PRSP and HNP (Health, Nutrition and Population) Resources for PRSP Teams and Appraisal Teams

PRSP and HNP (Health, Nutrition and Population) Resources for PRSP Teams and Appraisal Teams

Documents The Health Chapter in the PRSP Sourcebook (this presentation) Quick Guidelines for I-PRSP Teams (Africa Context, under development) Appraisal Checklists: WHO Framework I-PRSP Checklist

The Sourcebook Chapter Underlying Assumptions Poverty occurs at household and community levels. To find out why the system fails to reach the poor, need to look first at the household and community. Listen to voices of the poor, but some bottlenecks are systemic and require changes in ways of doing business regardless of the poverty performance. Prioritization is needed. Resources and capacity limited. No laundry lists.

The Sourcebook Chapter Logical Framework Health Outcomes -- assessing health outcomes for the poor and setting targets Poor Households/Communities -- their role in generating poor health outcomes Health System and Related Sectors -- assessing health sector performance to support poor households for better health outcomes Government Policies and Actions -- improving outcomes through government actions

Determinants of Health Outcomes Diagnostics Monitoring & Evaluation Health outcomes Households/Communities Health system & related sectors Government policies & actions Health outcomes Health & nutritional status; mortality Household behaviors & risk factors Use of public & private health services, dietary and sanitary practices, lifestyle, care & stimulation of children, etc. Household resources Income, assets, land, education, etc. Health service provision Availability, accessibility, quality of health services; Input markets Health financing Revenue collection, pooling and disbursement/ purchasing Overall health sector strategy, prioritysetting and resource allocation in public sector, monitoring & evaluation, advocacy, regulation Community factors environment, culture, values, social capital, ecology, geography, etc. Supply in related sectors Availability, accessibility, prices & quality of food, energy, roads, water & sanitation, etc. Other govt. policies, e.g. infrastructure, transport, energy, agriculture, water & sanitation, etc.

Step 1: Outcomes among the Poor (Focus on the Distribution) 180.0 Under-five mortality rate per 1000 live births 160.0 140.0 120.0 100.0 80.0 60.0 40.0 20.0 Poorest fifth 2nd poorest fifth Middle fifth 2nd richest fifth Richest fifth 0.0 Bolivia 1998 India 1992/93 Kenya 1998

Step 2: Household and Community (Asking WHY) Area Issues Diagnostic tools Policy angle Household Income, wealth, education, knowledge, gender bias Household surveys; various statistical methods Health finance; social protection; BCC and health education; advocacy for gender equality Community Physical factors, values & culture, social capital Community surveys, consultation exercises Transport & infrastructure; advocacy for changes in attitudes harmful to HNP outcomes; foster social capital

Step3: The Health System (Diagnostics) Determinants of Sector s performance Accessibility Availability Organizational quality Service Production Continuity Technical Quality Social Accountability Examples of problem Low access to PHC, to community based activities Shortages of drugs vaccines, trained staff Inconvenient opening hours, lack of privacy Price, perceived quality Weak linkages with community structures. Poor supervision Inefficacious services because of non respect of standards No voice of the poor in delivery of services Diagnostic tools Consultation exercises; household surveys Facility surveys Consultation exercises Consultation exercises Facility surveys Consultation exercises Allocative efficiency Low funding to cost-effective PHC Cost-effectiveness analysis Expenditures equity Low level of resources channeled to the poor Benefit incidence analysis

Step3: The Health System (Diagnostics) Determinants of Sector s performance Accessibility Availability Organizational quality Examples of problem Low access to PHC, to community based activities Shortages of drugs vaccines, trained staff Inconvenient opening hours, lack of privacy Service Production Price, perceived quality Mix Continuity Technical Quality Social Accountability Weak linkages with community structures. Poor supervision Inefficacious services because of non respect of standards No voice of the poor in delivery of services Allocative efficiency Low funding to cost-effective PHC Purchasing Expenditures equity Low level of resources channeled to the poor Structural problems to explore Mix. Core Packages and areas of responsibility. Human Resources Pharmaceuticals. Human Resources Human Resources. Community/civil society Participation Community participation. Contracting Contracting. Pharmaceuticals. Human Resources. Stewardship Community and civil participation Purchasing. Stewardship

Step 3: Financing Issues Area Issues Diagnostic tools Policy angle Collecting revenues Sustainability; balance between user fees and prepayment; fee waivers for the poor; making prepayments progressive Overall revenue levels; financing mix; survey analysis of fee waivers; progressivity and poverty-impact analyses Make financing sustainable; reduce emphasis on user fees and try fee waivers for poor; link prepayments to income via tax or social insurance Fund pooling Size, wealth & diversity of risk pools; covering the poor for major risks Analyses of pools who is covered in each and for what; gaps in coverage Merging pools esp. groups with different risks and resources Purchasing Using revenues to buy services for the poor Benefit incidence Needs-based geographical resource allocation mechanisms

Step 4: Policy Levels Problem Area Public Expenditure Making the Health System Function Better Targeted Intervention s that Work Issues Reallocations to improve targeting and efficiency of expenditure Increasing effectiveness, quality, and outputs through improved system performance. Improving receptiveness of the system to poor and excluded populations Implementable, businesslike, focused interventions for the poor Measurable and evaluated outcomes Actions 3-5 year plan for expenditure changes, taking into account reallocations and new resources Systemic reforms in incentives, contracting, ownership, insurance coverage, and coordination among partners Pilot testing Knowledge dissemination; training and communication about changes Projects and pilots in system context: targeted maternal and child health, nutrition, public health programs

PRSP Appraisal: WHO Framework Health Sector: Focusing on the health problems of the poor and ensuring that health systems serve the poor. Protecting the poor to limit the impoverishing effect of health expenditures. Ensuring system accountability towards the poor. Wider Considerations: Acting on the determinants of better health for the poor. Reducing the risks faced by the poor.

I-PRSP Appraisal: Checklist Targeting check: Diseases and Interventions:: Are resources flowing to address diseases of the poor? Are resources flowing to services that benefit the poor in a larger extent ie preventive, promotive services, and essential curative services? Are resources flowing to Behavior Change Communications Geographic and Level of services :Are resources flowing to appropriate levels of care delivery? Are resources flowing to regions with the most need? Are resources flowing to rural areas or to urban slums? Are best buys resources (benefits) flowing directly to low-income households? Recurrent cost check: Ensure no large capital investments, with expensive recurrent costs, are financed (e.g. tertiary and training hospitals) Ensure that increased financing of health staff is linked to increased performance of service aimed at reaching the poor Check the balance on inputs between the wage bill and non-salary recurrent costs while making sure that human resources are not constrained to the point of reducing efficiency

I-PRSP Appraisal: Checklist (2) Affordability check No user fees in basic social services if not accompanied by local retention of funds, community co management, and investment of local revenue in availability, access and quality improvements of services for the poor Higher subsidies to best buys than to average services Monitoring the equity impact of reforms