose, e.g. an analysis and/or writing workshops:
11. The workshop was:
a) Well-paced 1 2 3 4
b) Breaks were sufficient 1 2 3 4
c) A good mix between listening and activities 1 2 3 4
Comments:
12. How could this workshop be improved (use this space if you did not provide comments above)?
Preparation & webinars:
Handouts and materials (including on USB stick):
Other:
13. What did you like best about this workshop? ___________
14. What did you like least about this workshop?
THANK YOU!